SIXTEENTH ANNUAL REPORT NOVEMBER 2009 Arizona Department of Health Services Public Health Prevention Services Bureau of Women’s and Children’s Health ARIZONA CHILD FATALITY REVIEW TEAM SIXTEENTH ANNUAL REPORT NOVEMBER 2009 MISSION: To reduce preventable child fatalities through systematic, multidisciplinary, multiagency, and multi-modality 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 Janice K. Brewer, Governor, State of Arizona The Honorable Robert Burns, President, Arizona State Senate The Honorable Kirk Adams, Speaker, Arizona State House of Representatives Leadership for a Healthy Arizona Janice K. Brewer, Governor State of Arizona Will Humble, Interim 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 Bureau of Women’s and Children’s Health Child Fatality Review Program 150 North 18th Avenue, Suite 320 Phoenix, AZ 85007 (602) 364-1400 This publication can be made available in alternative formats. Please contact the Child Fatality Review Program at (602) 364-1400 (voice) or call 1-800-367-8939 (TDD). Permission to quote from or reproduce materials from this publication is granted when acknowledgment is made. TABLE OF CONTENTS ACKNOWLEDGMENTS.................................................................................................. 1 EXECUTIVE SUMMARY................................................................................................. 2 RECOMMENDATIONS ................................................................................................... 5 INTRODUCTION............................................................................................................. 8 2008 DEMOGRAPHICS.................................................................................................. 9 CHILD FATALITY REVIEW FINDINGS......................................................................... 13 PREMATURITY ............................................................................................................ 19 SUBSTANCE USE ........................................................................................................ 21 MOTOR VEHICLE CRASH FATALITIES ...................................................................... 25 DROWNINGS ............................................................................................................... 31 SUICIDES ..................................................................................................................... 35 HOMICIDES.................................................................................................................. 39 FIREARM-RELATED FATALITIES ............................................................................... 42 MALTREATMENT FATALITIES .................................................................................... 46 SUDDEN UNEXPECTED INFANT DEATHS ................................................................ 50 HOME SAFETY-RELATED DEATHS ........................................................................... 53 APPENDIX A: CHILD DEATHS BY AGE GROUP ....................................................... 56 APPENDIX B: DATA ANALYSIS METHODOLOGY...................................................... 63 APPENDIX C: ARIZONA CHILD FATALITY REVIEW TEAMS AND ARIZONA DEPARTMENT OF HEALTH SERVICES STAFF ......................................................... 64 State Child Fatality Review Team.............................................................................. 64 Apache County Child Fatality Review Team.............................................................. 65 Cochise County Child Fatality Review Team............................................................. 66 Coconino County Child Fatality Review Team........................................................... 67 Gila County Child Fatality Review Team ................................................................... 68 Graham County and Greenlee County Child Fatality Review Team .......................... 69 Maricopa County Child Fatality Review Team ........................................................... 70 Mohave County and La Paz County Child Fatality Review Team.............................. 72 Navajo County Child Fatality Review Team............................................................... 73 Pima County and Santa Cruz County Child Fatality Review Team............................ 74 Pinal County Child Fatality Review Team.................................................................. 76 Yavapai County Child Fatality Review Team............................................................. 77 Yuma County Child Fatality Review Team ................................................................ 78 Arizona Department of Health Services Bureau of Women’s and Children’s Health . 79 ACKNOWLEDGMENTS We wish to acknowledge the following individuals, businesses, and organizations for their efforts to reduce child deaths in our communities and their dedication to improving safety for all Arizona residents. • The Navajo Nation enacted booster seat legislation in 2009. • AAA Arizona champions traffic safety initiatives designed to save children's lives, including ongoing efforts to pass booster seat legislation in Arizona. • The City of Flagstaff adopted a bicycle helmet ordinance in September 2009. This ordinance will go into effect on January 1, 2010. • Bob Khan, Chief of the Phoenix Fire Department, raises awareness of child drowning prevention, reminds everyone to always keep children in sight when near water, and encourages people to learn CPR. • Patrick Kelly, Chief of the Tucson Fire Department, raises awareness of child drowning prevention and encourages people to assign a dedicated child watcher when children are near water. • Dave Munsey, KSAZ Fox 10 Meteorologist, reminds everyone to watch their children around water. • Prevent Child Abuse Arizona and Never Shake a Baby Arizona expanded education on the prevention of abusive head trauma to include more than 50 percent of birthing hospitals in Arizona. • Kiwanis of Zane Grey Country provided funding for safe cribs for infants in Gila County. 1 EXECUTIVE SUMMARY The Arizona Child Fatality Review Program was created in 1993 (A.R.S. § 36-342, 363501-4) and data collection began in 1994. Reviews of child deaths are completed by 12 local child fatality teams located throughout Arizona. The state team provides oversight to the local teams, produces an annual report summarizing review findings, and makes recommendations regarding the prevention of child deaths. These recommendations have been used to educate communities, initiate legislative action, and develop prevention programs. The Arizona Department of Health Services provides professional and administrative support to the state and local teams and analyzes data from all death reviews. In 2008, 1,038 children younger than 18 years of age died in Arizona. This was a decline from 2007, despite the fact that the population of children increased in Arizona during 2008. Arizona Child Fatality Review Teams reviewed 100 percent of child deaths and determined that 33 percent of these deaths could have been prevented (n=343). • 100 percent of homicides were preventable (n=60). • 100 percent of drownings were preventable (n=29). • 98 percent of motor vehicle crashes were preventable (n=80). • 96 percent of maltreatment deaths were preventable (n=49). For four percent of maltreatment deaths, local review teams were not able to determine preventability (n=2). • 95 percent of accidents were preventable (n=160). • 89 percent of suicides were preventable (n=31). For 11 percent of suicides, local review teams were not able to determine preventability (n=4). Deaths among all age groups declined in 2008 except for children ages one through four years. The percentage of children ages one through four years who died increased from 10 percent of all child deaths in 2007 (n=113) to 12 percent of all child deaths in 2008 (n=126). Deaths were disproportionately high among all minority children in Arizona during 2008. African American children comprised five percent of the population in Arizona, but 10 percent of the fatalities. American Indian children comprised seven percent of the population and eight percent of deaths. Asian children comprised three percent of the population and four percent of the deaths. Hispanic children accounted for 39 percent of the population and 44 percent of fatalities. Deaths due to prematurity increased among some minority groups during 2008. African American infants accounted for eight percent of deaths due to prematurity in 2007 (n=26) and 14 percent of deaths due to prematurity in 2008 (n=39). Asian infants comprised three percent of deaths due to prematurity in 2007 (n=10) and six percent of deaths due to prematurity in 2008 (n=16). 2 Deaths involving substance use (illegal drugs, prescription drugs, and/or alcohol) continued to increase in 2008. Twenty percent of all child deaths involved substance use (n=209), an increase from 2007 when substance use was involved in 17 percent of all child deaths (n=198). The rate of motor vehicle fatalities declined from 9.9 deaths per 100,000 children in 2006 to 4.7 deaths per 100,000 children in 2008. Motor vehicle crashes claimed 82 children’s lives in 2008, a decline from 2007 when 122 children died in motor vehicle crashes. Ten children died in all terrain vehicle (ATV) crashes in 2008. Ninety-eight percent of motor vehicle-related deaths were determined to have been preventable (n=80). Lack of vehicle restraints was identified as a preventable factor for 38 percent of motor vehicle crash fatalities (n=31). The rate of drowning fatalities increased from 1.4 deaths per 100,000 children in 2007 to 1.7 deaths per 100,000 children in 2008. Twenty-nine children died due to drowning during 2008, and 100 percent of these deaths were determined to have been preventable. The highest numbers of both pool drownings and open-water drownings were among children ages one through four years. The child suicide rate increased from 1.7 deaths per 100,000 children in 2007 to 2.0 deaths per 100,000 children in 2008. Thirty-five children took their own lives during 2008, and 89 percent of these deaths were determined to have been preventable (n=31). For 11 percent of suicides, local review teams were not able to determine preventability (n=4). The majority of suicides were among children ages 15 through 17 years (74 percent, n=26), and 26 percent were among children 14 years of age and younger (n=9). In 2008, the leading cause of death for children ages 15 through 17 years was firearm-related injuries (27 percent, n=37). This included firearm-related deaths due to both suicides (n=11) and homicides (n=26). Deaths due to maltreatment declined from six percent of all deaths in 2007 (n=65) to five percent of deaths in 2008 (n=51). For 23 maltreatment deaths, mandatory reporters did not notify Arizona Child Protective Services that the deaths were suspected to have been due to maltreatment even after the investigations. Substance use was involved in more than half of the child maltreatment deaths during 2008 (53 percent, n=27). Ninety-six percent of maltreatment deaths were determined to have been preventable (n=49). For four percent of maltreatment deaths, local review teams were unable to determine preventability (n=2). Ninety infants died in unsafe sleep environments in 2008, including 44 infants who were placed to sleep in adult beds and 13 who were placed to sleep on couches or chairs. Thirty-one infants were placed to sleep on their sides or stomachs. Forty-eight infants were bed sharing with adults and/or other children, and 25 of the adults who bed shared were using illegal drugs, prescription drugs, and/or alcohol. 3 Fourteen percent of all child deaths occurred in or around the home, and 89 percent of these deaths were determined to have been preventable (n=126). In 2008, 141 children died in or around the home, due to causes such as drownings, sleep-related suffocations, poisonings, falls, and fires. Seventy percent of these deaths were among children younger than five years of age (n=120). Successes Related to Previous Recommendations Deaths involving substance use In 2009, the Arizona Substance Abuse Partnership developed goals, objectives, and action steps to address prescription drug abuse among children and underage drinking. This group, which is part of the Governor’s Office of Children, Youth, and Families, is enlisting parents, communities, and pharmaceutical retailers to develop strategies to educate the public about the consequences of prescription drug abuse. The Division for Substance Abuse Policy is working with partner agencies to develop and implement a public awareness campaign regarding the proper disposal of prescription drugs. The Substance Abuse Partnership is also working to build capacity at the state level to enhance enforcement strategies to reduce underage drinking. In 2009, several communities throughout Arizona have held ‘Dump the Drugs’ events where residents drop off unneeded medications to be properly destroyed. Among many others, these included the cities of Cottonwood, Prescott, Show Low, Sierra Vista, White River, and Williams. Deaths due to motor vehicle crashes The Navajo Nation enacted legislation in 2009 which requires children less than four feet, nine inches in height to be restrained in booster seats while riding in vehicles. In September 2009, the City of Flagstaff enacted a city ordinance requiring children to wear helmets while riding bicycles within city limits. This ordinance will go into effect in January 2010. Deaths due to injuries In 2009, two First Things First Regional Councils offered grants to target injury prevention among children five years of age and younger. Unexpected infant deaths The Arizona Department of Health Services Bureau of Women’s and Children’s Health is developing infant safe sleep education, which will be distributed to child care facilities, emergency and transitional housing programs, and other agencies throughout Arizona in the Spring of 2010. The Phoenix Police Department is developing public service announcements to educate the public on infant safe sleep. These will be completed in January 2010. 4 Since 2006, the Tucson Police Department has distributed information about infant safe sleep to new parents through Tucson Medical Center’s Labor and Delivery Unit. The Arizona Unexplained Infant Death Council and the Arizona Sudden Unexpected Infant Death Investigation Task Force revised the Infant Death Investigation Checklist during 2009. Deaths due to prematurity In July 2009, the Community Health Nursing component of the High Risk Perinatal Program began including intraconception care in its activities with parents. The Arizona Department of Health Services Bureau of Women’s and Children’s Health produced new materials to address preconception health. These materials were made available to the public on the agency website. RECOMMENDATIONS Based on its review of child deaths that occurred during 2008 and in previous years, the State Child Fatality Review Team recommends specific actions to prevent future child deaths in Arizona: To Prevent Deaths due to Prematurity Recommendation to the Arizona Department of Health Services: Launch a preconception health awareness campaign which includes messaging that targets African Americans in Arizona. To Prevent Deaths due to Substance Use Recommendation to the Prescription Drug Subcommittee of the Arizona Substance Abuse Partnership: Develop culturally effective educational materials for parents/caregivers with children and adolescents regarding the safe storage and disposal of prescription medications and distribute these materials in English and Spanish to medical providers and pharmacists. To Prevent Deaths due to Motor Vehicle Crashes Recommendation to the Arizona Legislature: Enact legislation that requires the use of booster seats for children who are between five and nine years of age and are less than four feet, nine inches in height. Recommendation to the Arizona Legislature: Enact a primary seat belt law to allow law enforcement officers to ticket a driver for not wearing a seat belt. This has already been enacted in four Arizona Tribal Nations. Recommendation to the Arizona Game and Fish Department and all Arizona Law Enforcement Agencies: Increase enforcement of existing laws regarding children riding or driving all terrain/off-highway vehicles including helmet use, double riding, and licensing. 5 Recommendation to Arizona Injury Prevention Advisory Council: Convene a work group to collaborate with Arizona Game and Fish Department and local law enforcement agencies to develop statewide recommendations to promote safe all terrain/off-highway vehicle use among Arizona residents. To Prevent Drowning Deaths Recommendation to Arizona Legislature: Strengthen current legislation regarding pool fencing to require four-sided fencing with appropriate gates for all backyard pools where children live or play. Recommendation to the Drowning Prevention Coalition of Arizona: Develop strategies to reduce child drownings in spas and hot tubs. To Prevent Injury-Related Deaths among Children Recommendation to Arizona Department of Health Services: Provide local child death and injury data to Regional First Things First Councils so that they may utilize this information when developing regional grants to target injury prevention. To Prevent Deaths due to Suicide Recommendation to Arizona Department of Health Services: Develop a taskforce to explore the development and implementation of a Suicide Investigation Checklist for use by law enforcement when investigating child suicides. To Prevent Deaths due to Maltreatment Recommendation to all Arizona Law Enforcement Officers and Medical Examiners: Report every child death where child abuse or neglect is suspected to the Child Protective Services' Child Abuse Hotline promptly (1-888-SOS-CHILD), even if there are no other children living in the home. Recommendation to Arizona Department of Economic Security Division of Developmental Disabilities and its providers: Notify Child Protective Services’ Child Abuse Hotline (1-888-SOS-CHILD) promptly whenever a family refuses Developmental Disability services and neglect of a child’s medical or developmental condition is suspected. Recommendation to Arizona Department of Economic Security Division of Youth, Children, and Families: Educate staff that the decision to substantiate or unsubstantiate a maltreatment report should be based on a thorough child safety assessment and investigation and not solely on a determination of the manner of death by a medical examiner's office or findings by law enforcement. Recommendation to Arizona Department of Economic Security Division of Youth, Children, and Families and Children’s Justice Coordinators: Include information in the training of Department of Economic Security staff and other mandatory reporters regarding the increased risk for child abuse and neglect when a parent/caregiver lacks 6 the ability to appropriately care for a child, especially when the child has special needs or is medically fragile. Recommendation to the Arizona Legislature: Increase funding to the Arizona Department of Economic Security Division of Youth, Children, and Families in order to reinstate child maltreatment prevention programs and reduce the caseload of Child Protective Services Specialists to meet the existing Arizona Caseload Standards. To Prevent Sudden Unexpected Infant Deaths Recommendation to Arizona Department of Health Services: Develop an Infant Safe Sleep Message to be disseminated throughout the state. Recommendation to the Arizona Perinatal Trust: Include an evaluation of safe sleep policies for infants and safe sleep education programs for parents into its reviews and site visits of all Arizona birthing hospitals. Recommendation to the Arizona Unexplained Infant Death Council: Send a letter to all law enforcement agencies in Arizona reminding them of the statutory obligation to complete an Infant Death Investigation Checklist whenever a child younger than one year of age dies unexpectedly (A.R.S. § 36-2293). This letter should instruct law enforcement officers to promptly email or fax all completed Infant Death Investigation Checklists to the medical examiner’s office where the autopsy will be conducted. Recommendation to the Arizona Medical Association and the Arizona Osteopathic Association: Educate physicians that all sudden unexpected infant deaths should have death certificates completed by medical examiners as required by statute (A.R.S. § 36325 and A.R.S. § 11-593). Recommendation to Arizona Medical Examiners: The determination of the manner and cause of a sudden unexpected infant death should not be made without a review of the Infant Death Investigation Checklist, medical records, and an autopsy which includes radiographs, appropriate toxicology testing, and appropriate metabolic studies. 7 INTRODUCTION The Arizona Child Fatality Review Program was created in 1993 (A.R.S. § 36-342, 363501-4) and data collection began in 1994. A state team is mandated by statute to produce an annual report summarizing the findings. The state team is also authorized to study the adequacy of existing statutes, ordinances, rules, training, and services to determine what changes are needed to decrease the number of preventable child fatalities. Further, the state team is charged with educating the public regarding the number and causes of child fatalities. By statute, the state team includes representatives from: • Attorney General’s Office • Bureau of Women’s and Children’s Health in the Department of Health Services • Division of Behavioral Health in the Department of Health Services • Division of Developmental Disabilities in the Department of Economic Security • Governor’s Office for Children • Administrative Office of the Courts • Arizona Chapter of the American Academy of Pediatrics • Medical Examiner’s Office • Maternal Child Health Specialist who works with members of Tribal Nations • Private nonprofit organization of Tribal Governments • The Navajo Nation • United States Military Family Advocacy Program • Unexplained Infant Death Council • Prosecuting Attorney’s Advisory Council • Law Enforcement Officer’s Advisory Council with experience in child homicide • Association of County Health Officers • Child Advocate not employed by the state or a political subdivision of the state • A member of the public Actual reviews of child deaths are conducted by 12 local child fatality review teams. These teams are located throughout the state and must include local representatives from Child Protective Services, a county medical examiner’s office, a county health department, law enforcement, and a county prosecuting attorney’s office. Membership also includes a pediatrician or family physician, a psychiatrist or psychologist, a domestic violence specialist, and a parent. Child Fatality Review Process When a child younger than 18 years of age dies in Arizona, a copy of the death certificate is sent to the appropriate Local Child Fatality Review Team. The local team coordinator or chairperson then requests relevant documents which may include the child’s autopsy report, hospital records, Child Protective Services records, law enforcement reports, and any other information that may provide insight into the death. If the child was younger than one year of age at the time of death, the birth certificate is also reviewed. Legislation requires that hospitals and state agencies release this 8 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. According to the National Center for Child Death Review (www.childdeathreview.org), there are six steps to a quality review of a child’s death: 1. Share, question, and clarify all case information. 2. Discuss the investigation that occurred. 3. Discuss the delivery of services (to family, friends, schoolmates, community). 4. Identify risk factors (preventable factors or contributing factors). 5. Recommend systems improvements (based on any identified gaps in policy or procedure). 6. Identify and take action to implement prevention recommendations. Next, the local team completes a standardized Child Death Review Case Report (version 2.0) that includes extensive information regarding the circumstances surrounding the death. The Case Report was created by the National Center for Child Death Review. Local Child Fatality Review Teams review deaths throughout the year and submit all reviews to the Child Fatality Review Program by August 15th for inclusion in the annual report published each November. If a team has not completed a review by the August 15th deadline, the death will not be included in the published report. Staff members within the Arizona Department of Health Services Bureau of Women’s and Children’s Health enter all submitted Case Reports into a confidential database created by the National Center for Child Death Review. The Arizona Department of Health Services provides professional and administrative support for the teams, and analyses of the data are completed by staff within the Bureau of Women’s and Children’s Health. This is the sixteenth annual report issued by the Arizona Child Fatality Review Program. Each year, the state team has made recommendations regarding the prevention of child deaths. These recommendations are evidence-based and have been used to educate communities, initiate legislative action, and develop prevention programs. Because these reviews are completed by a multidisciplinary team of well-respected professionals, the team’s recommendations are often adopted. 2008 DEMOGRAPHICS During 2008, there were 1,038 fatalities among children younger than 18 years in Arizona. This was a decline from 2007 when 1,143 children died, despite the fact that the population of children increased by 1.3 percent in Arizona during 2008. Males accounted for 56 percent of deaths (n=586) and females accounted for 44 percent (n=452). More males died in each age group, a trend that has been observed in previous years. Figure 1 shows deaths among children by age group and sex. 9 Figure 1. Deaths Among Children by Age Group and Sex, Arizona 2008 (n=1,038) 250 227 Number of Deaths 200 Males (n=586) 196 Females (n=452) 150 115 96 100 89 68 58 52 35 32 50 48 22 0 Birth-27 Days 28-365 Days 1-4 Years 5-9 Years 10-14 Years 15-17 Years The largest percentage of deaths was among infants younger than 28 days (42 percent, n=423). Figure 2 shows deaths among children by age group. Figure 2. Deaths Among Children by Age Group, Arizona 2008 (n=1,038) 15-17 Years 13% (n=137) 10-14 Years 7% (n=74) Birth-27 Days 42% (n=423) 5-9 Years 6% (n= 67) 1-4 Years 12% (n=126) 28-365 Days 20% (n=211) Compared to 2007, there was an increase in the percentage of deaths among children ages one through four years in 2008. Each of the other age groups declined or 10 remained at the same percentage of total deaths. Table 1 shows deaths among children by age group for 2005 through 2008. Age Group 0-27 Days 28-365 Days 1-4 Years 5-9 Years 10-14 Years 15-17 Years Total Table 1. Deaths Among Children by Age Group, Arizona 2005-2008 2005 2006 2007 2008 434 38% 440 37% 485 42% 423 42% 233 20% 206 18% 225 20% 211 20% 130 11% 153 13% 113 10% 126 12% 85 7% 64 6% 67 6% 67 6% 86 8% 92 8% 92 8% 74 7% 180 16% 206 18% 161 14% 137 13% 1,148 1,161 1,143 1,038 Forty-four percent of child deaths in 2008 were among Hispanics (n=456), 34 percent were among Non-Hispanic Whites (n=353), 10 percent were among African Americans (n=102), eight percent were among American Indians (n=86), and four percent were among Asians (n=41). Figure 3 shows deaths among children by race/ethnicity. Figure 3. Deaths Among Children by Race/Ethnicity, Arizona 2008 (n=1,038) African American 10% (n=102) White, NonHispanic 34% (n=353) American Indian 8% (n=86) Asian 4% (n=41) Hispanic 44% (n=456) Deaths were over-represented among four racial/ethnic groups in 2008. African American children comprised five percent of the population in Arizona, but 10 percent of fatalities. American Indian children comprised seven percent of the population and eight percent of deaths. Asian children comprised three percent of the population and four percent of deaths. Hispanic children accounted for 39 percent of the population and 44 percent of child fatalities in 2008. Figure 4 shows deaths among children by race/ethnicity compared to population percentages. 11 Figure 4. Deaths Among Children by Race/Ethnicity Compared to Population, Arizona 2008 60% Percent of Deaths 2008 Fatalities 46% 44% 2008 Population 39% 40% 34% 20% 10% 5% 8% 7% 4% 3% 0% African American American Indian Asian Hispanic White, NonHispanic Compared to 2007, the percentages of African American and Asian child deaths increased during 2008. For all other races/ethnicities, the number of child deaths declined. Table 2 shows deaths among children by race/ethnicity for 2006 through 2008. Table 2. Deaths Among Children by Race/Ethnicity, Arizona 2006-2008 Race/Ethnicity 2006 2007 2008 African American 102 9% 75 7% 102 American Indian 111 10% 104 9% 86 Asian 19 2% 26 2% 41 Hispanic 505 42% 529 46% 456 White, Non424 37% 409 36% 353 Hispanic Total 1,161 1,143 1,038 10% 8% 4% 44% 34% Table 3 shows deaths among children by county of residence. There were increases in the percentages of deaths among children who resided in Apache, Pima, and Yuma Counties in 2008. The population of children increased slightly in each of these counties from 2007 to 2008 (Apache, less than one percent; Pima and Yuma, one percent each). The percentage of children who died in 2008 declined in Maricopa and Mohave Counties, even though the population of children in those counties increased slightly (one percent each). The percentage of child deaths in Pinal County declined in 2008, although the population of children in this county increased 11 percent. 12 Table 3. Deaths Among Children by County of Residence, Arizona 2007-2008 2007 (n=1,143) 2008 (n=1,038) County Number Percent Number Percent Apache 13 1% 20 2% Cochise 27 2% 24 2% Coconino 25 2% 21 2% Gila 17 1% 15 1% Graham 12 1% 11 1% Greenlee 0 -1 -La Paz 1 <1% 5 <1% Maricopa 648 57% 577 56% Mohave 27 2% 11 1% Navajo 39 3% 30 3% Pima 148 13% 165 16% Pinal 64 6% 52 5% Santa Cruz 6 <1% 6 <1% Yavapai 28 2% 17 2% Yuma 35 3% 39 4% Outside Arizona 53 5% 44 4% Total 1,143 1,038 CHILD FATALITY REVIEW FINDINGS Cause and Manner of Child Fatalities Cause of death refers to the injury or medical condition that resulted in death (e.g. firearm-related injury, pneumonia, cancer). Manner of death is not the same as cause of death, but specifically refers to the intentionality of the cause. For example, if the cause of death was a firearm-related injury, then the manner of death may have been intentional or unintentional. If it was intentional, then the manner of death was suicide or homicide. If it was unintentional, then the manner of death was an accident. In some cases, there was insufficient information to determine the manner of death, even though the cause was known. It may not have been clear that a firearm death was due to an accident, suicide, or homicide, and in these cases, the manner of death was listed as undetermined. Manners of death include: • • • • • natural (e.g., cancer) accident (e.g., unintentional car crash) homicide (e.g., intentional assault) suicide (e.g., self-inflicted intentional firearm injury) undetermined. In addition to reviewing medical examiner reports, Child Fatality Review Teams also review records from hospitals, emergency departments, law enforcement, Child Protective Services, and other sources. As a result of this comprehensive, 13 multidisciplinary approach, the teams’ determinations of cause and manner sometimes differ from those recorded on the death certificates. Natural deaths accounted for 68 percent of all child deaths during 2008 (n=702), 16 percent of child deaths were accidents (n=168), six percent were homicides (n=60), three percent were suicides (n=35), and seven percent were of undetermined manner (n=73). Figure 5 shows deaths among children by manner. Figure 5. Deaths Among Children by Manner, Arizona 2008 (n=1,038) Suicide 3% (n=35) Undetermined 7% (n=73) Homicide 6% (n=60) Accident 16% (n=168) Natural 68% (n=702) The distribution of manner of death varied by age group. Deaths among infants were primarily due to natural causes, while accidental deaths were more common among older children. Suicide occurred only among the two older age groups, and homicide occurred in all age groups. Figure 6 shows manner of child deaths by age group. 14 Figure 6. Manner of Child Deaths by Age Group, Arizona 2008 (n=1,038) 100% Percent of Deaths 80% Undetermined Suicide 60% Homicide 40% Accident Natural 20% 0% <28 Days 28-365 Days 1-4 Years 5-9 Years 10-14 Years 15-17 Years The percentage of deaths due to accidents declined during 2008, and the percentages of natural deaths and undetermined deaths increased. Table 4 shows deaths among children by manner for 2006 through 2008. Table 4. Deaths Among Children Birth Through 17 Years by Manner, Arizona 2006-2008 Manner 2006 2007 2008 Natural 743 64% 769 67% 702 Accident 270 23% 227 20% 168 Undetermined 37 3% 53 5% 73 Homicide 63 5% 66 6% 60 Suicide 48 4% 28 2% 35 Total 1,161 1,143 1,038 68% 16% 7% 6% 3% There were 420 deaths due to medical conditions in 2008, 271 deaths due to prematurity, and 20 deaths due to Sudden Infant Death Syndrome (SIDS). There were 82 motor vehicle-related deaths and 29 drownings. There were nine deaths due to exposure in 2008. Four of these children died of hyperthermia while crossing the Mexico-United States border, and four children were left in vehicles and died of hyperthermia. One child died of hypothermia. Table 5 shows deaths among children by cause. 15 Table 5. Deaths among Children Birth Through 17 Years by Cause and Manner, Arizona 2008 (n=1,038) Cause Accident Homicide Suicide Natural Undetermined Medical* 2 418 Prematurity 271 Motor vehicle crash 82 Undetermined 59 Firearm injury 2 33 14 Drowning 28 1 Suffocation 18 1 2 Hanging 2 18 1 SIDS 13 7 Blunt force trauma 16 Other 7 7 Poisoning 9 3 2 Fall/crush 9 Exposure 7 2 Fire/burn 4 Total 168 60 35 702 73 *Excluding SIDS and prematurity Total 420 271 82 59 49 29 21 21 20 16 14 14 9 9 4 1,038 The percentages of deaths due to drownings and firearm injuries increased, and the percentages of child deaths due to motor vehicle crashes, poisoning, and prematurity declined. Table 6 shows deaths among children by cause for 2007 and 2008. Table 6. Deaths Among Children Birth Through 17 Years by Cause, Arizona 2007-2008 Cause 2007 2008 Medical* 420 37% 420 40% Prematurity 321 28% 271 26% Motor vehicle crash 122 11% 82 8% Undetermined 34 3% 59 6% Firearm injury 48 4% 49 5% Drowning 23 2% 29 3% SIDS 37 3% 20 2% Suffocation 27 2% 21 2% Hanging 13 1% 21 2% Other 33 3% 14 1% Poisoning 24 2% 14 1% Blunt force trauma 18 1% 16 1% Fall/crush 9 1% 9 1% Exposure 8 1% 9 1% Fire/burn 6 1% 4 1% Total 1,143 1,038 *Excluding SIDS and prematurity Preventability In Arizona, the child fatality review process is grounded in the principles of public health and is focused on the prevention of all child deaths. Child Fatality Review Teams consider a child’s death preventable if something could have been done (by an 16 individual such as the caregiver or supervisor, or by the community as a whole) that could have prevented the death. Child Fatality Review Teams determined that 343 child deaths in 2008 were preventable (33 percent). This was a decline from 2007, when 34 percent of deaths were determined to have been preventable (n=390). Figure 7 shows deaths among children by preventability. Figure 7. Deaths Among Children by Preventability, Arizona 2008 (n=1,038) Undetermined 4% (n=38) Probably Preventable 33% (n=343) Probably Not Preventable 63% (n=657) One hundred percent of homicides were preventable (n=60), 95 percent of accidental deaths were preventable (n=160), and 89 percent of suicides were preventable (n-31). For 11 percent of suicides, local teams did not have enough information to determine preventability. Five percent of natural deaths were determined to have been preventable (n=32). Figure 8 shows preventable deaths by manner. 17 Figure 8. Preventable Deaths Among Children by Manner, Arizona 2008 (n=343) 100% 95% 100% Accident (n=160) Homicide (n=60) 89% 82% Percent of Deaths 80% 60% 40% 20% 5% 0% Natural (n=32) Undetermined (n=60) Suicide (n=31) Preventability also varied by age group. Children younger than one year of age had the lowest percentage of preventable deaths (18 percent, n=115). The highest percentage of preventable deaths was among children ages 15 through 17 years (77 percent, n=105). Figure 9 shows preventable deaths among children by age group. Figure 9. Preventable Deaths Among Children by Age Group, Arizona 2008 (n=343) Perc ent of Deaths 100% 77% 80% 55% 60% 45% 46% 36% 40% 20% 5% 0% <28 Days (n=21) 28-365 Days (n=94) 1-4 Years (n=58) 5-9 Years (n=24) 10-14 Years (n=41) 15-17 Years (n=105) During the review of each child’s death, teams identify factors believed to have contributed to the death. Although the presence of a contributing factor typically led to the determination that a death was preventable, this was not always the case. For example, the team might have concluded that an unsafe sleep environment (e.g. infant 18 left sleeping on a couch) was a contributing factor in an unexpected infant death. However, the team may not have had sufficient information (e.g. autopsy report, adequate scene investigation) to determine that the death could have been prevented. PREMATURITY Local teams consider a child’s cause of death to be prematurity if the infant was less than 38 weeks gestation and had no other underlying cause of death. Infants with congenital anomalies not compatible with life are not included in the prematurity category. In 2008, there were 271 deaths due to prematurity, which accounted for 26 percent of all child deaths. There were 321 deaths due to prematurity in 2007 (28 percent of all deaths). The rate of deaths due to prematurity in 2008 was 2.7 deaths per 1,000 live births. This was a decline from 2007 when the rate was 3.1 deaths per 1,000 live births. Figure 10 shows the rates of child deaths due to prematurity from 2005 through 2008. Figure 10. Rate of Child Deaths due to Prematurity (per 1,000 live births), Arizona 2005-2008 3.2 Deaths per 1,000 live births 3.1 3.0 3.0 2.9 2.8 2.7 2.6 2005 2006 2007 2008 In 2008, 58 percent of the premature infants who died were males (n=158) and 42 percent were females (n=113). Nearly half of the premature infants who died were Hispanic (46 percent, n=125), 29 percent were White, Non-Hispanic (n=79), 14 percent were African American (n=39), six percent were Asian (n=16), and four percent were American Indian (n=12). In 46 cases, at least one of the parents was a first generation immigrant, including four families from African countries and two from Asian countries. 19 The percentage of African American infants who died of prematurity increased from eight percent in 2007 (n=26) to 14 percent in 2008 (n=39). In 2007, the percentage of Asian children who died of prematurity was three percent (n=10). Figure 11 shows deaths due to prematurity by race/ethnicity for 2007 and 2008. Figure 11. Child Deaths due to Prematurity by Race/Ethnicity, Arizona 2007-2008 60% 2007 Percent of Deaths 5 0% 50% 2008 46% 40% 33% 29% 30% 20% 14% 10% 8% 5% 4% 6% 3% 0% African American American Indian As ian His panic White , NonHispanic In 2008, the majority of prematurity-related deaths were among infants who were 21 through 24 weeks gestational age (60 percent, n=162), followed by infants who were 25 through 37 weeks gestational age (21 percent, n=56). There were 49 infants who were 20 weeks or less (18 percent). For four infants, gestational age was unknown. There were 63 deaths due to prematurity among infants in multiple births (52 were twins, 10 were triplets, and one was a quintuplet). For 10 percent of deaths due to prematurity, prenatal care information was unknown to review teams (n=28). For 11 percent of the deaths, the mother reported that she did not receive any prenatal care (n=29). Seventy-nine percent of mothers started prenatal care within the first trimester (n=214). For almost half of the prematurity deaths, the mother was 20 through 29 years of age at the time of the birth (44 percent, n=119). Fourteen percent of the mothers were 19 years of age and younger (n=38), 34 percent were 30 through 39 years of age, and three percent of mothers were 40 years of age and older (n=9). Forty-seven percent of mothers whose infants died of prematurity were insured by the Arizona Health Care Cost Containment System (AHCCCS) (n=128). Ten percent of mothers had less than a high school education (n=27), 47 percent completed high 20 school (n=128), and 25 percent completed at least some college (n=69). For eight percent of mothers, educational status was unknown (n=23). For 85 percent of deaths due to prematurity, the mothers experienced pregnancy- or birth-related complications which may have contributed to the death (n=231), including 89 mothers who experienced preterm labor. Eleven mothers were known to have had non-gestational diabetes. Four percent of mothers reported using illegal drugs during pregnancy (n=11), and two percent reported heavy alcohol use (n=5). Nine percent of mothers reported smoking during pregnancy (n=24). Table 7 shows risk factors for prematurity deaths. Table 7. Risk Factors for Prematurity Deaths, Arizona 2008 Factor* Number Percent Mother had pregnancy or birth complications 231 85% Multiple birth 63 23% Smoking during pregnancy 24 9% Drugs and/or alcohol during pregnancy 16 6% Mother had chronic illness (e.g. diabetes) 13 5% *More than one factor may have been identified for each death SUBSTANCE USE Substance use (including illegal drugs, prescription drugs, and/or alcohol) was involved in 209 child deaths in Arizona during 2008, which accounted for 20 percent of all child deaths. In 2007, substance use was involved in 17 percent of all child deaths (n=198). In 2008, substance use contributed to 28 percent of accidents (n=59), 28 percent of natural deaths (n=59), 19 percent of deaths of undetermined manner (n=40), 16 percent of homicides (n=33), and nine percent of suicides (n=18). Figure 12 shows child deaths involving drugs and/or alcohol by manner. 21 Figure 12. Child Deaths Involving Drugs and/or Alcohol by Manner, Arizona 2008 (n=209) Undetermined 19% (n=40) Natural 29% (n=59) Suicide 9% (n=18) Homicide 16% (n=33) Accident 28% (n=59) Firearms accounted for 15 percent (n=32) of deaths involving drugs and/or alcohol, and motor vehicle crashes accounted for 14 percent of child deaths (n=30), including 21 children who died in crashes involving substance-impaired drivers. Sixteen deaths were due to prematurity (typically substance exposed preterm newborns). Table 8 shows child deaths involving drugs and/or alcohol by cause and manner in 2008. 22 Table 8. Child Deaths Involving Drugs and/or Alcohol by Cause and Manner, Arizona 2008 (n=209) Cause Accident Homicide Suicide Natural Undetermined Medical* 36 1 Firearm injury 23 9 Undetermined 1 30 Motor vehicle 30 crash Prematurity 16 Poisoning 9 2 2 SIDS 6 4 Suffocation 7 1 Drowning 7 1 Hanging 7 Other injury 1 5 Exposure 2 2 Blunt force trauma 4 Fire/burn 2 Fall/crush 1 Total 59 33 18 59 40 *Excluding SIDS and prematurity Total 37 32 31 30 16 13 10 8 8 7 6 4 4 2 1 209 Alcohol was involved in 76 child deaths in 2008 and 80 deaths in 2007; marijuana was involved in 57 deaths in 2008 and 76 deaths in 2007; methamphetamine was involved in 39 deaths in 2008 and 48 deaths in 2007; cocaine was involved in 21 deaths in 2008 and 31 deaths in 2007; and opiates were involved in 18 deaths in 2008 and 16 deaths in 2007. Table 9 shows substances involved in child deaths for 2007 and 2008. Table 9. Substances Involved in Deaths Among Children, Arizona 2007-2008 Substance* 2007 2008 Alcohol 80 7% 76 Marijuana 76 7% 57 Methamphetamine 48 4% 39 Cocaine 31 3% 21 Opiates 16 1% 18 *More than one substance could have been involved in a single death 7% 5% 4% 2% 2% Drugs and/or alcohol were determined to have been involved in child deaths among males and females in all age groups. Males of all ages accounted for 56 percent of all substance use-related deaths (n=117). Figure 13 shows child deaths involving substance use by sex and age group. 23 Figure 13. Child Deaths Involving Substance Use by Sex and Age Group, Arizona 2008 (n=209) 50 48 Females (n=92) Number of Deaths Males (n=117) 40 29 30 25 21 20 18 15 11 13 12 7 10 5 5 0 <28 Days 28-365 Days 1-4 Years 5-9 Years 10-14 Years 15-17 Years The individual who used the substance may have been the parent, child, an acquaintance of the child or family, a relative, or a stranger. For example, if the child was a passenger in a car hit by an intoxicated driver of another car, then the individual who used the substance was classified as “stranger.” In some deaths, more than one individual may have been using drugs and/or alcohol. For 73 deaths in 2008, the user was the parent, and for 43 deaths, the user was the child. In some deaths, more than one individual may have been using drugs and/or alcohol. Figure 14 shows child deaths involving drugs and/or alcohol by substance user for 2006 through 2008. 24 Figure 14. Child Deaths Involving Drugs and/or Alcohol by Substance User, Arizona 2006-2008 90 85 80 2006 73 2007 Number of Deaths 70 60 2008 58 51 50 43 40 30 29 22 16 20 11 10 8 4 2 7 10 6 8 10 3 0 Child Parent Acquaintance Acquaintance of child of parent Stranger Other relative MOTOR VEHICLE CRASH FATALITIES In 2008, 82 children died as the result of motor vehicle crashes in Arizona (eight percent of child fatalities). In 2007, 122 children died as the result of motor vehicle crashes in Arizona (11 percent of child fatalities). The rate of motor vehicle fatalities in 2008 was 4.7 deaths per 100,000 children, a decline from 2007 when the motor vehicle fatality rate was 7.2 deaths per 100,000 children. Figure 15 shows the rates of child deaths due to motor vehicle crashes from 2005 through 2008. 25 Figure 15. Rate of Child Deaths due to Motor Vehicle Crashes (per 100,000 children), Arizona 2005-2008 Deaths per 100,000 c hildren 12 9.9 10 8.4 8 7.2 6 4.7 4 2005 2006 2007 2008 The majority of motor vehicle-related deaths in 2008 were among males (52 percent, n=63) and 48 percent were among females (n=59). Forty-four percent of the children who died were Hispanic (n=36), 32 percent were Non-Hispanic White (n=26), 18 percent were American Indian (n=15), and six percent were other races/ethnicities (n=5). Figure 16 shows motor vehicle-related deaths by race/ethnicity. 26 Figure 16. Motor Vehicle-Related Deaths Among Children by Race/Ethnicity, Arizona 2008 (n=82) Other 6% (n=5) American Indian 18% (n=15) White, NonHispanic 32% (n=26) Hispanic 44% (n=36) The distribution of motor vehicle-related deaths by race/ethnicity was different in 2007 when 12 percent of the deaths were among American Indian children, 42 percent of the deaths were among Hispanics, 40 percent were among Non-Hispanic Whites, and five percent were among other races/ethnicities. Table 10 shows motor vehicle-related deaths among children by race/ethnicity for 2006 through 2008. Table 10. Motor Vehicle-Related Deaths Among Children by Race/Ethnicity, Arizona 2006-2008 Race/Ethnicity 2006 2007 2008 American Indian 14 11% 20 12% 15 18% Hispanic 56 46% 69 42% 36 44% White, Non45 37% 66 40% 26 32% Hispanic Other 7 6% 9 5% 5 6% Total 122 164 82 The largest percentage of motor vehicle-related deaths was among children ages 15 through 17 years (43 percent, n=35), followed by children ages 10 through 14 years (23 percent, n=19). Figure 17 shows motor vehicle-related deaths by age group. 27 Figure 17. Motor Vehicle-Related Deaths Among Children by Age Group, Arizona 2008 (n=82) <1 Year 10% (n=8) 1-4 Years 12% (n= 10) 15-17 Years 43% (n=35) 5-9 Years 12% (n=10) 10-14 Years 23% (n=19) Of the 72 children who died in non-all terrain vehicle crashes, 42 were passengers of motor vehicles, eight were drivers, 17 were pedestrians (16 percent), and two were on bicycles. Five child pedestrians were killed due to vehicle backovers. All of these children were struck by sport utility vehicles or trucks, and all were two years of age and younger. For three children who died in motor vehicle crashes, their exact locations were unknown. Figure 18 shows motor vehicle crashes by age group and location. This figure excludes deaths due to all terrain vehicle crashes. 28 Figure 18. Motor Vehicle-Related Deaths Among Children by Age Group and Location (Excluding ATV Crashes), Arizona 2008 (n=72) 20 Driver (n=8) 17 Passenger (n=42) Number of Deaths Pedestrian (n=17) On bicycle (n=2) Unknown (n=3) 10 10 8 8 8 5 4 3 2 2 2 1 1 1 0 <1 Year 1-4 Years 5-9 Years 10-14 Years 15-17 Years Among the total 42 passengers, 17 were located in the back seat, 17 were in the front seat, two were riding in truck beds, and four were in other or unknown locations. Two children died as a result of in utero trauma during motor vehicle crashes in 2008. Of the 17 children who were in front seats, seven were 13 years of age and younger. Thirty-eight percent of children were not properly restrained in vehicles (n=31). Nearly half of all children who were not properly restrained were ages 15 through 17 years (48 percent, n=15). Figure 19 shows lack of vehicle restraints by age group. 29 Figure 19. Motor Vehicle Crash Deaths with Improperly Restrained Children by Age Group, Arizona 2008 (n=31) <1 Year 16% (n=5) 1-4 Years 3% (n=1) 15-17 Years 48% (n=15) 5-9 Years 13% (n=4) 10-14 Years 19% (n=6) Ninety-eight percent of all motor vehicle crash fatalities during 2008 were determined to have been preventable (n=80). Lack of vehicle restraints was identified as a preventable factor for 31 motor vehicle crash fatalities among children (38 percent). Twenty-seven children died in crashes involving substance-impaired drivers, and for three of these deaths, the impaired driver was the child who died. For 23 deaths, excessive speed was a contributing factor (28 percent). Table 11 shows preventable factors for motor vehicle crash deaths among children. This table includes factors that were identified for the 10 deaths due to ATV crashes. Table 11. Preventable Factors for Motor Vehicle-Related Deaths Among Children, Arizona 2008 Factor* Number Percent Lack of vehicle restraint 31 38% Drugs and/or alcohol 27 33% Excessive driving speed 23 28% Reckless driving 20 24% Driver inexperience 17 21% Driver distraction 11 13% Lack of helmet 9 11% Red light running 6 7% *More than one factor may have been identified for each death All Terrain Vehicle Crashes Ten children died in all terrain vehicle (ATV) crashes. Two children were five through nine years of age and eight children were 10 years of age and older. Five of the children who died in ATV crashes were drivers, four were passengers, and one child’s 30 location was unknown to the review team. Two of the children who were driving were younger than 16 years of age. Eight of the ATV crashes were single vehicle, and two crashes involved collisions with other vehicles. Four of the single ATV crashes were rollovers. Figure 20 shows ATV crash deaths by age group and location. Figure 20. All Terrain Vehicle Crash Deaths Among Children by Age Group and Location, Arizona 2008 (n=10) 4 Driver (n=5) Passenger (n=4) Number of Deaths 3 3 Unknown (n=1) 2 2 2 1 1 1 1 0 5-9 Years 10-14 Years 15-17 Years Six children who died in ATV crashes were not wearing helmets. Three ATV drivers were known to have been travelling at excessive or unsafe speeds, and three were known to have been driving recklessly. In three cases, review teams identified drivers’ inexperience as contributing to the deaths. Two of the ATV crash deaths involved drugs and/or alcohol. DROWNINGS In 2008, there were 29 deaths among children due to drownings, which accounted for three percent of all child deaths. In 2007, there were 23 drowning fatalities among children (two percent of all child deaths). The rate of drowning fatalities in 2008 was 1.7 deaths per 100,000 children. This was an increase from 2007 when the drowning rate was 1.4 deaths per 100,000 children. Figure 21 shows the rates of child deaths due to drowning from 2005 through 2008. 31 Figure 21. Rate of Child Deaths due to Drowning (per 100,000 children), Arizona 2005-2008 Deaths per 100,000 children 2.5 2.2 1.9 2 1.7 1.5 1.4 1 2005 2006 2007 2008 Seventy-two percent of drowning deaths in 2008 were among males (n=21), and 28 percent were among females (n=8). Fifty-two percent of children who drowned were Hispanic (n=15), 28 percent were White, Non-Hispanic (n=8), 14 percent were American Indian (n=4), and seven percent were African American (n=2). Eighty-seven percent of the drownings were among children ages one through four years (n=25), seven percent were among children ages five through nine years (n=2), three percent were among children ages 15 through 17 years (n=1), and three percent were among infants younger than one year of age (n=1). Figure 22 shows drowning deaths by age group. 32 Figure 22. Drowning Deaths Among Children by Age Group, Arizona 2008 (n=29) 15-17 Years 3% (n=1) 5-9 Years 7% (n=2) <1 Year 3% (n=1) 1-4 Years 87% (n=25) Consistently since 2005, the largest percentage of drownings has been among children ages one through four years. The percentage of deaths in this age group increased from 53 percent in 2007 (n=12) to 87 percent in 2008 (n=25). Table 12 shows drownings among children by age for 2005 through 2008. Table 12. Drowning Deaths Among Children by Age Group, Arizona 2005-2008 Age Group 2005 2006 2007 2008 0-27 Days 1 3% 0 0% 1 4% 0 0% 28-365 Days 1 3% 2 10% 5 22% 1 3% 1-4 Years 20 57% 16 51% 12 53% 25 87% 5-9 Years 6 17% 4 13% 4 17% 2 7% 10-14 Years 1 3% 3 10% 1 4% 0 0% 15-17 Years 6 17% 6 16% 0 0% 1 3% Total 35 31 23 29 In 2008, 13 drowning fatalities occurred in pools (all were in ground), seven occurred in open water, three occurred in bathtubs, two occurred in hot tubs or spas, and one occurred in a bucket. Among the seven open water drownings, five were in canals, one was in a lake, and one was in a river. Table 13 shows drowning fatalities by location. 33 Table 13. Location of Child Drowning Fatalities, Arizona 2008 (n=29) Location Number Percent In ground pool 13 45% Canal 5 17% Other types of water 3 10% Bathtub 3 10% River/lake 2 7% Hot tub/spa 2 7% Bucket 1 3% Total 29 The highest number of pool drownings were among children ages one through four years (48 percent, n=14), and five of the seven open water drownings were also among children ages one through four years. Figure 23 shows drowning location by age group. Figure 23. Drowning Deaths Among Children by Age Group and Location, Arizona 2008 (n=29) 16 14 Pool, hot tub, spa (n=15) Number of Deaths 14 Bathtub (n=3) 12 Open Water (n=7) 10 Bucket (n=1) Other (n=3) 8 6 5 4 3 2 3 1 1 1 1 0 <1 Year 1-4 Years 5-9 Years 10-14 Years 15-17 Years One hundred percent of child drownings were identified as preventable (n=29). Lack of supervision was the most commonly identified preventable factor in child drowning fatalities (86 percent, n=25), followed by access to water (72 percent, n=21). Table 14 shows preventable factors for child drownings in Arizona during 2008. Table 14. Preventable Factors for Child Drownings, Arizona 2008 Factor* Number Percent Lack of supervision 25 86% Access to water 21 72% Drugs and/or alcohol 7 24% *More than one factor may have been identified for each death 34 SUICIDES In 2008, there were 35 suicides among children in Arizona, which accounted for three percent of all child deaths. In 2007, suicide accounted for two percent of all child deaths (n=28). The child suicide rate in 2008 was 2.0 deaths per 100,000 children. This was an increase from 2007 when the suicide rate was 1.7 deaths per 100,000 children. Figure 24 shows the rates of child suicides from 2005 through 2008. Figure 24. Rate of Child Deaths due to Suicide (per 100,000 children), Arizona 2005-2008 Deaths per 100,000 children 3 2.9 2.5 2.2 2 2 1.7 1.5 1 2005 2006 2007 2008 Seventy-one percent of the children who committed suicide during 2008 were males (n=25) and 29 percent were females (n=10). Fifty-one percent were Non-Hispanic White (n=18), 26 percent of suicides were Hispanic (n=9), 17 percent were American Indian (n=6), and six percent were other races/ethnicities (n=2). The distribution of suicides by race/ethnicity was different from 2007 when the largest percentage of suicides was among Hispanic children (54 percent, n=15). Table 15 shows suicides among children by race/ethnicity for 2006 through 2008. Table 15. Suicides Among Children by Race/Ethnicity, Arizona 2006-2008 Race/Ethnicity 2006 2007 2008 American Indian 9 19% 4 14% 6 Hispanic 13 27% 15 54% 9 White, Non24 50% 8 29% 18 Hispanic Other 2 4% 1 3% 2 Total 48 28 35 17% 26% 51% 6% In 2008, the majority of suicides were among children ages 15 through 17 years (74 percent, n=26), but 26 percent were among children 14 years of age and younger (n=9). 35 The youngest child who committed suicide in 2008 was 11 years old. Figure 25 shows suicides among children by age group. Figure 25. Suicides Among Children by Age Group, Arizona 2008 (n=35) 10-14 Years 26% (n=9) 15-17 Years 74% (n=26) The distribution of suicides by age group has remained consistent since 2006. Table 16 shows suicides among children by age group for 2005 through 2008. Age Group <10 Years 10-14 Years 15-17 Years Total Table 16. Suicides Among Children by Age Group, Arizona 2005-2008 2005 2006 2007 2008 0 0% 1 2% 0 0% 0 0% 13 36% 11 23% 7 25% 9 26% 23 64% 36 75% 21 75% 26 74% 36 48 28 35 Hangings accounted for 51 percent of child suicides in Arizona during 2008 (n=18) and firearm injuries accounted for 40 percent (n=14). The objects used in hanging suicides were ropes, electrical cords, belts, and neckties. Nine percent of child suicides were caused by poisonings (n=3). Figure 26 shows suicides among children by cause of death and age group. 36 Figure 26. Suicides Among Children by Cause of Death and Age Group, Arizona 2008 (n=35) 15 13 Number of Deaths Firearm (n=14) 11 Hanging (n=18) 10 Poisoning (n=3) 5 5 3 2 1 0 10-14 Years (n=9) 15-17 Years (n=26) The distribution of cause of death varied by the sex of the child. As has been observed in previous years, males were more likely to have used firearms to commit suicide. For hangings and poisonings, the distributions between males and females were less disparate. Figure 27 shows suicides among children by cause of death and sex. Figure 27. Suicides Among Children by Cause of Death and Sex, Arizona 2008 (n=35) 15 Number of Deaths 13 Females (n=10) 10 10 Males (n=25) 8 5 2 1 1 0 Firearm (n=14) Hanging (n=18) Poisoning (n=3) Identification of children at risk for suicide can be difficult, and warning signs are not always recognized or taken seriously. Fifteen children who took their own lives in 2008 were known to have talked about suicide to others (43 percent), 11 children were known to have made prior suicide threats (31 percent), and five children had made prior suicide attempts (14 percent). Only five children were known to have been on medication for mental illness at the time of their deaths (14 percent). Ten children who committed 37 suicide were known to have received prior mental health services (29 percent), but only six children were known to have been receiving mental health services at the time of their deaths (17 percent). Review teams were able to identify several factors that may have contributed to the children’s despondency prior to the suicides. The most commonly identified issue was family discord, which was identified in 13 suicides (37 percent). Table 17 shows factors that may have contributed to the child’s despondency prior to suicide. For nearly half of all suicides, important information regarding risk factors was unknown to review teams, even after review of law enforcement records. For example, in 49 percent of suicides, prior mental health services were unknown (n=17). For 43 percent of suicides, it was unknown if the child was receiving mental health services at the time of death (n=15). Improvements in the investigations of child suicides may increase review teams’ abilities to identify risk factors. Table 17. Factors That May Have Contributed to the Child’s Despondency Prior to Suicide, Arizona 2008 Factor* Number Percent Family discord 13 37% History of drug and/or alcohol use 9 26% Recent breakup with boyfriend or girlfriend 9 26% Failure at school 7 20% Recent argument with boyfriend or girlfriend 6 17% Recent argument with parents/caregivers 6 17% Recent problems with the law 4 11% Recent suicide by friend or relative 2 6% Victim of bullying 2 6% *More than one factor may have been identified for each death Eighty-nine percent of child suicides were determined to have been preventable (n=31). For 11 percent of suicides, local review teams were not able to determine preventability (n=4). Access to firearms was the most commonly identified preventable factor (37 percent, n=13), followed by drugs and/or alcohol (26 percent, n=9). Table 18 shows preventable factors for child suicides. Table 18. Preventable Factors for Child Suicides, Arizona 2008 Factor* Number Percent Access to firearms 13 37% Drugs and/or alcohol 9 26% Lack of mental health treatment** 8 23% *More than one factor may have been identified for each death **For 49 percent of suicides, it was unknown if the child had ever received mental health services (n=17). For 43 percent of suicides, it was unknown if the child was receiving mental health services at the time of death (n=15). 38 HOMICIDES Sixty children were victims of homicide in Arizona during 2008, compared to 66 in 2007. Homicide accounted for six percent of all child deaths in Arizona during 2007 and 2008. The child homicide rate in 2008 was 3.5 deaths per 100,000 children. This was a decline from 2007 when the homicide rate was 3.9 deaths per 100,000 children. Figure 28 shows the rates of child homicides from 2005 through 2008. Figure 28. Rate of Child Deaths due to Homicide (per 100,000 children), Arizona 2005-2008 4 Deaths per 100,000 children 3.9 3.8 3.8 3.6 3.6 3.5 3.4 3.2 2005 2006 2007 2008 Sixty-seven percent of homicide victims in 2008 were males (n=40) and 33 percent were females (n=20). More than half of child homicides were among Hispanics (53 percent, n=32), 22 percent were among White Non-Hispanics (n=13), 12 percent were among American Indians (n=7), 10 percent were among African Americans (n=6), and less than one percent were among Asian children (n=2). Children ages 15 through 17 years accounted for 50 percent of homicides (n=30). Twenty-five percent of homicides were among children younger than one year of age (n=15). Figure 29 shows homicides among children by age group. 39 Figure 29. Homicides Among Children by Age Group, Arizona 2008 (n=60) <1 Year 25% (n=15) 15-17 Years 50% (n=30) 1-4 Years 12% (n=7) 5-9 Years 3% (n=2) 10-14 Years 10% (n=6) Compared to 2007, the greatest increase in homicides was observed among children ages 15 through 17 years (from 39 percent in 2007 to 50 percent in 2008). Table 19 shows homicides among children by age group for 2005 through 2008. Table 19. Homicides Among Children by Age Group, Arizona 2005-2008 Age Group 2005 2006 2007 2008 0-27 Days 3 5% 4 6% 3 4% 1 2% 28-365 Days 9 15% 12 19% 13 20% 14 23% 1-4 Years 13 22% 11 17% 12 18% 7 12% 5-9 Years 3 5% 0 0% 7 11% 2 3% 10-14 Years 5 9% 7 11% 5 8% 6 10% 15-17 Years 25 43% 29 47% 26 39% 30 50% Total 58 63 66 60 In 2008, firearms were the leading cause of death among child homicides (55 percent, n=33), followed by blunt force trauma (27 percent, n=16). Figure 30 shows homicides among children by cause of death. 40 Figure 30. Homicides Among Children by Cause of Death, Arizona 2008 (n=60) Sharp force trauma 5% (n=3) Malnutrition/ dehydration 3% (n=2) Other injury 10% (n=6) Blunt force trauma 27% (n=16) Firearm 55% (n=33) For 30 percent of homicides, the perpetrator was unknown to review teams (n=18). In 15 percent, the perpetrator was someone that the child did not know (n=9). Biological parents or step-parents were the perpetrators in seven child homicides. Friends or acquaintances of the children accounted for an additional seven homicides. Table 20 shows homicides among children by perpetrator. Table 20. Homicides Among Children by Perpetrator, Arizona 2008 (n=60) Perpetrator Number Percent Unknown 18 30% Stranger 9 15% Parent/step-parent 7 12% Child’s friend/acquaintance 7 12% Rival gang member 7 12% Mother’s partner 5 8% Babysitter/child care worker 4 7% Neighbor 2 3% Sibling 1 2% Total 60 One hundred percent of child homicides were determined to have been preventable (n=60). Drugs and/or alcohol were the most commonly identified preventable factors in child homicides (57 percent, n=34), followed by access to firearms (55 percent, n=33). 41 Gang conflict was a factor in 10 homicides (17 percent). Table 21 shows preventable factors for child homicides in Arizona during 2008. Table 21. Preventable Factors for Child Homicides, Arizona 2008 Factor* Number Percent Drugs and/or alcohol 34 57% Access to firearms 33 55% Lack of supervision 19 32% Involvement in gang 10 17% *More than one factor may have been identified for each death FIREARM-RELATED FATALITIES There were 49 firearm-related fatalities in 2008, compared to 48 in 2007. Firearms accounted for five percent of all child deaths in 2008 and four percent in 2007. Eighty percent of the firearm-related deaths in 2008 were among males (n=39) and 20 percent were among females (n=10). More than half of firearm-related deaths were among Hispanics (59 percent, n=29), 25 percent were among Non-Hispanic Whites (n=12), eight percent were among African Americans (n=4), and eight percent were among other races/ethnicities (n=4). Seventy-six percent of these deaths were among children ages 15 through 17 years (n=37). There were 12 deaths due to firearms among children 14 years of age and younger. Figure 31 shows firearm-related fatalities among children by age group. 42 Figure 31. Firearm-Related Deaths Among Children by Age Group, Arizona 2008 (n=49) <10 Years 10% (n=5) 10-14 Years 14% (n=7) 15-17 Years 76% (n=37) The age group distribution in 2008 was similar to what has been observed in previous years. In 2007, there were 36 firearm-related deaths among children ages 15 through 17 years (75 percent), seven among children ages 10 through 14 years (15 percent), and five among children younger than 10 years of age (10 percent). Table 22 shows firearm-related deaths among children by age group for 2005 through 2008. Table 22. Firearm-Related Deaths Among Children by Age Group, Arizona 2005-2008 Age Goup 2005 2006 2007 2008 <10 Years 2 5% 1 2% 5 10% 5 10% 10-14 Years 7 16% 13 22% 7 15% 7 14% 15-17 Years 34 79% 46 76% 36 75% 37 76% Total 43 60 48 49 In 2008, 67 percent of firearm-related deaths were homicides (n=33), 29 percent were suicides (n=14), and four percent were accidents (n=2). Figure 32 shows firearmrelated deaths among children by manner. 43 Figure 32. Firearm-Related Deaths Among Children by Manner, Arizona 2008 (n=49) Accident 4% (n=2) Suicide 29% (n=14) Homicide 67% (n=33) Handguns accounted for the majority of firearm-related fatalities among children in 2008 (67 percent, n=33), followed by shotguns (10 percent, n=5). Table 23 shows types of firearms involved in child deaths during 2008. Table 23. Types of Firearms Involved in Child Deaths, Arizona 2008 (n=49) Type Number Percent Handgun 33 67% Shotgun 5 10% Assault rifle 4 8% Unknown 4 8% Hunting rifle 3 6% Total 49 Among the 49 firearm-related deaths, 16 percent of firearms were stored with ammunition (n=8), and 10 percent of firearms were stored loaded (n=5). The largest percentage of firearms belonged to parents or step-parents (18 percent, n=9). Figure 33 shows the owners of the firearms used in child fatalities. 44 Figure 33. Owners of Firearms Involved in Child Deaths, Arizona 2008 (n=49) Rival gang member 4% (n=2) Friend/ acquaintance 8% (n=4) Stranger 10% (n=5) Self 4% (n=2) Unknown 46% (n= 22) Other 10% (n=5) Parent/ s tep-parent 18% (n=9) For a large percentage of firearms, the storage location was unknown to the review teams (69 percent, n=34). One firearm was stored in a locked toolbox, but the remaining firearms were not stored in secured locations. Table 24 summarizes the locations of the firearms involved in child deaths during 2008. Table 24. Locations of Firearms Involved in Child Deaths, Arizona 2008 (n=49) Location Number Percent Unknown 34 69% Other not stored (unsecured location) 8 16% In or under furniture (e.g. in a drawer or under a bed) 3 6% Closet 2 4% Glove compartment of car 1 2% Locked toolbox 1 2% Total 49 One hundred percent of the firearm-related deaths in 2008 were determined to have been preventable. Drugs and/or alcohol were involved in 86 percent of firearm-related deaths (n=42). Lack of supervision was a factor in 41 percent of the deaths (n=20), and access to firearms was identified as a preventable factor for 35 percent of firearmrelated fatalities among children (n=17). Table 25 shows preventable factors for firearm-related fatalities in Arizona during 2008. 45 Table 25. Preventable Factors for Firearm-Related Deaths Among Children, Arizona 2008 Factor* Number Percent Drugs and/or alcohol 42 86% Lack of supervision 20 41% Access to firearm 17 35% Involvement in gang 9 18% *More than one factor may have been identified for each death MALTREATMENT FATALITIES To gain greater understanding of the contribution of neglect and abuse to child mortality, the Arizona Child Fatality Review Teams answered several questions regarding maltreatment. In order for a death to be classified as a result of maltreatment, the following three conditions must be met: 1. “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” applied to the circumstances surrounding the death (from the U.S. Department of Health and Human Services definition of maltreatment). 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 be obligated to report a similar incident to Child Protective Services. Deaths classified as maltreatment are also reported in other categories by manner and cause of death. For example, a death due to abusive head trauma would be classified as a manner of homicide with a cause of blunt force trauma, and a maltreatment death. An accidental or natural death might also be classified as a maltreatment death if, in the opinion of the team, a caretaker’s negligence or actions contributed to or caused the death. For example, it would be maltreatment if a child died in a motor vehicle crash due to the parent driving while intoxicated with the child in the car. The number of child maltreatment deaths presented in this report is not comparable to child maltreatment deaths reported by the Arizona Department of Economic Security (AzDES) for the National Child Abuse and Neglect Data System (NCANDS). NCANDS includes maltreatment deaths identified through Child Protective Services investigations, and because some maltreatment deaths identified by Local Child Fatality Review Teams may not have been reported to Child Protective Services or were within the jurisdiction of Tribal Nations, these deaths would not be included in AzDES’s annual report to NCANDS. However, when a Local Child Fatality Review team identifies a death due to maltreatment that has not been previously reported to Child Protective Services, the Local Child Fatality Review Program notifies Child Protective Services of the team’s assessment so that an investigation can be initiated. 46 In 2008, there were 51 deaths classified as maltreatment, which was five percent of all child deaths that year. This was a decline from 65 child maltreatment deaths in 2007 (six percent of all child deaths). In 2008, 53 percent of maltreatment deaths were among males (n=27) and 47 percent were among females (n=24). Forty-one percent of the children who died due to maltreatment were Hispanic (n=21), 25 percent were White, Non-Hispanic (n=13), 16 percent were African American (n=8), 16 percent were American Indian (n=8), and two percent were Asian (n=1). More than half of all maltreatment deaths were among children younger than one year of age (56 percent, n=29). Figure 34 shows maltreatment deaths among children by age group. Figure 34. Maltreatment Deaths Among Children by Age Group, Ariz ona 2008 (n=51) 10-14 Years 8% (n= 4) 15-17 Years 2% (n= 1) 5-9 Years 14% (n=5) 1-4 Years 20% (n=11) < 1 Year 56% (n=30) Homicide comprised almost half of child maltreatment deaths in Arizona (45 percent, n=23). Ten percent of maltreatment deaths were due to accidents (n=5). Maltreatmentrelated accidental deaths included unintentional injuries caused by significant negligence or substance abuse by a parent or guardian. Twenty-one percent of child maltreatment deaths were due to natural manners (n=11). Examples of maltreatment deaths due to natural manners of death included prenatal substance use resulting in premature birth, neglect which resulted in an illness, or failure to obtain medical care. Twenty-four percent of child maltreatment deaths were of undetermined manner (n=12). Figure 35 shows maltreatment deaths by manner. 47 Figure 35. Maltreatment Deaths Among Children by Manner, Ariz ona 2008 (n=51) Undetermined 24% (n= 12) Accident 10% (n=5) Homicide 45% (n=23) Natural 21% (n= 11) The leading causes of child maltreatment deaths were medical causes (27 percent, n=14) and blunt force trauma (25 percent, n=13). Table 26 shows maltreatment deaths among children by cause and manner. Table 26. Maltreatment Deaths Among Children by Cause and Manner, Arizona 2008 (n=51) Cause Accident Homicide Natural Undetermined Total Medical 2 11 1 14 Blunt force trauma 13 13 Undetermined 6 6 Other injury 4 4 Suffocation 1 1 2 4 Firearm injury 1 2 3 Exposure (hyperthermia) 1 2 3 Motor vehicle crash 1 1 Drowning 1 1 Fall/crush 1 1 Poisoning 1 1 Total 5 23 11 12 51 Sixteen percent of the maltreated children in Arizona during 2008 were known to have had physical, mental, and/or sensory disabilities (n=8), including two children with cerebral palsy. The majority of maltreatment incidents occurred in parental homes (84 percent, n=43), and four incidents occurred in the homes of babysitters (three were unlicensed day care homes; one was a licensed child care facility). Two maltreatment incidents occurred on 48 roadways, and one incident occurred in the home of the mother’s boyfriend. For one death, the maltreatment incident location was unknown to the review team. For 71 percent of maltreatment deaths, the perpetrator was the child’s biological parent (n=36), and for an additional 14 percent, the perpetrator was the mother’s boyfriend or a step-parent (n=7). Table 27 shows maltreatment deaths among children by perpetrator. Table 27. Maltreatment Deaths Among Children by Perpetrator, Arizona 2008 (n=51) Perpetrator Number Percent Mother 28 55% Father 8 16% Mother’s boyfriend 4 8% Step-parent 3 6% Unknown 3 6% Babysitter* 3 6% Licensed child care worker* 1 2% Other relative 1 2% Total 51 *May not have been under the jurisdiction of Arizona Child Protective Services There were seven fatalities among children two years of age and younger due to abusive head trauma during 2008. Five of these children were known to have been shaken. This was a decrease from 2007, when 11 children two years of age and younger died as a result of abusive head trauma. Ninety-six percent of the child maltreatment deaths in 2008 were determined to have been preventable (n=49). For four percent of maltreatment deaths, local review teams were not able to determine preventability (n=2). Drugs and/or alcohol contributed to 53 percent of the deaths (n=27). Lack of supervision contributed to 33 percent of maltreatment deaths (n=17). Table 28 shows preventable factors for child maltreatment deaths. Table 28. Preventable Factors for Maltreatment Deaths Among Children, Arizona 2008 Factor* Number Percent Drugs and/or alcohol 27 53% Lack of supervision 17 33% Unsafe sleep environment 7 14% *More than one factor may have been identified for each death Child Protective Services Involvement with Families of Children who Died due to Maltreatment Local Child Fatality Review Teams attempt to obtain records from child protective services agencies, including Arizona Child Protective Services and child protective agencies in other jurisdictions, such as tribal authorities and other states. If a child 49 protective agency investigated a report of maltreatment for any child in the family prior to the incident leading to the child’s death, then the family was considered to have had previous involvement with a child protective agency. This includes reports in which the maltreatment was or was not substantiated. In 2008, 59 percent of maltreated children were from families with prior child protective services involvement (n=30), and five of these children had prior involvement with Tribal Nation child protective services. Among these 30 families, eight were open cases with Arizona Child Protective Services at the time of the child’s death. Six open cases had recent allegations that were in the process of being investigated. For 23 maltreatment deaths, mandatory reporters did not notify Arizona Child Protective Services that the deaths were suspected to have been due to maltreatment even after the investigations. The number of maltreatments deaths that were not reported to Arizona Child Protective Services declined from 27 in 2007 to 23 in 2008. For four child maltreatment deaths during 2008, the children were in the care of individuals other than a parent, guardian, or custodian (as defined in A.R.S. § 8-201) and may not have been under the investigative jurisdiction of Arizona Child Protective Services. These deaths were investigated by law enforcement (as defined in A.R.S. § 13-3620). SUDDEN UNEXPECTED INFANT DEATHS Local review teams define sudden unexpected infant deaths as deaths that occur suddenly and unexpectedly in children younger than one year of age while not in the care of a medical professional. For these deaths, manner and cause of death may not be immediately obvious prior to investigation. Sudden infant death syndrome (SIDS) is a type of sudden unexpected infant death (SUID). Other types of SUID include infant deaths due to suffocation, asphyxia, poisoning, undetected metabolic or cardiac disorders, hypothermia and hyperthermia, as well as some abuse and neglect cases. Although the number of sudden unexpected infant deaths declined in 2008, these deaths comprised a larger percentage of total deaths than in 2007. There were 140 unexpected infant deaths in Arizona in 2008 (13 percent of all deaths that year). In 2007, there were 143 unexpected infant deaths in Arizona, which accounted for 12 percent of all child deaths. Fifty-nine percent of unexpected infant deaths in 2008 were among males (n=82) and 41 percent were among females (n=58). Non-Hispanic Whites accounted for 40 percent of sudden unexpected infant deaths (n=56), Hispanic infants accounted for 33 percent (n=46), African Americans accounted for 15 percent (n=21), American Indians accounted for nine percent (n=12), and three percent were among Asian children (n=5). 50 Nearly half of the deaths were among infants younger than three months of age (48 percent, n=67). Fifty-four deaths were among infants between three and six months of age (39 percent), and 19 infants who died unexpectedly were older than six months of age (13 percent). For 50 deaths, teams were unable to determine the cause of death (36 percent). Fortytwo deaths were due to medical causes (30 percent). Twenty-one sudden unexpected infant deaths were due to suffocation (15 percent) and 20 deaths were due to SIDS (14 percent). Table 29 shows sudden unexpected infant deaths by cause. Table 29. Sudden Unexpected Infant Deaths by Cause, Arizona 2008 (n=140) Cause Number Percent Undetermined 50 36% Suffocation 21 15% SIDS 20 14% Cardiovascular 17 12% Pneumonia/influenza 13 9% Other medical 9 6% Other injury 7 5% Unknown 3 2% Total 140 Investigation Law enforcement conducted scene investigations in 71 percent of sudden unexpected infant deaths (n=100). Seventy-six percent of sudden unexpected infant deaths were referred to medical examiners’ offices (n=106), and all of those cases received an autopsy. For the 34 deaths that were not referred to medical examiners, most were deaths due to medical causes (n=33). Ninety-five children were known to have had toxicology tests performed. Six children tested positive for nicotine, three tested positive for caffeine, and three tested positive for acetaminophen. Ninety-six children were known to have had x-rays. More than half of the 140 sudden unexpected infant deaths were determined to have been preventable (58 percent, n=81). For 16 deaths, local review teams were unable to determine if the death could have been prevented. Unsafe sleep environment was a contributing factor in 90 sudden unexpected infant deaths (64 percent), followed by lack of supervision (51 percent, n=71). Table 30 shows preventable factors for sudden unexpected infant deaths. Table 30. Preventable Factors for Sudden Unexpected Infant Deaths, Arizona 2008 Factor* Number Percent Unsafe sleep environment 90 64% Lack of supervision 71 51% Drugs and/or alcohol 48 34% Infant exposure to smoking 31 22% *More than one factor may have been identified for each death 51 Unsafe Sleep Environments Of the 140 sudden unexpected infant deaths, 68 percent occurred in sleep environments (n=95). Ninety of these environments were determined to have been unsafe. Suffocation was the cause of 21 unsafe sleep-related deaths, and 18 deaths were identified as SIDS. For 46 deaths that occurred in unsafe sleep environments, cause of death was undetermined by the review teams. Forty-eight infants were bed sharing with adults and/or other children. Twenty-five of the adults who were bed sharing with infants were known to have been using illegal drugs, prescription drugs, and/or alcohol. Forty-four infants were sleeping in adult beds, 13 were sleeping on couches or chairs, and two were sleeping in car seats or strollers. Thirty-one infants were put to sleep on their sides or stomachs. Forty percent of the 90 infants in unsafe sleep environments were known to have had a crib/bassinette in the home (n=36), although only 13 infants were sleeping in cribs/bassinettes at the time of their deaths. Thirteen percent did not have a crib/bassinette in the home (n=12). For 47 percent, local review teams did not know if a crib/bassinette was present in the home (n=42). Improvements in the investigations of all sudden unexpected infant deaths, including consistent completion of the Infant Death Investigation Checklist, may increase review teams’ abilities to identify risk factors (such as the lack of safety approved cribs in homes). Of the 13 infants who were sleeping in cribs/bassinettes, only three were placed to sleep on their backs. Six were placed to sleep in the cribs on their stomachs and three were placed to sleep in the cribs propped on their sides. For one death, it was unknown how the infant was placed to sleep in the crib. All 13 of the infants who died while sleeping in cribs/bassinettes had factors that made the environment unsafe, including non-supine sleep position, soft/excessive bedding, pillows, and/or stuffed toys. Sudden Infant Death Syndrome (SIDS) SIDS is the diagnosis given to the sudden death of an infant younger than one year of age that remains unexplained after a complete postmortem investigation, including autopsy, death scene investigation, and review of the child’s medical history. There were 20 deaths identified as SIDS in 2008, compared to 37 in 2007. Fifty-two percent of the children who died of SIDS were male (n=11) and 48 percent were female (n=9). Five of the infants who died of SIDS had been born prematurely (all were singleton births). Forty-five percent of the children who died of SIDS were White, Non-Hispanic (n=9), 30 percent were Hispanic (n=6), 15 percent were American Indian (n=3), and 10 percent were Asian (n=2). Investigation Eighteen SIDS deaths were known to have had law enforcement investigations of the death scenes. All 20 SIDS deaths received autopsies, and 19 had the official cause of 52 death determined by a medical examiner. Nineteen children who died of SIDS were known to have had toxicology tests performed. Five children tested positive for nicotine and three tested positive for caffeine. Seventeen of the 20 children were known to have had x-rays. All 20 SIDS deaths occurred in sleep environments. Three of the deaths occurred while the infant was sleeping in a crib or bassinette, and nine occurred while the infant was sleeping in an adult bed. Eight of the infants who died of SIDS were bed sharing with at least one adult or child. For nine infants, the sleep position was unknown to the review teams. Six infants were known to have put on their backs to sleep, and five of the infants who died of SIDS were put to sleep on their stomachs or sides. Only one child who died of SIDS was sleeping in a crib on his back. Of the 17 infants who were not in cribs or bassinettes, scene investigations showed that six of these families had a crib in the home. HOME SAFETY-RELATED DEATHS Deaths included in this section occurred in or around home environments (e.g. bedroom, driveway, or yard) and were due to accidents or were of undetermined manner. Suicides, homicides, and natural deaths were excluded. In 2008, 141 children died in or around the home (14 percent of all deaths that year). The majority of these deaths occurred among males (61 percent, n=86) and 39 percent were among females (n=55). Forty percent of deaths that occurred in or around the home were among White, NonHispanic children (n=57), 36 percent were among Hispanic children (n=51), 16 percent were among African Americans (n=22), seven percent were among American Indians (n=9), and one percent were among Asian children (n=2). More than half of the deaths that occurred in or around the home during 2008 were among infants younger than one year of age (55 percent, n=77). Thirty percent were among children ages one through four years (n=43). Figure 36 shows home safetyrelated deaths by age group. 53 Figure 36. Home Safety-Related Deaths Among Children by Age Group, Arizona 2008 (n=141) 10-14 Years 2% (n=3) 15-17 Years 5% (n=7) 5-9 Years 8% (n=11) 1-4 Years 30% (n=43) <1 Year 55% (n=77) For 38 percent of deaths, the cause of death was undetermined (n=53), and most of these deaths were among infants in unsafe sleep environments (n=46). The second most common cause of death was drowning (18 percent, n=25). Fifteen children drowned in family pools or hot tubs, three children drowned in bathtubs, and four children drowned in canals that ran directly behind the child’s home. Four children were crushed by heavy objects in the home, usually after climbing or pulling on these objects. Five children died as the results of falls. Four children died in home fires, and for two of these deaths, the kitchen stove/oven was the ignition source. One of these homes did not have a smoke detector. Table 31 shows child deaths that occurred in or around the home by cause. Table 31. Child Deaths In or Around the Home by Cause, Arizona 2008 (n=141) Cause Number Percent Undetermined 53 38% Drowning 25 18% Suffocation 20 14% Poisoning 9 6% SIDS 7 5% Fall/crush 6 4% Other 5 3% Motor vehicle backovers 4 3% Hyperthermia in vehicle 4 3% Fire 3 2% Hanging 3 2% Firearm-related injury 2 1% Total 141 54 Eighty-nine percent of home safety-related deaths were determined to have been preventable (n=126), and for nine percent, teams were not able to determine preventability (n=13). The most commonly listed contributing factors were lack of supervision (71 percent, n=100) and drugs and/or alcohol (54 percent, n=76). Table 32 shows preventable factors for home safety-related deaths. Table 32. Preventable Factors for Child Deaths In or Around the Home, Arizona 2008 Factor* Number Percent Lack of supervision 100 71% Drugs and/or alcohol 76 54% Access to water 17 12% *More than one factor may have been identified for each death 55 APPENDIX A: CHILD DEATHS BY AGE GROUP The following section of the report provides information on the causes and manners of child deaths by age group. The information provided for each age group can be used to guide prevention efforts within each stage of development. For the past four years, 100 percent of child deaths in Arizona have been reviewed, and data from 2005 through 2008 are included in the following tables. The Neonatal Period, Birth Through 27 Days Table 33. Deaths Among Children Ages Birth Through 27 Days by Cause and Manner, Arizona 2008 (n=423) Cause Accident Homicide Suicide Natural Undetermined Total Prematurity 256 256 Medical* 155 155 Undetermined 1 5 6 SIDS 2 1 3 Motor vehicle 2 2 crash Firearm injury 1 1 Total 2 1 414 6 423 *Excluding SIDS and prematurity Table 34. Deaths Among Children Ages Birth Through 27 Days by Cause, Arizona 2005-2008 Cause 2005 2006 2007 2008 Prematurity 263 61% 263 60% 281 58% 256 60% Medical* 155 36% 168 38% 180 37% 155 37% Undetermined 3 1% 2 0% 4 1% 6 1% SIDS 3 1% 1 0% 4 1% 3 1% Motor vehicle 4 1% 1 0% 5 1% 2 <1% crash Other 1 0% 4 1% 5 1% 1 <1% Suffocation 3 1% 1 0% 5 1% 0 0% Exposure 1 0% 0 0% 0 0% Drowning 1 0% 0 0% 1 0% 0 0% Total 434 440 485 423 *Excluding SIDS and prematurity 56 Table 35. Deaths Among Children Ages Birth Through 27 Days by Manner, Arizona 2005-2008 Manner 2005 2006 2007 2008 Natural 421 97% 432 98% 464 96% 414 98% Undetermined 3 1% 2 0% 6 1% 6 1% Accident 7 2% 2 0% 12 2% 2 <1% Homicide 3 1% 4 1% 3 1% 1 <1% Suicide 0 0% 0 0% 0 0 0% Total 434 440 485 423 The Post-Neonatal Period, 28 Days Through 365 Days Table 36. Deaths Among Children Ages 28 Days Through 365 Days by Cause and Manner, Arizona 2008 (n=211) Cause Accident Homicide Suicide Natural Undetermined Total Medical* 1 90 91 Undetermined 44 44 Suffocation 18 1 2 21 SIDS 11 6 17 Prematurity 15 15 Blunt force 9 9 trauma Motor vehicle 6 6 crash Other injury 2 2 4 Fall/crush 2 2 Exposure 1 1 Downing 1 1 Total 30 13 116 52 211 *Excluding SIDS and prematurity Table 37. Deaths Among Children Ages 28 Days Through 365 Days by Cause, Arizona 2005-2008 Cause 2005 2006 2007 2008 Medical* 122 52% 89 43% 83 37% 91 43% Undetermined 17 7% 14 7% 25 11% 44 21% Suffocation 19 8% 24 12% 21 9% 21 10% SIDS 34 15% 27 13% 33 15% 17 8% Prematurity 21 9% 29 14% 35 15% 15 7% Blunt force 7 3% 8 4% 8 3% 9 4% trauma Other non5 2% 8 4% 5 2% 6 3% medical Motor vehicle 1 0% 2 1% 7 3% 6 3% crash Drowning 1 0% 2 1% 5 2% 1 <1% Exposure 1 0% 0 0% 2 1% 1 <1% Fire/burn 3 1% 1 0% 6 3% 0 0% Poisoning 1 0% 2 1% 1 0% 0 0% Hanging 1 0% 0 0% 1 0% 0 0% Total 233 206 225 211 *Excluding SIDS and prematurity 57 Table 38. Deaths Among Children Ages 28 Days Through 365 Days by Manner, Arizona 2005-2008 Manner 2005 2006 2007 2008 Natural 178 76% 140 68% 147 65% 116 Undetermined 9 4% 12 6% 27 12% 52 Accident 19 8% 25 12% 38 17% 29 Homicide 27 12% 29 14% 13 6% 14 Suicide 0 0% 0 0% 0 0% 0 Total 233 206 225 211 55% 25% 14% 7% 0% Children, One Through Four Years of Age Table 39. Deaths Among Children Ages One Through Four Years by Cause and Manner, Arizona 2008 (n=126) Cause Accident Homicide Suicide Natural Undetermined Total Medical* 67 67 Downing 25 25 Motor vehicle 10 10 crash Undetermined 7 7 Other injury 2 2 4 Blunt force 4 4 trauma Poisoning 1 1 2 Firearm injury 1 1 2 Exposure 1 1 2 Fire/burn 1 1 Fall/crush 1 1 Hanging 1 1 Total 43 7 67 9 126 *Excluding SIDS and prematurity Table 40. Deaths Among Children Ages One Through Four Years by Cause, Arizona 2005-2008 Cause 2005 2006 2007 2008 Medical 56 43% 74 48% 45 40% 67 53% Drowning 20 15% 16 10% 12 11% 25 20% Motor vehicle crash 19 15% 34 22% 21 18% 10 8% Other non-medical 5 4% 4 3% 11 10% 7 5% Undetermined 5 4% 7 4% 8 7% 7 5% Blunt force trauma 10 8% 6 4% 7 6% 4 3% Firearm injury 0 0% 1 1% 2 2% 2 2% Poisoning 4 3% 1 1% 2 2% 2 2% Exposure 3 2% 1 1% 1 1% 2 2% Fire/burn 5 4% 4 3% 2 2% 1 1% Suffocation/choking 2 2% 5 3% 2 2% 0 0% Total 130 153 113 126 *Excluding SIDS and prematurity 58 Table 41. Deaths Among Children Ages One Through Four Years by Manner, Arizona 2005-2008 Manner 2005 2006 2007 2008 Natural 56 43% 74 48% 49 43% 67 53% Accident 54 42% 64 42% 45 40% 43 34% Undetermined 7 5% 4 3% 7 6% 9 7% Homicide 13 10% 11 7% 12 11% 7 5% Suicide 0 0% 0 0% 0 0% 0 0% Total 130 153 113 126 Children, Five Through Nine Years of Age Table 42. Deaths Among Children Ages Five Through Nine Years by Cause and Manner, Arizona 2008 (n=67) Cause Accident Homicide Suicide Natural Undetermined Total Medical* 42 1 43 Motor vehicle 10 10 crash Fall/crush 3 3 Firearm injury 1 1 2 Fire/burn 2 2 Downing 2 2 Hanging 1 1 Undetermined 1 1 Blunt force 1 1 trauma Exposure 1 1 Other injury 1 1 Total 19 2 42 4 67 *Excluding SIDS and prematurity Table 43. Deaths Among Children Ages Five Through Nine Years by Cause, Arizona 2005-2008 Cause 2005 2006 2007 2008 Medical 43 51% 30 47% 37 55% 43 64% Motor vehicle crash 23 27% 23 36% 13 19% 10 15% Other non-medical 2 2% 2 3% 7 10% 8 12% Drowning 6 7% 4 6% 4 6% 2 3% Fire/burn 6 7% 2 3% 1 1% 2 3% Hanging 0 0% 1 1% 1 1% 1 1% Blunt force trauma 2 2% 1 1% 1 1% 1 1% Suffocation 1 1% 0 0% 1 1% 0 0% Poisoning 1 1% 1 1% 2 3% 0 0% Total 85 64 67 67 *Excluding SIDS and prematurity 59 Table 44. Deaths Among Children Ages Five Through Nine Years by Manner, Arizona 2005-2008 Manner 2005 2006 2007 2008 Natural 43 51% 30 47% 37 55% 42 63% Accident 39 46% 32 50% 23 34% 19 28% Undetermined 0 0% 1 1% 0 0% 4 6% Homicide 3 4% 0 0% 7 10% 2 3% Suicide 0 0% 1 1% 0 0% 0 0% Total 85 64 67 67 Children, 10 Through 14 Years of Age Table 45. Deaths Among Children Ages 10 Through 14 Years by Cause and Manner, Arizona 2008 (n=74) Cause Accident Homicide Suicide Natural Undetermined Total Medical* 1 33 34 Motor vehicle 19 19 crash Firearm injury 4 3 7 Hanging 1 5 6 Poisoning 1 1 2 Fall/crush 2 2 Blunt force 1 1 trauma Fire/burn 1 1 Exposure 1 1 Other injury 1 1 Total 26 6 9 33 74 *Excluding SIDS and prematurity Table 46. Deaths Among Children Ages 10 Through 14 Years by Cause, Arizona 2005-2008 Cause 2005 2006 2007 2008 Medical 32 37% 38 41% 40 43% 34 46% Motor vehicle crash 21 24% 21 23% 27 29% 19 26% Firearm injury 7 8% 13 14% 7 8% 7 9% Hanging 7 8% 3 3% 6 6% 6 8% Other non-medical 1 1% 0 0% 4 4% 2 3% Fall/crush 0 0% 1 3% 3 3% 2 3% Poisoning 4 5% 2 2% 2 2% 2 3% Blunt force trauma 1 1% 3 3% 1 1% 1 1% Exposure 4 5% 4 4% 1 1% 1 1% Suffocation 3 3% 4 4% 0 0% 0 0% Drowning 1 1% 3 3% 1 1% 0 0% Total 86 92 92 74 *Excluding SIDS and prematurity 60 Table 47. Deaths Among Children Ages 10 Through 14 Years by Manner, Arizona 2005-2008 Manner 2005 2006 2007 2008 Natural 32 37% 38 41% 40 43% 33 45% Accident 34 40% 34 37% 35 38% 26 35% Suicide 13 15% 11 12% 7 8% 9 12% Homicide 5 6% 7 8% 5 5% 6 8% Undetermined 2 2% 2 2% 5 5% 0 0% Total 86 92 92 74 Children, 15 Through 17 Years of Age Table 48. Deaths Among Children Ages 15 Through 17 Years by Cause and Manner, Arizona 2008 (n=137) Cause Accident Homicide Suicide Natural Undetermined Total Firearm injury 26 11 37 Motor vehicle 35 35 crash Medical* 30 30 Hanging 13 13 Poisoning 7 2 1 10 Other 1 3 4 Exposure 4 4 Undetermined 1 1 Blunt force 1 1 trauma Downing 1 1 Fall/crush 1 1 Total 49 30 26 30 2 137 *Excluding SIDS and prematurity Table 49. Deaths Among Children Ages 15 Through 17 Years by Cause, Arizona 2005-2008 Cause 2005 2006 2007 2008 Firearm injury 34 19% 46 22% 36 22% 37 27% Motor vehicle crash 66 37% 83 40% 49 30% 35 25% Medical 34 19% 29 14% 35 22% 30 22% Hanging 10 6% 19 9% 6 4% 13 9% Poisoning 9 5% 5 2% 17 11% 10 7% Other 2 1% 4 2% 7 4% 4 3% Exposure 10 6% 4 2% 4 2% 4 3% Drowning 6 3% 6 3% 0 0% 1 1% Undetermined 2 1% 1 0% 4 2% 1 1% Fall/crush 4 2% 1 0% 0 0% 1 1% Blunt force trauma 2 1% 6 3% 0 0% 1 1% Fire/burn 1 1% 2 1% 3 2% 0 0% Total 180 206 161 137 *Excluding SIDS and prematurity 61 Table 50. Deaths Among Children Ages 15 Through 17 Years by Manner, Arizona 2005-2008 Manner 2005 2006 2007 2008 Accident 92 51% 109 53% 74 46% 49 36% Natural 35 19% 29 14% 34 21% 30 22% Homicide 25 14% 29 14% 26 16% 30 22% Suicide 23 13% 36 18% 21 13% 26 19% Undetermined 5 3% 3 1% 6 4% 2 1% Total 180 206 161 137 62 APPENDIX B: DATA ANALYSIS METHODOLOGY Child fatality review data include a variety of data sources that may not be available to other programs or research endeavors. Arizona statute facilitates data collection among protected data sources, including health and law enforcement records (A.R.S. § 36-3503). Confidentiality of records is strictly enforced, and meetings at which individual cases are reviewed are not open to the public. Case review records are destroyed after publication of the annual report. All reasonable efforts are made to obtain complete records for each death. However, if records are unavailable, case reviews may be conducted without some information. Records may be difficult to obtain for children who died in Arizona but lived in other states or countries and for children whose families only recently moved to Arizona. These cases may have had additional risk factors that were unknown to review teams. The reliability of child fatality data is dependent upon the accuracy of the records provided for review. Data presented in the Child Fatality Review Annual Report may differ from other published sources. After importing from the National Center for Child Death Review database, 2008 child death data were cleaned and analyzed using SAS software, Version 9.2 of the SAS System for Windows (copyright © 2008 SAS Institute Inc). 63 APPENDIX C: ARIZONA CHILD FATALITY REVIEW TEAMS AND ARIZONA DEPARTMENT OF HEALTH SERVICES STAFF State Child Fatality Review Team Chair Mary Ellen Rimsza, MD, FAAP University of Arizona College of Medicine American Academy of Pediatrics Members Markay Adams Arizona Department of Health Services Division of Behavioral Health Services Christy Alonzo Governor's Office for Children Frank Pavone Luke Air Force Base Beth Rosenberg Children’s Action Alliance Kathryn Bowen, MD University of Arizona College of Medicine Sara Salek, MD Arizona Department of Health Services Division of Behavioral Health Services David K. Byers Administrative Office of the Courts Valerie Seitz Luke Air Force Base Suzanne Cohen Maricopa County Attorney’s Office Kim Simmons Arizona Department of Economic Security Division of Developmental Disabilities Tim Flood, MD Arizona Department of Health Services Bureau of Public Health Statistics Randy Force Phoenix Police Department Wade Kartchner, MD Navajo County Public Health Services Bonnie Marcus Administrative Office of the Courts Janice Mickens Arizona Department of Economic Security Division of Children, Youth, and Families Gaylene Morgan Office of the Attorney General Sheila Sjolander Arizona Department of Health Services Bureau of Women’s and Children’s Health Tomi St. Mars, RN, MSN, CEN, FAEN Arizona Department of Health Services Bureau of Women’s and Children’s Health Roy Teramoto, MD Indian Health Services David Winston, MD, PhD Forensic Pathologist Pima County Forensic Science Center Consultant: Nancy Quay, MS, RN Phoenix Children’s Hospital 64 Apache County Child Fatality Review Team Chair/Coordinator Diana M. Ryan Apache County Youth Council Members Gladys Ambrose Navajo Nation Division of Social Services Commander Matrese Avila Apache County Sheriff’s Office Michael Downs Little Colorado Behavioral Health Center Lieutenant Fred Frazier Eagar Police Department Peggy Hart Arizona Department of Economic Security Division of Children, Youth, and Families Chief Mike Hogan Eagar Police Department Michael Johnson Apache County Public Health Services Chief Donny Jones St. Johns Police Department Elizabeth Kizer Apache County Public Health Services Detective Mike Nuttall Springerville Police Department Jim Pierson New Hope Safe House Ann Russell Arizona Department of Economic Security Division of Children, Youth, and Families Keli Sine-Shields Apache County Public Health Services James Sielski, DO St. Johns Family Care Jim Staffnik, PhD St. Johns Middle School Cathy Taylor, MD North Country Community Health Center Sandra Thompson Little Colorado Behavioral Health Center Michael B. Whiting Apache County Attorney’s Office 65 Cochise County Child Fatality Review Team Chair/Coordinator Hal Thomas, EdD Committee for the Prevention of Child Abuse Assistant Coordinator Nilda Townsend Recording Secretary Paula Peters Members Joy Craig Arizona Department of Public Safety Parent Representative Vincent Fero Arizona Department of Public Safety Guery Flores, MD Cochise County Medical Examiner’s Office Dee Foster Community Representative Tonianne Goebel Domestic Violence Specialist Angela Hillig Sierra Vista Police Department Maureen Kappler Cochise County Health Department Debbie Nishikida Arizona Department of Economic Security Division of Children, Youth, and Families Judy Pike Psychologist Melodi Polach Family Resource Specialist Rebecca Reyes, MD Pediatrician Rodney Rothrock Cochise County Sheriff’s Office Mary Scott Cochise County Prosecutor’s Office 66 Coconino County Child Fatality Review Team Chair/Coordinator Charles Dean Catholic Social Services Members Michel Begay Criminal Investigator Tuba City Barbara Bosch, MD Flagstaff Pediatric Care Diana Holt, PNP Children’s Health Center of Northern AZ Children’s Rehabilitation Services Dianna Hu, MD Tuba City Medical Center Indian Health Center Anitra Cruz Arizona Department of Economic Security Division of Children, Youth, and Families Roberta J. McVickers Coconino County Attorney’s Office Casey Hale Flagstaff Police Department Special Agent Terry Wade U.S. Federal Bureau of Investigation Terrence C. Hance Coconino County Attorney’s Office Lawrence Czarnecki, DO Coconino County Medical Examiner’s Office 67 Gila County Child Fatality Review Team Chair/Coordinator Jean M. Oliver Time Out, Inc. Members Lucinda Campbell, RN, BSN Gila County Health Department Diana Dunks Arizona Department of Economic Security Yvonne Harris Arizona Department of Economic Security Katrisha Stuler CASA Coordinator Detective Matt VanCamp Payson Police Department Paul Williamson Arizona Department of Economic Security Child Protective Services 68 Graham County and Greenlee County Child Fatality Review Team Chair/Coordinator Roxann Kopkie Parenting Arizona U Patricia Garcia Parenting Arizona Members Sherry Huges, RN (retired) Nurse U U Detective Kendall Curtis Thatcher Police Department Neil Karnes Graham County Health Department Robert Coons, DO Diane Thomas Graham County Sheriff’s Office Donna Whitten Arizona Department of Economic Security Division of Children, Youth, and Families 69 Maricopa County Child Fatality Review Team Chair Mary Ellen Rimsza, MD, FAAP American Academy of Pediatrics University of Arizona College of Medicine U Coordinator Susan Newberry, LBSW, MEd U Assistant Coordinator Arielle Unger, BA U Members Elisha Au Franklin, MC EMPACT-SPC U Sergeant Jesse Boggs Chandler Police Department Detective Jennifer Borquez Arizona Department of Public Safety Kathryn Coffman, MD St. Joseph's Hospital Suzanne Cohen Bureau Chief, Family Violence Bureau Maricopa County Attorney’s Office Cindy Copp, MSW Arizona Department of Economic Security Division of Children, Youth, and Families Shawn Cox, LCSW United States Attorney’s Office Frances Baker Dickman, PhD, JD Paul S. Dickman, MD Phoenix Children’s Hospital Division of Pathology Detective Frank DiModica Phoenix Police Department Amira El-Ahmadiyyah, LCSW Banner Health Cardon Children’s Medical Center Naomi Evanishyn, RS Salt River Pima-Maricopa Indian Community Michelle Fingerman, MS Childhelp National Hotline Rebecca Fitzpatrick, MSW Arizona Department of Economic Security Division of Children, Youth, and Families Tim Flood, MD Arizona Department of Health Services Bureau of Public Health Statistics Susan Hallett Arizona Department of Economic Security Division of Children, Youth, and Families Sergeant Mike Hill Tempe Police Department Richard Johnson, MSW Arizona Department of Economic Security Division of Children, Youth, and Families Sharon Jones, RHIT Hospice of the Valley Ilene Dode, PhD, LPC CEO Emeritus EMPACT-SPC 70 Karin Kline, MSW Arizona Department of Economic Security Division of Children, Youth, and Families Sergeant Patrick Kotecki Phoenix Police Department Susan Schmidt, Director Childhelp National Hotline Childhelp Cummings Community Center Childhelp Information Center Website Detective Chris Loeffler Phoenix Police Department Laurie Smith, MSN, PCNS-BC Banner Children’s Hospital Banner Desert Medical Center Terence Mason, RN Mesa Fire Department Connie Smyer Attorney Sandra McNally, MA, LISAC EMPACT-SPC Marilynn SoRelle, LPC Arizona Department of Economic Security Division of Children, Youth, and Families Christa Morgan Arizona Department of Economic Security Division of Children, Youth, and Families Tracy Norton Gila River Indian Community Ayrn O’Connor, MD Banner Health Good Samaritan Hospital Purvi Patel, MPH Maricopa County Department of Public Health Sergeant Jennifer Pinnow Arizona Department of Public Safety Kindra Portillo Arizona Department of Economic Security Division of Children, Youth, and Families Nancy Quay, MS, RN Phoenix Children’s Hospital Alana Shacter, MPH Arizona Department of Health Services Bureau of Women’s and Children’s Health Katrina Taylor Childhelp National Hotline Jon Terpay, Director Chandler/Gilbert Law Enforcement Academy Amy Terreros MS, RN, CPNP Phoenix Children’s Hospital Denis Thirion, MA EMPACT-SPC Sergeant Rick Van Galder Mesa Police Department Zannie Weaver U.S. Consumer Product Safety Commission Detective Sergeant David L. Wilson El Mirage Police Department Joseph Zerella, MD Stephanie Zimmerman, MD Phoenix Children’s Hospital 71 Mohave County and La Paz County Child Fatality Review Team Co-Chairs Vic Oyas, MD Havasu Rainbow Pediatrics U Daniel Wynkoop Psychologist Coordinator Leslie DeSantis Mohave County Sheriff’s Office U Members B.W. (Bud) Brown Mohave Mental Health Clinic U Kay Claborn Parent Representative Sergeant Rusty Cooper Kingman Police Department Craig Diehl, MD Pediatrician Detective Greg Kenyon Mohave County Sheriff’s Office Kosha Long Arizona Department of Economic Security Child Protective Services Patty Mead Mohave County Health Department Jennifer McNally Mohave County Health Department Betty Munyon Mohave County Victim/Witness Program Lieutenant Alan Nelson La Paz County Sheriff’s Office Detective Steve Parker Mohave County Sheriff’s Office Angelica Pichardo Mohave County Health Department Melissa Register Mohave County Probation Department Detective Cindy Slack Lake Havasu City Police Department Lieutenant Steve Smith Bullhead City Police Department Loralyn Staples Mohave County Probation Department Larry Tunforss Bullhead City Fire Department Steve Wilson Mohave County Attorney’s Office Rexene Worrell, MD Mohave County Medical Examiner 72 Navajo County Child Fatality Review Team Chair/Coordinator Janelle Virtue, RN Navajo County Public Health Services U Co-chair Susie Sandahl, RN Navajo County Public Health Services U Members Katy Aday WMAT Social Services U Gladys Ambrose Navajo Tribe Family Services Brock Bevell Lead Medical Examiner Investigator ABMDI Certified Navajo County Medical Examiner’s Office Greg Cardita Assistant Medical Examiner Investigator Navajo County Medical Examiner’s Office Detective Sergeant Roger Conaster Winslow Police Department Detective Sergeant Tim Dixon Holbrook Police Department Sherry Herring Navajo County Court Appointed Special Advocate’s Office Wade Kartchner, MD Navajo County Public Health Services Jane McRitchie Arizona Baptist Children’s Services Kateri Piecuch Arizona Department of Economic Security Division of Children, Youth, and Families Sylvia Pender Foster Care Review Board Amy Stradling Navajo County Public Health Injury Prevention Andrea Tsatoke, MPH Navajo County Community Outreach Gordon Tsatoke, Jr Indian Health Services Injury Prevention C.J. Wischmann Arizona Department of Economic Security Child Protective Services 73 Pima County and Santa Cruz County Child Fatality Review Team Chair Kathryn Bowen, MD Department of Pediatrics University of Arizona U Coordinator Becky Lowry U Members Susan Anderson University of Arizona U Norma Battaglia Tucson Fire Department Judith Becker, PhD Psychiatrist Karen Harper Southern Arizona Children’s Advocacy Center Lisa Hulette Pima County Health Department Karen Ives Pima County Juvenile Detention Kathy Benson, RN Sergeant Tim Brunenkant Marana Police Department Penelope Jacks Children’s Action Alliance – Southern Arizona Captain Norm Carlton Tucson Fire Department Lisa Jacobs Casa de los Niños Detective Robert Dobell Tucson Police Department Lynn Kallis Pilot Parents of Southern Arizona Lynn Edde, MD University of Arizona Department of Pediatrics Laura Kirsch, Doctoral Student School of Psychiatry University of Arizona Marty Fuentes Tohono O’odam Police Department Patricia Kleiman Special Needs Instructor Detective Vincent Garcia Tohono O’odam Police Department Christie Kroger Arizona Department of Economic Security Division of Children, Youth, and Families Amy Gomez Pima County Attorney’s Office Lori Groenewold, MSW Children’s Clinics for Rehabilitation Services Sarah Long Healthy Families Sergeant Jesus Lopez Pima County Sheriff’s Department Sandy Guizetti Family Courts 74 Stacey Meade Epidemiologist Community Representative Audrey Rogers Pima County Health Department Joan Mendelson Private Attorney Laurie San Angelo Attorney General’s Office Brenda Neufeld, MD Indian Health Services Tina Tarin, MEd Tucson Fire Department Luana Pallanes Pima County Health Department Captain Robert Torres Tucson Fire Department Bruce Parks, MD Forensic Pathologist Pima County Forensic Science Center Christine Trueblood CODAC-Healthy Families Eric Peters Pima County Medical Examiner’s Office Angela Tuzzolino Arizona Department of Economic Security Child Protective Services Cindy Porterfield, MD Pima County Medical Examiner’s Office Sergeant Carlos Valdez Tucson Police Department Carol Punske, MSW Arizona Department of Economic Security Division of Children, Youth, and Families Donald Williams Indian Health Services Barbra Quade Jewish Family Services David Winston, MD, PhD Forensic Pathologist Pima County Forensic Science Center 75 Pinal County Child Fatality Review Team Chair/Coordinator Leah Lara Against Abuse, Inc. U Members Detective Amy DeLeon Casa Grande Police Department U Robert Kull, MD (retired) Pediatrician Sylvia Lafferty Pinal County Attorney’s Office Mark Dyrdahl Arizona Department of Economic Security Division of Children, Youth, and Families Corporal Kent Ogaard Pinal County Sheriff’s Office Andrea Kipp Pinal County Sheriff’s Office Tom Schryer Pinal County Health Department Detective Gary Vance Apache Junction Police Department 76 Yavapai County Child Fatality Review Team Chair/Coordinator Barbara Jorgensen, MSN, RN Yavapai County Community Health Services U Secretary Carol Espinosa U Members Doug Brown Yavapai County Attorney’s Office B.J. Jordison Yavapai Regional Medical Center Esther Brohner CASA Dennis McGrane Yavapai County Attorney’s Office Sue Carlson Licensed Counselor Kathy McLaughlin Yavapai Family Advocacy Center Karen Dansby, MD Pediatrician LaRayne Ness Yavapai Regional Medical Center Pam Edgerton Yavapai County Sheriff’s Office Cynthia Ross Yavapai County Medical Examiner’s Office Bill Hobbs Yavapai County Attorney’s Office Becky Ruffner Prevent Child Abuse Arizona Dawn Kimsey Arizona Department of Economic Security Division of Children, Youth, and Families Kathy Swope School Nurse Yavapai County Education Services Agency U 77 Yuma County Child Fatality Review Team Chair Patti Perry, MD Pediatrician U Coordinator Chip Schneider Amberly’s Place U Members Diana Gomez Yuma County Health Department U Sonny Hixon Yuma County Sheriff’s Office Detective Debbie Machin Yuma Police Department Maria Nunez Yuma County Health Department Maria Ortega Arizona Department of Economic Security Child Protective Services Diane Umphress Executive Director Amberly’s Place Jim Miller SAFE KIDS Yuma County Health Department Tom Varela Yuma County Attorney’s Office Alice Nelson Parent Representative Robert Vigil Medical Examiner’s Office 78 Arizona Department of Health Services Bureau of Women’s and Children’s Health Injury Prevention and Child Fatality Review Section U Tomi St. Mars, RN, MSN, CEN, FAEN, Section Manager Jamie K. Smith, MS, MPH, Child Fatality Review Program Manager Alana Shacter, MPH, Injury and Child Fatality Epidemiologist Teresa Garlington, Administrative Secretary Office of Assessment and Evalution U Khaleel Hussaini, PhD, Office Chief Terri Baxter, Administrative Assistant III (Data Quality) Tia Davis, Data Manager Marilyn Seiler, Data Manager LaTonya VanDenburgh, Data Manager Terry Williamson, Data Manager 79 To obtain further information, contact: Arizona Department of Health Services Public Health Prevention Services Bureau of Women’s and Children’s Health Child Fatality Review Program 150 North 18th Avenue, Suite 320 Phoenix, AZ 85007 Phone: (602) 364-1400 Fax: (602) 364-1496 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/phs/owch/cfr.htm 80