Colorado Code § 26-1-139

Child fatality and near fatality prevention - process - department of human services child fatality review team - reporting - rules - legislative declaration - definitions
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(1) The general assembly hereby finds and declares that:
(a) It is of the utmost importance and a community responsibility to mitigate the
incidents of egregious abuse or neglect, near fatalities, or fatalities of children in the state due to
abuse or neglect. Professionals from disparate disciplines share responsibilities for the safety and
well-being of children as well as expertise that can promote that safety and well-being.
Multidisciplinary reviews of the incidents of egregious abuse or neglect, near fatalities, or
fatalities of children due to abuse or neglect can lead to a better understanding of the causes of
such tragedies and, more importantly, methods of mitigating future incidents of egregious abuse
or neglect, near fatalities, or fatalities.
(b) There is a need for agency transparency and accountability to the public regarding an
incident of egregious abuse or neglect against a child, a near fatality, or a child fatality that
involves a suspicion of abuse or neglect when the child or family has had previous involvement,
as defined in paragraph (c) of subsection (2) of this section, with the state or county within three
years prior to the incident.
(c) There is a need for a multidisciplinary team to conduct in-depth case reviews after an
incident of egregious abuse or neglect against a child, a near fatality, or a child fatality that
involves a suspicion of abuse or neglect and when the child or family has had previous
involvement, as defined in paragraph (c) of subsection (2) of this section, within three years prior
to the incident. The multidisciplinary reviews would complement that of the review conducted
by the Colorado state child fatality prevention review team in the department of public health
and environment pursuant to article 20.5 of title 25, C.R.S. The goal of the multidisciplinary
review shall not be to affix blame, but rather to improve understanding of why the incidents of
egregious abuse or neglect against a child, near fatalities, or fatalities of a child due to abuse or
neglect occur, to identify and understand where improvements can be made in the delivery of
child welfare services, and to develop recommendations for mitigation of future incidents of
egregious abuse or neglect against a child, near fatalities, or fatalities of a child due to abuse or
neglect.
(d) It is the intent of the general assembly to codify the department of human services
child fatality review team as well as modify certain aspects of its processes to promote an
understanding of the causes of each incident of egregious abuse or neglect, near fatality, or
fatality of a child due to abuse or neglect, identify systemic deficiencies in the delivery of
services and supports to children and families, and recommend changes to help mitigate future
incidents of egregious abuse or neglect against a child, near fatalities, or fatalities of children due
to abuse or neglect.
(e) It is further the intent of the general assembly to comply with the federal "Child
Abuse Prevention and Treatment Reauthorization Act of 2010", Pub.L. 111-320, which requires
states to allow for public disclosure of the findings or information about a case of child abuse or
neglect that resulted in a child fatality or near fatality, and to include in the disclosure the age,
gender, and race or ethnicity of the child to better understand trends and patterns of child
fatalities in Colorado as they relate to age, gender, and race or ethnicity.
(2) As used in this section, unless the context otherwise requires:
(a) "Incident of egregious abuse or neglect" means an incident of suspected abuse or
neglect involving significant violence, torture, use of cruel restraints, or other similar, aggravated
circumstances that may be further defined in rules promulgated by the state department pursuant
to this section.
(b) "Near fatality" means a case in which a physician determines that a child is in
serious, critical, or life-threatening condition as the result of sickness or injury caused by
suspected abuse, neglect, or maltreatment.
(c) "Previous involvement" means a situation in which the county department has
received a referral, responded to a report, opened an assessment, provided services, or opened a
case in the Colorado TRAILS system that is related to the provision of child welfare services, as
defined in section 26-5-101 (3).
(d) "Suspicious fatality or near fatality" means a fatality or near fatality that is more
likely than not to have been caused by abuse or neglect.
(e) "Team" means the department of human services child fatality review team
established in rules promulgated pursuant to section 26-1-111 and codified pursuant to
subsection (3) of this section.
(3) There is hereby established in the state department the department of human services
child fatality review team. The team shall have the following objectives:
(a) To assess the records of each case in which a suspicious incident of egregious abuse
or neglect against a child, near fatality, or child fatality due to abuse or neglect occurred and the
child or family had previous involvement, as defined in paragraph (c) of subsection (2) of this
section, within three years prior to the incident of egregious abuse or neglect against a child, near
fatality, or fatality of a child due to abuse or neglect;
(b) To understand the causes of the reviewed incidents of egregious abuse or neglect
against a child, near fatalities, or child fatalities;
(c) To identify any gaps or deficiencies that may exist in the delivery of services to
children and their families by public agencies that are designed to mitigate future child abuse,
neglect, or death; and
(d) To make recommendations for changes to laws, rules, and policies that will support
the safe and healthy development of Colorado's children.
(4) The team shall have the following duties:
(a) To review the circumstances around the incident of egregious abuse or neglect
against a child, near fatality, or child fatality;
(b) To review the services provided to the child, the child's family, and the perpetrator
by the county department for any county with which the family has had previous involvement, as
defined in paragraph (c) of subsection (2) of this section, within three years prior to the incident
of egregious abuse or neglect against a child, near fatality, or fatality of a child due to abuse or
neglect;
(c) To review records and interview individuals, as deemed necessary and not otherwise
prohibited by law, involved with or having knowledge of the facts of the incident of egregious
abuse or neglect against a child, near fatality, or fatality of a child due to abuse or neglect,
including but not limited to all other state and local agencies having previous involvement, as
defined in paragraph (c) of subsection (2) of this section, within three years prior to the incident
of egregious abuse or neglect against a child, near fatality, or fatality of a child due to abuse or
neglect;
(d) To review the county department's compliance with statutes, regulations, and
relevant policies and procedures that are directly related to the incident of egregious abuse or
neglect against a child, near fatality, or fatality;
(e) To identify strengths and best practices of service delivery to the child and the child's
family;
(f) To identify factors that may have contributed to conditions leading to the incident of
egregious abuse or neglect against a child, near fatality, or fatality, including, but not limited to,
lack of or unsafe housing, family and social supports, educational life, physical health, emotional
and psychological health, and other safety, crisis, and cultural or ethnic issues;
(g) To review supports and services provided to siblings, family members, and agency
staff after the incident of egregious abuse or neglect against a child, near fatality, or fatality;
(h) To identify the quality and sufficiency of coordination between state and local
agencies;
(i) To develop and distribute the following reports, the content of which shall be
determined by rules promulgated by the state department pursuant to subsection (7) of this
section:
(I) On or before July 1, 2014, and on or before each July 1 thereafter, an annual child
fatality and near fatality review report, absent confidential information, summarizing the reviews
required by subsection (5) of this section conducted by the team during the previous year. The
report must also include annual policy recommendations based on the collection of reviews
required by subsection (5) of this section. The recommendations must address all systems
involved with children and follow up on specific system recommendations from prior reports
that address the strengths and weaknesses of child protection systems in Colorado. The team
shall post the annual child fatality and near fatality review report on the state department's
website and distribute it to the Colorado state child fatality prevention review team established in
the department of public health and environment pursuant to section 25-20.5-406, C.R.S., the
governor, the health and human services committee of the senate, and the public health care and
human services committee of the house of representatives, or any successor committees. The
annual child fatality and near fatality review report must be prepared within existing resources.
(II) The final confidential, case-specific review report required pursuant to subsection
(5) of this section for each child fatality, near fatality, or incident of egregious abuse or neglect.
The final confidential, case-specific review report shall be submitted to the Colorado state child
fatality prevention review team established in the department of public health and environment
pursuant to section 25-20.5-406, C.R.S.
(III) A case-specific executive summary, absent confidential information, of each
incident of egregious abuse or neglect against a child, near fatality, or child fatality reviewed.
The team shall post the case-specific executive summary on the state department's website.
(5) (a) Each county department shall report to the state department any suspicious
incident of egregious abuse or neglect against a child, near fatality, or fatality of a child due to
abuse or neglect within twenty-four hours of becoming aware of the incident of egregious abuse
or neglect against a child, near fatality, or fatality of a child due to abuse or neglect. If the county
department has had previous involvement, as defined in paragraph (c) of subsection (2) of this
section, within three years prior to the incident of egregious abuse or neglect against a child, near
fatality, or fatality of a child due to abuse or neglect, the county department shall provide the
state department with all relevant reports and documentation regarding its previous involvement
with the child within sixty calendar days after becoming aware of the incident of egregious abuse
or neglect against a child, near fatality, or fatality of a child due to abuse or neglect. The state
department may grant, at its discretion, an extension to a county department for delays outside of
the county department's control regarding the receipt of all relevant reports and information
critical to an effective review, including but not limited to the final autopsy and law enforcement
reports, until such documents can be made available for review by the team.
(b) Within three business days after receiving from a county department the information
provided pursuant to subsection (5)(a) of this section, the department shall disclose to the public
that information has been received, whether the department is conducting a review of the
incident, whether the child was in the child's own home or in foster care, as defined in section
19-1-103, and the child's gender and age. The department may disclose the scope of the review.
(c) The team shall complete its review of each incident of egregious abuse or neglect,
near fatality, or fatality of a child due to abuse or neglect, draft a confidential, case-specific
review report, and submit the draft report to any county department with previous involvement,
as defined in paragraph (c) of subsection (2) of this section, within fifty-five calendar days after
the review team meeting. Any county department with previous involvement, as defined in
paragraph (c) of subsection (2) of this section, has thirty calendar days after the completion of
the draft confidential, case-specific review report to review the draft confidential, case-specific
review report and provide a written response to be included in the final confidential, case-
specific review report. A confidential, case-specific review report must be finalized and
submitted pursuant to paragraph (e) of this subsection (5) no more than thirty calendar days after
the county department's response is received by the team or upon confirmation in writing from
the county department that a written response will not be provided.
(d) The proceedings, records, opinions, and deliberations of the department of human
services child fatality review team shall be privileged and shall not be subject to discovery,
subpoena, or introduction into evidence in any civil action in any manner that would directly or
indirectly identify specific persons or cases reviewed by the state department or county
department. Nothing in this paragraph (d) shall be construed to restrict or limit the right to
discover or use in any civil action any evidence that is discoverable independent of the
proceedings of the department of human services child fatality review team.
(e) The team shall provide the final confidential, case-specific review report to the
executive director, the director for any county or community agency referenced in the report, the
county board of human services of any county department with previous involvement, as defined
in subsection (2)(c) of this section, the legislative members of the team appointed pursuant to
subsection (6)(f) of this section, the department of public health and environment, and the office
of the child protection ombudsman pursuant to section 19-3.3-103 (1)(a)(II)(B).
(f) The state department shall post on its website, within seven business days after the
report's finalization, a case-specific executive summary of the final confidential, case-specific
review report, absent confidential information as described in paragraph (i) of this subsection
(5), of each incident of egregious abuse or neglect against a child, near fatality, or child fatality
reviewed pursuant to this section.
(g) The case-specific executive summary for a child who was not in foster care, as
defined in section 19-1-103, at the time of the fatality must include:
(I) The child's name, date of birth, and date of fatality;
(II) The age, gender, and race or ethnicity of the child and a description of the child's
family, including the birth order of the child whose death is being reviewed;
(III) A statement of any child welfare services, as defined in section 26-5-101 (3), and
any other government assistance or services that were being provided to the child and are
recorded in the state's human services case management systems, including TRAILS, the
Colorado benefits management system, or the Colorado child care automated tracking system,
any member of the child's family, or the person suspected of the abuse or neglect;
(IV) The date of the last contact between the agency providing any child welfare service
and the child, the child's family, or the person suspected of the abuse or neglect;
(V) The age, income level, and education level of the legal caretaker at the time of the
fatality;
(VI) Information on the person or persons caring for the child at the time of the fatality;
and
(VII) Any other information required by rules promulgated by the state department
pursuant to subsection (7) of this section.
(h) The case-specific executive summary for a child who was in foster care, as defined in
section 19-1-103, at the time of the incident must include:
(I) The child's name, date of birth, and date of fatality;
(II) The age, gender, and race or ethnicity of the child;
(III) A description of the foster care placement;
(IV) The licensing history of the foster care placement;
(V) A statement of any child welfare services, as defined in section 26-5-101 (3), and
any other government assistance or services that were being provided to the child and are
recorded in the state's human services case management systems, including TRAILS, the
Colorado benefits management system, or the Colorado child care automated tracking system,
any member of the child's family, or the person suspected of the abuse or neglect;
(VI) The date of the last contact between the agency providing any child welfare service
and the child, the child's family, or the person suspected of the abuse or neglect; and
(VII) Any other information required by rules promulgated by the state department
pursuant to subsection (7) of this section.
(i) The case-specific executive summary or other release or disclosure of information
pursuant to this section shall not include:
(I) Any information that would reveal the identity of the child who is the subject of the
executive summary, any member of the child's family, any member of the child's household who
is a child, or any caregiver of the child;
(II) Any information that would reveal the identity of the person suspected of the abuse
or neglect or any employee of any agency that provided child welfare services, as defined in
section 26-5-101 (3), to the child or that participated in the investigation of the incident of
fatality, near fatality, or egregious abuse or neglect;
(III) Any information that would reveal the identity of a reporter or of any other person
who provides information relating to the incident of fatality, near fatality, or egregious abuse or
neglect;
(IV) Any information which, if disclosed, would not be in the best interests of the child
who is the subject of the report, any member of the child's family, any member of the child's
household who is a child, or any caregiver of the child, as determined by the state department in
consultation with the county that reported the incident of fatality, near fatality, or egregious
abuse or neglect and the district attorney of the county in which the incident occurred, and after
balancing the interests of the child, family, household member, or caregiver in avoiding the
stigma that might result from disclosure against the interest of the public in obtaining the
information.
(V) Any information for which disclosure is not authorized by state law or rule or
federal law or regulation.
(j) The state department may not release the case-specific executive summary if the state
department, in consultation with the county, determines that making the executive summary
available would jeopardize any of the following:
(I) Any ongoing criminal investigation or prosecution or a defendant's right to a fair
trial; or
(II) Any ongoing or future civil investigation or proceeding or the fairness of such
proceeding.
(k) If at any point in the review process it is determined that the incident of egregious
abuse or neglect against a child, near fatality, or fatality is not the result of abuse or neglect, the
review shall cease.
(l) The state department or any county department may release to the public any
information at any time to correct any inaccurate information reported in the news media, so
long as the information released by the state department or county department is not explicitly in
conflict with federal law, is not contrary to the best interest of the child who is the subject of the
report, or his or her siblings, is in the public's best interest, and is consistent with the federal
"Child Abuse Prevention and Treatment Reauthorization Act of 2010", Pub.L. 111-320.
(6) The team consists of up to twenty members, appointed on or before September 30,
2011, as follows:
(a) Three members from the state department, appointed by the executive director;
(b) Two members from the department of public health and environment, appointed by
the executive director of said department;
(c) Three members representing county departments, appointed by a statewide
organization representing county commissioners;
(d) At least eight additional multidisciplinary members, to be appointed by the members
described in paragraphs (a) to (c) of this subsection (6), including but not limited to
representatives from the office of the child protection ombudsman and from the fields of child
protection, physical medicine, mental health, education, law enforcement, district attorneys,
child advocacy, and any others as deemed appropriate;
(e) For the purposes of participating in a specific case review, additional members may
be appointed at the discretion of the members described in paragraphs (a) to (c) of this
subsection (6) to represent agencies involved with the child or the child's family in the twelve
months prior to the incident of egregious abuse or neglect against a child, a near fatality, or
fatality; and
(f) Two members of the general assembly, one appointed by the majority leader of the
senate and one appointed by the majority leader of the house of representatives; except that, if
the majority leaders are from the same political party, the minority leader of the house of
representatives shall appoint the second member. The members appointed pursuant to this
paragraph (f) are nonvoting members and are not required to be present at any meeting of the
team.
(6.5) Members of the team serve three-year terms and are eligible for reappointment
upon the expiration of the terms. Vacancies shall be filled in a manner and within a time frame to
be determined by rules promulgated by the state department pursuant to subsection (7) of this
section; except that any vacancy of a member appointed pursuant to paragraph (f) of subsection
(6) of this section shall be filled by the appointing authority.
(6.7) The members of the team appointed pursuant to paragraph (f) of subsection (6) of
this section are entitled to receive compensation and reimbursement of expenses as provided in
section 2-2-326, C.R.S.
(7) The state department shall promulgate additional rules, as necessary, for the
implementation of this section, including but not limited to the confidentiality of information in
incidents of egregious abuse or neglect against a child, near fatalities, or child fatalities.

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