Administrative Review Division

Child Fatality Review Team

House Bill 1181 was passed during the 2011 Colorado legislative session, codifying the Child Fatality Review Team and providing statutory authority through the addition of section 26-1-139 of the Colorado Revised Statutes. The statute also outlines the guidelines regarding the team's purpose, structure and reporting procedures.

Learn more about the Child Fatality Review Team

The Child Fatality Review Team (CFRT) reviews incidents of fatal, near fatal, or egregious abuse or neglect determined to be a result of child maltreatment, when the child or family had previous involvement with the child welfare system within the last three years. The process includes a review of the incident, identification of contributing factors that may have led to the incident, the quality and sufficiency of service delivery from state and local agencies, and the families’ prior involvement with the child welfare system. After considering the identified strengths, as well as systemic gaps and/or deficiencies, recommendations are put forth regarding policy and practice considerations that may help prevent future incidents of fatal, near fatal, or egregious abuse or neglect, and/or strengthen the systems that provide direct service delivery to children and families. Each incident reviewed by the CFRT results in a written report that is posted to the CDHS public notification website (with confidential information redacted). Specifically, statute requires that a case-specific executive summary, absent confidential information, be posted on the CDHS website within seven (7) days of finalizing the confidential case-specific review report.

The CFRT is a multidisciplinary team of up to twenty members, as outlined in C.R.S. 26-1-139. Representation includes, but is not limited to: members from the CDHS, the Colorado Department of Public Health and Environment (CDPHE), mental health, law enforcement, district attorneys, county commissioners, county departments of human and/or social services, legislators, and many more critical disciplines responsible for representing and/or providing services to the children and families of Colorado. The team meets monthly to review incidents of egregious, near fatal, or fatal child maltreatment when the child or family has also had prior involvement with the child welfare system within three years prior to the incidents.  The CFRT currently operates under relevant criteria for excellence in child death reviews, as published by the National Center for Fatality Review and Prevention in 2018. Recent understandings have emerged on a national level that reviews should focus on system level changes and the CFRT has also come to understand the importance of adopting a systems model approach to case reviews; an approach that helps create a space to have vulnerable conversations with counties of human or social services about their practices and lessons learned from these tragedies, while keeping children and families at the center of the review. While child welfare is responsible for intervening with families when there is an allegation of child abuse or neglect, and providing appropriate and necessary services to families in order to keep children safe, all systems and communities have a responsibility to help make families in our communities healthier and more resilient.

There are three full-time ARD staff members who are dedicated to the review process. These staff work closely with the Colorado Department of Public Health and Environment’s (CDPHE) Child Fatality Prevention System (CFPS) team to consider data from each system and make joint recommendations based upon these findings. Each review process serves a different purpose and each process is supported by the respective agency. The CFPS staff members at the CDPHE serve as the two state appointees from the CDPHE to the CFRT, and the CFRT staff are involved with and participate in CFPS workgroups and state review meetings. SB 13-255 requires that, as a result of collaboration, the two child fatality review teams make joint recommendations. To find out more information about Colorado's comprehensive child fatality review and prevention the CDPHE and CFRT processes and how they together, make up Colorado's Child Fatality Review and Prevention System, click here.

In order to streamline the notification process, CDHS's Administrative Review Division has created one email 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:

303.866.7904 | cdhs_cfrt_notification@state.co.us

It is important to note that for purposes of satisfying the county department's timely obligation to notify CDHS of an incident that is suspicious for an egregious abuse and/or neglect, or near fatality or fatality of a child, an initial email 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.

Download the state prescribed incident reporting form here.

More information

Visit the Child Fatality Reviews page for more information, including:

• Defining Egregious Incidents of Child Maltreatment
• Public Notifications
• Colorado Child Maltreatment Fatality Review Annual Reports

Legislation

§ C.R.S.26-1-139: Statute Governing the Child Fatality Review Team

Contact

Child Fatality Review Team
303.866.7904 | cdhs_cfrt_notification@state.co.us

Qualitative case reviews

The ARD conducts qualitative case reviews on a variety of child welfare populations. These include foster care reviews, assessment reviews, in-home services reviews, foster care home reviews, hotline quality assurance, and screen-out reviews.

Learn more about qualitative case reviews

Types of qualitative case reviews

Foster care reviews

The ARD reviews all children in the child welfare system who are in out-of-home care for at least six months, and every six months thereafter as long as the child remains in care. Reviews are also conducted for the youth in the Division of Youth Services who are in a community placement. These reviews also take place every six months the youth is in community placement.

Assessment reviews

The ARD's assessment reviews focus the referral and assessment process. The ARD conducts these reviews twice a year for Colorado's 10 large counties and once a year for the middle-sized counties and balance of the state. A representative sample by county of assessments and cases are pulled for review.

In-home services reviews

The ARD's in-home services review process allows for an in-depth look at service delivery, safety, risk and well-being for those families receiving in-home services. ARD conducts these reviews twice a year for Colorado's 10 large counties and once a year for the middle-sized counties and balance of the state. A representative sample by county of assessments and cases are pulled for review.

Foster home certification review

The purpose of the annual foster home certification review is to determine if county departments of human/social services are in compliance with certification requirements for foster homes and kinship foster homes as outlined in the Code of Colorado Regulations, Colorado Revised Statutes, and federal law. A thorough qualitative case review of the county-certified provider case file is completed to determine if the certifying county and provider are in compliance with rules and regulations during the review period to provide a safe living environment for children in out-of-home care. This unit is also responsible for:

• Monitoring Stage II investigations of county certified foster homes when the Institutional Abuse Review Team (IART) recommends the need for a Stage II investigation
• Reviewing and following up on all County Critical Incident Reporting (7.701.52)

Institutional abuse screen-out review

The purpose of the monthly statewide institutional abuse screen-out review is to determine if county departments of human/social services are appropriately screening out institutional abuse referrals as outlined in the Code of Colorado Regulations and Colorado Revised Statutes. A random sample of statewide screened out institutional abuse referrals is reviewed monthly and a thorough and qualitative case review of the counties' decision to screen out the institutional abuse referrals is completed based on information contained within Trails. The source for all information used during this review is the Colorado Trails database. A review of each hotline call can be completed when needed.

Hotline quality assurance

House Bill 1271 was signed in May 2013 and required the development of a statewide hotline system to facilitate the reporting of suspicions regarding child abuse and neglect. On Jan. 1, 2015, the statewide hotline system became operational. Callers with suspicions of child abuse and/or neglect can call either a county-designated hotline phone number or the statewide toll-free phone number (844-CO-4-KIDS). With the addition of new programmatic functions to Colorado's child welfare system, ARD was provided resources to conduct qualitative reviews of the state's hotline system and provide essential feedback/technical assistance for system improvement. Quality assurance reviews of the state's hotline system encompass all 64 counties and the Hotline County Connection Center.

Rule regarding Colorado's hotline system:

• House Bill 13-1271
• Colorado Revised Statutes 19-3-304, 19-3-307, 26-5-111,
• Colorado Code of Regulations, Social Services Rules (Volume 7)

Screen-out review

In order to better inform policy and practice related to the screening of referrals, and examine the accuracy of referral acceptance decision-making, the ARD created processes to evaluate the screening decisions made by county departments of human or social services for both the child welfare and adult protective services systems. The child and adult screen-out reviews are held independently of one another and are conducted once each year, when staffing resources allow.

Adult Protective Services Quality Assurance

Adult Protective Services Quality Assurance (APS QA) is the unit responsible for conducting annual, qualitative case reviews for the adult protective services system. APS QA regularly assesses the quality of services provided to at-risk adults in Colorado by the county departments of human or social services, as well as assures that issues identified by APS QA are addressed.  The combination of data and reports from these annual qualitative case reviews allows Colorado to fulfill this duty while simultaneously providing a mechanism to measure, and provide feedback on, case practice and processes designed to improve outcomes for at-risk adults served through the county departments of human/social services.  

The APS QA unit conducts reviews of the following populations: assessment/investigation; provisioning of services; and county-held guardianship.

Publications and reports

The ARD publishes a variety of data reports and publications related to child welfare practice and policy. 

Administrative Review Annual Reports

Below are annual reports representing the efforts of ARD each year.

Colorado Child Maltreatment Fatality Review Annual Reports

Colorado Revised Statute 26-1-139 requires an annual report to the legislature, on or before July 1st of each year, reflecting aggregate information with regard to fatal, near fatal, and egregious incidents of child maltreatment that occurred in the prior calendar year. The annual reports focus on several different subsets of information and highlight data gathered from fatal, near fatal, and egregious incidents of child maltreatment that occurred in a given calendar year. The data provides an overview of the trends, characteristics and demographics of children and families involved with such incidents, and is presented in an effort to better understand and identify the factors associated with such incidents of abuse or neglect.

Out-of-Home Quarterly Reports

Each quarter, ARD publishes data gathered during the federally required Administrative Reviews (also known as foster care reviews). For any additional reports, please email Marc Mackert, ARD director, at marc.mackert@state.co.us.

Foster Youth in Transition Reports

Qualified Residential Treatment Placement Reports

Instruments and instructions

Each review process is guided by an instrument and set of accompanying instructions. The instruments and instructions are created through collaborative work groups consisting of county and state experts in the related areas of practice. They are based on federal and state statute, as well as CDHS program rules. Current versions of the instruments and instructions are available below.

 

Read Informational Memo IM-OPSO-2015-005 regarding qualitative case review instruments and the instrument pilot period.

Trainings

ARD Instrument Walk Through (Oct. 17, 2022)