Kentucky’s Child Fatality and Near Fatality External Review Panel released their 2022 Annual Child Fatality Report, which consists of a comprehensive review of every child death and near death within the 2021 fiscal year 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 just recently released updated data as well. 

The report shows an unfortunate trend that youth under the age of 4 are most susceptible to child fatality. In 2021, 67% of all cases were children under the age of 4. The report shows that the most common cause for fatality or near fatality is neglect. With a total of 135 neglect cases, 44 ending in fatality and 91 in near fatality. 

Other reported reasons for child fatality or near fatality in the commonwealth include overdose/ingestion of medications, physical abuse, abusive head trauma, SUDI (sudden unexpected death of infant), natural causes/medical diagnosis, drowning/near drowning, blunt force trauma – not inflicted, suicide, gunshot (homicide), gunshot (accidental), gunshot (suicide), burn, failure to thrive, smoke inhalation, and traumatic asphyxia.

Several factors can lead to a fatality or near fatality which also indicates there are several ways to prevent these incidents from ever happening. With our youngest children identified as most vulnerable, 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 Charities® 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. What of the following recommendations will you implement today to ensure the safety of children in the commonwealth?

A summary of the panel’s key recommendations: 

Department for Community Based Services:

  • Revise Standards of Practice (SOP) and/or the Structured Decision Making (SDM) manual to allow for consideration of history of prior CPS involvement, age of victim, or professional reporting source as factors in decision making regarding acceptance of CPS reports

Family Recovery Court:

  • Administrative Office  of the Courts should develop a budgetary proposal to expand Family Recovery Courts throughout Kentucky and present the proposal to the Interim Joint Committee on Appropriations and Revenue, Budget Review Subcommittee on Justice and Judiciary, and the Kentucky Opioid Abatement Advisory Commission for appropriations.

Safe Care:

  • The Department for Community Based Services should ensure all notifications of substance exposed infants are referred to the Plan of Safe Care (POSC) program, regardless of whether the case is accepted for investigation.


  • The Cabinet for Health and Family Services, Department for Community Based Services and the Department for Public Health should apply for funding from the Kentucky Opioid Abatement Council, to purchase medication lockboxes that can be distributed during home visits.

Youth Suicides:

  • The Kentucky Department of Professional Licensing should ensure all mental health counselors are providing consistent messaging on safe storage of medication and firearms to the caregivers of children in their practice.

Child-Access Prevention Laws:

  • The Kentucky General Assembly, through the Judiciary Committee, should research national legislative models pertaining to Child-Access Prevention and Safe Storage Laws and develop legislation to implement Child-Access Prevention laws in Kentucky.

Safe Sleep:

  • The Kentucky Society of Addiction Medicine should disseminate Safe Sleep material to all MAT providers and strongly encourage safe sleep education when serving parents and/or caregivers of infants. Education should emphasize the danger of co-sleeping while impaired, even on prescribed medications.


  •  The Kentucky Coroners’ Association and the Department of Criminal Justice and Training should ensure all coroners and deputy coroners understand how to conduct a multidisciplinary investigation. This should include the purpose behind contacting the local DCBS and DPH and obtaining the proper medical history to determine if medical neglect could have played a role in the death.

Law Enforcement:

  • The Department of Criminal Justice Training and the Kentucky State Police Academy should convene a workgroup with representatives from DCBS, forensic pediatrics, and medical examiners to develop a specialized training focused on child fatality and near fatality investigations. This training should focus on the recognition of potential abuse or neglect cases, prompt drug testing when impairment is suspected, collaborative investigations, and pursing criminal charges.

Check out the 2022 Annual Report for a comprehensive list of recommendations.