Home Contra Costa County Report: Most Children’s Deaths in Contra Costa Reviewed by Expert Team Were Preventable

Report: Most Children’s Deaths in Contra Costa Reviewed by Expert Team Were Preventable

by ECT

CONCORD —  According to the recently released Contra Costa County Child Death Report, most deaths of children in Contra Costa between the years of 2008-2012 could have been prevented by safe sleeping practices, more active adult supervision and other interventions.

The report was prepared by the Child Death Review Team, a multidisciplinary group that includes representatives from multiple County agencies including health services, law enforcement, social services, probation, crisis, and EMS. The team examined 155 coroner’s cases over a five-year period involving children under age 18. Coroner cases are classified as accidents, homicides, suicides, natural or undetermined.

The Child Death Report did not examine natural deaths where a child had been under medical care for disease, cancer or other known health conditions. The coroner’s cases reviewed in the report represent about one-third of all child deaths in the county during the study period.

CoCo-County-Child-Death-Report-1The report concluded that 65% of the deaths reviewed were likely preventable. “To put it another way, 100 of those 155 deaths did not need to happen,” said Dr. Jim Carpenter, a child abuse pediatrician who serves as the team’s chair.

According to the report, a disproportionate share of the deaths reviewed involved infants before their first birthdays. Of the 49 studied infant deaths, 73% were classified as sleep-related fatalities in which the babies died from causes such as Sudden Infant Death Syndrome (SIDS) or accidental overlay. All but two were in unsafe sleep environments.

Dr. Carpenter said most sleep-related infant deaths can be prevented by safe sleeping practices, including sleeping on the back and avoidance of bed-sharing. The Child Death Review Team recommended that medical staff at hospitals and clinics should model and educate parents of newborns about safe-sleeping practices.

The report identified other preventable tragedies including nine fatal drownings, two deaths from fires and two children left alone in hot cars. Those deaths could have been prevented by more active supervision, the report concluded. The Child Death Review Team also determined that nearly all 20 fatal motor-vehicle accidents reviewed, most involving unsafe driving by teens, to be preventable.

CoCo-County-Child-Death-Report-2Adolescent deaths from homicide and suicide were also studied. Homicides involving firearms were present in 90% of cases, and 87% of cases involved people of color. Suicides were often impulsive acts precipitated by emotional stress and strife at home or school. Prevention of these deaths is multimodal.

The release of this report coincides with SIDS Awareness Month and the findings coincide with the opinions of child death review teams across the nation. Prevention of many of these deaths must start with education and awareness of the various risks associated with childhood injuries leading to death. The solutions to these tragedies are everyone’s responsibility including teens, parents, the public, social services agencies, government and society at large.


Executive Summary of the Report

This report is based upon the multi-disciplinary reviews of 155 child deaths by the Contra Costa County (CCC) Child Death Review Team (CDRT) covering the years 2008-2012.

The review is limited to CCC Coroner cases of children less than 18 years of age. It does not include many natural deaths where the child had been under medical care for, say, cancer or other known health conditions.

Coroner cases are classified as accidents, homicides, suicides, natural or undetermined. Reviewed deaths represent about one third of all child deaths in CCC over the study period. The total number of child deaths
in CCC between 2008 and 2012 was 496. Of these deaths, 198 or 40% occurred in neonates in the first
month of life and 91 or 18% occurred in infants after the first month of life.

The primary goal of Child Death Review is to understand why children die and to take action to prevent other death or injury. The main conclusions from this review are below.

  1. Preventability: The Contra Costa County CDRT determined that 65% of the deaths reviewed were
    probably preventable by a variety of interventions. In other words, about 100 of the 155 deaths did
    not need to happen. Interventions such as active supervision, safe sleeping practices and more
    limited access to firearms would have prevented many of these deaths.
  2. Ethnicity: We identified ethnic disproportion regarding deaths with, for example, higher rates of African-Americans and Hispanics dying from homicide and sleep-related death compared to Asians and Caucasians. Whether this was more related to socio-economic status could not be determined by the reviews.
  3. Age: The age distribution of deaths favored the very young and the older teens with most deaths in infants or teens aged 15 to17. Infants tended to die in unsafe sleeping environments whereas teens died in accidents, homicide or suicides.
  4. Gender: Males die at a higher rate than females in most classifications of death.
  5. Classification of Death: Accidents or preventable injuries represented the largest percentage of deaths reviewed and were considered preventable for the most part. Homicides, natural, undetermined and suicides followed in order of frequency. Undetermined deaths included a number of sleep-related deaths that were undetermined because the autopsy could not differentiate a Sudden Infant Death Syndrome (SIDS) form an accidental overlay.
  6. Accidental Deaths: were primarily from a Motor Vehicle Collision (MVC) and bed sharing. There were also drownings, fire and 2 children left in cars. All of these deaths were determined to be preventable.
    1. Motor vehicle-related deaths could have been prevented by safer driving and use of seatbelts.
    2. Sleep-related deaths could have been prevented by following safe sleeping practices.
    3. Fire-related deaths could have been prevented by active supervision, working smoke detectors and fire escape plans.
    4. Drownings could have been prevented by active supervision, use of personal flotation devices, working barriers or alarms for pools, and less adolescent risk-taking behaviors.
    5. e. Children left in the car deaths would not have happened with active supervision.
  7. Homicides: were 94% male and 90% involved the use of a firearm. Hispanics and AfricanAmericans constituted 87% of these deaths although they make up only 47% of the CCC population.
    The CDRT determined that the majority of these deaths were preventable although many modalities
    would be necessary besides limiting easy access to firearms.
  8. CoCo-County-Child-Death-Report-3Suicides: were seen in 14 over the 5 year period. Suicides in teens are often an impulsive act precipitated by strife at home or school. 3 of the suicides were by train, 3 by firearm and the rest by asphyxiation. Prevention is multimodality and is the purview of the Crisis Center (see appendix).
  9. Natural Cause of Death: includes medical conditions and SIDS. The majority of these deaths
    occurred in the first year of life with most of these sleep-related deaths. Prevention of these deaths
    includes safe sleeping practices and improved access to healthcare.
  10. Undetermined Cause of Death: was primarily sleep-related death in infancy with an autopsy that
    could not discriminate SIDS from accidental overlay. Most of these deaths were determined to be
    preventable with use of safe sleeping practices.
  11. CoCo-County-Child-Death-Report-4Child Abuse or Neglect-related Deaths: accounted for 3 or 4 fatalities for physical abuse and 16
    deaths from neglect. The neglect-related deaths included drowning, fire, children left in cars, and 2
    untreated illnesses. Prevention includes parenting classes, active supervision and other modalities.
  12. Sleep-related Deaths: include 37 infants whose deaths were classified as natural (SIDS), accidental
    (overlay), or undetermined (either SIDS or overlay). Most if not all of these deaths could have been
    prevented with safe sleeping practices.
  13. Firearm-related Deaths: were predominantly homicides with 3 suicides and one accidental death.
    African-Americans and Hispanics were over-represented in these deaths. Prevention of firearmrelated death is multimodality beginning with limiting easy access to firearms.
  14. Recommendations for Prevention of Childhood Death and Injury in CCC:
    1. Safe to Sleep Campaign for CCC targeting all birthing hospitals, medical providers, home
      visitors, childcare providers and the public.
    2. Promotion of active supervision of children to prevent drowning, fire death, children left in
      cars, and other injuries.
    3. Promotion of safe storage of firearms, buyback programs, assault weapon ban, research in
      the public health aspects of firearm injury, trigger lock give aways.
    4. Promotion of Child Abuse Prevention in all forms including home visitation, parenting
      classes, and mandated reporter trainings.
    5. School drop-out prevention programs, after-school programs, alternative education, bullying
      prevention, teen recreation programs, mentor programs and others.
    6. Promote access to healthcare including mental healthcare and substance abuse treatment.

The death of a child is a tragedy. A preventable death of a child is an unacceptable tragedy. The majority of
the 155 deaths reviewed by the CDRT between 2008 and 2012 were deemed preventable and often by means
no more complicated that the adequate supervision of children.

Some of the findings of this report may come as a surprise to the reader but the reasons children die
in Contra Costa are for the most part, the same reasons that children die in the rest of the USA.

Teens die from three primary manners of death: 1) accidents (better called preventable injuries) with motor vehicle crashes being the single most common cause of death, 2) homicides with 90% involving firearm, and 3) suicides. In the first year of life, the most likely cause of death is related to an unsafe sleeping environment resulting in SUIDS,

SIDS or accidental asphyxia. This is found by all CDRT’s across the country. This has led to a national movement encouraging safe-sleeping practices to be taught, practiced and reinforced from prenatal care, birth and the perinatal period, through the first year of life.

Adequate and active supervision of children would have prevented virtually all of the deaths from fire, drowning and being left in a car.

Which brings us to asking who is responsible for preventing unnecessary child fatalities in Contra
Costa County? The answer is simple: All of us.
Parents are the first and foremost protectors of children. Active supervision includes noticing someone else’s
child about to step in the street or the pool. Preventing injury includes using proper restraints in cars on your
children and yourself and driving safely and defensively. It includes practicing safe-sleeping in the first year of life, even if you shared a bed with your first child without a problem. It includes checking your smoke
detectors annually and having a carbon monoxide detector also. It includes using personal flotation devices
on boats even if it is unlikely that you or your children would fall out. It includes always checking the car seat for a sleeping infant even if you have errands and appointments to get to. Prevention of injuries includes
checking in with your teen and recognizing distress or risk-taking behaviors. Prevention includes safe storage
of a firearm if you have to have a firearm at all.

Teens have a shared responsibility in being aware of their influence on each other and the lack of foresight they may demonstrate in many decisions. Suicides, homicides and MVC’s are fatal consequences of the

Law enforcement have the responsibility of enforcing laws and also often coming to the rescue when injuries
occur. We salute our Emergency Medical Services that have consistently gotten first responders to injuries in
a timely fashion. We would like to decrease their calls by the 65% of potentially, preventable fatalities they
have to respond to.

The media has a role in injury prevention by provision of child safety public service announcements and
stories that educate but do not sensationalize child fatality.

Legislators have a role in child injury prevention and have clear successes in the laws regarding child car
restraints and the graduated driver’s license. Many extant laws such as regarding smoke detectors in rental
units and barriers around pools tend not to be enforced until a tragedy occurs.

It is hoped that this report will elucidate the preventability of childhood injury and fatality so that these 155
children did not die in vain.

It is hoped that the people of Contra Costa County will agree that prevention of child injury and death is a
priority and reachable goal.

The following are some steps to consider for our community:

  1. Safe to Sleep county wide project. Trainings have already taken place at Contra Costa Regional
    Medical Center (CCRMC) for perinatal nurses and pediatricians. A survey of all delivering hospitals
    regarding the delivery of the Safe to Sleep message to parents is in process with all hospitals being
    offered trainings. It has been estimated that 1,000 infants will survive each year in the US if safesleeping practices are more universally practiced.

    Los Angeles County did a county-wide Safe to Sleep campaign 2 years ago, funded by First 5 monies
    and have already seen a decline in sleep-related deaths in infants.

  2. Treat firearm-related injury and death as a public health problem. Blocking research funds for
    the CDC serves no function other than allowing the continuation of gun-related violence and death.
    Safe storage of firearms should be part of child safety discussions in the doctor’s office and not made
    illegal, as it is presently in the state of Florida. The firearm is a consumer product and should be
    made safer and monitored by the Consumer Product Safety Commission (CPSC).
  3. Suicide prevention can only occur if we look out for each other and provide adequate mental
    health services. The majority of teen suicides occur as impulsive acts in response to the myriad
    stressors of adolescence colliding with parents, peers and schools. A growing trend is social media
    induce stress and bullying. Parents need to maintain communication with their teens. Teens need to
    be aware of their influence on each other. Schools need to serve as both places of education but also
    providers of counselling and conflict resolution. The Crisis Center is to be applauded for its decades
    of service to the people in crisis of Contra Costa County (see appendix).
  4. Homicide prevention requires so much more than dealing with easy access to firearms.
    People in poverty need opportunities other than joining gangs. Mentor programs, teen recreation
    programs, summer jobs for teens, bullying prevention, after school programs, school drop-out
    prevention and others should be created, supported and nurtured.
  5. Child fatality review teams also need to be supported and nurtured. All members of the CCC
    CDRT are volunteers from agencies and programs in CCC and squeeze in their case reviews with
    their many other duties. The reason there are not annual reports as suggested by statute has to do
    twitch the lack of funding. This report is possible only due to funds by the department of
    Epidemiology and FMCH.

It is hoped that subsequent reports will be both funded and be more frequent. It is also hoped that agencies
that participate in CDRT will continue to support provision of personnel and time to this endeavor.

For the full report: Click here.

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