By Bailey Brewer, Intern with Kentucky Youth Advocates

Kentucky’s Child Fatality and Near Fatality External Review Panel released their 2023 Annual Report, which consists of a comprehensive review of every child death and near death within the state fiscal year 2022 referred to the panel by the Department for Community Based Services and Department for Public Health. This panel is required by state law to meet throughout the year to review each child’s case and make recommendations to prevent future incidents. 

This report and recommendation should be taken into consideration in tandem with the annual national Child Maltreatment Report, which was also just recently released with updated child maltreatment data for federal fiscal year 2022.

The Review Panel’s report reveals that the majority of cases the panel reviewed involved very young children, with 75% of the cases involving children less than 4 years old. The report also established that the most common cause of fatalities or near-fatalities is neglect, with a total of 101 neglect cases. A common thread in the findings is the significance of unsafe access to deadly/potentially deadly items and substances, particularly the unsafe access to firearms, opioid medications, and cannabis/THC-containing products. These incidents accounted for over 80% of fatalities and near-fatalities caused by neglect. 

An alarming trend noted in the report is the increased amount of illicit substances accessible to children and the potency of the substances, increasing the risk of ingestion by children. 

Other causes of child fatalities and near-fatalities in the report include:

  • Unsafe sleep – particularly in cases where caretakers are under the influence of medications and/or drugs
  • Physical abuse
  • Sudden Unexpected Death of Infant (SUDI)
  • Abusive Head Trauma
  • Torture
  • Sexual abuse.

The report also points out that there are many characteristics that impacted the number of fatalities and near-fatalities in FFY2022, including:

  • DCBS issues – primarily associated with staffing issues
  • Family financial issues
  • Substance abuse by caregivers and in the home
  • Caregiver and child mental health issues
  • Domestic violence
  • Lack of a family support system
  • Housing instability

These characteristics indicate that there are several ways to prevent these tragic incidents from occurring in the first place. The report shockingly revealed that it estimates that 90% of the cases reviewed could have been prevented. With the understanding that children under the age of 4 are particularly vulnerable in Kentucky, special consideration should be taken to address primary and secondary prevention with families who have children ages 4 and under. The report addresses many recommendations (below) for systems to ensure that communities work together to create safe environments for children.

The tragedy of child fatality and near fatality is 100% preventable.

We all have a role in preventing child maltreatment and the sometimes-fatal consequences of that. Kentucky Youth Advocates is a proud partner of The Kosair for Kids® Face It® Movement, a statewide campaign that builds awareness around child abuse and neglect prevention, promotes best practices to keep kids safe, and advocates for policies to prevent and end child maltreatment. Face It offers resources for families and communities, such as Medication Safety in the Home – a tool with tips for safely storing medications to prevent accidental ingestions by children. 

What of the following recommendations will you implement today to ensure the safety of children in the commonwealth?

A summary of the Review Panel’s key recommendations:

Overdose/Ingestion Cases:
The Department for Public Health should partner with Kentucky healthcare systems to integrate a screening for medication or illicit substance safe storage into the standard electronic health record intake for all pediatric encounters. 

Plan of Safe Care:
The Panel recommends the Kentucky Governor’s Office convene a task force with the goal of developing and implementing a robust Plan of Safe Care to address the needs of substance exposed infants and their caregivers across the Commonwealth. The task force should consist of House & Senate members, Executive Branch personnel, External Child Fatality and Near Fatality Review Panel members, and community stakeholders.

Physical Abuse:
The Kentucky Board of Medical Licensure and Kentucky Board of Nursing should encourage all primary care providers who care for children to complete an Intimate Partner Violence screening safely with their caregivers, to refer to resources for those with a positive screening, and to securely document those results. 

Family Recovery Court:
The Panel hereby requests the Administrative Office of the Courts to prepare and present information regarding any barriers identified in Kentucky which may prevent the full implementation of Family Recovery Courts.  

Department for Community Based Services:
DCBS should explore creating a specialized branch or other processes within Centralized Intake to focus on handling referrals made by a professional reporting source.  

Child-Access Prevention Laws:
The Kentucky General Assembly, through the Judiciary Committees, should research national legislative models pertaining to Child-Access Prevention and Safe Storage Laws with the goal of developing legislative action to encourage and support safe storage practices. 

Youth Suicides:
The Panel recommends that if the Department for Behavioral Health, Developmental and Intellectual Disabilities (DBHDID) does not believe they are the appropriate entity to implement the psychological autopsy, they should identify the recommended agency.

Check out the 2023 Annual Report for a comprehensive list of recommendations.