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Safety Alerts

Know the Risk Factors for Child Fatality


As part of the Children’s Safety Net Action Plan, DHS has launched several reviews in an effort to understand how and why child deaths occurred in the past and how we may be better prepared to prevent such occurrences in the future. These reviews have yielded a wealth of information that will enhance our ability to ensure the safety of children in our care. In studying child fatalities among SCOH cases, reviewers noted several common factors. Being alert to these factors can help us better identify children at greatest risk, aid our decision making processes and guide our practices.

Common Factors in Child Fatalities
  • Child was under 1 year old.
  • Court-ordered mental health services were not in place.
  • Parent was a single parent that was a DHS client as a child.
  • The child who died was not acknowledged in a revised FSP or Risk Assessment at the time of their birth.
  • Provider’s documentation did not note an alert or critical incident report informing DHS of the pregnancy or the child’s birth.
  • No documentation of joint visit of the SCOH provider and CYD social worker to see new-born child.
  • Fatality Review Committee findings and recommendations were not shared with CYD staff, the SCOH provider or CAPE.
  • Multi-Disciplinary Team findings and recommendations were not shared with CYD Staff, the provider or CAPE.