WESTCHESTER COUNTY Child Fatality Review Team RELEASES
FOURTH independent CHILD FATALITY REVIEW REPORT
Westchester County District Attorney Janet DiFiore and County Executive Andrew Spano announced that Westchester County’s Child Fatality Review Team (CFRT) has completed its fourth independent Child Fatality Review Report.
The Westchester County CFRT reviews the death of any child who was provided services by the Westchester County Department of Social Services and/or agencies under contract with Westchester County or whose death was the result of suspicious circumstances.
Westchester County was the fourth county in New York State to have an approved CFRT.
Westchester’s Team is the first team in the State to successfully write its own state mandated child fatality reports. Westchester County remains the only county in the State to examine child deaths beyond the scope of matters required by state law for the purpose of preparing independent reports that proactively address issues related to these child deaths.
In this case, the Team’s independent report concluded that the public would benefit from more information concerning co-sleeping and the dangers surrounding the delay in reporting child fatalities to the New York State Central Register of Child Abuse and Maltreatment.
The independent report findings and recommendations are as follows:
New York State Social Services Law requires the death of a child to be reviewed with regard to the services provided by the Westchester County Department of Social Services and agencies under contract with Westchester County. That review was undertaken and completed and is reflected in a Fatality Review Report prepared pursuant to New York State Social Services Law (“SSL”) §§ 20(5) and 422-b. In recognition of the goal of preventing future child fatalities, the Westchester County Child Fatality Review Team (CFRT) has pledged to review each child fatality and make all appropriate recommendations beyond that which is required by state statute.
As such, and based upon its protocols, the Westchester County Child Fatality Review Team makes the following findings and recommendations concerning its review involving the death of a four day old infant child who had been sleeping on a full-sized futon with four other occupants, two adults and two children ages one and four. Police and Emergency Medical Services responded to the scene following a 911 call and approximately two hours later the child’s death was reported to the State Central Registry (SCR).
Based upon the facts of this fatality, the leading research of experts in the field of child safety and safe sleeping, and the delay in reporting the fatality to the SCR, our Team makes the following recommendations:
Continued training and education of all first responders to incidents of child fatalities which on first impression do not appear to be suspicious is required to heighten awareness of the need to preserve the integrity of the scene and gather evidence which may be necessary to ultimately determine the circumstances of the child’s death.
The fatality reviewed by the CFRT in this instance was reported approximately two hours after the death to the SCR. The call to the SCR was not made by the first mandated reporter to learn of the child’s fatality and the circumstances surrounding it.
Delays in alerting the proper investigative agencies of the fatality can provide an opportunity for the destruction or loss of evidence at a scene. Indeed, prompt reports are vital to law enforcement’s and the Department of Social Services’ ability to expeditiously investigate the facts surrounding the fatality as well as act to protect abused or maltreated children, their siblings, or other children who may be at risk.
Pursuant to SSL § 413 emergency
medical technicians, hospital personnel, peace officers, police officers, and
others are mandated reporters. As such, the law mandates them to call the SCR at
1-800-635-1522 if, while acting in their professional capacity, they reasonably
suspect that a child less than eighteen years of age is the victim of child
abuse or maltreatment. However, the reality of the circumstances of many child
fatalities is that the known facts at the earliest stages of the discovery of
the fatality do not lend themselves to quick determinations of a reasonable
suspicion of abuse and maltreatment.
The cause of death of the child may require an autopsy in conjunction with an investigation by several responding agencies into the circumstances of the fatality. Facing grief stricken family members under tragic circumstances, first responders to child fatality scenes are not always focusing on documenting the physical scene and may delay in notifying other investigative agencies. This delay may result in the loss, albeit an inadvertent one, of physical evidence.
The Westchester County Child Fatality Review Team will make every effort to assist in the continued training and education efforts aimed all first responders. Since the occurrence of the fatality which is subject to this report, measures have already been put into place including the recently approved police protocols approved by every police agency in Westchester County that encourage multi-disciplinary child abuse investigations and prompt reporting to the SCR.
A joint effort of Team members including the Medical Examiner to prepare a manual for first responders highlighting what conditions and facts should be recorded and steps taken to preserve evidence is underway. Mandated reporters may find additional information concerning their role and responsibility on the New York State Office and Children and Family Services website at www.ocfs.state.ny.us
The Westchester County Fatality Review Team also takes this opportunity to reiterate the need to raise public awareness of the grave risks to the infant who shares a bed with multiple persons. Previously, the Team issued an independent report involving the death of an infant child less than 6 months old who had been sleeping on a queen-sized mattress with three other occupants, two adults and one child.
In 1999 the U.S. Consumer Product Safety Commission (“CPSC”) issued a report promoting safe sleeping for babies. According to the statistics released by that agency in 1999, over the prior seven year period “121 [babies died] due to a parent, caregiver or sibling rolling on top of or against the baby while sleeping.” More than 75% of these deaths were of babies less than three months old. (U.S. Consumer Product Safety Commission, Press Release # 99-175).
As the CPSC’s statistics were only based upon incidents voluntarily reported to that agency, the actual number of infant deaths caused in this manner was not ascertainable and appears based upon subsequent events to be underreported. In fact, here in Westchester County this is the second independent report issued by the Westchester County Fatality Review Team regarding safe sleeping practices for babies.
More recently the Public Advocate for the City of New York in the September 2005 report entitled A Pattern of Preventable Deaths, 2004 Child Fatality Report,
found that the most frequent cause of preventable infant death was improper sleeping positions and the large majority of these deaths were caused by co-sleeping.
The report states that 15 children known to NYC_ACS died from co-sleeping in 2004.
The American Academy of Pediatrics (AAP) specifically recommends that parents or caregivers:
Place infants (up to 12 months old) on their backs to sleep; make sure the infant’s head remains uncovered during sleep and do not bundle the infant in clothing and blankets; avoid overheating the infant; and be sure that the infant is sleeping in a safety approved crib. (AAP website: www.aap.org)
While the AAP does not specifically recommend against bed-sharing or co-sleeping, the AAP has recognized that this practice creates a risk of infant suffocation by overlying by an adult particularly if multiple family members share an adult bed, an adult in the bed is in an unnaturally depressed state of consciousness, such as from alcohol or mind-altering drugs, or if the co-sleeping occurs on a sofa.
(AAP, vol. 105, no. 3, March 2000: Changing Concepts of Sudden Infant Death Syndrome: Implications for Infant Sleeping Environment and Sleep Position (RE9946).
The New York State Office of Children and Family Services (OCFS) and the New York State Department of Health (NYDOH) also encourage parents and caretakers to avoid co-sleeping if they are excessively tired, have used medication, alcohol, or illegal drugs. It is warned that the sharing of space with one or more adults or siblings increases the risk of the infant becoming entrapped in bedding or smothered during the shifting that may occur during sleep. (Child Abuse Prevention Section: Back to Sleep and Safe to Sleep at www.ocfs.state.ny.us).
An infant death attributed to co-sleeping is a preventable death. The Westchester County Child Fatality Review Team has pledged and restates that it shall maintain statistics on the occurrences of child fatalities attributed to a co-sleeping situation and which are not otherwise attributable to any other cause of death. As stated above, first responders will be instructed to document through photographs sleeping surfaces and ascertain to the extent possible the use of alcohol and drugs of the adult co-sleepers. The Team shall also continue its initiative in educating the public of the risks of co-sleeping to infants and to encourage safe sleeping practices.
The Westchester County CFRT was formed by the District Attorney and County Executive to thoroughly examine the fatality of any child less than 18 years old who was the subject of a report to the State Central Register of Abuse and Maltreatment or who at the time of death was residing in a foster care placement through the Westchester County Department of Social Services. The team has elected to prepare the SSL § 20(5)(a) State Report which is then approved and issued by OCFS.
Although it did not apply in the subject case, effective December 14, 2006, the CFRT must now also examine the fatality of any child who dies while the Department of Social Services has an open child protective services or preventive services case involving the child or the child’s family. Additionally the Westchester County CFRT also considers the death of any child that is unexplained, undetermined or due to suspicious circumstances.
By law the CFRT includes representatives from the Westchester County District Attorney’s Office, the Westchester County Department of Social Services (Child Protective Services), the Westchester County Office of Medical Examiner, the Westchester County Attorney’s Office, the Westchester County Department of Health, the New York State Office of Children and Family Services, a forensic pediatrician, members of the police department(s) who handled the investigation of a specific case and emergency medical services.
Our local CFRT also includes representatives of the Westchester County Mental Health Department and Victims Assistance Services.