In 2022, the Child Abuse and Neglect Advisory Committee requested more information on Virginia’s regional child death review teams. The interest of the committee led to an informational webinar in September 2023 on child fatality review processes in Virginia. Around this time, multiple changes were occurring to these processes. These changes and the panel discussion prompted the creation of this report to provide a detailed document on the various agencies and processes involved in child fatality reviews.
It soon became apparent that this was an incredibly complex and complicated issue. Obtaining data that was comparable from different agencies, identifying all the key components and players, having discussions with various partners to understand their roles and challenges, and compiling national best practices were necessary to provide the best possible report. Nearly every layer explored revealed additional information that required further research and discussion. What started as a reference document on child fatality review teams developed over two years into a deep dive into the intricacies and challenges Virginia faces in its response to child deaths at both the investigation and review stages and ultimately the barriers in the prevention of these deaths.
Child deaths overall, and specifically those due to maltreatment, have been increasing both nationally and in Virginia for the last several years. Nationally, between 2021 and 2022, there was a 3.3% increase in all-cause infant mortality. Child fatalities due to abuse and neglect increased 9.6% from 2019 to 2023. In State Fiscal Year 2021, Virginia experienced the highest rate of child maltreatment deaths in the past decade. Our youngest children continue to be the most vulnerable to child maltreatment deaths. Nationally, 66.9% of these deaths involved a child younger than three years old. Virginia’s rate is above the national average with 76% of child maltreatment deaths in SFY 2023 involving a child under three years old.
The purpose of this report is fourfold:
- provide a central reference document outlining the current efforts for child fatality investigations and review in Virginia,
- to highlight available data on these cases,
- to identify where gaps in data exist and,
- to provide points for consideration on ways to improve child fatality investigation and review processes to increase effective prevention strategies and protect our most vulnerable Virginians.
Bottom Line Up Front: Child deaths are increasing at an alarming rate and Virginia’s current lack of adequate coordination between state and local partners, low number and limited scope of case reviews, lack of accurate and transparent data, and lack of training and support for professionals does not provide an opportunity for effective identification and prevention strategies.
Child Fatality Investigations and Review (Full Report)
Executive Summary
Report Infographic (PDF)