Child Deaths IN MICHIGAN 2006 Michigan Child Death State Advisory Team S i x t h A n n u a l REPORT A Report on Reviews conducted in 2004 A report on the causes and trends of child deaths in Michigan based on findings from community-based Child Death Review Teams. With recomendations for policy and practice to prevent child deaths. The Michigan Department of Human Services Michigan Public Health Institute ACKNOWLEDGEMENTS We wish to acknowledge the dedication of the nearly twelve hundred volunteers from throughout Michigan who serve our state and the children of Michigan by serving on Child Death Review Teams. It is an act of courage to acknowledge that the death of a child is a community problem. Their willingness to step outside of their traditional professional roles, and examine all of the circumstances that lead to child deaths, and to seriously consider ways to prevent other deaths, has made this report possible. Many thanks to the local Child Death Review Team Coordinators, for volunteering their time to organize, facilitate and report on the findings of their reviews. Because of their commitment to the child death review process, this annual report is published. The Michigan Department of Community Health, Office of the State Registrar, Division for Vital Records and Health Statistics has been especially helpful in providing the child mortality data and in helping us to better understand and interpret the statistics on child deaths. The Michigan Department of Human Services provides the funding and oversight for the Child Death Review program, which is managed by contract with the Michigan Public Health Institute. Permission to quote or reproduce materials from this publication is granted when acknowledgement is made. Additional copies may be ordered from the Michigan Public Health Institute. This report is also available at www.michigan.gov/dhs and www.keepingkidsalive.org. Child Deaths IN MICHIGAN Michigan Child Death State Advisory Team SIXTH ANNUAL REPORT A report on reviews conducted in 2004 To understand how and why children die in Michigan, in order to take action to prevent other child deaths. Submitted to The Honorable Jennifer Granholm, Governor, State of Michigan The Honorable Mike Bishop, Majority Leader, Michigan State Senate The Honorable Andy Dillon, Speaker of the House, Michigan House of Representatives MICHIGAN CHILD DEATH STATE ADVISORY TEAM 2004-2005 CHAIR TED FORREST Manager Children’s Protective Services Program Michigan Department of Human Services MEMBERS DAVID BLOCKER VINCENT J. PALUSCI, MD, FAAP Investigator Professor of Pediatrics, Office of the Children’s Ombudsman Wayne State University School of Medicine G. PAUL CLOUTIER Medical Director, Child Protection Center Native American Affairs Specialist Children’s Hospital of Michigan Office of Native American Affairs Michigan Department of Human Services DOUGLAS M. PATERSON Director SANDRA FRANK, JD Bureau of Family, Maternal Executive Director and Child Health Tomorrow’s Child Michigan Dept of Community Health SHIRLEY MANN GRAY MARGARET PENNINGER, JD Manager of Social Work Services Assistant Prosecutor Children’s Hospital of Michigan Berrien County VIRGINIA R. HARMON NANCY STIMSON Deputy Director, retired Detective Sergeant Michigan Department of Community Health Lapeer County Sheriff’s Department BRIAN HUNTER, MD FRANK VANDERVORT, JD Forensic Pathologist Clinical Assistant Professor of Law Sparrow Health Systems University of Michigan Law School SGT. GREGORY A. JONES JACQUELINE WOOD Prevention Services Section Early Childhood Education Consultant Michigan State Police Michigan Department of Education JOSEPH MARSHALL, MD STEVE YAGER Professor, Department of OB/GYN Director Michigan State University Office of Family Advocate College of Human Medicine Michigan Department of Human Services CHILD DEATH REVIEW PROGRAM STAFF 2004-2005 Michigan Public Health Institute LORI CORTEVILLE, MS JANE PATERSON, MSW Senior Data Analyst Project Coordinator * ROSEMARY FOURNIER, BSN * PATRICIA TACKITT, RN, MA Fetal and Infant Mortality Review Coordinator Urban Case Coordinator HEIDI HILLIARD, BS J. ROBIN BELL Community Health Consultant Community Health Consultant LYNDA MEADE, MPA MICHELLE VOLKER Senior Project Coordinator Office Manager Michigan Department of Human Services TED FORREST Manager Children’s Protective Services *Funding for these positions supported in part by the Michigan Department of Community Health, the Wayne County Health Department and/or the Detroit Department of Health and Wellness Promotions. Table of Contents INTRODUCTION 9 SECTION ONE: THE MICHIGAN CHILD DEATH REVIEW PROCESS 11 Conducting a Local Review Taking Action State Support State Advisory Team National Center for Child Death Review SECTION TWO: A TEN YEAR RETROSPECTIVE LOOK AT CHILD DEATH REVIEW 21 SECTION THREE: A SUMMARY OF MICHIGAN CHILD MORTALITY DATA AND CHILD DEATH REVIEW TEAM FINDINGS 31 A Note on the Data Used in this Report Michigan Child Mortality: 1990-2004 Data from Death Certificates Michigan Child Death Review: Summary of 2004 Findings SECTION FOUR: NATURAL DEATHS 49 Overview Natural Infant Deaths Excluding SIDS, Ages 0-1 Sudden Infant Death Syndrome Natural Child Deaths, Ages 1-18 SECTION FIVE: ACCIDENTS (UNINTENTIONAL INJURIES) 67 Overview Motor Vehicle Suffocation and Strangulation Fire Drowning Other Causes SECTION SIX: HOMICIDES 99 Overview Firearm and Weapon Child Abuse and Neglect Other Causes SECTION SEVEN: SUICIDES 117 Overview Child Death Review Team Findings from CDR Case Reports SECTION EIGHT: UNDETERMINED DEATHS 127 Overview Child Death Review Team Findings from CDR Case Reports SECTION NINE: FETAL AND INFANT MORTALITY REVIEW 133 Introduction FIMR Background FIMR Process FIMR Role in Public Health Community Involvement Michigan FIMR Network Findings Conclusions Next Steps SECTION TEN: APPENDICES 153 Appendix A: Progress on Implementing the Recommendations of the Michigan State Advisory Team Appendix B: Local Child Death Review Team Coordinators, 2004 Appendix C: Number of Cases Reviewed and Reported by County Appendix D: Total Deaths, Michigan Residents, Ages 0-18, by County of Residence and Age Group, 2004 Appendix E: Total Deaths, Michigan Residents, Ages 0-18, by County of Residence and Age Group, 1994–2004 Introduction Children are not supposed to die. The death of a child is a profound loss not only to the child’s parents and family, but also to the larger community. In order to reduce the numbers of these tragic losses, we must first understand how and why our children are dying. The Child Death Review (CDR) process was implemented in Michigan in 1995 to do just that. CDR brings together a multidisciplinary group of people at the county level to conduct in-depth reviews of child deaths. These reviews identify the adverse factors that led to the death. The reviews motivate communities to take action to eliminate these factors in order to prevent similar tragedies in the future. The review process also aims at improving a community’s response to child deaths, including investigations and provision of services to those affected by the death. The Michigan Child Death State Advisory Team studies county review team findings. The state team was authorized by Public Act 167 of 1997 to identify and make recommendations on policy and statutory changes pertaining to child fatalities and to guide statewide prevention, education and training efforts (Appendix B lists recommendations from past annual reports on which some type of action has been taken). It is required to publish these annual reports on child fatalities, based on the compilation of death data reported by the state registrar, as well as data received from the county level CDR teams across the state. This sixth annual report covers deaths reviewed in 2004. In that year, county teams reviewed 802 child deaths. This report is written in memory of all of the children in Michigan who have died. The Michigan Child Death State Advisory Team issues this report with the hope that it will encourage additional efforts, both in local com- munities and among our state leaders, to keep every child in Michigan safe and healthy. Child Deaths IN MICHIGAN section one The Michigan Child Death Review PROCESS Conducting a Local Review Purpose Child Death Review (CDR) brings together multi-disciplinary groups of people to conduct comprehensive reviews of child deaths in order to identify the factors that may have contributed to the deaths. The reviews are designed to motivate communities and inform state agencies to take action in order to prevent other similar tragedies in the future. Membership There is no legislative mandate to participate on a review team, yet nearly 1,200 local professionals on 74 teams that cover all 83 counties demonstrate a tremendous volunteer commitment to the review process. Statute does re- quire that where teams are established, they include at least the county medical examiner, the prosecuting attorney, a law enforcement officer and representatives from local public health and the county Department of Human Services. Most teams have even broader representation. The average team size is 15 members. Representation on Local Child Death Review Teams, 2004 Agency Number Law enforcement. 298 Local public health. 132 Medical examiners’ offices. 117 County Department of Human Services. 113 County prosecutors’ offices. 110 Hospitals. 100 Community Mental Health. 58 Emergency medical services. 55 Schools. 46 Health clinics and physicians. 41 Courts. 31 Other social services. 25 Community collaboratives.