NYS Seal




The effectiveness of the child fatality review process in New York State.


To assess the child fatality review process in New York State in order to determine whether the existing systems to review child fatalities are adequate to ensure timely and effective investigations.

December 7, 2005
10:30 AM

Pace University
One Martine Avenue
Graduate Center, Room 206
White Plains, NY

The investigation of child fatalities is one of the most important functions of state and local child protection systems. The current fatality review process varies greatly depending on where the fatality occurred and which entity is conducting the review. The Enactment of the federal Child Abuse Prevention and Treatment Act Amendments of 1996 (CAPTA) required states to conform to federal guidelines regarding child fatality review teams in order to receive grants for child welfare prevention and treatment programs. Chapter 136 of the laws of 1999 amended various provisions of New York State's Social Services Law for the purpose of conforming state law to the new federal requirements and to improve the state's child protective system. Among the requirements added was the authorization for local or regional fatality review teams to investigate child fatalities that are reported to the statewide central register of child abuse and maltreatment and, fatalities of any children who are in foster care at the time of their death.

Incidents that have been publicized over the last several months raise serious concerns about the investigation and corrective action that takes place in the wake of a child fatality. They also raise grave concerns about the quality of the child protection and the care that children in New York State are receiving - sometimes in state-supported programs. Such incidents include: the death of two very young brothers who were known to Child Protective Services and were killed while trapped in a bathroom filling with hot water; the death of a child in a family-based child care program, just after an inspector had been there to check on that program; and the death of a three month old child who was found unresponsive with numerous fractured bones and bruises in a homeless shelter in New York City. Many questions seem to have gone unanswered following these tragedies. How did these and other children die and who is responsible for their deaths? Could something have been done to protect them? Were there opportunities to help these children? What has been done in the wake of these tragedies to improve our child serving and protecting systems?

The Committee is interested in hearing testimony from interested parties to assess the utilization of fatality review teams across New York and to analyze the efficacy of the fatality reports that are completed by the Office of Children and Family Services. The Committee is hoping to obtain testimony about how fatality reviews are conducted in various localities, what best practices have been established in the fatality review process, and whether the reviews have increased public awareness of child abuse, fostered change to better protect children and prevented future deaths.

Please see below for a list of subjects to which witnesses may direct their testimony, which will be discussed at the hearing.

Persons wishing to present pertinent testimony to the Committee at the above hearing should complete and return the enclosed reply form as soon as possible. It is important that the reply form be fully completed and returned so that persons may be notified in the event of emergency postponement or cancellation.

Oral testimony will be limited to 10 minutes' duration. In preparing the order of witnesses, the Committee will attempt to accommodate individual requests to speak at particular times in view of special circumstances. These requests should be made on the attached reply form or communicated to Committee staff as early as possible. In the absence of a request, witnesses will be scheduled in the order in which reply forms are postmarked.

Ten copies of any prepared testimony should be submitted at the hearing registration desk. The Committee would appreciate advance receipt of prepared statements.

In order to further publicize these hearings, please inform interested parties and organizations of the Committee's interest in hearing testimony from all sources.

In order to meet the needs of those who may have a disability, the Assembly, in accordance with its policy of non-discrimination on the basis of disability, as well as the 1990 Americans with Disabilities Act (ADA), has made its facilities and services available to all individuals with disabilities. For individuals with disabilities, accommodations will be provided, upon reasonable request, to afford such individuals access and admission to Assembly facilities and activities.

William Scarborough
Member of Assembly
Committee on Children and Families


  1. The Office of Children and Family Services is charged with investigating and reporting on every fatality of a child whose care has been transferred to an authorized agency and every child whose death has been reported to the statewide central register of child abuse and maltreatment. Is the fatality review process completed by the Office of Children and Family Services an effective process? Are written reports issued within six months from the date of death as required by the Social Services Law? Are the reports helpful in identifying issues in the child protective and law enforcement systems that may have contributed to the child's death? Are local governments provided appropriate and necessary information to make needed changes to better protect children and prevent future deaths? What changes, if any, should be made to the way that the Office of Children and Family Services conducts its investigation of child fatalities and issues its reports?

  2. How many fatality review teams are there in this state? Should there be more? Has the utilization of these teams increased public awareness of child abuse and protocols used by child protective service agencies? If so, how? If not, what needs to change? How do the state and local districts interface?

  3. How does a fatality review team become established? What role does the OCFS play in this establishment? Are there barriers to establishing these teams? If so, how can they be overcome? Are people who are allowed to serve on the team, but who are not mandated by statute to serve on the team, typically included as members of the fatality review team? Is there coordination amongst the members of the teams? If not, what are the roadblocks? What are some suggestions to improving the way that fatality review teams function?

  4. How and when does the fatality review team begin an investigation? What is the timeframe in which the review team is obligated to complete its investigation? Does the team have the authority to subpoena information? Does the local DSS have the ability to disregard/reject requests for information?

  5. Are there challenges unique to establishing fatailty review teams for smaller counties? Are there other unique challenges for establishing fatality review teams in larger cities? Please explain.

  6. Should fatality review teams be allowed to investigate a broader range of child fatalities? If so, what standard should be in place to govern which deaths they are authorized to review?

  7. What changes, if any, should the Legislature consider that would improve the fatality review team process in New York State? What resources would be required to insure effective change?

  8. Should there be one uniform way that child fatalities are reviewed statewide or does the current patchwork of Office of Children and Family Services investigations and reports and various local and regional child fatality review teams create a sufficient system for the effective and timely investigation of child fatalities? Are there any established best practices to serve as models for the review of child fatalities?


Persons wishing to present testimony at the public hearing on The Effectiveness of the Child Fatality Review Process in New York State are requested to complete this reply form as soon as possible and mail it to:

Jennifer Best
Committee Assistant
Assembly Committee on Children and Families
Room 522 - Capitol
Albany, New York 12248
Email: bestj@assembly.state.ny.us
Phone: (518) 455-4371
Fax: (518) 455-4693

box I plan to attend the public hearing on The Effectiveness of the Child Fatality Review Process in New York State to be conducted by the Assembly Committee on Children and Families on December 7, 2005.

box I plan to make a public statement at the hearing. My statement will be limited to 10 minutes, and I will answer any questions which may arise. I will provide 10 copies of my prepared statement.


I will address my remarks to the following subjects:

box I do not plan to attend the above hearing.

box I would like to be added to the Committee mailing list for notices and reports.

box I would like to be removed from the Committee mailing list.


I will require assistance and/or handicapped accessibility information. Please specify the type of assistance required:








*** Click here for printable form ***

New York State Assembly
[ Welcome Page ] [ Committee Updates ]