Child Death Review Team

MCCAPC faciliates the Child Death Review Team (CDRT) For Madera County


Children are not supposed to die. Sadly, they do, often from preventable causes. These needless deaths cause us pain, which moves us to seek others. We can honor each child’s death by working together.

Professionals dedicated to protecting children have few predictable opportunities to collaborate and systematically share information. Prevention, intervention, and case management effectiveness are compromised because agencies and community organizations do not have a process to share important information about a family or child they are serving.

Purpose of Child Death Review

Child Death Review provides a multi-disciplinary forum to systematically collect, analyze, and understand child/family/agency factors that led to and followed a child’s death. The forum also allows for organized prevention and intervention efforts involving government agencies and the community. 

A Child Death Review Team should have a cocise mission statement identifying what the members determine is the purpose(s) of their reviews. The most commonly stated purpose is preventing fatal and non-fatal child injuries. In drafting a mission statement, the Team might also consider the following:

Prevention of fatal/severe child injury with agency and/or community action:

  • Formal programs based on data and literature
  • Actions based on lessons from individual cases

Data collection and analysis to address risk factors and system problems:

  • Information for policy, protocols, and program planning
  • Materials for reports and public education

Case tracking for outcome data collection and alysis:

  • Feedback to decision-makers to improve case and system management
  • Improved ongoing case management and service to survivors

Identify and add resources:

  • Team training
  • Connections to other teams, new programs, and the community at large

Resource via ICAN

candles, flame, candlelight-199097.jpg

Madera County Children's Death Review Team

The Madera County Children's Death Review Team meets monthly to investigate the unexpected deaths of children under 18 years old.

We aim to understand the causes of a child’s death. We advocate for policies and programs that enhance child health, safety, and protection to prevent future child fatalities.

The loss of a child is an immensely painful event. The Madera County CDRT Team has a commitment to carefully analyze the circumstances surrounding the death of children under 18 in the county when it appears to be non-medical and preventable. We aim to extract useful details for preventing future child deaths, provide support to grieving families, especially siblings, and identify situations involving criminal activities.

Professionals from various agencies openly share their records, helping us create a clearer picture of what led to a child’s death. This process highlights areas where procedures failed or were insufficient in safeguarding children’s lives, leading to valuable recommendations for improvement. The diverse makeup of our team fosters robust discussion and education among members. Each participant gains a broader perspective on the collective responsibility for children’s well-being, which we hope they can share with their colleagues.

Sometimes, a child’s death becomes a significant community event, raising concerns about personal or legal liability for agencies and individuals involved. To maintain cooperation, our team operates discreetly.

In certain cases, individuals working with children may experience deep sorrow and guilt when a child in their care passes away. In such instances, our role includes providing support to those whose actions were reasonable and appropriate, and when the child’s death was not realistically preventable.

Through our discussions, team members have gained insight into the varied roles of people who share a common concern for children but perform different functions. We continually strive to enhance coordination and collaboration between agencies. Team members take
this knowledge back to their respective groups to promote cooperation, as this is crucial because for every child who dies, there are potentially a hundred others at risk who, fortunately, survive.