The SRA or designee will ensure the case record is changed to controlled access immediately when there is an active case.
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:
- F/NF investigation (DPP-115, Investigative Assessment, Notification of Findings, AOC records, and Prevention Plans);
- Prior investigations;
- Court records;
- Medical records;
- EMS records;
- Autopsy records;
- Law enforcement records;
- Case plans and evaluations;
- Service recordings; and
- Any other pertinent professional documents.
Footnotes