In 1997 the Coroner's Case Review Subcommittee joined the Cuyahoga County Child Death Review Steering Committee (CDR). This transition provided the community with more effective tools to summarize and report findings from the case reviews being conducted on selected cases of unexpected child deaths.
All cases of child deaths investigated by the coroner's office are included in the database. Additionally, cases of intentional, accidental and SIDS deaths are selected for comprehensive review.
The 1999 database contained 63 cases, of these 28 had in-depth reviews. Reviewed cases included 20 infants, four 1-9 years, and four 10 - 17 years. The leading cause of death was "undetermined", with eight of nine rulings related to cases with unsafe sleep environments. There were also five homicides, four SIDS deaths, three accidents and one suicide.
At monthly case review team meetings cases are discussed in detail, and factors associated with the case are identified. The leading groups of factors are listed below.
| Category of Factors | Number of cases with at least one factor | Total number of factors identified |
| Any factor in any category | 28 | 135 |
| Environmental factors | 23 | 42 |
| Maternal or child medical factors | 11 | 29 |
| Substance use factors | 10 | 14 |
| Social support or cultural factors | 9 | 10 |
| Child history factors | 6 | 8 |
| Systems issues | 5 | 10 |
These factors provide important insights for strengthening child protection efforts in the county. By coordinating results with the CDR, the energies of the committed individuals and organizations working to prevent the deaths of children are maximized.
Learning Objectives: At the end of this session participants will be able to describe the dynamics of improving child death reviews for coroner's cases, and will be able to recognize leading causes of death and factors associated with such deaths
Keywords: Child Health, Death
Presenting author's disclosure statement:
Organization/institution whose products or services will be discussed: None
I do not have any significant financial interest/arrangement or affiliation with any organization/institution whose products or services are being discussed in this session.