Child Fatality Review Team

What are Child Fatality Review Teams?

In 2000, the Massachusetts State Legislature enacted M.G.L. c,38, §2A, which called for the establishment of a state-wide system of Child Fatality Review Teams (CFRTs). The purpose of these teams is to collect and review data on the causes of child deaths, and to recommend changes in policies and programs that will help reduce preventable child death and injuries, and improve services to families. In July 2008, the statute was amended to include the review of "near fatalities." A near fatality is defined as "an act that, as certified by a physician, places a child in serious or critical condition." The law created one State Team and eleven Local Teams.

The Massachusetts State CFRT is chaired by the Chief Medical Examiner and its members include representatives from the Attorney General's office, the Massachusetts DA's Association and the Juvenile Court, the commissioners of several state agencies (Departments of Children and Families, Public Health, Youth Services, Mental Health, Mental Retardation, Education, etc.), key law enforcement officials, the Massachusetts SIDS Center, and pediatric experts from the Mass. Chapter of the American Academy of Pediatrics and the Massachusetts Hospital Association.

Each Local (county) Team is headed by a district attorney and is comprised of representatives from several agencies including, but not limited to, the Office of the Chief Medical Examiner, the Juvenile Court, the Massachusetts Center for Sudden Infant Death Syndrome, the Departments of Public Health and Children and Families, pediatric child abuse teams, law enforcement representatives and child advocates.

Suffolk County Child Fatality Review Team

The Suffolk County CFRT is chaired by the Suffolk County District Attorney's Office. The Team includes the following agencies: Suffolk County District Attorney's Office, Boston Public Health Commission, Boston Children's Hospital, Boston Medical Center, Children's Advocacy Center of Suffolk County, MA Department of Children and Families, MA Department of Mental Health, MA Department of Public Health, MA Center for Sudden Infant Death Syndrome, Office of the Chief Medical Examiner, and the Office of the Child Advocate.

Massachusetts law requires local teams to meet four times per calendar year; the Suffolk County CFRT meets monthly to review fatalities of Suffolk County residents. Additionally, in cases where the injury or fatality of a non-resident was directly related to Suffolk County, the Team may choose to review the case or hold a joint review with the child's former county of residence. The Suffolk County CFRT reviews all deaths of children under age 18 which are not classified as a "natural death"on the death certificate, with the exception of Sudden Unexpected Infant Death (SIDS). Cases with an ongoing criminal investigation are deferred for review until completion of the criminal case.

Since 2000, Suffolk County has reviewed more than one hundred preventable child fatalities. Recommendations from these reviews are submitted to the State Child Fatality Review Team. The State CFRT reports annually to the Governor, the General Court and the public. The Suffolk County CFRT also participates in the National Child Death Review Case Reporting System, a national, web-based data collection system.

How do Child Fatality Review Teams work?

Pursuant to the law, Local teams meet periodically throughout the year to review cases. These reviews are collaborative processes that work to understand the causes of and decrease the number of preventable child deaths. Teams do this by collecting and reviewing data about the circumstances surrounding a child death, promoting cooperation between agencies that protect child and family welfare, and promoting changes in policy or programs that will help prevent child deaths and better serve families.

The types of information teams look for when conducting a review include:

  • What factors contributed to the death?
  • Are there policies or programs that aren't working as well as they could?
  • What other information do people need to know in order to keep children safe?
  • Where is more research needed?
  • How can families be better supported?

Child Fatality Review Teams are not looking to assign blame when a child has died. Teams try to identify system failures that may have been a factor in a child's death. The focus is not to answer "how could this death have been prevented,"but rather "how can we prevent similar deaths in the future?"

Local teams report statistics and recommendations to the State Team, who then reviews all the data and advises the Governor's office, the General Court and the public through recommendations and prevention measures to ensure that good systems are in place to help children and families.

How do teams review cases?

Preventing child death is such an important objective that the law allows teams to collect all records and information related to the cause of death of a child for their reviews.


All information is kept strictly confidential. Child Fatality Review laws are very strict about keeping records and identifying information confidential.

  • Team meetings are not open to the public.
  • Any discussion and information shared during reviews cannot be disclosed outside the team and is exempt from being used in court proceedings.
  • Team members and ad-hoc persons may not disclose information relating to the team's business.
  • Only broad statistics and general recommendations are reported. Reports may not contain any identifying information.

How do CFRTs help children and families in Massachusetts?

According to state statistics, the leading causes of death for children ages 1-17 are injury related (such as car accidents, fire-related injuries and suicides). These injuries are highly preventable. The leading causes of deaths for infants <1 year are prematurity, birth defects, pregnancy complications and SIDS. By better understanding the causes and circumstances of these deaths, CFRTs are able to influence effective changes in laws, policies and agency practices.

Resources and Information

Coping with a child's death can be extremely hard—not only for family and friends, but for first responders and service providers as well. Many supports and resources are available for responders to a crisis scene and family service providers. Members of CFRTs are often directly involved with many of these services.

Susan Goldfarb
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National Center for Child Death Review


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