Massachusetts
Child Fatality Review
Annual Report
Fiscal Year 2023
About the Child Fatality Review Program
The Massachusetts Child Fatality Review (CFR) program convenes a multidisciplinary group of state
agency representatives, health care experts, and law enforcement officers who analyze birth and
death records, medical records, social service files, autopsy reports, and police records. The program
comprises 11 local teams—one in each of the Commonwealth’s judicial districts—and the State Team
with 16 seats. The local teams conduct individual fatality review of child fatalities that aim to
understand the circumstances and causes of child deaths. For team membership, see Appendix A.
State Team and Local Team Membership. When a review identifies an opportunity to improve policy
or practice, the local team issues a recommendation to the State Team. The State Team reviews these
recommendations and gathers evidence from outside experts. The State Team then works with its
members to change policies and practices under their purview when appropriate, and issues
recommendations for consideration by the Governor and state legislature.
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Preface
The loss of a child is devastating to families and can have a profound impact on communities. Since 2001,
the Massachusetts Child Fatality Review (CFR) program has worked to learn from such deaths and find
ways to protect the health and safety of children in the future. The CFR program convenes
multidisciplinary teams of practitioners and government officials to conduct comprehensive reviews of
the circumstances surrounding child deaths. Those reviews help identify changes in policy and practice
that can prevent similar deaths.
This Fiscal Year 2023 (FY23) Annual Report of the State CFR Team describes program findings and
activities from July 1, 2022 through June 30, 2023 and is released in compliance with the program’s
authorizing statute (M.G.L. Chapter 38 § 2A). This report and the activities of the State Team would not
be possible without collaboration between the Office of the Chief Medical Examiner (OCME), The Office
of the Child Advocate (OCA), and the Department of Public Health (DPH). Through this collaboration, the
CFR program is developing more timely reports with deeper explorations of the causes and prevention of
child fatalities.
The State Team is immensely grateful to the local teams who carry out the psychologically taxing review
of individual child fatalities. Child fatality review is not an easy task; without exception, local teams
conduct professional, thorough, and thoughtful reviews that are foundational to the State Team’s work.
Finally, the State Team would like to thank the many partners who helped gather data and inform
discussions about child fatality, including DPH’s Injury Surveillance Program, Dr. Sadiqa Kendi and
Fatemeh Naghiloo at Boston Medical Center, and Laura Rios-Ruggiero and Bex Reno at John Snow Inc.
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Table of Contents
Preface ........................................................................................................................................................... 2
Executive Summary ....................................................................................................................................... 4
The State of Child Fatalities ........................................................................................................................... 5
Program Activities .......................................................................................................................................... 5
State Team ................................................................................................................................................. 5
Local Teams................................................................................................................................................ 5
Training and Technical Assistance to Local Teams ........................................................................................ 5
Evaluation Findings .................................................................................................................................... 7
Outcomes ................................................................................................................................................... 8
Next Steps .................................................................................................................................................. 9
Conclusions .................................................................................................................................................... 9
References ...................................................................................................................................................10
Appendix A. State Membership and Local Team Leadership ......................................................................11
State Team Membership .........................................................................................................................11
Local Team Leadership ............................................................................................................................12
Appendix B. Previously issued Recommendations ......................................................................................13
Issued in the FY2022 Annual Report:.......................................................................................................13
Issued in the FY2021 Annual Report:.......................................................................................................14
Issued in the FY2020 Annual Report ........................................................................................................14
Appendix C. State and Local Team Profiles .................................................................................................16
Appendix D. Local Team Guidelines ............................................................................................................17
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Executive Summary
Massachusetts (MA) is a national leader in safeguarding the health and wellbeing of children, as
demonstrated by low child and infant mortality rates. Public health data for 2022 are not yet available as
of the writing of this report. However, national literature points to increasing child and infant fatalities
primarily due to deaths involving firearms, motor vehicles, and medical events like sepsis and pregnancy
complications.1 Previous analysis from the CFR program demonstrates that despite low child and infant
fatality rates overall, deep disparities exist along geographic, race/ethnicity, and gender lines. For the CFR
program to succeed in preventing fatalities, these disparities must be explored and addressed
systematically.
With the aim of understanding the needs of the CFR program and improving systematic reviews, the OCA
conducted State and Local Team needs assessments in 2017 and 2018. The assessments identified the
need to standardize practices across the Local Teams and clarify the role and functions of the State Team.
Since that time, CFR staff worked to draft Local Team Guidelines and improve the function of the State
Team, including a year-long in-depth exploration of disparities and Social Determinants of Health.2 In
FY23, program staff brought that work to the Local Teams by developing and launching a 12-month
community of practice (CoP). The CoP gathered Local Team leaders and coordinators to explore key
topics-- including principals of racial equity, self-care, best practices in record collection, protecting
confidentiality, facilitating fatality reviews, and identifying and documenting root causes of fatalities-- in
an action oriented and equitable way.
To further support Local Teams in identifying needs and trends that can inform their fatality reviews,
support staff at DPH generated data profiles that explore jurisdiction specific Social Determinants of
Health alongside infant and child fatality data. The data profiles are meant to help Local Teams identify
disproportionality in fatalities and understand which Social Determinants of Health may have
contributed to a fatality. The data profiles can be found in Appendix C.
The CoP culminated in the final draft of the first ever Local CFR Team Guidelines, which was approved by
the State Team at the beginning of FY24. See Appendix D. for the final guidelines. The guidelines are
intended to provide basic operating standards to enhance consistency of local reviews across the
Commonwealth. They also provide frameworks and principles that support Local Team members in
moving beyond the review of immediate facts of the fatality to a broader review of the societal forces
that may affect the risks and opportunities surrounding a fatality.
While conducting the CoP, Local Teams continued to meet, review child fatalities, and generate
recommendations and problem statements for consideration by the State Team.3 The State Team
focused on operating the CoP and establishing the Local CFR Team Guidelines (Appendix D.). As a result,
the State Team is not issuing new prevention recommendations this year. This focus was necessary to
improve the CFR Program throughout the state and will result in improved processes and
1 https://jamanetwork.com/journals/jama/article-abstract/2802602;
https://blogs.cdc.gov/nchs/2023/11/01/7479/#:~:text=A%20new%20Vital%20Statistics%20Rapid,rate%20since%2
02001%20to%202002.
2 See the FY22 CFR Annual Report for more information.
3 The CFR statute calls on local teams to submit action-oriented recommendations, however, the state team
encourages local teams to describe problems identified during case reviews to the state team in lieu of a
recommendation if no recommendation is identified.
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recommendations in the future. The State Team reaffirms their support of the previously issued
recommendations, which are listed in Appendix B.
The State of Child Fatalities
In March of 2023, the Journal of The American Medical Association published an article titled “The New
Crisis of Increasing All-Cause Mortality in US Children and Adolescents.”4 According to the article, in
2021, the national rate of child fatalities increased. This is a concerning reversal of a three-decade trend
of decreasing child morality nationally, as is primarily driven by deaths involving firearms and motor
vehicles. As described in the FY22 CFR report, Massachusetts did see a slight increase in child fatalities
from 390 in 2020 to 397 in 2021. While 2022 fatality data were not yet available at the time this report
was written, additional data will be provided in the FY24 CFR Annual Report.
Massachusetts continues to experience low rates of infant and child fatalities compared to other U.S.
States, a testament to the strong child and family service provider network in the Commonwealth. Still,
the FY22 CFR annual report highlights that rates of mortality vary substantially across geographic regions
and identities.5 Boys, children of color, and children and infants living in urban centers are all at higher
risk of fatality. The scale of inequities in child deaths is particularly marked for infants. These inequities
are not rooted in biological or genetic differences between races and ethnicities, nor are they inherent to
other aspects of a child’s or infant’s race or ethnicity. Rather, they are linked to social determinants of
health, including factors like socioeconomic status and access to health care. For the CFR program to
succeed in preventing fatalities, these disparities must be explored and addressed systematically.
Program Activities
State Team
The State Team met a total of four times in FY23. Those meetings focused on program transitions,
updates about the CFR CoP, and development of the Local Team Guidelines—a set of standard practices,
foundational frameworks, and expectations that Local Teams are expected to follow when conducting
fatality reviews.
Local Teams
In FY23, eight of the 11 Local Teams met a total of 22 times and reviewed 71 fatalities. Three teams did
not meet in FY23. Those meetings resulted in six prevention recommendations and two continuous
quality improvement recommendations. The State Team is currently analyzing those recommendations
with the support of subject matter experts to generate recommendations for the legislature and other
audiences.
Training and Technical Assistance to Local Teams
In 2017, the OCA conducted a Local Teams Needs Assessment and followed up with an State Team Needs
Assessment in 2018. These assessments identified the need to standardize practices across the Local
Teams to ensure the Commonwealth had a consistent approach to analyzing fatalities. From 2019
through 2021, CFR program staff worked to draft Local Team Guidelines and refine the State Team’s
4 https://jamanetwork.com/journals/jama/article-abstract/2802602
5 For more information, see the FY22 CFR Annual Report
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approach to their work, including defining and refining a database and recommendation review process.
Following a year-long State Team focus on equity and Social Determinants of Health in FY22, CFR
program staff were ready to bring the concepts and draft guidelines to the Local Teams.
As such, DPH and the OCA, with support of subcontractor JSI Research & Training Institute, Inc. (JSI),
developed and facilitated a Community of Practice of Massachusetts CFR Local Teams (CFR CoP). During
the CoP planning process, program staff were also approached by Dr. Sadiqa Kendi, an expert in pediatric
injury prevention with a focus on health equity, who is the Division Chief of the Pediatric Emergency
Medicine Division at Boston Medical Center and Boston University School of Medicine. Dr. Kendi sought
funding from Johns Hopkins University to carry out the Pediatric Injury Equity Review (PIER) project, in
collaboration with three Local Teams, and the findings of which were woven into the CoP.
DPH, OCA, and JSI convened the CFR CoP over 12 sessions from July 2022 through June 2023. The
purpose of the CFR CoP was to improve consistency, efficacy, and inclusion of equity across Local Teams’
case review processes. Participants in the CFR CoP engaged in mutual learning and best practices
sharing; received technical assistance (TA) for implementing the forthcoming Massachusetts CFR Local
Team Guidelines and instruction on how to think through problem statement definition; refined their
understanding and enhancement of CFR processes; and honed skills in self-care practices.
The CFR CoP was designed with an explicit aim to accomplish 10 goals:
1. Increase application of an equity and multi-level social-ecological model lens to case review
processes.
2. Increase advancement of health and racial equity through Local Team recommendation
development.
3. Increase the ability of Local Teams to integrate prevention frameworks and social and structural
determinants of health into recommendation development.
4. Enhance the understanding and ability of Local Teams to implement the forthcoming
Massachusetts CFR Guidelines.
5. Improve communication and networking between Local Teams.
6. Improve communication between Local Teams and the State Team.
7. Improve self-care practices among Local Team members.
8. Increase proportion of Local Teams’ child fatality cases that are reviewed.
9. Enhance CFR processes for Local Teams – making processes easier and improving the quality of
review findings
10. Refine Massachusetts CFR Guidelines.
Each session focused on a different topic (Table 1). Expert faculty Sadiqa Kendi facilitated two of the 12
sessions. Sessions were well attended with the majority of the Local CFR Teams represented throughout
the CoP.
Additionally, to help Local Teams understand disparities and the Social Determinants of Health that
contribute to them, the CFR program designed 12 infographics, one for reach Local Team jurisdiction and
one for the entire state, that contain team-specific data about fatality rates, trends and inequities in
infants ages 0 to 12 months and children ages one through 17 years old. Those infographics can be found
in Appendix C. of this report.
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Table 1. CoP Topics by Month
Month Topic
July Introduction & Orientation to the CoP
August Laying the Foundation: Developing Shared Norms & Selecting Fatalities
September Self & Team Care
October Exploring Your Positionality & Getting to Know Your Community
November Best Practices in Record Collection
December Protecting Confidentiality
January Facilitating fatality reviews
February Protecting Confidentiality
March Unpacking a Fatality
April Reflecting on CoP Learnings & Remaining Needs
May Conducting Reviews, Time Management, and Fatality Volume
June Celebration of Learning & Next Steps
Evaluation Findings
For continuous quality improvement purposes, and to measure the impact of the CoP, several
evaluations were conducted over the course of the CoP. Baseline data related to Local Team knowledge,
attitude and practice were assessed in an application that the Team completed before the start of the
CoP. These same questions were asked at the midpoint and end of the CoP.
Brief surveys were also disseminated following each session to assess participant’s satisfaction with, and
knowledge learned, or skills gained during the session.
On average, post-session survey respondents were satisfied (4.3 out of scale 1=not at all satisfied to
5=very satisfied) with CoP sessions. Participants expressed learning the following during the sessions:
• Meeting facilitation, technical skills
• Understanding health and racial equity in the CFR context
• Case selection and prioritization best practices
• Benefits of themed reviews
• Team an