150N. 18thAvenue,Suite 500
Phoenix,Arizona 85007-3247
(602) 542-1025
(602)542-1'062FAX

JANET NAPbUI'ANO, GOVERNOR
CAnmRINi

R. EDEN, DIRECTOR

The Honorable JanetNapolitano
Governor, State of Arizona
1700 West Washington
Phoenix, AZ 85007

Dear GovernorNapolitano:
On behalf of the Arizona Department of Health Seivices, the Eleventh Annual Report of the
Arizona Child Fatality Review Team is forwarded to you in compliance with A.R.S. § 36-3501

C.3.
Sincerely,

cather~~ 1ZJL
Director
CRE:SMN :tn

Enclosure(1)

Leadership
for a HealthyArizona

Arizona Department of Health Services
Public Health Prevention Services
Office of Women and Children's Health
150 N. 18thAvenue, Suite 320
I
Phoenix, AZ 85017-3242
Phone: (602) 542-1875
Fax: (602)542-1843
http://www.hs.state.az.us/cfhs/index.htm

November15,2004

Dear Friendsof Arizona's Children:
Over the past 12 months, the local child fatality review teams in 14 Arizona counties reviewed
937 of the 1,053 deaths of Arizona children that occurred in 2003. This report summarizesthe
fmdings of the review teams regarding these deaths. The mission of the Arizona Child Fatality
Review Program is to reduce child deathsby identifying preventable deaths through case
reviews. In 2003, the Arizona Child Fatality Review Program concluded that 240 or 26% of the
deathsreviewed could have beenprevented by either individual or community action.
Most preventable deaths are due to accidents. The two most common accidents that killed
Arizona children in 2003 were motor vehicle crashesand drowning. Thus, this report especially
focuses on the circumstances surrounding these deathsand provides recommendations for
preventing these deaths including better supervision of young children around water, pool
fencing ordinances, seat belt enforcementand teen driving restrictions.
In 2003, 16 young children died in backyard pools. Appropriate securedpool fencing that
isolates the pool from the home could have prevented most of these deaths. There were 105
motor vehicle deathsreviewed and over 90% of these deathswere preventable. For example
only 16 of the 74 children who died when they were passengersin a motor vehicle were
restrained although restraints were known to be available in 92% of the motor vehicles.
The death of a child is a tragedy, not only for their family, but for our entire community. These
deaths are even more tragic when we recognize how easily so many of them could have been

prevented.
Sincerely,

"?J/~~
(::ve~~
,-"l:2
-'.,,/
A..
~ary ~n Rimsza
M.D.
.~)-eG.-~6d
~ ) hID
Chair, Arizona Child Fatality Review Program

ELEVENTH ANNUAL REPORT
NOVEMBER 2004

Arizona Department of Health Services
Public Health Prevention Services
Office of Women’s and Children’s Health

Leadership for a Healthy Arizona

Janet Napolitano, Governor
State of Arizona

Catherine R. Eden, Ph.D., Director
Arizona Department of Health Services

MISSION
Setting the standard for personal and community health through
direct care delivery, science, public policy and leadership.

Arizona Department of Health Services
Public Health Prevention Services
Office of Women’s and Children’s Health
Child Fatality Review Program
150 North 18th Avenue, Suite 320
Phoenix, Arizona 85007
(602) 542-1875

This publication can be made available in alternative format. Please contact the Child Fatality
Review Program at (602) 542-1875 (voice) or call 1-800-367-8939 (TDD).
Permission to quote from or reproduce materials from this publication is granted when
acknowledgment is made.

ARIZONA CHILD FATALITY REVIEW TEAM

ELEVENTH ANNUAL REPORT

NOVEMBER 2004

MISSION
To reduce preventable child fatalities through systematic,
multidisciplinary, multiagency, and multimodality review of child
fatalities in Arizona; through interdisciplinary training and
community-based prevention education; and through data-driven
recommendations for legislation and public policy.

Submitted to
The Honorable Janet Napolitano, Governor, State of Arizona
The Honorable Ken Bennett, President, Arizona State Senate
The Honorable Franklin “Jake” Flake, Speaker
Arizona State House of Representatives

ACKNOWLEDGMENTS
We wish to acknowledge the dedication and tireless support of more than 250 volunteers from
throughout Arizona. Without their efforts this report would not be possible. These people
continue to share their valuable time and expertise to make the child fatality review program
a success. We also wish to extend a special thank you to Lisa Anne Shamus M.P.H., Research
and Statistical Analysis Manager at the Arizona Department of Health Services, for her
assistance in preparing this report.
This year we would also like to acknowledge a very special volunteer, Shirley Rau, who has
donated more than 800 hours in the past three years to the Arizona Child Fatality Review Team.
Shirley is a retired medical records supervisor who regularly drives from her home in
Cottonwood, Arizona, to Phoenix to help us prepare more than 600 files annually for review in
Maricopa County. Her experience and knowledge of medical records and organizational skills
are invaluable to our team. The child fatality review process in Arizona has been successful only
because of the work and dedication of volunteers like Shirley. The Child Fatality Review Team
wishes to express our sincere appreciation to Shirley for all the work she has done.

i

EXECUTIVE SUMMARY
The mission of the Arizona Child Fatality Review Program is to reduce child deaths by
identifying preventable deaths through case reviews of children who died in Arizona. A child’s
death is considered to be preventable if an individual or the community could reasonably have
done something that would have changed the circumstances that led to the child’s death. The
Child Fatality Review Team develops recommendations for legislation, public policy and
community education to help prevent deaths in the future.
There were 1,053 child deaths reported in Arizona during 2003 and 937 of these deaths (89%)
have been reviewed for this report. The findings and recommendations in this report are based
on the cases reviewed by the Child Fatality Review Team.
The Child Fatality Review Team focused their recommendations this year on the reduction of
highly preventable fatalities due to motor vehicle crashes and drowning. Motor vehicle crashes
killed 105 children in 2003. Nine out of ten of these deaths could have been prevented.
Among motor vehicle deaths, the majority were children in a car or truck, some were
pedestrians, and others were riding some other kind of motorized vehicle. Driving under the
influence of alcohol or drugs and the driver’s youth were factors in many of these deaths. Only
one in five children who died as the result of riding or driving in a car or truck were using
restraints. The Child Fatality Review Team’s first full year of data is from 1995. Since then, at
least 397 Arizona children who died due to motor vehicle crashes were not wearing seat belts at
the time of the crash. Motor vehicles crashes have consistently been the most common cause of
preventable death for Arizona children.
The Child Fatality Review Team supports legislation to increase the use of restraints such as seat
belts and infant restraints and to increase restrictions on teen driving. Parents should model safe
behaviors for children through their use of seat belts and always buckle up their children.
Drowning deaths continue to be a major cause of preventable deaths in young children,
especially those under five-years old. Twenty-eight children drowned in 2003. Fourteen were
children under age five who died in backyard pools. The vast majority of these deaths could
have been prevented by better supervision of the child and secured pool fencing. Since 1995,
337 Arizona children have died in backyard pools.
The Child Fatality Review Team supports legislation designed to decrease drowning deaths in
children. The team recommends uniform, statewide pool-fencing ordinance that restricts young
children’s access to pools, and education of parents that they should never leave children
unsupervised around water.
Homicide, suicide and child maltreatment accounted for 79 of the deaths in 2003. Violent deaths
are major public health concerns in Arizona and are significant categories of preventable deaths.

ii

KEY 2003 FINDINGS
ALL CHILD DEATHS
•

1,053 children died in Arizona.

•

57% (599) of them died before reaching their first birthday.

•

While infants (birth to one year) are disproportionately represented in overall deaths,
they are far less likely to die from preventable causes.
o 48% of deaths of children 1 through 17 years of age reviewed were
determined to be preventable.
o 9.3% of infant deaths reviewed were determined to be preventable.

PREVENTABLE DEATHS
•

26% (240) of the 937 reviewed deaths among children birth through 17 years were
preventable.

•

Excluding deaths during the first year of life, 48% (185) of the 386 deaths of children
1 through 17 years of age reviewed were preventable.

•

66% (159) of the 240 preventable deaths were due to unintentional injuries
(accidents).

•

33% (79) of the 240 preventable deaths were associated with lack of supervision of a
child.

•

50% or more reviewed child deaths of residents of Apache, Navajo, and Yavapai
County were preventable, compared to only 18% of the child deaths of residents of
Maricopa County.

•

The most common cause of preventable death was motor vehicle crash, followed by
drowning.

MOTOR VEHICLE CRASH
•

There were 105 motor vehicle deaths and over 90% of these deaths were preventable.

•

74 children died as a result of being in a car or truck that was involved in an accident.
Only 16 (22%) of these children were using restraints, such as seat belts or car seats.

•

The driver’s youth was determined to be a factor in 43 deaths.
iii

•

Driver intoxication (alcohol or drugs) was known to be a factor in the deaths of 29
children.

•

Seven children died while driving or riding on all terrain vehicles.

DROWNING
•

There were 28 drowning deaths in 2003 and 89% of these deaths were preventable.

•

Sixteen children died in backyard pools. In eight of these deaths, the pool was not
fenced and in another three, the pool was fenced but the gate was not locked. In the
remainder of the deaths the team did not have information on the pool fencing/locks.

•

88% of the children who died in backyard pools were under five years old.

•

Inadequate supervision of the child was determined to have been a factor in the
drowning deaths.

•

Two young children gained access to the backyard pool through a “doggie door.”

•

No child drowned in a bathtub in 2003. One child drowned in a bucket.

KEY RECOMMENDATIONS
•

Support legislation that will increase seat belt use by children and adults.

•

Support legislation to increase restrictions on teen driving.

•

Support legislation to decrease drowning deaths in children, such as a uniform,
statewide pool-fencing ordinance that restricts young children’s access to pools.

•

Parents should model safe behaviors for children, through their use of seat belts and
always buckle up their children.

•

Parents should never leave children unsupervised around water.

iv

TABLE OF CONTENTS
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i
Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ii
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Characteristics of Children Who Died . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Reviewed versus Not Reviewed Cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Child Fatality Review Team Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Cause and Manner. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Motor Vehicle Crashes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Drowning Deaths . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10
Maltreatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Homicide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Suicide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Unexpected Infant Deaths. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Preventable Deaths . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Looking Forward . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Barriers to 100% Completion of Death Reviews . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Arizona Child Fatality Review Team . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Technical Assistance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Child Fatality Review Staff. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Local Child Fatality Review Teams . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27

INTRODUCTION
The Arizona Child Fatality Review Program was created in 1993 (A.R.S. § 36-342, 36-350-4)
and began data collection in 1994. A statewide team was mandated by statute to provide
oversight of the program, develop the data collection system, and produce an annual report
summarizing their findings. The state team also approves the development of each local team
that is responsible for reviewing the child deaths in their own community and provides additional
support and training for local team members as needed. By statute, the state team includes
representatives of the Arizona Chapter of the American Academy of Pediatrics, Indian Health
Service, law enforcement, a prosecuting attorney’s office, a county health department, a military
advocacy program, child protective services, American Indian agencies, and a county medical
examiner’s office.
The statute also outlines the composition of each local team. These teams must include local
representatives from child protective services, the county medical examiner’s office, the county
health department, law enforcement, and the county prosecuting attorney’s office. Other team
members include a pediatrician or family physician, a psychiatrist or psychologist, a domestic
violence specialist and a parent.
When a child dies in Arizona, a copy of the death certificate is sent to the local child fatality
review team. The local team then requests the child’s autopsy report, hospital records, child
protective services records, law enforcement reports and any other relevant documents that
provide insight into the child’s death. If the child was under one year of age at the time of the
death, the birth certificate is also reviewed. The enabling legislation requires that hospitals and
state agencies release this information to the Arizona Child Fatality Review Program’s local
teams. Team members are required to maintain confidentiality and are prohibited from
contacting the child’s family.
After reviewing all the documents, the local team makes an assessment of the preventability of
each child’s death and completes a standardized data sheet that includes extensive information
regarding the circumstances surrounding the death. The Arizona Child Fatality Review Program
defines a child’s death as preventable if an individual or the community could reasonably have
done something that would have changed the circumstances that led to the child’s death. If the
local team members cannot come to a consensus regarding the preventability of a child’s death,
the preventability is listed as unknown. The local teams review deaths throughout each year and
must submit them to the state team by August 15th of the following year. This deadline for
completion of reviews is necessary so that the state team can utilize the local team data to
prepare an annual report that is published each November. If a team has not received sufficient
information to complete a review by the August 15th deadline, the death will not be reviewed.
This is the eleventh annual report issued by the Child Fatality Review Team. Fourteen child
fatality review teams located throughout Arizona reviewed 937 of the 1,053 deaths that occurred
in 2003. More than 250 team members contributed over 4,000 hours of volunteer time to review
these deaths. The Arizona Department of Health Services and Arizona State University provides
professional and administrative support for the teams.

1

During 2004, the Arizona Child Fatality Review Program made significant progress in several
areas, including the following:
•

In August 2004, the Arizona Child Fatality Review Program established a database link
with Arizona’s vital records. This link enabled the Arizona Child Fatality Review Team
to compare the deaths reviewed by the local teams with the state’s vital statistics,
allowing a more complete set of data. This is the first year that the program has included
information in the annual report on child fatalities that were not reviewed by the local
teams. The Arizona Child Fatality Review Program will now be able to regularly provide
recorded death information to the local teams in a timely manner, which will help
increase the number of cases they are able to review.

•

The Arizona Child Fatality Review Program provided data to several professionals for
research and presentations on preventing child deaths in Arizona. Research and
presentation topics included deaths attributed to drowning, motor vehicle crashes, Sudden
Infant Death Syndrome (SIDS) and other unexpected infant deaths, exposure, and
infectious disease.

•

The Arizona Child Fatality Review Prevention Subcommittee was created this year to
identify and promote prevention activities in order to reduce child deaths. The
subcommittee has begun its work and will focus initially on prevention of motor vehicle
crashes and drowning fatalities.

•

The Arizona Child Fatality Review Program has reallocated funding and now provides
funding to all local child fatality review teams.

•

William Marshall, M.D. and Kathryn Bowen, M.D., of the Pima County team, wrote a
paper entitled “Child Deaths of Unknown Cause: Analysis of 7 Years Experience,” which
was accepted for publication in Clinical Pediatrics.

•

Mary Ellen Rimsza M.D. presented data on preventable drowning deaths in Arizona at
the U.S. Consumer Product Safety Commission hearing in July 2004.

•

Tala Dajani, M.D. gave a presentation at the Pediatric Academic Society Meeting on the
Arizona Child Fatality Review and drowning deaths.

•

As recommended in last year’s annual report, the Healthy Families Arizona program has
expanded.

•

The Arizona Department of Health Services, Injury Prevention/Emergency Medical
Services for Children Program provided small grants to the local teams that resulted in
development of the following initiatives to reduce childhood injuries:
o A portable bedroom mock-up was created with signs indicating unsafe sleeping
situations and sleep packets were developed and distributed to parents of new
babies to reduce the risk of SIDS.

2

o Age-appropriate safety information sheets and assessment forms created by the
American Academy of Pediatrics were purchased and distributed to families in
need of routine health counseling and injury prevention instruction.
o A bicycle helmet education program was used to educate children on helmet
protection and to promote their social acceptability.
o

“Never Shake a Baby” posters were distributed statewide.

The remainder of this report presents information on characteristics of children who died in
Arizona, Child Fatality Review Team findings, and recommendations to prevent further deaths
among children. Throughout the document, findings are broken down by race and ethnicity. In
order to give these findings context, Figure 1 below shows the overall population distribution by
race and ethnicity for children under age 18 in Arizona (Source: United States Bureau of the
Census, release date September 30, 2004).
Figure 1. Race and Ethnicity for Children Birth through 17 Years in Arizona

Hispanic
39%

American
Indian
7%
Other
3%

NonHispanic
61%

Asian/
Pacific
Islander
(n=16)
2%

Black
4%

White
84%

This report focuses only on childhood death, which may be seen as the tip of the iceberg. The
same factors that kill some children lead to even more nonfatal injuries every year. The lessons
learned from this report may be applied more generally to reduce childhood injury and improve
child health and safety.

3

CHARACTERISTICS OF CHILDREN WHO DIED
There were 1,053 fatalities among children birth through 17 years of age in Arizona during 2003.
More than one-third of them were in the neonatal period, which is before the 28th day of life.
Males were disproportionately represented among child deaths, with 58% of the deaths overall.
Among adolescents, 71% of the deaths were boys. Figure 2 shows the number of boys and girls
who died in each age group.
Figure 2. Age Group and Gender for all Deaths
Children Birth through 17 Years
224

Females

Males

174
93

108

107
69

71

67
23

Under 28 days

28-365 days

1-4 years

34

5-9 years

39

44

10-14 years

15-17 years

While Hispanic children make up 36% of the population of children under the age of 18 in
Arizona, they accounted for 46% of children who died in 2003. Deaths also seem to occur at
disproportionately high rates in American Indian children (11% of deaths versus 7% of the
population) and Blacks (7% of the deaths compared to 4% of the population). Figure 3 shows
the numbers of children who died within each racial group, and the proportions of Hispanic
versus Non-Hispanic ethnicity.

Figure 3. Race and Ethnicity for all Deaths of Children Birth through 17 Years

Hispanic
(n=481)
46%

American
Indian
(n=112)
11%

NonHispanic
(n=572)
54%

White
(n=850)
80%

4

Asian/
Pacific
Islander
(n=16)
2%

Black
(n=75)
7%

There are 15 counties in Arizona. None of them stands out as having an excess number of
childhood deaths among its residents compared to their population proportions. Table 1 shows
the distribution of child deaths by the child’s county of residence.
Table 1. Child Deaths by County of Residence
As Reported on Death Certificate
Apache
23
(2%)
Cochise
29
(3%)
Coconino
24
(2%)
Gila
11
(1%)
Graham
5
*
La Paz
3
*
Maricopa
596 (57%)
Mohave
25
(2%)
Navajo
41
(4%)
Pima
142 (13%)
Pinal
45
(4%)
Santa Cruz
3
*
Yavapai
18
(2%)
Yuma
30
(3%)
58
(6%)
Outside Arizona
Total
1,053 (100%)
*Less than 1% of total
According to death certificate data, the majority of deaths (69%) were due to natural causes,
which include all medical causes of death, and 21% were due to accidents. The manner of death
could not be determined in approximately 2% of deaths. (See Figure 4.)
Figure 4. Manner of Death
from Death Certificate
Pending
Investigation
(n=6)
1%

Suicide (n=29)
3%

Accident (n=222) Undetermined
21%
(n=26)
2%

Natural (n=725)
69%

Homicide (n=45)
4%

5

REVIEWED VERSUS NOT REVIEWED
The Child Fatality Review Team is never able to review 100% of deaths. Of the 1,053 childhood
fatalities in 2003, 937 were reviewed, representing 89% of fatalities recorded in Arizona vital
statistics data. However, due to the linking of vital statistics death certificate data with the child
fatality review data, information is available this year to compare deaths that were reviewed by
the local teams, with those that were not reviewed. In general, reviewed cases were similar to
non-reviewed cases in terms of gender, race, and ethnicity. Differences were found in age,
county of death, county of residence, manner of death, and month of death.
Children ages five through nine had the fewest deaths. These deaths were also the least likely to
be reviewed. Infant deaths were the most likely to be reviewed. Figure 5 shows the percent of
cases reviewed within each age group.
Figure 5. Percent Reviewed within Age Groups
Less than 28 Days (n=365/398)

92%

28 - 365 Days (n=186/201)

93%

1 - 4 Years (n=126/140)

90%

5 - 9 Years (n=44/57)

77%
87%

10 - 14 Years (n=92/106)
15 - 17 Years (n=124/151)

82%

Ninety-three percent of natural deaths were reviewed, compared to only 76% of suicides and
77% of deaths where the manner was undetermined. Figure 6 shows the percent of deaths
reviewed for each manner of death, excluding the six deaths in which the manner of death was
pending.
Figure 6. Percent Reviewed by Manner of Death
91%

Homicide (n=41/45)
76%

Suicide (n=22/29)
Accident (n=179/222)

81%

Natural/Not specified (n=672/725)

93%

Undetermined (n=20/26)

77%

6

The month in which a child died influenced whether or not the death was reviewed. Ninety-four
percent of deaths occurring in the spring were reviewed compared to 75% of those occurring in
December. Nearly 25% of all of the deaths that were not reviewed occurred in December.
Differences were found in review status for both county of death and county of residence at the
time of death. Of the three children who were residents of La Paz County when they died, none
of the deaths were reviewed. Seventy-six percent of Navajo County residents’ deaths were
reviewed and 57% of deaths that occurred in Arizona to non-Arizona residents were reviewed.
In terms of county of death, reviews were conducted on a smaller percent of children who died in
Apache County (71%), Cochise County (59%), La Paz County (9%), and Navajo County (62%).
The remainder of this report discusses the 937 deaths that were reviewed by the local child
fatality review teams.

7

CHILD FATALITY REVIEW TEAM FINDINGS
The local child fatality review teams reviewed 937 childhood deaths, representing 89% of the
total childhood deaths that occurred in Arizona during 2003. Reviews include categorization of
both cause and manner, as well as a determination of preventability. Their findings related to
each of these are presented in this section.
CAUSE AND MANNER
The cause of death is any injury or disease that results in death. Manner of death explains how
the death came about. Manners of death can generally be categorized as natural, homicide,
suicide, accident, or undetermined. In addition to reviewing medical examiner reports, child
fatality review teams review other medical records, records from law enforcement agencies,
Child Protective Services and schools. From these reviews, they determine the cause and
manner of death, which sometimes differ from those found on the death certificate due to their
multidisciplinary review.
Seventy-one percent of the childhood deaths reviewed were due to natural causes, including 252
deaths due to prematurity. One in five of the deaths were due to accidents and 56% of the
accidental deaths were due to motor vehicle crashes. Forty-two Arizona children were
murdered; 15 of these children were shot and 12 were beaten. Twenty-four children committed
suicide. Table 2 shows a cross-tabulation of the cause and manner of death for reviewed cases.
Table 2. Cause and Manner of Death for Reviewed Cases
Cause

Accident

Homicide

104

Undetermined

105

33

Gunshot Wound

4

15

Drowning

28

Suffocation

13

3

Blunt Force Trauma

2

12

Hanging

3

Poisoning

5

Other Non Medical

23

Total
252

1

SIDS

33
9

1

29
28

4

20
14

10

13

1

3

9

11

1

34

Other Medical
Undetermined

Suicide

252

Prematurity
MVC

Natural

5

374

2

376

5

13

24

Total

187

42

664

24

20

937

Percent of Manner

20%

4%

71%

3%

2%

100%

8

MOTOR VEHICLE CRASHES
Fewer children died as a result of motor vehicle crashes in 2003 (105 in 2003 compared to 127 in
2002). However, motor vehicle crashes remain the most common cause of preventable
childhood deaths. Among motor vehicle deaths, the majority were children in a car or truck,
some were pedestrians, and others were riding some other kind of motorized vehicle.
Older children are more likely to be victims of motor vehicle fatalities than younger children,
with the 15-17 year old age group being particularly vulnerable. Fifteen through 17 year olds
make up only 16% of the population under 18, but represented 42% of the motor vehicle crash
deaths among children. Boys were more likely to die due to a motor vehicle crash than girls.
Figure 7 shows the number of boys and girls who died as the result of motor vehicle crashes in
various age groups.
Figure 7. Reviewed Motor Vehicle Crash Cases
by Age and Gender
30
25
Female

Male
14

11
2

0

Under 365 days

5

7

1-4 years

6

5

5-9 years

10-14 years

15-17 years

American Indians are disproportionately represented among motor vehicle crash fatalities.
Representing only 7% of the population of children, American Indians accounted for 16% of the
motor vehicle fatalities. Figure 8 shows motor vehicle crash fatalities by race and ethnicity.
Figure 8. Race and Ethnicity for Reviewed Motor Vehicle Crashes

Hispanic
(n=42)
40%

American
Other (n=1) Indian
1%
(n=17)
16%

NonHispanic
(n=62)
60%

White
(n=84)
80%

9

Asian/
Pacific
Islander
(n=2)
2%
Black
(n=1)
1%

Restraints. Seventy-five of the children who died in motor vehicle crashes were riding in a car
or truck at the time of their death. Only one in five of them (16 out of 75) were using restraints.
Yet, restraints were known to be available in 92% of the motor vehicles.
Type of Crash. Eleven fatalities were children who were pedestrians when they were struck by
a car or truck. Seven more children were killed while riding on all terrain vehicles, and four
were riding motorcycles. The eight remaining deaths were the result of accidents involving a
scooter, an airplane, jet skis, a train, a forklift, and three in which the type of crash was unknown.
Substance Use. Alcohol or drugs were factors in 33 (31%) of the deaths. This may be an
underestimate of the number of deaths in which alcohol or drugs played a role because this
information was not included in the reports received by the child fatality review teams in 30 of
the cases reviewed.
Age as a Factor. Age of the driver was considered to be a factor in 43 of the motor vehicle
crash deaths, including six of the seven all terrain vehicle deaths and 34 of the 87 deaths that
were associated with auto/truck collisions.
Preventability. Ninety-five of these deaths were determined to be preventable. In eight of these
deaths the team could not determine if the death was preventable and in two cases they felt the
death was not preventable.
Seating. Seating was known in 58 of the cases reviewed. In 19% of the cases, the child who
died was the driver. Among the remaining children who were passengers, 47% were seated in
the right front passenger seat (22 out of 47 passengers).
DROWNING
Twenty-eight Arizona children drowned in 2003. This compares with 31 deaths in 2002.
Twenty-five of the 28 deaths were determined to be preventable
The majority (64%) of the children who
drowned were one through four years old
(n=18). There was only one drowning death
under the age of one, four deaths occurred in the
5 through 9 age group, three were in the 10
through 14 year age group, and two were
adolescents.
Seventy-nine percent of the children who
drowned were boys. There were no drowning
deaths in girls over the age of four. (See Figure
9.)

10

Figure 9. Reviewed Drowning
Deaths by Gender
Females
(n=6)
21%

Males
(n=22)
79%

While American Indian children represent only 7% of children in the population, they
represented 11% of the drowning deaths. Blacks comprise 4% of the population, and accounted
for 7% of the drowning deaths. Forty-three percent of the children who drowned were Hispanic.
Backyard pool drowning deaths continue to be a major cause of preventable deaths in young
children. In 2003, 16 children died in backyard pools, which accounted for over half (57%) of
the drowning deaths. Fourteen of these children were under five years old. Local child fatality
teams determined that at least 15 of these 16 deaths could have been prevented. (In one case
there was insufficient information available to determine preventability). Figure 10 shows the
location of drowning deaths.
Figure 10. Location of Drowning Deaths
Bucket (n=1)
4%

Canal (n=4)
14%

Private
Residence Pool
(n=16)
57%

Other (n=2)
7%

Lake/River
(n=4)
14%

Multi-Family
Private Pool
with Fence
(n=1)
4%

In eight of these deaths, the pool was not fenced and in another three the pool was fenced but the
gate was not locked. In the remainder of the deaths, the team did not have information on the
pool fencing/locks. Since 1995, 337 Arizona children have died in backyard pools. Whereas
eight children drowned in bathtubs in 2002, no child drowned in a bathtub in 2003.
MALTREATMENT
There were 37 deaths that were associated with child maltreatment in 2003 compared with 36 in
2002. The number of child maltreatment deaths included in this report is not comparable to child
maltreatment deaths reported by the Arizona Department of Economic Security for the National
Child Abuse and Neglect Data System (NCANDS). The Department of Economic Security only
reports on child fatalities when an investigation has determined (substantiated) that the death was
the result of abuse or neglect. Child Protective Services investigates allegations of child
maltreatment deaths when a report alleges that a child is at risk. The number reported to
NCANDS will not include maltreatment fatalities in which the child is deceased at the time the
report is made and there are no other children in the home. Therefore, it is likely that the number
included in this report will be greater than the number of maltreatment deaths reported to
NCANDS. The Child Fatality Review Team has a very specific protocol for determining

11

whether or not maltreatment was a factor in the child’s death. Three conditions must be met for
the review team to classify the death as a result of maltreatment:
1) The circumstances surrounding the death must conform to the U.S. Department of Health
and Human Services definition of maltreatment: “An act or failure to act by a parent,
caregiver, or other person as defined under State law which results in physical abuse,
neglect, medical neglect, sexual abuse, emotional abuse, or an act or failure to act which
presents an imminent risk of serious harm to a child.”
2) The relationship of the individual accused of committing the maltreatment to the child
must be the child’s parent, guardian or caretaker.
3) A team member who is a mandated reporter would feel obligated to report a similar
incident to Child Protective Services.
Deaths included in this category are also reported in other categories such as homicide, accident,
suicide or natural (medical) as appropriate. Examples of homicide deaths associated with
maltreatment include deaths due to shaken baby syndrome and examples of medical deaths
associated with maltreatment include deaths that were associated with parental failure to seek
medical attention when their child is obviously ill. An accidental death might also be included in
this category if, in the opinion of the team, a caretaker’s negligence was the cause of the
accidental death. For example, a suffocation death due to co-sleeping might be considered to be
due to maltreatment if the parent was intoxicated due to drugs or alcohol. Substance abuse by
the alleged perpetrator was determined to be a factor in 16 of the maltreatment-related deaths.
Table 3. Causes of Death for Reviewed Maltreatment-Associated Deaths
Cause

Accident

Homicide

Natural

Suicide

Undetermined

Total

Blunt Force Trauma

11

11

Exposure

1

1

2

3

Gunshot Wound

1

Motor Vehicle Crash

2

1
2

Neurological Diseases

1

1

Poisoning

3

5

Shaken Infant

5
1

SIDS
2

1

3

5

Unknown
Total
Percent of Manner

1

1
37

5

23

6

1

2

14%

62%

16%

3%

5%

12

3
1

3

Prematurity

Suffocation

3

100%

Table 3 above shows the causes and manner of death for maltreatment-associated deaths. Most
children who died and were maltreated died due to homicide, but five died due to accidents and
six died due to medical problems. Blunt force trauma, shaken infant syndrome and suffocation
resulted in the greatest number of maltreatment deaths in children. Within child fatalities due to
maltreatment, substance abuse contributed to one suicide, four of the five accidental deaths, four
of the six natural deaths, six of the 23 homicide deaths, and one of the deaths in which the
manner could not be determined. Lack of medical care contributed to four of the six natural
deaths listed above.
Infancy is the greatest period of risk for death due to child maltreatment. Reviews completed
revealed that 57% of children whose death was attributed to maltreatment were under the age of
one year. Children under the age of five years accounted for 84% of all child maltreatment
deaths. While only 42% of childhood deaths are girls, they represent 54% of maltreatment
deaths. Figure 11 shows the age and gender distribution of maltreatment deaths.
Figure 11. Reviewed Maltreatment Cases by Age Group and Gender
Female
8

Male

8
7
4

3

3
2

2

Under 28 days

28-365 days

1-4 years

5-17 years

Ten of the children whose deaths were associated with maltreatment were American Indians,
representing 27% of all maltreatment deaths, even though American Indians represent only 7%
of children under age 18. Hispanics were also overrepresented compared to their population
percentages with 57% of all maltreatment deaths, and only 36.2% of the population. (See Figure
12.)
Figure 12. Race and Ethnicity for Reviewed Child Maltreatment Cases

Hispanic
(n=21)
57%

American
Indian
(n=10)
27%

NonHispanic
(n=16)
43%

White
(n=24)
65%

Asian/
Pacific
Islander
(n=1)
3%
Black
(n=2)
5%

13

HOMICIDES
Forty-two children were victims of homicide in 2003. Child victims of homicide primarily died
as the result of gunshot wounds and blunt force trauma (See Table 2 on page 8). Nearly onethird of the homicide victims (31%) were less than one year old, and nearly half (48%) were
adolescents (ages 15 through 17). Males, adolescents age 15 through 17, and Hispanic youth had
the greatest risk of being victims of homicide. Twice as many boys (n=28) than girls (n=14)
were murdered. (See Figure 13.)
Figure 13. Reviewed Homicide Cases by Age Group and Gender
Female

Male
18

7

6

5
3
1

Under 365 days

1-4 years

1

1

5-14 years

15-17 years

Similar to the findings related to child maltreatment deaths, American Indians and Hispanic
children are overrepresented among homicides (see Figure 14 below).
Figure 14. Race and Ethnicity for Homicides

Hispanic
(n=24)
57%

NonHispanic
(n=18)
43%

White
(n=28)
67%

American
Indian
(n=9)
21%

Asian/
Pacific
Islander
(n=1)
2%
Black
(n=4)
10%

14

SUICIDE
Twenty-four children committed suicide in 2003. Nine of the 24 children who committed
suicide were less than 15 years old, and 15 were in the 15 through 17 age group. Only three of
the suicide victims were girls. Figure 15 shows the age and gender distribution for suicides.
Figure 15. Reviewed Suicide Cases by Age Group and Gender
Female

Male

13

8
2

1

Under 15 years

15 through 17 years

Both Whites and American Indians are overrepresented among suicides compared to their
population proportions. Figure 16 shows the distribution of suicide deaths by race and ethnicity.
Figure 16. Race and Ethnicity for Reviewed Suicide Deaths
Hispanic
(n=2)
8%

Black
(n=1)
4%

NonHispanic
(n=22)
92%

White
(n=16)
67%

American
Indian
(n=6)
25%

Asian/
Pacific
Islander
(n=1)
4%

Most children who commit suicide do so by either using a gun or hanging. Figure 17 shows the
causes of death for suicides.
Figure 17. Causes of Suicide Deaths

Gunshot wound
(n=9)
38%

Hanging
(n=10)
41%

Poisoning
(n=3) 13%
Motor vehicle crash
(n=1)
4%

Strangulation (n=1)
4%

15

UNEXPECTED INFANT DEATHS
This category of death includes infants less than one year old who died unexpectedly. Included
in this category are infants who died of Sudden Infant Death Syndrome (SIDS), suffocation and
natural causes. In 2003, 33 children died of SIDS and 19 died of suffocation. Suffocation deaths
included in this category were primarily the result of overlying during co-sleeping with adults or
positional asphyxia. Positional asphyxia often is the result of an unsafe sleeping environment,
such as a couch.
A major reason for the decrease in SIDS deaths is the American Academy of Pediatrics “Back to
Sleep” Campaign, which encourages parents to put infants to sleep on their backs instead of on
their stomachs. The number of deaths due to SIDS in Arizona continues to decrease. Part of the
decrease may be due to increased identification of deaths due to suffocation, which may have
been attributed to SIDS. Figure 18 shows the trends in SIDS and suffocation deaths over time.
Figure 18. SIDS and Suffocation Deaths in Infants: 1995-2003
SIDS

Suffocation

80
78
60
51

40

51
44
35

39

36

37

7

10

12

'00

'01

'02

20
0

6

10

'95

'96

14
'97

14

9
'98

'99

33
19

'03

Because of the increasing number of deaths due to suffocation, these deaths are described in
more detail. The 19 deaths were considered preventable. In three cases the team could not
determine if the death was preventable. Eleven of these suffocation deaths were attributed to cosleeping. That is, the baby was placed in bed with an adult or another child who suffocated the
infant while sleeping. In the other three cases, the infant was sleeping alone but on inappropriate
soft bedding. In three of these deaths the parent was intoxicated and co-sleeping with the infant
at the time of the death. No racial or ethnic group is disproportionately represented among SIDS
deaths.

16

PREVENTABLE DEATHS
A child’s death is considered to be preventable if an individual or the community could
reasonably have done something that would have changed the circumstances that led to the
child’s death. The local child fatality review teams determined that 240 of the child deaths
reviewed were preventable, representing more than one in four deaths. The teams were unable
to reach a conclusion regarding preventability in 117 cases. Circumstances precluding a
determination of preventability include such things as the team not receiving necessary records,
or the fact that an autopsy was not performed. It is likely that some of the cases in which
preventability was not determined were, in fact, preventable.
The deaths of older children -- especially adolescents -- were more likely to be preventable.
Whereas only 3% of neonatal deaths were preventable, 63% of the deaths among 15 through 17
year olds were preventable. Figure 19 shows the percent of deaths determined to be preventable
within age subgroups.
Figure 19. Preventable Deaths by Age
Under 28 days
(n=11/365)

3%
24%

28-365 days (n=45/187)
1-4 years (n=49/126)

39%

5-9 years (n=17/44)

39%

10-14 years (n=40/91)

44%

15-17 years (n=78/124)

63%

The deaths of boys were more likely than the deaths of girls to have been preventable. Twentytwo percent of female deaths were preventable, compared to 28% of male deaths.

17

Remarkably, 42% of American Indian children’s deaths were determined to have been
preventable, compared to the statewide rate of 26%. The deaths of Black children were less
likely to have been determined to be preventable. Figure 20 shows the percent of deaths that
were preventable by race and ethnicity. It is important to note that each death is categorized by
both race and Hispanic/Non-Hispanic ethnicity.
Figure 20. Preventable Deaths by Race and Ethnicity
Non-Hispanic (n=149/516)

29%

Hispanic (n=91/421)

22%

White (n=183/746)

25%

Black (n=10/70)

14%
27%

Asian/Pacific Islander (n=4/15)

42%

American Indian (n=41/98)
25%

Other (n=2/8)

Deaths due to accidents were much more often determined to be preventable than natural deaths
(85% compared to 5%, respectively). Figure 21 shows the percent of deaths determined to be
preventable by manner of death.
Figure 21. Preventable Deaths by Manner
85%

Accident (n=159/187)

76%

Homicide (n=32/42)

Natural (n=31/664)

5%

67%

Suicide (n=16/24)

Undetermined (n=2/20)

10%

18

The local child fatality review teams, using guidelines developed by the state team, assigns the
cause and manner of preventable deaths. The manner provides information about the type of
death and is not necessarily the immediate cause of death as listed on the death certificate. For
example, a gunshot wound might be the immediate cause of death, but the manner might be
homicide or suicide.
The most common cause of preventable death was motor vehicle crashes, followed by drowning.
Gunshot wounds and suffocations were also relatively frequent as causes of death. Table 4
summarizes cause and manner of death for all 240 preventable deaths.
Table 4. Cause and Manner of Preventable Deaths
Cause
Blunt Force Trauma

Accident

Homicide

1

10

Natural

Suicide

Undetermined

11
1

Cardiac Disease

Total

1

Choking

3

3

Drowning

25

25

Exposure

5

Fall

1

1

Fire/Burn

2

2

1

2

Gastrointestinal Disease
Gunshot Wound

4

Hanging

3

10

2
7

21

6

9

3

Infectious Disease
Motor Vehicle Crash

6

94

3
1

95

Neoplastic Disease

1

1

Neurological Disease

2

2

1

5

Other

4

Poisoning

4

1

Prematurity
Respiratory Disease

1

1

6

8

8

1

2

4

Shaken Infant

4
12

SIDS

12

4

Stab/Laceration

4
1

Strangulation
Suffocation

11

Unknown

1

2

1
2

15
1

Total

159

32

31

16

2

Percent of Manner

66%

13%

13%

7%

1%

19

240
100%

LOOKING FORWARD
The death of a child is a sentinel event that is a measure of a community’s overall well being.
The mission of the Arizona Child Fatality Review Program is to reduce child fatalities through
community-based prevention education and data-driven recommendations for legislation and
public policy.
Arizona’s child death rate is above the national average. Twenty-six percent of the deaths that
occurred in 2003 could have been prevented, especially deaths due to injuries. Substance abuse
was a contributing factor in the deaths of 77 children. Many deaths could be prevented through
more diligent adherence to already well-known prevention strategies including continuing public
safety campaigns, better supervision of young children, enforcement of laws regarding pool
fencing and automobile restraints.
Homicide, suicide and child maltreatment accounted for 79 of the deaths in 2003. Violent deaths
are a major public health concern in Arizona and represent a significant category of preventable
deaths. Effective strategies for the prevention of these deaths are complex and difficult. Early
recognition of depression, better access to mental health services, and elimination of guns from
the homes of troubled youth are some of the strategies that could be used to reduce the number of
suicide deaths. The child fatality review data can be used to target prevention programs in these
areas toward population groups at highest risk for violence. Reducing deaths due to homicide,
suicide and child maltreatment should be a major community effort.
There are success stories in preventing child deaths in our community. Although some of the
decrease in SIDS is probably due to the increased identification of suffocation deaths, much of
the decline is due to effective parent education about sleep position for infants. Also, motor
vehicle crash deaths are rare for infants probably due to availability and use of infant seat
restraints.
A major challenge facing the Child Fatality Review Program is to procure adequate and
sustainable funding to support the program’s infrastructure at both the state and local levels.
Sustainable funds are required to maintain the state and local child fatality review processes,
collect valid data, communicate information gathered in the review process, and disseminate
information to prevent child fatalities throughout Arizona. Each case requires hours of work.
Records must be collected and reviewed; reviews must be scheduled and conducted by the
teams; and data must be gathered, recorded, and entered into the child fatality review database.
At least annually, the data must be analyzed, aggregated, and reported. Without the active and
continuing involvement of volunteers, the process could not exist.
BARRIERS TO 100% COMPLETION OF DEATH REVIEWS
•

Local teams were unable to obtain several death certificates and other records for review.

•

Comprehensive death scene investigations remain a significant challenge. The Infant
Death Checklist, now mandated for use by law enforcement officers during investigations

20

of unexplained infant deaths, is frequently not completed and thus unavailable for review
by the local teams.
•

Access to behavioral health records continues to be especially challenging. While some
teams reported improvement, others expressed that continued work is needed in this area.

In the next year, the Arizona Child Fatality Review Team will pursue the following:
•

Continue to promote local and statewide efforts to prevent child fatalities.

•

Promote collaboration between county and tribal officials to improve child death reviews
in Arizona.

•

Provide ongoing training of the review process and data reporting to local child fatality
review teams.

•

Continue to pursue adequate and sustainable resources for the state and local child
fatality review process.

•

Increase the percentage of child fatalities that are reviewed. The recent establishment of
a database link with Arizona’s Vital Records will result in the local child fatality teams
receiving more timely notification of child deaths, which should assist the local teams in
their efforts.

•

Continue to promote usage of the Infant Death Checklist by law enforcement.

RECOMMENDATIONS
Recommendations to Prevent Child Fatalities From Motor Vehicle Crashes
•

Enact legislation to increase use of seat belts by children in Arizona.

•

Enact legislation to reduce teen motor vehicle crash deaths due to driving inexperience.

•

Parents should model safe behaviors for children, through their use of seat belts and
buckle up their children every time.

•

Children should be seated in the back seat of the car, whenever possible, preferably in the
center.

21

Recommendations to Prevent Child Drownings
•

Enact legislation to increase backyard pool fencing so that young children do not have
access to backyard pools.

•

Never leave children unsupervised around water.

Recommendations to Prevent Child Maltreatment Fatalities, Homicides, and Suicides
•

Ensure adequate funding of Child Protective Services, community child abuse prevention
and treatment programs, and behavioral health services and substance abuse treatment.

•

Report all suspected child maltreatment to the Child Abuse Hotline (1-888-SOS-CHILD),
the appropriate tribal or military social services agency, and/or a law enforcement
agency.

•

Enforce and expand legislation that restricts children’s access to guns.

•

Support public campaigns and parenting education that focus on prevention of violencerelated deaths, including firearm safety.

•

Remove guns and ammunition from the home of children who are at risk for suicide.

•

Know the warning signs of depression and suicide and see that children who are at risk
are provided behavioral health services as quickly as possible.

Recommendations to Reduce Preventable Risk Factors Related to SIDS and Suffocation
Deaths of Infants
•

Ensure safe sleeping arrangements for infants by placing sleeping infants on their backs
in a crib that meets current safety standards, has a firm tight-fitting mattress, and is free
of all soft bedding and materials.

•

Parents should never sleep with infants while under the influence of alcohol or drugs,
including medication that may cause sedation.

•

Discuss SIDS risk factors and infant positioning with childcare providers, grandparents,
and other caregivers.

•

Decrease your child’s risk for SIDS by not exposing babies to tobacco smoke before and
after birth.

22

ARIZONA CHILD FATALITY REVIEW TEAM
Mary Ellen Rimsza, M.D., Chairperson
Arizona Chapter, American Academy of Pediatrics
School of Health Management and Policy, Arizona State University
Gaylene Morgan

Paul Ahler
Arizona Prosecuting Attorney’s Advisory
Council

Office of the Attorney General
Angie Rodgers
Governor’s Office for Children

Vjollca Berisha
Maricopa County Department of Public
Health

Beth Rosenberg
Children’s Action Alliance

Kathryn Bowen, M.D.
University of Arizona
College of Medicine

Kim Simmons
Arizona Department of Economic Security
Division of Developmental Disabilities

David K. Byers
Administrative Office of the Courts

Margaret Schildt
Navajo Nation

Kipp Charlton, M.D.
Arizona Unexpected Infant Death Council

Jeff Serrano
Arizona Department of Health Services
Behavioral Health Services

Cathryn Echeverria
Arizona Department of Health Services
Office for Children with Special Health Care
Needs

Roy Teramoto, M.D.
Indian Health Services
David Winston, M.D.
Pima County Medical Examiner

Tim Flood, M.D.
Arizona Department of Health Services
Bureau of Health Statistics

Linda Wright
Parent Assistance
Office of the Supreme Court

Kevin Harper
Department of Juvenile Corrections
Janice Mickens
Arizona Department of Economic Security
Administration for Children, Youth, and
Families

23

CHILD FATALITY REVIEW TEAM PREVENTION COMMITTEE
Chair
Angie Rodgers
Governor’s Office for Children

Members
Paul Ahler
Maricopa County Attorney Office

Beth Rosenberg
Children’s Action Alliance

Tim Flood, M.D.
Arizona Department of Health Services

Eleanor Strang
Arizona Department of Health Services

Gaylene Morgan
Attorney General Office
Consultants
Rebecca Ruffner
Prevent Child Abuse, Inc.

Nancy Quay, R.N.
Phoenix Children’s Hospital

CHILD FATALITY REVIEW DATA COMMITTEE
Chair
Lori Roehrich
University of Arizona

Members
Kathryn Bowen, M.D.
University of Arizona

Mary Ellen Rimsza, M.D.
Arizona State University

Tim Flood, M.D.
Arizona Department of Health Services

Roy Teramoto, M.D.
Indian Health Services

Gaylene Morgan
Attorney General Office

24

LOCAL TEAM COORDINATOR COMMITTEE
Co-Chairs
Lori Roehrich
University of Arizona
Sandy Smith
Arizona State University

Members
Clarisa Read
Santa Cruz County Team

Irene Klim
Navajo County Team

Maria André
Yuma County Team

William Marshall, M.D.
Pima County Team

Kipp Charlton, M.D.
Maricopa County Team

Lucile Antone-Morago
Gila County Team

Donna Coca
Graham County Team

Rick Paterson
La Paz County Team

Charlie Dean
Coconino County Team

Rebecca Ruffner
Yavapai County Team

Leslie DeSantis
Mohave County Team

Diane Ryan
Apache County Team

Dee Foster
Cochise County Team

25

TECHNICAL ASSISTANCE
Christopher Mrela, Ph.D.
Arizona Department of Health Services
Assistant Registrar of Vital Statistics
Office of Epidemiology and Health Statistics
Nancy Quay, R.N.
Phoenix Children’s Hospital
Rebecca Ruffner, Director
Prevent Child Abuse, Inc.

ARIZONA DEPARTMENT OF HEALTH SERVICES
OFFICE OF WOMEN’S AND CHILDREN’S HEALTH
ASSESSMENT AND EVALUATION STAFF
Joan Agostinelli, Manager
Lisa Anne Schamus, Research and Statistical Analysis Unit Manager

CHILD FATALITY REVIEW STAFF
Susan Newberry, Unit Manager
Therese Neal, Local Team Manager
Teresa Garlington, Administrative Secretary

26

APACHE COUNTY LOCAL TEAM
Chair/Coordinator
Diana Ryan
Youth Council and Child Fatality Review Team
Members

Scott Hamblin, M.D.
Matrese Avila
Apache County Sheriff's Office Medical Examiner
Mountain Avenue Clinic
Pastor Doug Ball
Peggy Hart
New Hope Ranch
DES/Administration for
Children, Youth and Families
Criss Candelaria
Apache County Attorney’s
Chief Mike Hogan
Office
Eagar Police Department
Brad Carlyon
Sergeant Donny Jones
Apache County Attorney’s
St. Johns Police Department
Office
Mike Downs
Little Colorado Behavioral
Health Centers
Lieutenant Fred Frazier
Eagar Police Department

Vicki Lee
Parent
Detective Mike Nuttall
Springerville Police
Department

27

Jim Staffnik, Ph.D.
St. Johns Schools
Keli Sine
A.C. Tobacco Youth
Prevention Program
Chief Steve West
Springerville Police
Department
James Sielski, M.D.
North County Community
Health Center
Ann Russell
DES/Administration for
Children, Youth and Families
PJ Ray
Parent

COCHISE COUNTY LOCAL TEAM
Chair
Guery Flores, M.D.
Cochise County Medical Examiner
Coordinator
Dee Foster
Committee for the Prevention of Child Abuse
Members
Sam Caron
Psychologist

Jan Groth
Community Representative

Paula Peters
Recording Secretary

Joy Craig
Parent

Charles Irwin
Juvenile Court Judge

Shirley Pettaway
Ft. Huachuca
Army Community Services

Dean Ettinger, M.D.
Pediatrician

Maureen Kappler
Cochise County Health and
Social Services

Judith Pike
Community Representative

Vincent Fero
Arizona Department of Public
Safety

Patricia Marshall, R.N.
Community Representative

Rebecca Reyes, M.D.
Pediatrician

Todd Glauser, M.D.
Cochise County Medical
Examiner

Debbie Nishikida
DES/Administration for
Children, Youth and Families

Chris Roll
Cochise County Attorney

T.A. Goehel
Domestic Violence Specialist

Pedro Pacheco, M.D.
Pediatrician

28

Rodney Rothrock
Cochise County Sheriff’s
Office

COCONINO COUNTY LOCAL TEAM
Chair
J.R. Brown, Ed.D.
Catholic Social Services of Central and Northern Arizona
Coordinator
Charles Dean
Catholic Social Services
Members
Anita Cruz
DES/Administration for
Children, Youth and
Families
Terrence C. Hance
Coconino County Attorney

Diana Holt, P.N.P
Children’s Health Center
of Northern Arizona
Children’s Rehabilitation
Services
Dianna Hu, M.D.
Tuba City Medical Center
Indian Health Service

29

Roberta J. McVickers
Coconino County Attorney
Walter Miller
Flagstaff Police
Department

GILA COUNTY LOCAL TEAM
Chair/Coordinator
Lucille Antone-Morago
Against Abuse, Inc.
Co-Chair
Members
Ramona Cameron
DES/Administration for
Children, Youth and Families
Melinda Fairfield
Horizon Human Services
Jeanne Golden
Rim Guidance Center
Mary Gonzales
DES/Administration for
Children, Youth and Families
Cecelia Gonzales
Gila County Juvenile
Wynn Hoke
Rim Guidance Center-Payson

Billie Holiday
Horizon Human Services

Catherine Ray
Blake Foundation

Jim Katches
Tonto Apache Tribe
Probation Office

Norma Runion
Time Out Shelter

Kristin Klee
DES/Administration for
Children, Youth and Families
Sherry Martindale
Gila County Court
Appointed Special Advocate
Mary Meyers
DES/Administration for
Children, Youth and Families

30

Sergeant Tom Tieman
Payson Police Department
Detective Matt Van Camp
Payson Police Department
Cecille Masters-Webb
Gila County Court Appointed
Special Advocate
Carole White
Gila County Probation
Department

GRAHAM COUNTY LOCAL TEAM
Chair
Allen Perkins
Graham County Attorney’s Office
Coordinator
Donna Coca
Graham County Child Abuse Task Force
Members
Kenneth Angle
Graham County Attorney

Ned Rhodes
Kendall Curtis
Thatcher Police Department Thatcher Police Department

Robert Coons, D.O.
Graham County Medical
Examiner

Cathy Hays
Parents Anonymous of
Arizona

Jean Crinan
Mount Graham Safe House

Sherry Hughes
Medical/Community

Joan Crockett
Child and Family Resources,
Inc.

Neil Karnes
Graham County Health
Department

Sharon Curtis, MD
Gila Valley Clinic

Allen Perkins
Graham County Attorney’s
Office

31

Diane Thomas
Graham County Sheriff’s Office
Don Thomas
Providence Corporation
Donna Whitten
DES/Administration for
Children, Youth and Families

MARICOPA COUNTY LOCAL TEAM
Chair
Kipp Charlton, M.D.
Department of Pediatrics
Maricopa Medical Center
Coordinator
Sandy Smith
ASU Sports Medicine
Members
Eric Benjamin, M.D.
Phoenix Children’s Hospital

Sergeant Randy Force
Phoenix Police Department

Detective Tom Magazzeni
Tempe Police Department

Kathy Coffman, M.D.
St. Joseph’s Hospital

Steve Giardini
Emergency Medical Services
Mesa Fire Department

Bev Ogden
Governor's Community
Policy Office
Division for Prevention of
Family Violence

Michael Collins
Mesa Police Department
Cindy Copp
DES/Administration for
Children, Youth, and
Families
Shawn Cox
Victim Services
Ilene Dode
EMPACT, SPC
Suicide Prevention
Mark Fischione, M.D.
Maricopa Medical
Examiner’s Office

Ravi Gunawardene, M.D.
Maricopa Medical Center
Newborn Nursery
Kate Holdeman
Maricopa Medical Center
MedPro
Richard Johnson
DES/Administration for Children,
Youth, and Families
Philip Keen, M.D.
Maricopa County Medical
Examiner
Linda Kirby
Phoenix Fire Department

Timothy Flood, M.D.
Arizona Department of
Health Services

32

Deborah L. Perry
Arizona SIDS Advisory
Council
Nancy Quay
Phoenix Children’s Hospital
Rick Saylers
Phoenix Fire Department
Sergeant Tom Shields
Mesa Police Department
Zannie E. Weaver
United States Consumer
Product Safety Commission

MARICOPA COUNTY LOCAL TEAM COMMITTEES
Accident/Other
Unintentional Injuries
Chair
Kate Holdeman
Members
Tim Flood, M.D.
Zannie Weaver
Homicide
Chair
Sergeant Mike Smallman
Members
Kathy Coffman, M.D.
Michael Collins
Cindy Copp
Bev Ogden
Shawn Cox
Philip Keen, M.D.

Motor Vehicle Crashes
Chair
Nancy Quay, R.N.

SIDS/Postneonatal
Chair
Kipp Charlton, M.D.

Members
Naomi Evanishyn
Steve Fullerton
Linda Kirby
Terry Mason

Members
Sergeant Randy Force
Richard Johnson
Philip Keen, M.E.
Susan Newberry
Deborah Perry

Neonatal
Chair
Ravi Gunawardene, M.D.
Members
Sandy Smith
Other/Undetermined
Kipp Charlton, M.D.

33

Suicide
Chair
Ilene Dode
Members
Alicia Herzog, MSW
Detective Tom Magazzeni

MOHAVE COUNTY LOCAL TEAM

Co-Chairs
Vic Oyas, M.D.
Havasu Rainbow Pediatrics
Daniel Wynkoop
Psychologist
Coordinator
Leslie DeSantis
Mohave County Sheriff’s Office
Members

Robyn Atkins
Mohave County Health
Department
Sergeant Rusty Cooper
Kingman Police
Department
Lynn Crane
Parent Representative
Pat Creason
Lake Havasu Interagency

Shana Kaznoski, D.O.
Rick Lambert
Mohave County Attorney’s
Office
Patty Mead
Mohave County Health
Department
Jennifer McNally
Mohave County Health
Department

Brenda Truesdell
DES/Administration for
Children, Youth and
Families
Detective Steve Wolf
Lake Havasu Police
Department
Jace Zack
Mohave County Attorney’s
Office
Additional Members:

Craig Diehl, M.D.
Pediatrician

Donald Nelson, M.D.
Medical Examiner

Detective Chuck Falstad
Bullhead City Police
Department

Detective Steve Parker
Mohave County Sheriff’s
Office

Jody Hall
Mohave Medical
Examiner’s Office

Cynthia Ross
Mohave Medical
Examiner’s Office

Lee Jantzen
Mohave County Attorney’s
Office

Chief Sam Roundy
Colorado City Marshall’s
Office

34

B.W. (Bud) Brown
Mohave Mental Health
Clinic
Bill Johnston
Kingman Fire Department
Betty Munyon
Mohave County
Victim/Witness Program
Melissa Register
Mohave County Probation
Department

NAVAJO COUNTY LOCAL TEAM
Chair/ Coordinator
Irene Klim
Navajo County CASA Program
Members
Gail Buonviri
Office of Environmental
Health Services

Tracy Letcher
Navajo County Health
Department

Mary Flynn-Tyler
Navajo County Health
Department

Jim Currier
Navajo County Attorney’s
Office

Kateri Piecuch
DES/Administration for
Children, Youth and
Families

Janelle Virtue
Navajo County Health
Department

Detective Sgt. Tim Dixon
Holbrook Police
Department

Elaine Sawyers
Navapache Regional
Medical Center

Toni Garver
Navajo County Sheriff’s
Office, Medical Examiner
Investigator

Lieutenant Jim Sepi
Winslow Police
Department

Commander Billy Kahn Sr.
Whiteriver Police
Department

Sergeant Chad Shultz
Pinetop/Lakeside Police
Department

35

Jan Wolfe, R.N., ANE
Winslow Indian Health
Care Center

PIMA COUNTY LOCAL TEAM
Chair
William N. Marshall, Jr., M.D.
Department of Pediatrics
University of Arizona
College of Medicine
Coordinator
Lori Roehrich
University o Arizona
Members

Nancy R. Avery
Tucson Fire Department
Fire Prevention/Public
Education
Kathryn A. Bowen, M.D.
University of Arizona
College of Medicine
Sergeant Tim Brunenkant
Marana Police Department
Diane Calahan
South Arizona
Children’s Advocacy Center
Elaine Flaherty
Court Appointed Special
Advocate
Sergeant Brad Foust
Pima County Sheriff’s
Department
Bruce Geiger
Pima County Attorney's
Office

Sergeant Kevin Hall
Tucson Police Department

Patricia Nye, M.D.
Indian Health Services

Sergeant Chuck Hangartner
Tohono O’odham Police
Department

Luana Pallanes
Pima County Health
Department

Lisa Hulette
Pima County Health
Department

Bruce Parks, M.D.
Pima County Medical
Examiner

Karen Ives
Wee Care Baby Proofing and
Pool Fencing

Cindy Porterfield, M.D.
Pima County Medical
Examiner

Kathleen Mayer
Pima County Attorney’s
Office

Carol Punske, M.S.W.
DES/Administration for
Children, Youth and Families

Joan Mendelson
Private Attorney’s

Audrey Rogers
Pima County Health
Department

John Nagore
Tucson Fire Department
Brenda Neufeld, M.D.
Indian Health Services

Lori Groenewold, M.S.W.
Tucson Medical Center

36

Detective Mike Strong
Tucson Police Department

PINAL COUNTY LOCAL TEAM
Chair
Robert Babyar, M.D.
Pinal County Child Fatality Review Team
Sun life Family Health Center
Coordinator
Lucille Antone-Morago
Against Abuse, Inc.
Pinal County Child Fatality Review

Members

Mary Allen
Pinal County Health
Department

Kristy Hunt
Pinal County Attorney’s
Office

Marybeth Barr
Pinal County Attorney’s
Office

Sylvia Lafferty
Pinal County Attorney’s
Office

Mary Gonzales
DES/Administration for
Children, Youth and
Families

Rebecca Lauchner
Pinal County Juvenile
Court

David Harrowe, M.D.
Department of Public
Health Gila River Indian
Community

James McCormack
Pinal County Attorney’s
Office

37

Beverly White
DES/Administration for
Children, Youth and
Families
Chuck Teegarden
Pinal County Attorney’s
Office
Gary Vance
Coolidge Police
Department

SANTA CRUZ COUNTY LOCAL TEAM
Chair
Oscar Rojas, M.D.
Coordinator
Clarisa Read
Members
Sharon Calvert, Ph.D.
Psychologist Site

Chief John Kissenger
Nogales Police Department

Maria Pina, M.D.
Pediatrician

Martha Chase
Santa Cruz County
Attorney

Bruce Parks, M.D.
Santa Cruz County
Medical Examiner

Mark Seeger
DES/Administration for
Children, Youth, and
Families

Sheriff Tony Estrada
Santa Cruz County Sheriff
Department

Denise Pierson
Domestic Violence
Specialist

38

YAVAPAI COUNTY LOCAL TEAM
Chair
James Mick, M.D.
Child Fatality Team Chairman
Coordinator
Rebecca Ruffner
Prevent Child Abuse, Inc.
Members
Chief David Curtis
Central Yavapai Fire
District

Detective Wendy Johnson
Yavapai County Sheriff’s
Office

LaRayne Ness
Yavapai Regional Medical
Center

Karen Gere
Yavapai County Office of
the Medical Examiner

Dawn Kimsey
DES/Administration for
Children, Youth and
Families

Sally Ohanesian
Prescott Unified School
District

Sandra Halldorson
Yavapai Community
Health Services
Michael James
Court Appointed Special
Advocate

Dennis McGrane
Yavapai County
Attorney’s Office
Kathleen McLaughlin
Yavapai Family Advocacy
Center

39

Nancy Russotti
Family Resource Center
Yavapai Regional Medical
Center

YUMA COUNTY LOCAL TEAM
Co-Chair
Patti Perry, M.D.
Pediatric and Adolescent Medicine
Co-Chair
Gregory R. Warda, M.D.
Yuma Regional Medical Center Nursery
Coordinator
Maria L. André

Members
Dave Brooks
Yuma County Health
Department
James Coil
Deputy Yuma County
Attorney
Cynthia Koehler, M.D.
Yuma County Medical
Examiner

Jim Miller
SAFEKIDS
Yuma County Health
Department

Raul Vasquez
DES/Administration for
Children, Youth, and
Families

Alice Nelson
Parent/Citizen

Detective Anton Vasquez
Yuma County Sheriff’s
Office

Detective Christian Segura
Yuma Police Department

40

To obtain further information, contact:
Susan Newberry, Manager
Arizona Department of Health Services
Public Health Prevention Services
Office of Women’s and Children’s Health
Assessment and Evaluation Section
Child Fatality Review Program
150 North 18th Avenue, Suite 320
Phoenix, AZ 85007
Phone: (602) 542-1875
FAX: (602) 542-1843
E-Mail: newbers@azdhs.gov

Information about the Arizona Child Fatality Review Program may be found on the Internet
through the Arizona Department of Health Services at:
http://www.azdhs.gov/cfhs/azcf/index.htm

ARIZONA DEPARTMENT OF HEALTH SERVICES
PUBLIC HEALTH PREVENTION SERVICES
OFFICE OF WOMEN AND CHILDREN’S HEALTH
CHILD FATALITY REVIEW PROGRAM
150 North 18th Avenue, Suite 320
Phoenix, Arizona 85007
(602) 542-1875

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