Child Fatality Reviews

Section 7.106.13(A) of the Colorado Code of Regulations states:

Within twenty-four (24) hours (excluding weekends and holidays) of a county department becoming aware of an egregious incident of abuse and/or neglect, or near fatality or fatality of any child, which is suspicious for abuse and/or neglect, the county department shall call or email the following known information to the state department, which shall also be documented on the state prescribed form:

Name and age of victim
The referral identification number generated by the state automated case management system
Known circumstances around the egregious incident of abuse and/or neglect, near fatality or fatality
A description of physical injuries or medical condition of the child(ren) at the time of receipt of the information
The names and ages of surviving or non-injured child(ren) who may be at risk
A brief description of family/caregiver's prior involvement with child welfare, if any
The actions taken by the county department to date and future actions to be taken
The involvement of other professionals in the case
Whether the child was in out-of-home placement at the time of the incident
For fatal incidents, the county shall enter the child's date of death in the state automated case management system.

In order to streamline the notification process, the Administrative Review Division (ARD) has created one e-mail address and one phone number that county staff shall use for purposes of notifying the State Department when the county becomes aware of an egregious incident of abuse and/or neglect, or near fatality or fatality of a child, which is suspicious for abuse and/or neglect.

Email: cdhs_cfrt_notification@state.co.us
Phone: 303-866-7904

It is important to note that for purposes of satisfying the county department's timely obligation to notify the State Department of an incident that is suspicious for an egregious abuse and/or neglect, or near fatality or fatality of a child, an initial e-mail or phone call is sufficient. The county shall complete and submit the state prescribed form when they have secured the information requested on the form.

Defining Egregious Incidents of Child Maltreatment

In 2012, legislation in Colorado broadened the purview of the Child Fatality Review Team to those incidents caused by child maltreatment that are "near fatal" and "egregious." Unlike fatal and near fatal incidents, which have relatively objective criteria, incidents of egregious abuse or neglect (egregious incidents) involve more subjectivity when differentiating at the high end of child maltreatment severity. The purpose of this document is to provide more detailed guidance for implementation of the egregious definition.

Click here to access the most recent version of "Defining Egregious Incidents of Child Maltreatment."

Colorado Child Maltreatment Fatality Review Annual Reports

On July 1, 2015, in accordance with the statutory responsibility established through 26-1-139, C.R.S., CDHS respectfully submitted the "2014 Child Maltreatment Fatality Report." Through feedback received from stakeholders as the report was used after its release, a number of changes were made to the report to ensure accuracy and clear interpretation of data contained in the report. CDHS recognizes the importance of the Child Maltreatment Fatality Report and regrets the need for changes to the report. We are committed to the accuracy of the data in the report, and felt it was important to note the changes.

Public Notifications

This web page serves as the CDHS public notification system for fatalities, near fatalities and egregious incidents of child maltreatment, as outlined in the Colorado Revised Statutes § 26-1-139.

PLEASE NOTE: At the time of public notification, maltreatment of a child is suspected, but not confirmed. This initial notification only informs the public that CDHS has been notified about a qualifying incident for possible review. Whether the maltreatment is substantiated or unsubstantiated may not be known for minimum of 30 days and in some circumstances longer, as the county human services agency conducts an assessment of the allegations and the family.

If the allegations of fatal, near fatal, or egregious abuse or neglect are substantiated and the child and/or child’s family had previous involvement with a county Human Services agency during the prior three years, a review by the state Child Fatality Review Team (CFRT) will be initiated. The status of each report can be found in “Outcome of County Investigation” column on the public notification page. Until the assessment is complete, the report will be marked as “Pending.”

Follow this link for a detailed outline of the CFRT Process Timeline.

History of the Child Fatality Review Process

During the 2011 Colorado legislative session, House Bill 1181 was passed which codified the Colorado Department of Human Services" (CDHS) Child Fatality Review Team (CFRT) and provided statutory authority through the addition of section 26-1-139 of the Colorado Revised Statutes. The statute outlines the guidelines regarding the CFRT's purpose, structure, and reporting procedures.

In 2012, statute was amended when Senate Bill 12-033 was passed, adding to the purview of the CFRT, the review and public disclosure of non-confidential information regarding egregious and near fatal incidents to the existing requirement of public disclosure of information regarding fatal incidents of child abuse and neglect. These changes allow the CFRT to gain a better understanding of the causes, trends, and system responses to child maltreatment and develop recommendations in policy, practice and systemic changes to improve the overall health, safety, and wellbeing of children in Colorado and mitigate future child fatalities.

Beginning August 1, 2012, Colorado county DHS agencies began reporting all egregious and near fatal incidents (in addition to the already required child fatalities) suspicious for abuse and neglect, within 24-hours of becoming aware of the incident. The Fatality Review Public Notification webpage was created as a means to provide “public disclosures of findings or information about a case of child abuse or neglect that resulted in a child fatality or near fatality” as required under the federal “Child Abuse Prevention and Treatment Reauthorization Act,” 42 U.S.C. § 5101 et seq. Public Notifications are posted within three business days of the CDHS receiving the information from the county DHS. Public Notification of an incident simply denotes maltreatment of a child is suspected, not confirmed.

After amendments were made to statute in 2012, the CFRT reviewed egregious and near fatal incidents in addition to the reviews they were already completing on fatal incidents. Senate Bill 12-033 indicated cases were to be set for review within 30 days of receiving the necessary documentation from the county DHS agency, when the following things are true:

The incident was substantiated for abuse or neglect.
The child or family had "previous involvement" with a county DHS agency that was directly related to the incident.
The previous involvement with the DHS agency occurred within two years prior to the incident.

The definition for "previous involvement," as defined in Senate Bill 12-033, was a situation in which the county department received a referral, responded to a report, opened an assessment, provided services, or opened a case in the Colorado Trails system, except when:

The situation did not involve abuse or neglect,
The situation occurred when the parent was seventeen years of age or younger and before he or she was the parent of the deceased child,
The situation occurred with a different family composition and a different alleged perpetrator.

In 2013, statute was further amended with the passage of Senate Bill 13-255. The bill removed the three aforementioned exemptions as they relate to previous involvement of a family with the county DHS agency. Additionally, the time frame of previous involvement that qualified for review was extended from two years to three years. Statute previously required the CFRT to complete a draft, confidential, case-specific review report following the CFRT review and submit the draft to any DHS agency with previous involvement with the child or family related to the incident within 30 days. That 30-day period was extended to 55 days.

Language was also added to statute to ensure that any information released to the public by the CFRT is “not explicitly in conflict with federal law, is not contrary to the best interests of the child who is the subject of the report, or his or her siblings, is in the public’s best interest, and is consistent with the Federal Child Abuse Prevention and Treatment Reauthorization Act of 2010, P.L. 111-320.”

Previous statute required the CDHS, on or before April 30, 2013, and each April 30th thereafter, to prepare an Annual Child Fatality and Near Fatality Review Report, absent confidential information, summarizing the reviews conducted by the team during the previous year. Senate Bill 13-255 amended the date to, on or before July 1, 2014, and on or before each July 1 thereafter. The CDHS was given the additional duty to make annual policy recommendations that address “all systems involved with children and to follow up on specific system recommendations from prior reports that address the strengths and weaknesses of child protection systems in Colorado” in the annual report. This report will be transmitted to the Governor, appropriate legislative committees, the Colorado State Child Fatality Prevention Review Team established in the Department of Public Health and Environment pursuant to section 25-20.5-406, C.R.S., and made available to the public on the Administrative Review Division, Child Fatality Review Team webpage website within seven days of finalization of the report.

Additional information:

Guide to County Internal Fatality Review Processes

County department internal reviews are required when there has been an incident of fatal, near fatal, or egregious child maltreatment, and the county holds current or prior involvement within three years of the incident. The guidance was developed in an effort to assist county departments through the internal review process and to better identify and understand the risk factors associated with fatal, near fatal, and egregious incidents of child maltreatment.

Click here for the guide.

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