Child Death Review Team (CDRT)
Child Death Review Team
Child Death Review Team & Fetal Infant Mortality Review
Child Death Review Team
The CAP Center facilitates the work of the Sacramento County Child Death Review Team (CDRT) which reviews the death of every child in Sacramento County. The primary function of the Sacramento County CDRT is to identify how and why children die in order to facilitate the creation and implementation of strategies to prevent future child deaths. The purpose of the multidisciplinary CDRT is to:
- Ensure that all child abuse-related deaths are identified;
- Enhance the investigations of all child deaths through multi-agency review;
- Develop a statistical description of all child deaths as an overall indicator of the status of children; and
- Develop recommendations for preventing and responding to child deaths based on said reviews and statistical information.
Sacramento County’s CDRT is unique in that it reviews the deaths of ALL Sacramento County children from birth through 17 years of age and has been reviewing deaths and collecting data since 1990. Now, the Sacramento County CDRT serves as a model to replicate for other California counties. The Sacramento County CDRT has been included in national studies highlighting CDRT best practices.
Fetal Infant Mortality Review
Fetal Infant Mortality Review (FIMR) reviews Sacramento County resident cases of deaths among infants born prior to 23-weeks of gestation and fetal demise cases. The FIMR case review process is similar to CDRT and involves women’s health clinics that provide maternal health data. This includes information on family planning, risk factors for premature birth, prenatal care, social support, life changes, and stress.
The purpose of the Sacramento County Fetal Infant Mortality Review is to seek to reduce fetal and infant deaths, by:
- Reviewing selected cases;
- Identifying factors associated with these deaths;
- Determining if these factors represent social or system problems which require change; and
- Presenting recommendations for systems changes to improve outcomes.
Equity Statement
“Health equity science investigates patterns and underlying contributors to health inequities and builds an evidence base that can guide action across public health programs, surveillances, policies, communications, and scientific inquires to move toward eliminating, rather than simply documenting, inequities.”
— The Centers for Disease Control and Prevention Health Equity Science Team
The Sacramento County Child Death Review Team (CDRT) and Fetal Infant Mortality Review (FIMR) Case Review Team are committed to promoting the practice of health equity science in their collection, review, and analysis of fetal and child death data, and an equity-centered approach to fatality review and prevention.
The CDR and FIMR Teams remain committed to using a health equity lens in case review and data analysis, which include identifying and promoting the visibility of disparities and disproportionality, and prevention recommendations that eliminate racial inequities. The CDR and FIMR Teams remain intentional and explicit in data collected, reviewed, and reported.
The following comprehensive CDRT & FIMR reports of child deaths were compiled by Sacramento County’s CDRT:
(Please Note: FIMR Data is only available in the Annual Reports starting in 2015)
2017-2021 CDRT Report
2017-2021 Key Findings and Recommendations
The Prevention Advisory Committee (PAC) serves as a Community Action Team, to review aggregate data, identify key findings, and develop prevention recommendations. The PAC comprises of members from CDRT, FIMR, and Youth Death Review Subcommittee (YDRS), as well as other prevention-focused representatives, including but not limited to, county agencies, Safe Kids Greater Sacramento, First 5 Sacramento, and Black Child Legacy Campaign. The following recommendations were created by the PAC for the 2017-2021 years and were approved by the CDRT.
Overall Trends
The five-year child death rate decreased from 36.5 in 2016 to 33.0 for 2017-2021. Rates vary by year, with a high of 37.3 in 2021, and a low in 2020 of 31.1. Over the past ten years, the All Child Death rate for children living in Sacramento County decreased, while Injury-Related and Undetermined Deaths increased.
Regarding systems involvement, 85 percent of all child deaths had at least one or more systems involvement. Government Aid is the number one system of involvement for all deaths across all five years, with 62 percent of families receiving government aid.
Sacramento County will finalize and implement the Family First Prevention Services Act (FFPSA) plan to increase and improve cross-sector collaboration, communication, and assessments for acuity, as it relates to quality referrals, warm handoffs, and follow-up for services, by the end of 2025. The Child Safety Forward Sacramento Prevention Cabinet should continue to review social drivers of health involved in child death data and develop findings to prioritize Strategic Plan activities and actions.
Sacramento County should also continue quality improvements and culturally responsive updates to Mandated Child Abuse Reporter Training (MCART) and continue to offer services to break generational cycles of child welfare involvement. Child, Youth and Family System of Care (AB2083) and Child Safety Forward Sacramento should review data and continue to identify opportunities for cross-sector collaboration.
Documented family history of domestic violence increased across all deaths, including those reviewed at CDRT and FIMR. Twenty-four percent of All Child Deaths had reported history of domestic violence from 2020-2021, with a high of 31 percent in 2021, and up from 21 percent from 2017-2019. Documented domestic violence history for reviewed Fetal Deaths was also up, at 20 percent from 202-2021, with a high of 32 percent, and up from 15 percent 2017-2019.
Sacramento County should support local domestic violence service agencies in providing services to pregnant and parenting families.
Respiratory Deaths due to COVID-19 were tracked but occurred at a lower than reportable number (<5).
Homicides: Child Abuse and Neglect Homicides
There were 20 CAN Homicides, as a result of 18 incidents, from 2017-2021. All 20 were Sacramento County resident children and occurred in Sacramento County. Seventy percent of decedents were between the ages of 0-5 years. Eighty-five percent had history of Child Protective Services Involvement.
The Child Safety Forward Sacramento Prevention Cabinet should prioritize and implement their recommendations most directly related to children ages 0-5 in order to eliminate child abuse and neglect death and critical injuries. CDRT will continue to work with the Sacramento County Prevention Cabinet to identify patterns of systems involvement in children who die from CAN Homicides, to improve referrals and linkages to preventative resources.
Homicides: Third-Party Homicides
There were 24 Third-Party Homicides, from 2017-2021, who were Sacramento County residents that died in Sacramento County. There were two additional out-of-county residents whose injuries leading to death were sustained in Sacramento County, for a total of 26. Fifty-four percent of the total were Black/African American children.
Sacramento County should expand and enhance neighborhood-based programs focused on reducing Third-Party Homicide through violence prevention, interruption, and intervention, through cross-sector collaboration. Building on and expanding the neighborhood infrastructure that has been created through the Black Child Legacy Campaign (BCLC).
Infant Sleep-Related Deaths
There was a total of 67 Infant Sleep-Related Deaths from 2017-2021, with a low of ten in 2019 and a high of 19 in 2021. Seventy percent had history of Sacramento County Child Protective Services involvement.
The Safe Sleep Baby Education Campaign should build on existing efforts to further engage and educate parents, both prenatally and postnatally, who receive services from hospitals and local medical clinics, by strengthening the integration of infant safe sleep policies, practices, messaging, and training for staff. This includes continuing to expand training and education efforts to reach parents and caregivers of infants with Child Protective Services (CPS) referrals to decrease the prevalence of Infant Sleep-Related Deaths.
African American Disproportionality
The deaths of Black/African American children in Sacramento County have been historically higher, or disproportionate, when compared to the deaths of children of all other race/ethnicity. From 2017-2021, Black/African American Children represented an average of 10 percent of the Sacramento County Child Population and represent a disproportionate 21 percent of all 2017-2021 child deaths among Sacramento County Residents. This is an increase from 15 percent in 2016.
The Black/African Child Death Rate ranged from a low of 53.5 in 2017 to a high of 91.3 in 2021, disproportionate to the All Other Race/Ethnicity Child Death Rates. with a low of 27.6 in 2020 to a high of 31.1 in 2021.
From 2017-2021, in the four categories of death in which Black/African American children have historically been disproportionately represented, Black/African American Sacramento County resident children comprised:
- Third-Party Homicide | 54 percent (14 of 26)
- Infant Sleep-Related Deaths | 28 percent (19 of 67)
- Perinatal Conditions Deaths | 23 percent (36 of 157)
- CAN Homicides | 20 percent (4 of 20)
Sacramento County should continue to partner with, invest in, and fund the efforts to reduce the deaths of Black/African American children in Sacramento County, which is disproportionate to the deaths of other children. CDRT recommends continuing and increasing programs and funding for community engagement and education focused on best practices identified to prevent Child Abuse and Neglect Homicides, Third-Part Homicides, Infant Sleep-Related Deaths, and deaths due to Perinatal Conditions, including, but not limited to, the Black Child Legacy Campaign; Birth & Beyond Family Resource Centers; Pregnancy Peer Support and Safe Sleep Baby campaign funded by First 5 Sacramento; Public Health Nursing programs such as Black Infant Health, Nurse Family Partnership, African American Perinatal Health; Sacramento city and county financial supports; and additional community efforts.
Injury-Related Youth (Ages 10-17 Years) Deaths: Firearms
Firearms were used in 29 percent (26 of 90) of Injury-Related Youth (ages 10-17) Deaths, 2017-2021 including 56 percent (26 of 46) of Third-Party Homicide and Suicide Deaths.
Sacramento County law enforcement should collaborate with the District Attorney’s Office, Public Defender’s Office, and trusted community groups/organizations, with the support of county agencies, to develop a community and culturally responsive strategic plan for action to reduce youth gun violence.
Injury-Related Youth (Ages 10-17 Years) Deaths: Poison/Overdose Deaths
There were nine Poison/Overdose Deaths of Youth ages 10-17, in 2020-2021, compared to two Poison/Overdose Deaths of Youth ages 10-17, from 2017-2019. Of the nine, from 2020-2021, 89 percent involved Fentanyl, compared to zero from 2017-2019
Sacramento County should continue supports that are already implemented that can be utilized and/or expanded. Substance use awareness should specifically include information/education on Fentanyl and the misuse of prescription medications. Awareness should be provided in schools and on social media and begin in the 6th Grade.
Injury-Related Youth (Ages 10-17 Years) Deaths: Suicide
There were 26 Suicide deaths of children ages 10-17 from 2017-2021, with a high of seven in 2017, 2018, and 2020. All were Sacramento County resident youth and occurred in Sacramento County. Seventy-seven percent experienced history with Child Protective Services Family Involvement.
Detailed school information was known for 54 percent of Suicide Deaths. Thirty-one percent attended school districts that have not actively participated or have declined participation in the CDRT Youth Death Review Subcommittee, limiting access to more complete information to identify prevention strategies.
Warning Signs for of Youth Suicide Death include 54 percent of Decedents having history of mental health services, and 12 percent receiving mental health services at time of death.
Sacramento County should improve data collection for Injury-Related Youth Deaths by encouraging full participation of Sacramento County School Districts, and Private and Charter Schools on the Youth Death Review Subcommittee (YDRS).
Based on available school information, the Youth Death Review Subcommittee recommends the continued use of the mental health screening tools, identified and currently used by San Juan, Folsom Cordova, and Sacramento City Unified School Districts, and Robla School District.
Injury-Related Youth (Ages 10-17 Years) Deaths: Third-Party Homicide
There were 18 Third-Party Homicides of children aged 10-17 years, from 2017-2021, who were Sacramento County residents. There were two additional out-of-county residents whose injuries leading to death were sustained in Sacramento County, for a total of 20.
Third-Party Homicides were the second leading cause of Injury-Related Youth Deaths (ages 10-17 years) for the five-year period of 2017-2021. Preceded by Suicide (26)
Sacramento County should increase access to community centers and recreational activities, including but not limited to, pools and parks to provide opportunities for community engagement of youth and families after 5:00pm.
Fetal Infant Mortality Review: Overall Trends
From 2017-2021, there were 88 deaths of infants who were born prior to 23-weeks of gestation (Live-Birth Deaths) and 404 fetal deaths (deaths in utero) with fetal death certificates, for a total of 492 Fetal Infant Mortality Review (FIMR) cases among Sacramento County residents. Sacramento County's goal is to review at least 25 percent of FlMR cases. In 2017-2021, 53 percent (260 of 492) of cases were reviewed.
Fetal Infant Mortality Review: Maternal Health
Sixty-six percent of Fetal Deaths and 54 percent of Live-Birth Deaths reviewed by FIMR identified mother’s pre-pregnancy Body Mass Index (BMI) was Overweight or Obese.
Sacramento County should continue to provide current and new education, supports, and services for maternal health.
Fetal Infant Mortality Review: Prior Fetal Loss and Late-Term Loss
Twenty-six percent of FIMR cases experienced prior fetal loss, as well as 19 percent experiencing a late-term loss (at 37-weeks of gestation or more).
Sacramento County should provide trauma informed support and care for families who have experienced prior fetal loss and/or late term loss.
