Santa Clara County Children's Death Review Team

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Structure and procedures

Our goals are to:

• Improve our understanding of how and why children die
• Demonstrate the need for and to influence policies and programs to improve child health, safety and protection
• Prevent other child deaths

The death of a child is a profoundly painful and distressing event. Members of the Santa Clara County Multidisciplinary Child Abuse Team resolved to carefully examine the circumstances leading up to the death of a child (age 18 and under) within the county that did not appear to be from a clearly medical, non-preventable reason. The team developed a protocol closely modeled on pioneering work by Michael Durfee, M.D. in Los Angeles. The goals were to learn and discuss details that would be useful in the prevention of future deaths, to assure that the family members and especially the siblings in a family that had lost a child were supported and protected, and to identify situations where crimes had been committed.

Since that time, Children’s Death Review Teams (CDRTs) have been developed throughout California and the United States. Although the teams differ from locale to locale, all adhere to a similar philosophy and goals. Team discussions alternate between dull bureaucratic rambles and gripping intensity. People from a wide variety of agencies and professions share their records in an honest and straightforward way. Under these circumstances, the team is often able to construct at least a partial picture of the circumstances leading to a child’s death. We are able to identify where procedures broke down or were inadequate to the task of preserving life. Many recommendations for improvements in the way we do things have come out of this process.

The multi-disciplinary nature of the team provokes a great deal of discussion and education among members. Each participant, in effect, becomes trained to see more of the ways in which the well-being of children is a shared responsibility of many different groups. Our hope is that the members incorporate this knowledge and help expand the perspective of their fellow workers.

Sometimes a child’s death becomes a very newsworthy event in the community, and agencies and individuals may be concerned about personal or legal liability. By keeping a low profile, the team can better secure and maintain the cooperation of the involved groups.

Sometimes people that work with children themselves feel great sadness and guilt when a child dies. At times an important part of our task is providing support to workers who had a child die while in their care, when we believe that their work was reasonable and appropriate and that the child’s death was not realistically avoidable.

In the discussions, team members have learned a great deal about the way people, who share a common concern for children but who have very different functions, do their work. The struggle to improve the coordination and cooperation between agencies is an ongoing task. Members of the team have been able to take information back to their primary group to help in this process of collaboration. This is important because for each child who dies there are perhaps one hundred children who will be at risk but are fortunate and lucky enough to survive.