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Effective: 11/26/2024

2.14 Fatality and Near Fatality Investigations and Fatalities on Active Cases

Legal Authority

Introduction

​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​The Department for Community Based Services (DCBS) investigates all reports of a child fatality or near-fatality that occur due to alleged abuse or neglect by a:
  • ​Parent;
  • Guardian; or 
  • Other person exercising custodial control or supervision of the child. 
KRS 620.050 requires that the Cabinet for Health and Family Services (CHFS/Cabinet) conduct an internal review of any case where child abuse or neglect has resulted in a fatality or near-fatality and the Cabinet had prior involvement with the child or family.  This statute also requires the Cabinet to submit a report to the governor, the General Assembly, and the state child fatality review team by September 1 of each year.  The report includes a summary of the internal reviews and an analysis of historical trends.

All media inquiries are referred to the CHFS Office of Public Affairs at (502) 564-7042.  ​​




​

Practice Guidance

Practice Guidance for Receiving and Accepting the Report  ​

  • ​​Reports of improper use of vehicle (child) restraints and sudden unexpected infant death (SUID) do not meet acceptance criteria unless there are other allegations of maltreatment documented.
  • Notifications to the service region administrator (SRA) and/or to the Division of Protection and Permanency (DPP) are not required for referrals that do not meet acceptance criteria or reports determined to have a non-investigatory response; except for the fatality of a child involved in a pending investigation or open ongoing case (please see procedures below).
  • Central intake (CI) staff should request that the reporting source provide information regarding the contributing link between the maltreatment and the child’s fatal or near-fatal condition.
  • A fatality/near-fatality designation cannot be used with a threat of dependency or any non-investigatory response subprogram.  
  • The CI branch manager can consult with the system safety review team (SSRT) as needed, through the Division of Service Region (DSR) consultation process.  
  • The region should assign staff that has no prior involvement with the family to investigate the fatality/near-fatality referral. ​

Practice Guidance for Notifications 

  • The System Analysis Report (SAR) is an internal document not included in the case file, and is not distributed to outside entities. 
  • A written notification letter, drafted by the SRA or designee, shall be sent to the court and Protection and Advocacy (P&A). 
  • Notification to parents should be face-to-face or by phone.​

Practice Guidance for the Investigative Process 

  • ​Records collected should include:
    • Birth records;
    • Pediatric records;
    • Hospital records;
    • Immunization records; and/or
    • Any other records related to the specific health needs of the child.
  • SSW should consult with the SSRT regarding how to proceed if a coroner refuses to request an autopsy and the SSW asserts the need for an exam. 
  • KRS 72.025 and KRS 72.405 mandate that the coroner require a post-mortem examination, which may include an autopsy, on the death of any child where the cause of the death appears to be:
    • ​Violence;
    • Child abuse;
    • Suicide;
    • Drugs;
    • Sudden unexpected infant death (SUID/SIDS); or
    • A variety of other unexpected or unexplained causes.
  • Information gathered during an investigation, including prior DPP involvement with the family, can be shared with the medical examiner if requested.
  • The SSW should participate in local child fatality response teams to assist in cross-communication and sharing of information between different agencies.
  • The SSW shall determine in consultation with the FSOS if filing court petitions is necessary for the safety of any surviving children when a substantiated finding is made with the fatality/near-fatality designation.  The SSW should assess the frequency of the perpetrator’s contact and access to the surviving children and other protective capacity issues within the family.
  • The SSW should assess for SUID/SIDS and safe sleep in all investigations.  Please see the Sudden Unexpected Infant Death Information Sheet.

    ​

Procedure

​Procedure for Receiving and Accepting the Report

The CI Staff: 
  1. Determines if the referral meets criteria as outlined in SOP 2.3 Acceptance Criteria by consultation and approval with the FSOS or the CI branch manager; 
  2. ​Screens the allegation to determine acceptance criteria for the alleged maltreatment and then determines how the alleged maltreatment directly contributed to the child’s fatal or near-fatal condition.  
    1. The fatality designation is used in the intake when a child's death has occurred. 
    2. The near-fatality designation is used in the intake when the child has a near-fatal condition as defined in KRS 600.020 (40) as an injury that, as certified by a physician, places a child in a serious or critical condition.  Staff shall use the Determining a Near Fatality Tip Sheet to decide if the child's condition meets the criteria for the near-fatality designation. ​
  3. ​Designates the intake in TWIST as a fatality/near-fatality using the Determining Fatality, Near Fatality Designation Flow Chart to determine designation in accordance with Child Abuse Prevention and Treatment Act (CAPTA), Chapter 67, subchapter 1 and KRS 600.020 (40). When screening substance-affected infant referrals, any of the following factors/circumstances support the application of fatality/near fatality designation when a physician certifies they are present: 
    1. ​​An infant is intoxicated at birth requiring treatment with Naaracan or another reversal agent (unless the substance is legally prescribed to the mother).1
      1. ​Most treatment for withdrawal is provided for comfort and is not a life-saving measure. However, there are some substances such as benzodiazepines, that create potentially life-threatening withdrawal. 
    2. ​​Withdrawal from substances with known potentially life-threatening withdrawal symptoms, such as benzodiazepines (if not legally prescribed to the mother). 
    3. Complications from placental abruption, such as prematurity, anemia, and hypoxic injury, can be associated with acute use of a substance like cocaine or methamphetamine, with known toxic effects on the placenta.2
    4. ​​The regional after-hours protocol shall be used for screening, designation, determination, and assigning reports that are made outside of regular business hours.  SOP 1.12 On Call Activities defines on-call activities. 
  4. Determines the initiation response timeframes as defined in SOP 2.6 Completing the CPS Intake; and 
  5. Immediately notifies the SRA or designee when the intake meets acceptance criteria and has been designated as a fatality/near-fatality.   

Procedure for Notification of Fatality/Near Fatality Designated Referrals

  1. The SSW or other regional staff immediately notifies the SRA, or designee, when an investigation is accepted and has a fatality/near-fatality designation.
  2. The SRA or designee completes sections I and II of the System Analysis Report (SAR) form and emails DPP.childfatality@ky.gov within forty-eight (48) working hours.
  3. ​The SRA or designee notifies, in writing, the judge of the court of jurisdiction and the guardian ad litem (GAL) for active court cases within five (5) working days when:
    1. ​Any child fatality occurs in an active court case; and
    2. A near-fatality investigation is accepted in an active court case.
  4. The SSRT assigns the case a fatality or near-fatality number and re-distributes the numbered form to the SRA or designee for use throughout the investigation. 
  5. The SSRT distributes the numbered SAR to the DSR director, the Office of Legal Services (OLS)​, and the Division of Administration and Financial Management’s (DAFM) Records Management Section.  
  6. The SRA or designee notifies P&A at 5 Mill Creek Park Frankfort, KY 40601 when:
    1. ​The child is identified as a client of P&A and DCBS has accepted an investigation designated as a fatality; 
    2. The child fatality occurs as a result of placement in a seclusion room pursuant to 922 KAR 1:390; or
    3. The child fatality occurs as a result of a therapeutic hold pursuant to 922 KAR 1:300.
  7. The SRA or designee ensures all efforts are made to notify the child’s legal parent(s) of the fatality or near-fatality when:
    1. ​The child is in the custody of the Cabinet and placed outside of the birth parent’s home.
    2. Ensures all efforts to notify the child's legal parents) are documented in service recordings.  

​​Procedure for Notifications of Fatality on Pending Investigations or Active Ongoing Cases (Otherwise Known as an Active Fatality)​​

  1. ​When the death of a child  occurs on any pending investigation and/or active ongoing case, the following notifications occur:
    1. ​Active staff or supervisor immediately notify CI of the information received about the child’s death; 
    2. CI notifies the SSRT and staff, supervisor, and SRA or designee of the region involved;
    3. The SRA or designee ensures staff involved in the active case, or other staff at the discretion of the SRA or designee, completes sections I and II of the SAR form and emails it to DPP.childfatality@ky.gov within forty-eight (48) working hours;
    4. The SRA or designee notifies, in writing, the judge of the court of jurisdiction and the GAL for active court cases within five (5) working days of any fatality occurring in an active court case;
    5. The SRA or designee notifies P&A at 5 Mill Creek Park Frankfort, KY 40601 when:
      1. ​​The child fatality occurs as a result of placement in a seclusion room pursuant to 922 KAR 1:390; or
      2. The child fatality occurs as a result of a therapeutic hold pursuant to 922 KAR 1:300.
    6. ​The SRA or designee makes all efforts to notify the child’s legal parent(s) of the fatality or near-fatality and documents in the service recordings when:
      1. ​The child is in the custody of the Cabinet and placed outside of the birth parent’s home.
The SSRT: 
  1. ​​​​Assigns the case an active fatality or near-fatality number and distributes the numbered SAR to the SRA or designee for use throughout the review process. 
  2. Distributes the numbered SAR to the DSR director, OLS, and DAFM Records Management Section. 
​The SRA or Designee: 
  1. ​Ensures documentation for home visits, contacts, case plans, etc. that were completed prior to the death of the child is updated within three (3) working days.
  2. Immediately reviews the status of any pending investigation, determines the amount of work needed for completion, and develop a plan for completion. 
  3. Ensures all pending investigations are completed by the due date, or if already past the due date, within fifteen (15) working days from SAR notification. 
  4. Collaborates with the SSRT to negotiate an extension of these timeframes when barriers exist to meeting them. 
    ​​​

Procedure for Securing and Updating the Case Record for Fatality/Near Fatality Designated Cases

The SRA or designee will ensure the case record is changed to controlled access immediately when there is an active case.  

Active Ongoing Cases: 
  1. ​All ongoing contact (to include recruitment and certification (R&C) case management) with the family immediately stops in an in-home or out-of-home care (OOHC) ongoing case for at least fourteen (14) calendar days when an investigation associated with the fatal or near-fatal incident has been initiated.  The SSW should not have any face-to-face contact with the family within the fourteen (14) calendar day period.
    1. ​Documentation for home visits, contacts, case plans, etc. that was completed prior to the fatal/near-fatal incident will be updated within three (3) working days for any fatality or near-fatality in an active case, including fatalities where maltreatment has not been alleged.   
    2. Ongoing work may resume with the family after the initial fourteen (14) calendar day period at the discretion of the SRA or designee.  
Active Pending Investigations: 
​The SRA or designee shall:
  1. Immediately review the status of any pending investigation;
  2. Determine the amount of work needed for completion and develop a plan for completion;  
  3. Email the plan of completion to the system safety analyst within three (3) working days; 
  4. Ensure that all pending investigations are completed, entered into TWIST, and approved within fifteen (15) working days of the fatal/near-fatal incident; 
  5. ​Ensure that staff support is available to assist in managing trauma experienced through their involvement with the fatality/near-fatality as outlined in SOP 1.13 Debriefing of Protection and Permanency Staff-Reaction and Emotional Responses to Trauma following their regional protocol. 
  6. Collaborate with the SSRT to negotiate and extend these timeframes when barriers exist to meeting them. 

Procedure for the Investigative Process

 The SSW shall:
  1. ​Follow procedures and practice guidelines outlined in SOP 2.10 Initiating the Report,  SOP 2.11 Investigation Protocol, and SOP 2.13 Structured Decision Making Safety and Risk Assessments,​  and follow any initiation timeframes set forth by CI staff or the on-call FSOS.  Investigative services shall also include:
    1. ​Engagement with law enforcement for joint investigation;
    2. Collaboration and consultation with first responders, coroners, medical examiners, and medical professionals; and
    3. Collection of all available medical records and review of all records relevant to the fatality/near-fatality.
  2. Determine the alleged perpetrator’s access to other children of which they may exercise a caretaking role and address any safety threats with those children to determine what safety response is necessary. 
The service region shall:
  1. Provide the system safety analyst an update on the status of the investigation within thirty (30) calendar days of the fatality/near-fatality investigation being received.  The update shall include:
    1. The ​anticipated finding and rationale for the finding;
    2. Information regarding the cause of death or mechanism of injuries as determined by the autopsy or pediatric forensic medical consult; and
    3. Summary of tasks to be completed.
Making a Finding and Completing the Investigative Assessment
 
  1. The designation of fatality/near-fatality shall only be applied to a substantiated finding of maltreatment when the maltreatment has been found to directly contribute to the child’s fatal/near-fatal condition. 
  2. The fatality/near-fatality designation shall only be applied to the subprogram most closely related to the child’s fatal/near-fatal condition.  Only one subprogram can have a fatality/near-fatality designation. 
  3. The investigation shall not be finalized until the receipt of finalized reports from the medical examiner, pediatric forensic medicine, or other solicited experts collaborating or reviewing the child’s injuries or conditions. 
    1. ​In situations in which these reports are delayed for an extended time and staff believes there is sufficient evidence to substantiate the referral, a consultation will occur between the SSW, FSOS assigned to the fatality/near fatality investigation, the service region administrative associate (SRAA)/service region clinical associate (SRCA) assigned to the investigation team, and SSRT on the action steps needed to move forward with a finding.
    2. If the decision to substantiate the referral is made and pending reports are received that do not support that decision, the above consult will again convene to discuss amending the finding.   
  4. ​The SRCA or SRAA shall review the completed investigative assessment prior to FSOS approval.
  5. The SRCA or designee shall provide notification of the completion of the investigative assessment to the SSRT upon approval by completion of section III of the SAR. 
  6. The region may consult with the SSRT or the Child Protection Branch at any time during the investigation as needed.  

Procedure for System Safety Review-DCBS Internal Review Process

All cases where a child fatality has occurred in an active case and/or accepted as an investigation with the fatality/near-fatality designation will have an initial review by the SSRT and will be presented to the multi-disciplinary team (MDT) for consideration of a comprehensive analysis.

The SSRT will complete an initial case review, which will include a review of the circumstances of the fatal/near-fatal incident, allegations, details of prior investigations, and the provision of ongoing services.  The goal of this initial review is to identify features that may be recommended for a more in-depth analysis.  Particular attention will be given to history occurring within the twenty-four (24) months prior to the fatal/near-fatal incident.  The details of this process can be found in the System Safety Review Process Manual.

The process focuses on understanding the complex nature of child welfare work and​​​ factors that influence decision-making and practice in real time. It moves away from the simplistic approach, which tends to assess blame and results in the application of quick fixes that fail to address the underlying issues.  The system safety analyst assigned will complete an initial case review within thirty (30) days of fatality/near-fatality notification, identifying potential features for further consideration.
  • An MDT will review the case to decide whether further analysis of the case is recommended. 
  • Cases selected by an MDT for further analysis will be given to the system safety analyst for a human factors debriefing.
  • Cases not selected for further analysis will be documented in the SAR and will be scored by the system safety analyst in the System Analysis Scoring Tool after the completion of a pending fatality/near-fatality investigation.
  • Information gathered in the human factors debriefings will be presented by the system safety analyst to regional mapping teams.
    • ​Regional mapping teams will consist of various frontline staff, regional staff, and local community partners;
    • ​The mapping teams will work to identify systemic issues influencing practice.  
  • Influences revealed in the mapping process will be scored to identify factors impacting practice.  
  • ​Factors identified will be presented to DCBS leadership for consideration of systematic program improvements.
 

Procedure for External Fatality and Near Fatality Review Panel 

KRS 620.055 establishes an external child fatality/near-fatality review panel to conduct comprehensive reviews of child fatalities and near-fatalities reported to CHFS, suspected to be a result of abuse or neglect.  The panel shall be attached to the Justice and Public Safety Cabinet for staff and administrative purposes. 

The external review panel is composed of governmental appointees and various professionals from other entities related to child welfare.  The external panel meetings are open to the public and media outlets.  This panel has the authority to review and analyze all DCBS records and any other records related to fatality/near-fatality cases. 

The region(s) shall provide all agency records to the SSRT for submission to the external review panel within thirty (30) calendar days of the fatality/near-fatality investigative assessment approval.

The SSRT is responsible for providing all records to the external review panel.  The file is to be divided and scanned in sections in chronological order:
  1. F/NF investigation (DPP-115, Investigative Assessment, Notification of Findings, AOC records, and Prevention Plans);
  2. Prior investigations;
  3. Court records;
  4. Medical records;
  5. EMS records;
  6. Autopsy records;
  7. Law enforcement records;
  8. Case plans and evaluations;
  9. Service recordings; and
  10. ​Any other pertinent professional documents.

​​​Footnotes​​

  1. Withdrawal symptoms are not the same thing as acute intoxication. 
  2. Can be applicable in either pre-term or full-term delivery.​​


Documents

Revisions

11/2024

  • Notifications to the service region administrator (SRA) and/or to the Division of Protection and Permanency (DPP) are not required for referrals that do not meet acceptance criteria or reports determined to have a non-investigatory response; except for the fatality of a child involved in a pending investigation or open ongoing case (please see procedures below).
  • The notification to the court and Protection and Advocacy (P&A) will be a written letter drafted by regional staff. A written notification letter, drafted by regional staff, shall be sent to the court and to Protection and Advocacy (P&A). 
​​3.  Designates the intake in TWIST as a fatality/near-fatality using the Determining Fatality, Near Fatality Designation Flow Chart. When screening substance-affected infant referrals, any of the following factors/circumstances support the application of fatality/near fatality designation when a physician certifies they are present: 
    1. ​​An infant is intoxicated at birth requiring treatment with Naaracan or another reversal agent (unless the substance is legally prescribed to the mother).1
      1. ​Most treatment for withdrawal is provided for comfort and is not a life-saving measure. However, there are some substances such as benzodiazepines, that create potentially life-threatening withdrawal. 
    2. ​​Withdrawal from substances with known potentially life-threatening withdrawal symptoms, such as benzodiazepines (if not legally prescribed to the mother). 
    3. Complications from placental abruption, such as prematurity, anemia, and hypoxic injury, can be associated with acute use of a substance like cocaine or methamphetamine, with known toxic effects on the placenta.2
    4. ​​​The regional after-hours protocol shall be used for screening, designation, determination, and assigning reports that are made outside of regular business hours.  SOP 1.12 On Call Activities defines on-call activities. ​
​​4.  When this occurs, the CI staff will designate the intake in TWIST as a fatality/near-fatality. 
    1. ​​​​​The fatality designation is used in the intake when a child’s death has occurred. 
    2. The near-fatality designation is used in the intake when the child has a near-fatal condition as defined in KRS 600.020 (40) as an injury that, as certified by a physician, places a child in a serious or critical condition.  Staff shall use the Determining a Near Fatality Tip Sheet to decide if the child’s condition meets the criteria for the near-fatality designation.
    3. The regional after-hours protocol shall be used for screening, designation, determination, and assigning reports that are made outside of regular business hours. SOP 1.12 defines on-call activities. 

​

​B.  Ensures all efforts to notify the child's legal parents) are documented in service recordings.  ​


Procedure for Notifications of Fatality on Pending Investigations or Active Ongoing Cases (Otherwise Known as an Active Fatality)​​

  1. ​When the death of a child  occurs on any pending investigation and/or active ongoing case, the following notifications occur:
    1. ​Active staff or supervisor immediately notify CI of the information received about the child’s death, unless CI has already been notified; 
    2. CI notifies the SSRT and staff, supervisor, and SRA or designee of the region involved;
    3. The SRA or designee ensures staff involved in the active case, or other staff at the discretion of the SRA or designee, completes sections I and II of the SAR form and emails it to DPP.childfatality@ky.gov within forty-eight (48) working hours;
    4. The SRA or designee notifies, in writing, the judge of the court of jurisdiction and the GAL for active court cases within five (5) working days of any fatality occurring in an active court case;
    5. The SRA or designee notifies P&A at 5 Mill Creek Park Frankfort, KY 40601 when:
      1. ​​The child fatality occurs as a result of placement in a seclusion room pursuant to 922 KAR 1:390; or
      2. The child fatality occurs as a result of a therapeutic hold pursuant to 922 KAR 1:300.
    6. ​The SRA or designee makes all efforts to notify the child’s legal parent(s) of the fatality or near-fatality and documents in the service recordings when:
      1. ​The child is in the custody of the Cabinet and placed outside of the birth parent’s home.
The SSRT: 
  1. ​​​​Assigns the case an active fatality or near-fatality number and distributes the numbered SAR to the SRA or designee for use throughout the review process. 
  2. Distributes the numbered SAR to the DSR director, OLS, and DAFM Records Management Section. 
​The SRA or Designee: 
  1. ​Ensures documentation for home visits, contacts, case plans, etc. that were completed prior to the death of the child is updated within three (3) working days.
  2. Immediately reviews the status of any pending investigation, determines the amount of work needed for completion, and develop a plan for completion. 
  3. Ensures all pending investigations are completed by the due date, or if already past the due date, within fifteen (15) working days from SAR notification. 
  4. Collaborates with the SSRT to negotiate an extension of these timeframes when barriers exist to meeting them. 
​6. Collaborate with the SSRT to negotiate and extend these timeframes when barriers exist to meeting them. ​


  1. ​In situations in which these reports are delayed for an extended time and staff believes there is sufficient evidence to substantiate the referral, a consultation will occur between the SSW, FSOS assigned to the fatality/near fatality investigation, the service region administrative associate (SRAA)/service region clinical associate (SRCA) assigned to the investigation team, and SSRT on the action steps needed to move forward with a finding.
  2. If the decision to substantiate the referral is made and pending reports are received that do not support that decision, the above consult will again convene to discuss amending the finding.   



Footnotes​​

  1. Withdrawal symptoms are not the same thing as acute intoxication. 
  2. Can be applicable in either pre-term or full-term delivery.​​
    ​