Kentucky’s Child Fatality and Near Fatality External Review Panel has released its 2024 Annual Report, which includes a comprehensive review of every child death and near-death in the state fiscal year 2023 referred to the panel by the Department for Community Based Services and the Department for Public Health.

This state-mandated panel meets throughout the year to review each case and make policy recommendations aimed at preventing future incidents. This report should be considered alongside the recently released national Child Maltreatment report, which provides updated data on child maltreatment trends in Kentucky and across the United States.

The Review Panel’s report shows a continuing trend of Kentucky’s youngest children being the most vulnerable, with 76% of reviewed cases involving children under age four. In total, the Panel reviewed 219 cases, including 70 fatalities and 149 near-fatalities. The most common cause of fatality or near-fatality was neglect – such as unsafe access to deadly means or supervisory neglect – which was cited in 165 cases (53 fatalities, 112 near-fatalities).

The report also highlights a concerning rise in overdose and ingestion cases, which continue to be a leading factor in child fatalities and near-fatalities. Every fatal overdose/ingestion case reviewed involved a child four years old or younger, reinforcing the heightened vulnerability of Kentucky’s youngest children. The data indicates a significant increase in fentanyl exposure and THC ingestion cases rose again, reflecting the growing concern of unsafe access to medications, illicit substances, and other harmful household products.

Unsafe access to firearms remains another significant and preventable risk. Of the 12 firearm cases the panel reviewed, 11 of which resulted in child deaths due to firearms with the average age for accidental firearm incidents being just 3 years and 9 months old. 

Other leading causes of child fatalities and near-fatalities included:

  • Physical abuse
  • Abusive head trauma
  • Sudden Unexpected Death in Infancy (SUDI)
  • Drowning/near-drowning
  • Youth Suicide

Additionally, many of the reviewed cases shared common family characteristics, including:

  • 73% experienced financial issues
  • 68% experienced ongoing DCBS involvement
  • 67% had a history of prior DCBS involvement
  • 54% had substance abuse present in the home
  • 52% had a caregiver with substance abuse issues
  • 51% experienced environmental neglect

Every child fatality and near fatality is 100% preventable.

We all have a role to play in preventing child maltreatment and its potentially fatal consequences. Kentucky Youth Advocates is a proud partner of The Kosair for Kids® Face It® Movement, a statewide campaign dedicated to raising awareness, promoting best practices for child safety, and advocating for stronger policies to prevent and end child maltreatment.

Face It offers resources for families and communities, including Medication Safety in the Home, a tool that provides practical guidance on safely storing medications to prevent accidental ingestion by children.

Recommendations

The Review Panel’s recommendations outline critical steps that policymakers, state agencies, and communities can take to address the root causes of these tragedies and implement meaningful prevention efforts. Below are key recommendations from the 2024 report aimed at reducing child fatalities and near-fatalities in Kentucky.

Overdose/Ingestion

The Department for Public Health should conduct an aggressive public safety campaign targeting proper medication safe storage, and saturating these critical tools throughout Kentucky communities. The campaign should also encourage the use of fentanyl and xylazine testing strips and Naloxone in pediatric ingestions.

Plan of Safe Care

The Panel recommends the Governor’s Office convene a task force to develop and  implement a Plan of Safe Care for SEIs and their caregivers, including policymakers and child welfare experts.

Department for Community Based Services

The Department for Community Based Services should assess and document CPS staff’s use of virtual contacts (phone, Zoom, etc.) across all practice areas. This review should be integrated into Continuous Quality Improvement (CQI) and the Case Review Process, with any necessary SOP or practice guideline updates issued by January 2026.

Child-Access Prevention

The Kentucky General Assembly, through the Judiciary Committee, should explore model legislative strategies to encourage and support safe storage of firearms. Recommended options for explorations include: 1) Child-Access Prevention and Safe Storage Laws, 2) funding for evidence-based prevention education, and 3) provision of gun locks with every firearm sold to give responsible gun owners the tools to securely store weapons.

Note: SB 105 and HB 581, filed this legislative session, would require gun owners to secure their firearms in a lock box or with a gun lock when they’re not in use and to report any lost or stolen firearms or ammunition to the police.

Youth Suicides

DBHDID and DPH/MCH should convene a workgroup to assess resources needed for statewide Psychological Autopsy implementation. The group should launch pilot projects to identify barriers such as legal authority, staffing, and funding.

Educational Issues

The Kentucky Department for Education should coordinate a presentation with the Panel regarding best practice standards for addressing truancy issues, and the use of virtual school or other non-traditional instructional formats, especially with high risk children.