6301. Child Fatality/Near-Fatality Reviews

Approval:   Jennifer Strus, Assistant secretary

Original Date:

Revised Date: October 31, 2016

Sunset Review: October 31, 2019


Child fatality or near-fatality reviews are used to examine cases involving a fatality and near-fatality of a child and meet specific criteria to:

  1. Increase our understanding of the circumstances surrounding the child's death or near fatal injury.
  2. Examine existing CA policies and procedures to determine the need for policy development or revision, or recommend legislative change. 
  3. Evaluate CA services and community response to the identified needs of the family and to identify areas for education and training.  
  4. Build community alliances, expertise and commitments for program improvements, policy, and procedural changes, and improved multi-disciplinary collaboration.


This policy applies to CA staff.


RCW 74.13.640


  1. A Child fatality or near-fatality review is required for a child under age 18 and the following conditions apply:
    1. The cause of the child’s death or near-fatality is believed to be abuse or neglect.  
    2. There is an open case on the family or CA was providing services to the deceased or injured child within 12 months prior to the fatality or near fatal injury. Adoption support or Tribal Payment Only cases do not meet these criteria, unless there has been another active service provided to the child during the 12 months preceding the death or near-fatality.
  2. The critical incident practice consultant or critical incident review specialist (CIRS) must consult with the Office of the Family and Children’s Ombuds (OFCO) to determine if a child fatality or near-fatality review should be conducted in any case when it is unknown if the death or fatal injury is a result of child abuse or neglect.
  3. The child fatality or near-fatality review process is not a personnel investigation, and the report must not include the name of the employee.
  4. When conducting a child fatality or near-fatality review, the CIRS must:
    1. Organize and facilitate a multidisciplinary Child Fatality or Near-fatality Review Team unless the assistant secretary requests facilitation by an impartial professional.
    2. Consult with the Assistant Attorney General’s office prior to each review when there are legal questions or complex legal issues.
    3. Consult with the CA legislative liaison and the CA assistant secretary when a legislator participates in the review.
    4. Consult with the CA assistant secretary and Department of Social and Health Services (DSHS) Communications Director when a media representative participates in the review.
    5. Consult with the regional administrator (RA) when a CA staff member requests to observe a child fatality or near-fatality review.
    6. Invite committee members who:
      1. Have no prior or direct involvement with the case.
      2. Have professional expertise relevant to the specific issues of the case such as service providers, foster parent representatives, child advocates, medical professionals, law enforcement, and CA staff.
      3. Represent a child’s ethnic or cultural heritage.
    7. Require all review team members, consultants and observers to sign a Child Fatality Case Review Confidentiality Agreement Form DSHS 27-128 or Child Near-fatality Case Review Confidentiality Agreement DSHS Form 27-129 before reviewing CA records or documents.
    8. Request case information from the assigned caseworker, supervisor or area administrator prior to the review.
    9. Arrange interviews with CA caseworkers or any persons involved with the family or the deceased or injured child as appropriate for the review. 
    10. Ensure observers do not participate in review discussions.
  5. The critical incident practice consultant must:
    1. Track the progress and completion of the review in coordination with the Field Operations Division.
    2. Collaborate with the headquarters statewide quality assurance unit manager to track completion of all review recommendations requiring implementation.
    3. Document the completed review in the Administrative Incident Response System (AIRS) under the same incident number identified in the initial AIRS report.
  6. The CIRS must ensure the child fatality review or near-fatality review report includes:
    1. The committee’s discussion and findings addressing policy and case practice or individual employee actions and decisions in the specific case under review.
    2. The committee’s recommendations (if applicable).
  7. The CIRS must ensure the child fatality review report is completed and posted on the public website within 180 calendar days of a child’s death.
  8. When a Child Fatality Review report cannot be completed within the timeframe, CA must request an extension from the Governor. The CIRS will document the request for an extension in the follow-up section in the AIRS report.
  9. The CIRS or designee:
    1. Sends all fatality and near-fatality reports to the DSHS secretary and CA assistant secretary, and CA division directors and regional administrators, as applicable.
    2. Makes fatality and near-fatality reports available to all CA staff.
    3. Provides a copy of all fatality and near-fatality reports to OFCO.
    4. Provides a copy of all redacted child fatality reports to legislative committees and the public though posting on the DSHS internet.
    5. Prepares and distributes the quarterly report findings to the legislature.
  10. The RA or designee collaborates with the CA Headquarters Quality Assurance staff to review the recommendations, and track implementation status and outcomes in response to policy, legislative or training recommendations. The statewide portion of the action plan will include a timeline and monitoring for progress and completion.
  11. All requests for information and documentation about the child fatality report, near-fatality report, or related documents must be forwarded to the Public Disclosure Unit.



Office of the Family and Children's Ombuds