Addressing Child Maltreatment Deaths and Serious Injuries

(Originally published September 2012)

by Alan Puckett

On the evening of July 14th, paramedics were called to the Ware residence because 1-year-old Jessie was not breathing. After attempting unsuccessfully to resuscitate her, they determined she died of asphyxiation. The infant’s distraught father, Steve, admitted that he was responsible, stating that he had stuffed baby wipes in her mouth to stop her crying. When he noticed her struggling for breath, he
discovered that they were too firmly lodged in her throat to remove. Jessie’s mother, Susan Ware, was attending a parent training class at the time.

The incident followed two prior reports to the hotline in the previous two months because of suspected abuse. The first report was made by a nurse after Jessie was brought to the hospital by the maternal grandmother because of bruises on the infant’s buttocks. Initially, Susan Ware stated the bruises were inflicted by her husband, Steve, but she later claimed they were the result of her striking the infant out of frustration. Jessie was temporarily placed with the maternal grandmother until a worker who had served as Ms. Ware’s private therapist in the past requested that she be assigned to the case. The caseworker argued that her previous relationship with Ms. Ware would enhance work with the family.

Jessie was subsequently returned to her parents for follow-up services. After a second report for unexplained injuries, the caseworker suggested that the maternal grandmother was deliberately staging these crises in order to have Jessie returned to her home. She suggested that they avoid using the maternal grandmother as a caretaker for Jessie. Child protection investigators deferred to the caseworker in decisions regarding future risk to Jessie rather than conducting a comprehensive and independent assessment of the family.
--Rzepnicki & Johnson (2005)

Official statistics on the number of child deaths from abuse and neglect, and estimated incidence rates of maltreatment fatalities per 100,000 children in the general population, have fluctuated within a relatively narrow range for the past several years. The following table shows numbers of reported maltreatment fatalities and estimated national incidence rates for years 2006-2010, drawn from the National Child Abuse and Neglect Data System (NCANDS).

Child Fatality Rates per 100,000 Children, 2006–2010 (unique count)

(Note: "States" refers to states and U.S. territories)

Reporting    States             Child pop. of             Reported unique    Rate per                   Child pop. of           Estimated unique
Year              Reporting      reporting states        child fatalities          100,000 children     all 52 state              child fatalities

2006                    49              69,002,501                    1,382                          2.00                        75,028,427                  1,500
2007                    50              70,676,241                    1,608                          2.28                        75,342,238                  1,720
2008                    51              73,157,339                    1,670                          2.28                        75,411,627                  1,720
2009                    50              71,801,093                    1,668                          2.32                        75,512,062                  1,750
2010                    51              74,079,060                    1,537                          2.07                        75,512,062                  1,560


SOURCE: U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. (2011). Child Maltreatment 2010.
Available from


The death or serious injury of a child due to abuse or neglect in an open or recently open case is the worst-case scenario for professionals in the public child protection system. Fortunately, such events are rare and occur in only a small fraction of all families who come to the attention of child protection agencies. Whatever the circumstances, any child’s death should raise the question, “What might have prevented this tragedy?”

When a critical incident does occur in a family known to the child protection system—sometimes, though not always, caused in part by failures within the system itself--news media may offer premature accounts implicitly or explicitly indicting caseworkers and agencies, suggesting ineptitude, malfeasance and failure to protect, under an apparent presumption of guilt, without careful review of all the facts.
In some states, law and policy prohibit child protection agencies from using information in the case record to explain agency actions or inaction when that would involve release of confidential information about children and their families. A number of states, however, have amended their laws in recent years to allow greater disclosure of case information following a child’s death from suspected abuse or neglect. More states, arguably, should follow this path, and more likely will do so in any event.

In the wake of critical incidents, caseworkers and supervisors sometimes lose their jobs, and may become targets of civil litigation or even criminal prosecution; competent agency leaders may be sacrificed to appease the outcry; and public trust in and support for child protection efforts may be seriously damaged. The harm may radiate far beyond the initial tragedy; the repercussions from these atypical but searing events can paralyze agencies and drive the entire child protection process toward undue caution and a tendency to be more intrusive with families, bringing many more children into out-of-home care than is necessary.

As the dust begins to settle, agencies frequently tout new practice models, improved assessment tools, and additional administrative requirements for caseworkers, but sometimes fail to address fundamental issues in the system itself. Many jurisdictions continue to have low standards for caseworker education and training, and pay accordingly; caseworkers often carry excessive caseloads and are further burdened by additional administrative requirements which can make it difficult to actually spend time with children and their families. Internal reviews often focus on compliance issues without fully examining the organizational and workplace context within which failures of child protection continue to occur.

There is no substitute for thorough, painstaking investigation to inform efforts at prevention. The fact that many public child protection agencies fail to consistently utilize methodical, prevention-oriented case review as the foundation for ongoing quality improvement efforts is perhaps the most unfortunate side effect of a near-sighted focus common in this field. Many child protection agencies attend closely to a single high-profile child fatality but do not step back to study the common elements among such incidents. Failing to learn from the death or injury of a child compounds the tragedy in that case. Failing to uncover patterns among incidents and apply those lessons as practice changes makes it likely that errors which could have been avoided will occur in the future, potentially in many other cases.
The fact that deaths and serious injuries caused by child maltreatment occur in relatively few cases presents a significant challenge because it is difficult to compile enough data to clearly identify trends and patterns among cases, especially in small and medium sized communities. Thus, it is vitally important to collect systematic data on child maltreatment fatalities when they occur and, when possible, on “near misses” as well, and to aggregate data at the regional, state, and national levels for careful analysis.

Two states provide good examples of real-world processes for prevention oriented review of critical incidents in child protection cases. While they follow different models, both are based on the use of case level and aggregate data, and are designed to support improved safety outcomes for children involved with the child protection system by informing ongoing quality improvement efforts.

Palusci, (2010) describe the implementation of a Citizen Review Panel process in Michigan. State Citizen Review Panels (CRPs) were mandated by 1996 federal legislation reauthorizing the Child Abuse Prevention and Treatment Act (CAPTA). CRPs make recommendations for the improvement of child protection policy and practice, and have been implemented in various ways around the country. Michigan's process is based on a multidisciplinary, public health Child Death Review Team model (National Center on Child Death Review which has been tailored specifically to inform ongoing quality improvement efforts within the state child protection system.

Michigan's CRP was established in 1999 with member volunteers from the state's existing Child Death Review board. Panel members brought expertise in forensic medicine, pediatrics, law enforcement, child law, child protective services, public health, mental health, education, and child advocacy. The state social services agency provided funding for a support staff position to help with collecting case information for reviews. Cases chosen for review were those included in state reports to the NCANDS system of child abuse and neglect fatalities; other cases also involving acts meeting state civil or criminal definitions of abuse or neglect; and those cases in which the panel determined that a child death was attributable to "serious acts of omission."

The CRP’s findings and recommendations reflect agreement within the Panel, and are compiled into an annual report issued to the director of the state child welfare agency. The child welfare agency issues a formal response to each annual report, and identifies actions or changes planned in response to the report's findings and recommendations.

Palusci, reviewed 356 Michigan child deaths and 436 state CRP findings from 1999 through 2004. Their study broke this into two 3-year periods for analysis, providing time for CRP recommendations from the first period to be implemented and affect outcomes during the second period. Child maltreatment deaths per year and an estimated incidence rate of deaths per 100,000 children were compared for the two 3-year periods.

The study's findings indicated a decline in both total child maltreatment deaths (186 per year during the 1999-2001 period versus 170 per year during the 2002-2004 period) and in the incidence rate of deaths per year in the population (2.4 per 100,000 for 1999-2001 versus 2.2 per 100,000 for 2002-2004)1. Further analyses showed that a number of specific CPS practice issues identified as being associated with child maltreatment deaths (inappropriate screen-out of referrals or delay in acceptance of complaints and case assignment; incomplete or insufficient investigation of reports; excessive time between case assignment and contact with the family, etc.) also decreased between 1999-2001 and 2002-2004. While the authors note that the study is not able to definitively establish that CRP case review led to a reduction in child maltreatment deaths in Michigan, it is clear that Michigan’s CRP process is a model with potential to reduce child maltreatment deaths.

Working with the Department of Children and Family Services (DCFS) Office of the Inspector General (OIG) in Illinois, Tina Rzepnicki and colleagues have adapted a process called "Root Cause Analysis" (RCA) for review of child fatalities in cases with DCFS involvement up to one year prior to a child's death. RCA was developed for analysis of negative outcomes in high-risk work, and has been applied in reviewing airline crashes, accidents in the chemical industry, and failed military operations. Branching backward from the critical event, an RCA analysis develops a causal "tree" to identify not only immediate antecedents of the event but also secondary or contextual factors which contributed indirectly to the negative outcome.

In a 2010 article, Rzepnicki and colleagues suggested that child protection agencies fall into a category of organizations dealing with critical work in which risks of failure are high and where the consequences of error can be catastrophic. Because of these factors, they wrote, child protection agencies should be transformed into "High Reliability Organizations" which emphasize safety and reliability through use of multiple checks in the performance of critical functions and error reduction "through decentralization of authority, strong organizational culture, and continuous training" and by "learning through trial and error, supplemented by anticipation and simulation."
The Illinois system, which Rzepnicki, (2012) characterize as being "currently in the beginning stages of development and implementation", emphasizes a systems perspective which "assumes that errors occur in a dynamic rather than static organizational environment and takes into account the contributions of individual behavior, interaction and communication patterns, organizational culture, and administrative and policy factors."

Care must be taken in the analysis to distinguish information which a caseworker had, or should have uncovered, prior to a critical incident from information which only became available after the event. Identifying the root causes of critical incidents is one vital step in prevention, but a distinction must also be made between causal factors which can be modified and those which cannot. A focus on modifiable causal factors is the foundation for systemic change and improved child safety.

In developing the Illinois RCA system, overlapping samples of records from cases involving the death or serious injury of a child were analyzed using three different case review strategies. One trial involved use of a commercial root cause analysis software tool with a sample of OIG cases; a second analysis involved reviewing a sample of OIG investigations cases without the software tool; and the third was based on analysis of original case files.

The combined analyses identified a number of decision making errors, including (consider the case summarized at the beginning of this column): failure to access or use available information; failure to recognize an accumulation of risk resulting from multiple factors; and failure to implement and adequately monitor a safety plan. Contextual factors which had contributed to primary or direct errors were also identified, including lack of adequate supervisory oversight or support; failures to communicate policies clearly; inadequate staffing practices, etc.

An early outcome of this development process has been legislation in Illinois requiring the OIG to address patterns of practice errors which contribute to child safety issues. One concrete step taken as a result has been the creation of a training curriculum for DCFS child protection caseworkers and supervisors intended to improve critical thinking skills in assessing cuts, welts and bruises. These injuries often appear as early indicators of danger to a child but may be overlooked or dismissed under what the authors refer to as the "Rule of Optimism", i.e., an adherence to initial impressions and dismissal of conflicting evidence.

Both the Michigan and the Illinois case review systems remain works in progress. They serve, however, as examples of innovative approaches to the improvement of child protection policy and practice through careful, systematic analysis of data from cases involving child injuries and fatalities. These are two initiatives which child protection agencies in other states can study and consider in developing their own prevention-oriented quality improvement case review systems.

About the author: Alan Puckett is a Systems Improvement Advisor with Casey Family Programs in Seattle and works with child welfare jurisdictions around issues of safety and risk. 



Palusci, V.J., Yager, S. & Covington, T.M. (2010). "Effects of a Citizens Review Panel in preventing child maltreatment fatalities". Child Abuse & Neglect 34 (5), 324-331.

Rzepnicki, T. L. & Johnson, P.R. (2005). "Examining decision errors in child protection: A new application of root cause analysis". Children & Youth Services Review 27, 393-407.

Rzepnicki, T.L., Johnson, P.R., Kane, D., Moncher, D., Coconato, L.A. & Shulman, B. (2010). “Transforming Child Protection Agencies into High-Reliability Organizations: A Conceptual Framework”. Protecting Children 25 (1), 48-62.

Rzepnicki, T., Johnson, P., Kane, D.; Moncher, D., Coconato, L., Shulman, B. (2012). "Learning from data: The beginning of error reduction in Illinois child welfare". In Rzepnicki, T.L., McCracken, S., and Briggs, H.E., Eds. From Task-Centered Social Work to Evidence-Based and Integrative Practice: Reflections on History and Implementation. Chicago: Lyceum Books, Inc.



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