Posted: August 4, 2017 at 4:28 am

In 2014, 253 children between the ages of birth and 17 died in West Virginia. Of those deaths, 97 could have been prevented, according to the Child Fatality Review report submitted to the state government at the end of 2016. The report, which was the first submitted in a decade despite state legislation requiring it annually, noted that 40 out of the 97 children were infants, who died before seeing their first birthday. Of the remaining 57 children, 40 percent died in automobile accidents.

Several panels of volunteers made up of medical professionals, emergency responders, police investigators, and child protective services workers produced the report. They studied the cases of child deaths from birth to 17 years of age in 2014. Among the key findings: after accidents, suicide was the second most common cause of death for children between the ages of 1 and 17. Four of the 13 suicides were children between the ages of 10 and 14. Additionally, half of the kids who committed suicide did so with firearms. Of the 40 preventable infant deaths, 28 were linked to unsafe sleep practices.

“If more people see [Child Fatality Reviews], then more people will be able to stop these preventable deaths, especially the deaths due to co-sleeping,” said Corporal Marlene Moore of the West Virginia State Police. Moore was a member of the Child Fatality Review Team. “I’ve seen parents who have neglected their children… I have also seen parents who genuinely are trying to do everything they can for their child, they just have limited room and finances.”

The Child Fatality Review, also known as the Child Death Review, is a national program to keep kids alive by examining the circumstances of the deaths of all children. Reviewers identify patterns and risk factors and offer recommendations and measures to prevent future fatalities. In West Virginia, the Office of the Chief Medical Examiner oversees the annual report. Standardized death scene investigation tools, particularly for infant deaths, have been put in place since the review became state policy. The Child Fatality Review has also produced information on drowning prevention and air bag safety for dissemination to draw attention to problems.

West Virginia adopted legislation in 1996, mandating an annual report to its governor based on all cases in the calendar year. Since then, only two reports, the 2007 report and the 2016 report, have been produced. One problem with producing the report is the members of the review teams are volunteers, and a relatively small budget is allocated to West Virginia’s Review.

Kentucky added more than $200,000 to its allocated Child Death Review funds between 2013 and 2015, so in 2016, the state spent more than $418,000. Ohio spent $150,ooo. Toby Wagoner, the communications director for West Virginia’s Department of Health and Human Resources, said the state spent $46,745 for all fatality review teams in 2016. West Virginia has only the 2007 report available on the National Center for Fatality Review and Prevention’s website, while states like Ohio have reports available from 2001-2016.  In Kentucky, the Review process has resulted in graduated driver’s license legislation (limiting hours when 16-year-olds can drive as well as requiring additional supervision and passenger limitations), and educational materials for birthing hospitals to help prevent head trauma. The Review findings have also contributed to Kentucky’s Safe Sleep Campaign.



In 2013, the state adopted new legislation to break the Fatality and Mortality Review Team up among four different panels; the unintentional pharmaceutical drug overdose fatality review panel, child fatality review panel, domestic violence fatality review panel and the infant and maternal mortality review panel. Panel members participate in the review without compensation. Until last summer one full-time person, Maggie Molitor, the Coordinator for the fatality review teams managed the reports, at that time, the OCME hired an epidemiologist and data analyst to work on the review.

Perhaps unsurprisingly, the 2016 review team found a correlation between families living in poverty and infant deaths in 2014. About 67.5 percent of the preventable infant deaths occurred in families living below the poverty line. The 2016 report did not measure the overall economic status of children who died, but the 2007 report noted that 58.2 percent of preventable child fatalities happened to children in poverty.

“There’s also the bigger picture to look at,” said Penny Womeldorff, director of WV Health Start/HAPI Project. “When you look at the economic status, where you live, and where you work, your access to health care… that can impact mom’s health long term and that can impact the health of the baby even while it’s growing inside of mom.”

Story, video and graphics by Nick Foutrakis