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Local Child Fatality Review Teams


The Indiana Child Fatality Review Program attempts to better understand how and why children die, take action to prevent other deaths, and improve the health and safety of our children.


Understanding the circumstances causing a child’s death will help prevent other deaths, poor health outcomes, and injury or disability in other children.

Overview of the Program

Child Fatality Review (CFR) is a collaborative process that can help us better understand why child fatalities occur within the community and help us identify how we can prevent future deaths. CFR teams are multidisciplinary, professional teams that will conduct a comprehensive, in-depth review of a child’s death and the circumstances and risk factors involved, and then seek to understand how and why the child died so that future injury and death can be prevented.

On July 1, 2013, a new Indiana law (IC 16-49) went into effect, requiring child fatality review teams in each county, with coordination and support for these teams to be provided by the Indiana Department of Health (IDOH). Prior to this, the local child fatality review teams fell under the auspices of the Indiana Department of Child Services (DCS) and were required in each of the 18 DCS regions. IC 16-49, also required that a coordinator position be created under the IDOH to help support and coordinate the local teams and Statewide Child Fatality Review Committee--whose members are appointed by the Governor.

The county prosecuting attorney in each county is required by this new legislation to establish a Child Fatality Committee whose membership includes: the prosecuting attorney or their representative, the county coroner or deputy coroner, and representatives from the local health department, DCS, and law enforcement. The Child Fatality Committee is responsible for selecting members to serve on the Local Child Fatality Review Team and determining whether to establish a county child fatality review team or enter into an agreement with another county or counties to form a regional child fatality review team.

Each local child fatality review team will be made up of a coroner/deputy coroner, a pathologist, and pediatrician or family practice physician, and local representatives from law enforcement, the local health department, DCS, emergency medical services, a school district within the region, fire responders, the prosecuting attorney’s office, and the mental health community. The teams are required to review all deaths of children under the age of 18 that are sudden, unexpected or unexplained, all deaths that are assessed by DCS, and all deaths that are determined to be the result of homicide, suicide, accident, or are undetermined.

Essentially, the teams will review all child deaths that are not medically expected. To determine which cases meet the criteria for review, the local teams will examine death certificates provided to the team by the local health officer in each county. The local teams will provide the aggregate data collected from their reviews to the Statewide Child Fatality Review Committee. The Statewide Committee will then endeavor to classify the details of these deaths, identify trends, and inform efforts to implement effective statewide strategies designed to prevent injuries, disability, and death for our children. By working together to understand the circumstances involved in a child’s death, we can make Indiana a healthier and safer place for our children.


Pam Ashby
Child Fatality Programs Director

Brittany Rutledge
Northern CFR Coordinator

Crystal Gummere
Central CFR Coordinator

Rachel Eckstein
Southern CFR Coordinator

Alexis Builta
SUID/SDY Case Registry Manager