Teri Covington "Child Death Review Teams" - Part 2- NDPA Symposium 2012

664

74 63 29 12 29 12 18

79 128

18

347

0

100

200

300

400

500

600

700

Categories are not mutually exclusive

All Drownings and Layer of Protection Breached

Ages 10-14

Ages 15 - 18

Over 18 Years Old

Yes Count 8 48 10

% 3% 12% 45%

No Count 161 186 6

% 53% 48% 27%

N/A Count 40 16 0

% 13% 4% 0%

UK Count 95 136 6

% 31% 35% 27%

Total Count 304 386 22

% 100% 100% 100%

Child Used Drugs or Alcohol Leading up to Drowning

n-=712

Natural 0%

Accident 92%

Suicide 0%

Homicide 4%

Undetermined 2%

Pending 1%

UK 1%

Drowning Deaths by Manner N=2,440

Under age 1

Ages 1 - 4

Ages 5 - 9

Ages 10-14

Ages 15-18

Yes/Probable 78% 67% 57% 35% 26%

No 9% 18% 20% 41% 47%

Unknown 13% 15% 23% 24% 27%

Total

100% 100% 100% 100% 100%

Yes/Pro-bable 56%

No 25%

UK 19%

Did an Act of Omission or Commission Cause or Contribute to the Death

N=2,440

303

26

81

26 14 6 43

690

2

73 56

0 1

68

0

100

200

300

400

500

600

700

800

Poor/absent suprvsn

Child abuse Child neglect

Other neg. Assault, not abuse

Suicide Other

Caused

Contributed

Categories are not mutually exclusive

Type of Act N= 1,355

Yes 50%

No 12%

UK 38%

Percentage of Drowning Deaths By Supervisor Impairment (Supervision="no, not needed" excluded)

n=2104

Not Specified

8%

No, not needed

14%

No, but needed

34%

Yes 39%

Unable to determine

5%

Percentage of Drowning Deaths By Supervision Level

n=2440

Supervision

Supervision Level

Drowning deaths only All Accidental Deaths in System

Not Specified 201 8.2% Not Specified 1731 9.6% No, not needed 336 13.8%

No, not needed 5610 31.1%

No, but needed 831 34.1%

No, but needed 2265 12.6%

Yes 960 39.3% Yes 7555 41.9%

Unable to determine 112 4.6%

Unable to determine 881 4.9%

Total 2440 100.0% Total 18042 100.0%

30 38

112

561

331

14 5

120

0

100

200

300

400

500

600

Drug Alcohol Asleep Distracted Absent Illness Disability Other

(Supervision="no, not needed" excluded)

(n=1052 marked "impaired" in 2104 cases)

Categories are not mutually exclusive

62 of 2104 cases were

supervisor drug and/or alcohol

impaired. (Count of 62 is

mutually exclusive.)

Type of Impairment

Feb. 2012: A one-year-old child from Indiana who died Wednesday is believed to have drowned in the baptismal pool of a church where he regularly attended daycare. Employees at Praise Fellowship Assembly of God in Indianapolis found Juan Cardenas Wednesday afternoon in a pool used to perform baptisms, which was filled with about two feet of standing water. The toddler had become lost in the church shortly after arriving for daycare. Investigators are now interviewing witnesses to determine what went wrong at the daycare center, which was cited for 18 minor violations the last time it was inspected in November 2011. "We have our homicide investigators here, along with members of our child abuse team trying to determine how the child actually got there," "This was preventable," Emily Barrow of Child Care Answers in Indianapolis told the Star. "Licensed facilities have a sight and sound regulation; child care ministries do not."

Toddler Juan Cardenas

September 2011: A 17-year-old Federal Way boy died Saturday evening after swimming in Lake Tapps, a reservoir that's a popular recreational destination. Harris had been at a family barbecue when he went into the lake to retrieve a football. He then began to struggle and disappeared into the water, according to the reports. Family members swam out to where he had last been seen but couldn't find him.

Teenager Robert Harris

On the Lake Tapps North Park website, a warning states that the lake is fed by water from a glacier: "Lake Tapps water averages 50 degree in the summers — this is not the same as air temperature.“ Paramedic Jewitt said that the cold water "is very debilitating ... even for a strong swimmer.“ He said it seemed to him that his unit was answering an average of two calls a year reporting drowning at Lake Tapps. "They're horrible calls to run, just horrible," he said

Little Abal Gavin

BAKERSFIELD, Calif. — A 2-year-old boy has died, less than a day after he fell into a backyard pool during a family gathering….the door was left open to the pool….Police are calling this case a tragic accident, and no charges will be filed.

Feb 2012. "From the day her son was born, Neha Patel said, she hated him. On Thursday, that hatred reached a fatal level, according to the Polk County Sheriff's Office. Investigators said Patel slapped Ishan, her 1-year-old son, then purposefully left him alone to drown in a bathtub half full of water at their Lakeland home. When she returned 10 minutes later and found him unconscious, she refused to perform CPR, even though she knew the procedure, the sheriff's office said. This absolutely makes me sick," Polk County Sheriff Grady Judd after hearing of Patel's confession. "To think of the torture that this child endured is beyond imagination.

Baby Ishan Patel

May 2011, Enumclaw, WA: The water was too deep, the river too strong and the boy too young. He was 2½, and he died Friday. He’d been camping with his parents in the Greenwater area, east of Enumclaw. One uncertain step, and the rain-swollen Greenwater River swept him away, according to Ed Troyer, Pierce County Sheriff’s spokesman. The boy’s mother and a family friend, who also brought children, were making lunch at a campsite near the river. The boy’s father was due to arrive later. Both parents work for local law enforcement agencies. Troyer declined to say which ones. The boy was sitting in a small chair, waiting for lunch. The next moment, he was gone. Troyer said the incident serves as a grim warning to holiday campers and picnickers: “Stay out of creeks and rivers,”

Toddler Grant Hayes

http://www.kcra.com/r/24503658/detail.html

http://www.kcra.com/r/24503658/detail.html

Toddler Valdez

Yes 10%

No 43%

UK 47%

Percentage of Drowning Deaths by History of Child Maltreatment

n=2440

171 of 252 cases were identified thru CPS

Yes 5%

No 66%

UK 29%

Percentage of Drowning Deaths By Open CPS Case with Child

n=2440

CPS Histories

Of the yes, 50% were infants

Caregiver Responsibility Study

Vignette Caregiver not responsible-no neglect

Some responsibilityneglect related

Caregiver responsible-definitely neglect

Significant? P value

10 month old in bathtub-mom answers doorbell

1.4% 37.3% 61.2%

Mom had prior CPS 3 years earlier

0.4% 28.2% 71.4% .018

3 yr old poor boy at picnic, wanders to pond. Parents distracted

2.9% 56.2% 40.9%

Same story-but boy not poor

2.5% 51.5% 46% .500

What to Do?

http://www.bakersfieldnow.com/news/local/Police-investigate-the-near-drowning-of-a-2-year-old-139787643.html -

Media campaign Provider education Parent education Patient education School Program Community Project Other prevention project New policies New/amended laws Modify consumer product Recall consumer product Modify space

Other, specify

Primary Prevention: Keeping kids from getting hurt

Improve reporting

Improve assessments

Provide services

Improve services Change policy Pass a law Train workers Increase funding

Secondary Prevention: Helping hurt kids and families: Improve CPs Practices

CDR Team Recommendations

and Actions

Media campaign 145 School program 64 Community safety project 170 Provider education 70 Parent education 194 Public forum 28 Other education 58 New policy 35 Revised policy 22 New program 18 New services 15 Expanded services 19 New law 47 Amended law 23 Enforcement of law 31 Modify consumer product 8 Recall consumer product 2 Modify public space 20 Modify a private space 30 Other 46 Total 1045