The Department for Community Based Services (DCBS/Department) Division of Protection and Permanency (DPP) investigates all reports of child fatalities or near fatalities that occur due to alleged abuse or neglect by a:
- Guardian; or
- Other person exercising custodial control or supervision of the child; even if there are no remaining children in the home; except if the child is in a facility operated by the Department of Juvenile Justice. A child fatality or near fatality in a DJJ-operated facility is referred to the Justice Cabinet for investigation under a memorandum of understanding between DJJ and the Cabinet for Health and Family Services.
KRS 620.050 requires that the Cabinet for Health and Family Services (CHFS/Cabinet) conduct an internal review of any case where child abuse and neglect has resulted in a fatality or near fatality and the cabinet had prior involvement with the child or family. This statute also requires that the cabinet submit a report by September 1 of each year to the governor, the General Assembly, and the state child fatality review team that 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.
Near fatality is defined by KRS 600.020(38) as an injury that, as certified by a physician, places a child in serious or critical condition.
DPP also tracks child deaths that are not related to suspected abuse or neglect when (see SOP 2.14.2 for further procedure):
- There is an active investigation;
- There is an active ongoing case and/or received ongoing services in the twelve (12) months preceding the death; or
- The child is in out of home care.
DPP is notified of all child fatalities or near fatalities utilizing the Child Fatality/Near Fatality Summary Document.
In order to assure coordination of appropriate information dissemination, all media inquiries are referred to the Office of Communications at (502) 564-6786.
- 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 infant death syndrome (SIDS) or a variety of other unexpected or unexplained causes.
- Information gathered during the course of an investigation, including prior DPP involvement with the family, can be shared with the medical examiner if requested.
- In cases where abuse or neglect is substantiated and has resulted in a fatality or near fatality and there has been a previous assessment on the child or family, the case is considered to have previous protection and permanency involvement and is required per KRS 620.050(12) to have an internal review.
- Prior involvement with the family includes staff that:
- Have completed a previous assessment involving the family;
- Have been previously assigned as an ongoing case manager for the family;
- Are currently assigned as an ongoing case manager for the family;
- Are currently investigating the child or family; or
- Have supervised an investigation or ongoing case involving the family.
- The SSW is encouraged to participate in local child fatality response teams to assist in cross communication and sharing information between different agencies.
Procedure for Receiving and Accepting the Report
The Central Intake Staff: The SSW:
- Determines if the referral meets criteria as outlined in SOP 2.3 Acceptance Criteria by consultation and approval with the FSOS and Central Intake Branch Manager;
- Screens the allegation to determine acceptance criteria for the alleged maltreatment and then identify a link that the alleged maltreatment directly contributed to the child’s fatal or near fatal condition. When this occurs the centralized intake staff will designate the intake in TWIST as a fatality/near fatality.
- The fatality designation is used in the intake when a child’s death has occurred.
- The near fatality designation is used in the intake when the child has a near death condition as defined in KRS 600.020 (40) as an injury that, as certified by a physician, places a child in serious or critical condition. Staff shall use the “determining a near fatality tip sheet” to decide if the child’s condition meets criteria for the near fatality designation.
- The regional after hour 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.
- Determines the initiation timeframes as defined in SOP 2.10.
- Immediately notifies the Service Region Administrator (SRA) or, in the absence of the SRA, the designee when the intake meets acceptance criteria and has been designated as a fatality/near fatality.
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 SRA and/or to the Division of Protection and Permanency (DPP) are not required for resource links or law enforcement assist referral.
Intake 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 risk of harm (neglect) or dependency sub-program.
Centralized intake branch manager can consult with system safety analyst as needed.
The region should assign staff that have had no prior involvement with the family to investigate the fatality/near fatality referral.
Procedure for Notifications
- The SSW or other regional staff immediately notifies the SRA (or in the absence of the SRA, a designee) when an investigation is accepted and has a fatality/near fatality designation and when a child fatality occurs in an active case.
- The SRA or designee completes sections I and II of the System Analysis Report (SAR) form and emails DPP.firstname.lastname@example.org within forty eight (48) business hours.
- The SRA or designee notifies, in writing, the judge of the court of jurisdiction and the guardian ad litem for active court cases within five (5) business days when:
- Any child fatality occurs in an active court case; and
- A near fatality investigation is accepted in an active court case.
- The central office system safety analyst 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.
- The system safety analyst distributes the numbered SAR to the director of service regions, office of legal services, and records management.
- The SRA or designee notifies the Division of Protection and Advocacy at 5 Mill Creek Park Frankfort, KY 40601 when:
- The child is identified as a client of Kentucky’s Protection and Advocacy Division and DCBS has accepted an investigation designated as a fatality;
- The child fatality occurs as a result of placement in a seclusion room pursuant to 922 KAR 1:390; or
- The child fatality occurs as a result of a therapeutic hold pursuant to 922 KAR 1:300.
- The SRA or designee notifies the child’s legal parent(s) of the fatality or near fatality when:
- The child is in the custody of the cabinet and placed outside of the birth parent’s home.
Practice Guidance for Notifications
The System Analysis Report (SAR) is an internal document and is not included in the case file and is not distributed to outside entities.
The notification to the court and to Protection and Advocacy will be a written letter drafted by regional staff.
Notification to parents should be face to face or by phone
Procedure for Investigative Process
SRA or designee will ensure the case record is changed to controlled access immediately when there is an active case.
Active Ongoing Cases:
All ongoing contact (to include R&C case management) with the family immediately stops in an in home or out of home ongoing case for a period of at least fourteen (14) days. The SSW should not have any face to face contact with the family within the fourteen (14) day period:
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.
Ongoing work may resume with the family after the initial fourteen (14) day period at the discretion of the SRA or designee.
Active Pending Investigations:
- The SRA or designee shall:
- Immediately review the status of any pending investigation;
- Determine the amount of work needed to complete and develop a plan for completion;
- Email the plan of completion to the central office system safety analyst within three (3) business days;
- Ensure that all pending investigations are completed, entered into TWIST, and approved within fifteen (15) calendar days of the fatal/near fatal incident; and
- Ensure that support to staff is available to assist them in managing trauma experienced through their involvement with the fatality/near fatality as set forth in SOP 1.13 in accordance with their regional protocol.
Conducting the Investigation
The SSW shall:
Follow procedures and practice guidelines set forth in SOP 2.10 and SOP 2.11 and follow any initiation timeframes set forth by central intake staff or the on-call FSOS. Investigative services shall also include:
Engagement with law enforcement for joint investigation;
Collaboration and consultation with first responders, coroners, medical examiners, and medical professionals; and
Collection of all available medical records and review of all records relevant to fatality/near fatality.
Determine the alleged perpetrator’s access to other children of which they may exercise a caretaking role and address any safety issues with those children to determine what safety response is necessary.
The service region shall:
- Provide the system safety analyst an update of the status of the investigation within thirty (30) calendar days of the fatality/near fatality investigation being received. The update shall include:
- Anticipated finding and rationale for the finding;
- Information regarding the cause of death or mechanism of injuries as determined by the autopsy or pediatric forensic medical consult; and
- Summary of tasks to be completed.
Making a Finding and Completion of the Investigative Assessment
- The designation of fatality/near fatality shall only be applied to a substantiated finding of maltreatment when the maltreatment has been found to directly contributed to the child’s fatal/near fatal condition.
- 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.
- The investigation shall not be finalized until the receipt of finalized reports from medical examiner, pediatric forensic medicine, or other solicited experts collaborating or reviewing child’s injuries or conditions.
The regional SRCA or AA shall review the completed investigative assessment prior to FSOS approval.
- The regional SRCA or designee shall provide notification of the completion of investigative assessment to central office system safety analyst upon approval by completion of section III of the SAR.
- The region may consult with the system safety review team or the child protection branch at any time during the investigation as needed.
Practice Guidance for Investigative Process
Records collected should include:
SSW should consult with the system safety analyst 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:
Information gathered during the course of 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 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 sudden unexpected infant death (SUID/SIDS) and safe sleep in all investigations. See the Sudden Unexpected Infant Death information sheet.
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 system safety analyst and will be presented to the multi disciplinary team (MDT) for consideration of a comprehensive analysis.
The system safety review team will complete an initial case review, which will include a review of the circumstances of the fatal/near fatal incident, allegations and 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 the factors that influence decision-making and practice in real-time. It moves away from the simplistic approach, which has a tendency 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.
A multi disciplinary team (MDT) will review the case to make a determination on whether further analysis of the case is recommended.
Cases selected by MDT for further analysis will be given to the system safety analyst for 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 for the purpose of conducting comprehensive reviews of child fatalities and near fatalities reported to the Cabinet for Health and Family Services, 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 to 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 system safety review team for submission to the external review panel within thirty (30) days of the fatality/near fatality investigative assessment approval.
The system safety review team 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.
- Conduct an investigation when the referral meets criteria to:
- Assess whether the fatality or near fatality was the result of abuse or neglect;
- Assess risk to any child(ren) in the home (including survivor of a near fatality); and
- Protect any children remaining in the home;
- Immediately notifies the service region administrator (SRA) or, in the absence of the SRA, the designee for all fatalities or near fatalities that are alleged to be as a result of suspected child abuse or neglect;
- Informs the SRA or designee if the case:
- Is currently open for open investigation;
- Is currently open for ongoing services;
- If the child is in the custody of the cabinet;
- Provides the SRA or designee with the following information:
- Name and age of victim;
- Names of parents or caretaker and alleged perpetrator;
- Known circumstances around the fatality or near fatality;
- Description of physical injuries or medical condition of the child at the time of fatality or near fatality;
- Names, ages and location of additional children in the family and any actions taken for their safety;
- Description of protection and permanency history with the family or caretaker, if any;
- Actions taken by protection and permanency to date and future actions to be taken, including initiation of an investigation; and
- Involvement of other professionals in the case;
- Notifies law enforcement immediately by telephone (unless law enforcement was the reporting source).2
The SRA or designee:
- Notifies the central office child fatality liaison by completing parts I and II of the DPP-126 Child Fatality/Near Fatality Summary Document emailing it to DPP.email@example.com, within twenty-four (24) hours, exclusive of weekends and holidays; 3
- Follows procedures SOP 2.14.2 Notification and Funeral Preparation During a Child Fatality or Near Fatality Investigation for notification of the birth family and committing court in cases where the fatality or near fatality is abuse or neglect related and the child is in out of home care;
- Preferably assigns staff that have had no prior involvement with the family to investigate the child fatality or near fatality.
The central office child fatality liaison:
- Reviews the Child Fatality/Near Fatality Summary Document for accuracy and completeness;
- Assigns the case a fatality or near fatality number;
- Re-distributes the numbered notice to the SRA or designee for use throughout the investigation;
- Distributes the initial document to designated central office staff;
- Tracks the investigation through completion;
- Offers consultation and assistance as needed; and
- Reviews the assessment and provides feedback to the region.
Fatality/Near Fatality in an Open Case or Pending Investigation
Upon receipt of a fatality or near fatality on a pending investigation the intake SSW:
- Immediately notifies the SRA or designee of the fatality or near fatality investigation; and
- Marks the case as controlled access.
The SRA or designee:
- Immediately reviews the status of the pending investigation;
- Obtains the following information:
- Length of time between referrals;
- The amount of work remaining to be completed on the investigation; and
- The quality of the work conducted;
- Consults with the central office fatality liaison regarding:
- How to assign and complete the investigation; and
- The finding of the pending investigation;
- Directs the intake SSW on how to proceed with the intake;
- Directs the investigative SSW on how to proceed with the investigation; and
- Determines if the control access designation remains.
Upon receipt of the fatality or near fatality investigation on an open ongoing case the SSW:
- Immediately stops all ongoing contact with the family in an in home or out of home ongoing case for a period of at least fourteen (14) days;
- Documents all efforts and information in TWIST (ADT, case plan evaluations, contacts), within three (3) working days of the report date of the child fatality or near fatality; and
- Coordinates services for the child(ren), as necessary, in an in home or out of home ongoing case;
- Resumes work with the family after the initial fourteen (14) day period, at the discretion of the SRA or designee;
- For child victims who are in out of home care the following procedures are followed:
- Procedures for DCBS foster homes:
- The R&C worker follows the procedures outlined above; and
- The provide case is assigned for review in central office;
- Procedures for PCCs:
- The investigating SSW and/or FSOS follows the procedures outlined in SOP 2.15 Specialized Investigations and SOP 2.15.1 Investigations of Foster or Adoptive Homes (DCBS or Private Child Placing (PCP) Agencies);
- Collects the PCC records relating to the child by the SSW; and
- The SSW provides the records to the central office fatality liaison and they are assigned for review in central office.
The SRA or designee:
- Notifies in writing the judge of the court of jurisdiction and the guardian ad litem for active court cases when a child fatality or near fatality occurs, as soon as practical, but no later than five (5) working days after receipt of the report;
- Notifies the Department of Public Advocacy, Protection and Advocacy Division, in the Justice and Public Safety Cabinet if:
- A child identified as a protection and advocacy client dies as a result of alleged abuse or neglect by a caregiver; or
- If the child fatality occurred as a result of:
- Placement in a seclusion room pursuant to 922 KAR 1:390; or
- Therapeutic hold applied pursuant to 922 KAR 1:300;
- Provides support to staff to assist them in managing the trauma experienced through their involvement with the fatality/near fatality (refer to SOP 1.13 Debriefing of Protection and Permanency Staff-Reaction and Emotional Responses to Trauma).
Fatality/Near Fatality Investigation and Documentation
- Follows investigative guidelines set forth in SOP Chapter 2 Intake and Investigation as well as the following procedures when completing a fatality or near fatality investigation;
- Determines the safety of any surviving children, including other foster children and natural children, through immediate assessment to assure their safety if child abuse or neglect is suspected;
- Includes the following in the assessment:
- Arranging for physical examinations to check for any current injuries to the surviving children, if indicated;
- Determining whether there has been any history of prior abuse or neglect to the children or other family members by the alleged perpetrator;
- Interviewing the children separately and in a safe environment to assess present emotional condition, and to determine to what extent they may have witnessed family violence;
- Observing interaction between parent or caretaker and children;
- Discussing parent or caretakerâ€™s own family history;
- Making collateral contacts with neighbors, schools, and extended family;
- Determining whether the surviving children were present during the time frame of the deceased childâ€™s injuries and therefore may have witnessed what occurred;
- Referring immediately to mental health counseling, if appropriate;
- Developing immediately a prevention plan for siblings, pending the completion of the investigation, if they remain in the home; and
- Checking TWIST records for a history of child abuse/neglect, court records for a history of domestic violence and criminal records for alleged perpetrator and other adults in the home;
- Consults with the central office child fatality liaison regarding how to proceed if a coroner refuses to request an autopsy, and the SSW asserts the need for an exam; 4
- Interviews first responders to the fatality or near fatality including, but not limited to, law enforcement and emergency medical staff as collaterals in the fatality or near fatality investigation;
- Obtains all medical records for the child, and seeks consultation from the fatality nurse administrator regarding the injuries to the child fatality or near fatality both chronic and acute as well as siblings when indicated;
- Makes every effort to interview the alleged perpetrator, but does not interfere with the investigation by law enforcement;
- Clearly documents if the perpetrator refuses to be interviewed and reasons for delays in the investigation or interview with the perpetrator;
- Enters a date of death for the child, if applicable;
- Consults with regional office upon completion of a fatality or near fatality investigation and approval of findings;
- Documents regional consultation in the assessment; and
- Submits the ADT to the central office fatality liaisons for review prior to finalization of the assessment in TWIST.
- Never utilizes an abbreviated assessment in a child fatality or near fatality investigation.
The Internal Review Process
The SRA or designee:
- Contacts the central office child fatality liaison to schedule an internal child fatality or near fatality review meeting, within sixty (60) calendar days of receipt of the report of child fatality or near fatality when the Cabinet has substantiated abuse or neglect and had prior involvement with the child and/or family to discuss:
- Previous protection and permanency (DPP) involvement;
- The current investigation;
- Existing practice to identify areas for improvement; and
- Opportunities for staff training and development; and
- The region's plan to track and monitor improvement outcomes.
- Invites other DCBS staff to participate at their discretion;
- May invite the regional continuous quality improvement (CQI) specialist to assist in tracking and monitoring regional improvement areas; and
- Completes sections III and IV of the Child Fatality/Near Fatality Summary Document and submits to the central office child fatality liaison within ten (10) working days of the internal review meeting.
- The following people are required to participate in the internal child fatality or near fatality review meeting:
- SRA or designee;
- SRAA or SRCA;
- FSOS supervising the fatality/near fatality investigation;
- SSW investigating the child fatality or near fatality;
- SSW and FSOS who were assigned cases in the previous twenty-four (24) months; and
- The central office child fatality or near fatality liaison.
The central office child fatality liaison:
- Reviews the summary document and finalizes it by removing the "Draft" watermark;
- Provides copies of the summary document to the SRA or designee; and
- Distributes the summary document to:
- Cabinetâ€™s general counsel;
- Assistant Director of Protection and Permanency; and
- Director of Service Regions; and
The Regional Review Process
If the fatality or near fatality investigation is unsubstantiated but the agency has had contact with the family in the twenty-four (24) months preceding the death, the following procedure is followed by the SRA or designee:
- Completes a review of the agencyâ€™s interactions with the family leading up to the fatality or near fatality investigation;
- Identifies areas of strength in the case work as well as areas for improvement; 5
- Meets with staff about the strengths and areas for improvement;
- Develops a plan of action around the improvement areas;
- Identifies a plan to monitor improvement outcomes;
- Completes sections III & V of the Child Fatality/Near Fatality Summary Document; and
- Submits the summary document to the central office fatality liaison once the investigative assessment has been finalized.
The child fatality liaison:
- Reviews the document for accuracy and ensures it is completed appropriately;
- Removes the draft watermark to finalize the document;
- Provides a copy of the document to the SRA or designee; and
- Files the final document in the childâ€™s file in central office.
Preparation of case files for the child fatality and near fatality external review panel
Upon request from the division of service regions or division of protection and permanency, the SRA or designee:
- Makes a copy of the child fatality or near fatality investigation;
- Gathers all prior case work, assessments and investigations from the field;
- Makes copies of the prior case work;
- Ensures all copies:
- Are single sided;
- Do not have staples/paperclips/binder clips/rubber bands;
- Have not been hole punched;
- Are complete with any and all prior investigations, assessments, and ongoing work (all documentation contained in the agency case fileâ€“prevention plans, after care plans, notification letters, etc.);
- Provides the intake summary, DPP-115 and CQA/ADT printed from TWIST for archived cases;
- Completes the DPP-127 Checklist for Fatality/Near Fatality Cases; and
- Delivers the copies to the central office child fatality liaison.
The central office child fatality liaison:
- Ensures all appropriate cases are provided to the external panel;
- Adds the Child Fatality/Near Fatality Summary Document to the file prior to release; and
- Prepares and organizes the cases for release to the external panel.
Notification of Family and Court When a Fatality/Near Fatality Occurs in an OOHC Case
The service region administrator (SRA) or designee:
- Appoints a SSW or supervisor to immediately notify the childâ€™s parents of the fatality or near fatality when:
- The child is in the custody of the cabinet and placed out of the birth parentâ€™s home in a:
- Foster home;
- Cabinet facility;
- Psychiatric unit/hospital; or
- Private child-caring facility; and
- Parentâ€™s parental rights are intact;
- Notifies a child's biological or legal parents of the child's fatality or near fatality if parental rights have been terminated, there are special circumstances including ongoing contact with the child, and a finalized adoption has not occurred.