When a child dies, a new county board is tasked with finding out why and whether similar deaths could be prevented.
Members of the county’s child fatality review board are asked to examine circumstances around a child’s death. That could include identifying lax rules that lead to drownings, getting more information about a new, deadly drug or finding out whether bullying led a teen to commit suicide.
Since the board was formed about a year ago, fewer than 20 children died in Johnson County and the majority were drug overdoses that didn’t require additional investigation, Johnson County Coroner Craig Lutz said.
Members have met a few times but haven’t had any cases that they’ve decided to take a deeper look into yet, Prosecutor Brad Cooper said. The county has few child deaths compared to higher population areas such as Indianapolis or Fort Wayne, Cooper said.
But in a case where the details about why a child died are unclear, the review team will allow more people with different specializations to review the death and offer ideas for how to prevent a similar situation from happening again, Lutz said.
Indiana repeatedly ranks among the worst states in the nation on child death rates. A new state law approved in 2013 required county prosecutors to set up child death review boards to collect more information about child deaths with the goal of finding ways to better identify preventable deaths and take action to stop them.
Those teams consist of members from multiple agencies, including the prosecutor’s office, the county coroner, department of child services, police officers, firefighters, hospital staff and doctors, who are tasked with studying a death to determine what happened and why.
The main goal of the county review team is to identify patterns or come up with ideas that could help prevent a certain type of death. For example, if the county had multiple children dying because parents weren’t following safe sleep practices, the review team could work closely with the hospital or other agencies to provide more information to new parents on safe sleep habits, Cooper said.
In its first year, the board hasn’t had any cases requiring all team members to meet and discuss a death, Cooper said. The entire board doesn’t review every death case, because in any death multiple representatives are already working on a thorough investigation.
For example, in a shaken baby case, the police, prosecutor and doctors determine what happened in order to decide whether to file criminal charges. In an overdose death, the coroner, police and department of child services will investigate to determine what the child may have taken, where he got it from and how widespread the drug is.
The county review board is responsible for investigating any case of sudden, unexpected or unexplained deaths of anyone less than 18 years old. The board also is supposed to investigate any deaths as a result of abuse, neglect, homicide, suicide or accident, according to state law.
“It’s mainly an overall checks and balances thing. It’s a case-by-case situation on determining neglect issues, recall issues. If it’s something involved in a car accident, looking into child safety, airbags, seat belts, were they properly restrained in the car? Being able to maybe identify a pattern or something like that, that’s where a lot of it came from,” Lutz said.
Although the group hasn’t worked as a whole on a specific case, members have already taken some steps to help prevent other deaths without needing an official report from the board, Lutz said.
When a Center Grove teenager died from an overdose of a new drug called N-Bomb, the coroner and police worked quickly to spread information about the drug to the community. Police hosted an informational meeting to inform parents about N-bomb, what it looks like and what it can do, which was well-attended, Lutz said. Investigators from the police department quickly tracked down and arrested the dealers and supplier who sold the drugs to the dead teen.
“In a roundabout way, you’ve got the coroner’s office doing an investigation. You’ve got the sheriff’s office doing the investigation and multiple sets of eyes involved,” Lutz said.
The board may meet early this year to take a closer look at the death of an 11-year-old special needs child, Cooper said. The child had Down syndrome, functioned at the level of a 1-year-old and died after getting his head stuck between slats of the crib.
“That may actually precipitate us getting together with everyone else and figure out if that was a part of something that should have been recalled and let the people know who are still selling these cribs. It may be a safety feature that needs to be added to these cribs. Other child review teams have worked with a local hospital. They provide a little something in the side of the crib protectors that will stop a child from putting its head through,” Cooper said.
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The county has had a child fatality review board in place for about a year. Here’s who involved and what they do:
The board: Required members include the coroner; the prosecutor; at least one representative from the county health department, school district, police department, emergency medical service and fire department; a pediatrician or family practice doctor, a pathologist and a mental health care provider; and Department of Child Services representative and attorney. Other members can include representatives from a local hospital, probation department, court-appointed special advocate program, Department of Natural Resources or Prevent Indiana Child Abuse.
The job: To review any child death case that is sudden, unexpected or unexplained, and any cases determined to result from child abuse or neglect, homicide, suicide or accident.
The goal: To identify patterns or factors that led to the child’s death and that could be prevented. For example, if multiple infants die because parents aren’t following safe sleep guidelines, the board could work with local hospitals or other groups to increase awareness.
Johnson County’s team: The board hasn’t met to discuss or further investigate any specific case. Board members are completing investigations and reports as part of their typical duties. For example, the coroner, police, Department of Child Services and prosecutor work together to investigate a shaken baby death.
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