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Child Death Review Board lays out safe‑sleep, suicide, firearm and abusive‑head‑trauma recommendations; commission asks for task‑force follow up
Summary
The Child Death Review Board presented findings and recommendations after reviewing cases from 2010–2023, urging statewide safe‑sleep education, better suicide case reporting, firearm safe‑storage work and continued funding for abusive‑head‑trauma prevention. Commissioners discussed task forces and declined to immediately adopt all recommendations, requesting further refinement.
Liz Koff, program manager for the Child Death Review Board (CDRB), summarized the board’s 2023 review and annual recommendations, drawing attention to clusters of causes and opportunities for prevention.
Koff reported that CDRB reviewed roughly 400 cases spanning 2010–2023, including about 95 unsafe‑sleep deaths, 54 suicides and 48 firearm‑related deaths (split between homicides and suicides). She said the board’s recommendations emphasize: expanding safe‑sleep education statewide (with attention to rural areas and non‑parent caregivers), improving law‑enforcement reporting and creating a standardized reporting form for suicide deaths so child‑welfare agencies can be notified more consistently, developing public education and an interim study on the mental‑health and economic costs of firearm deaths, and continuing funding for the Period of PURPLE Crying and other abusive‑head‑trauma prevention programs.
During discussion, commissioners pressed for clarity on what the commission’s approval would obligate OCCY to do and whether specific recommendations would be enforceable or require additional work groups and legislative action. Several members voiced concern about mandating notification to child welfare in all suicide deaths without defining the mechanics and safeguards; others suggested forming task forces to further refine recommendations and implementation steps. One participant noted that statistics about toxicology and drug presence (11 percent methamphetamine, 9 percent fentanyl among bodies processed by the medical examiners’ offices) were reported to the group by a medical‑examiner source during CDRB meetings.
A motion to approve the CDRB recommendations was made and seconded, but commissioners ultimately withdrew the motion to allow work groups and refinement of specific recommendations. Commissioners directed staff to consider task forces or smaller subcommittees to flesh out feasible next steps, collection standards and reporting forms and to return with more concrete implementation proposals.
