Child Death Review Team (CDRT)

Child Death Review Team

The CAP Center facilitates the work of the Sacramento County Child Death Review Team (CDRT) which reviews the death of every child in Sacramento County. The primary function of the Sacramento County CDRT is to identify how and why children die in order to facilitate the creation and implementation of strategies to prevent future child deaths.The purpose of the Multidisciplinary Child Death Review Team (CDRT) is to:

  • Ensure that all child abuse-related deaths are identified;
  • Enhance the investigations of all child deaths through multi-agency review;
  • Develop a statistical description of all child deaths as an overall indicator of the status of children; and
  • Develop recommendations for preventing and responding to child deaths based on said reviews and statistical information.

Sacramento County’s CDRT is unique in that it reviews the deaths of ALL Sacramento County children from birth through 17 years of age and has been reviewing deaths and collecting data since 1990. Now, the Sacramento County CDRT serves as a model to replicate for other California counties.  The Sacramento County CDRT has been included in national studies highlighting CDRT best practices. 

For instance, in 2009, the United States Government Accountability Office (GAO) conducted an analysis of national child abuse and neglect data, including the challenges states face in collecting and reporting information on child fatalities from maltreatment to HHS.  As part of this process, the GAO conducted site visits to several organizations across the nation, including Sacramento County’s CDRT.  During this visit, CDRT was able to help provide to the GAO a more in-depth understanding of issues regarding the collection and reporting of child fatality data.


The following comprehensive CDRT reports of child deaths were compiled by Sacramento County’s CDRT: 

2016 CDRT Report

2015 CDRT Report

2013-2014 CDRT Report

2010_2012 CDRT Report

20 Year Retrospective

2009 Annual CDRT Report.pdf

2008 Annual CDRT Report

2007 CDRT Annual Report

2006 CDRT Annual Report

2005 CDRT Annual Report

2004 CDRT Annual Report


The CAP Center recently published the 2010 – 2012 Three Year Report and presented it to the Sacramento County Board of Supervisors on January 27, 2015.

According to the report, 413 children, birth through 17 years of age, who were residents of or whose injuries occurred in Sacramento County, died during the period 2010-2012.  Below is a breakdown of 2010-2012 deaths by causes:

  • Natural causes – 79% (325 of 413)
  • Injury related – 19% (80 of 413)
  • Undetermined – 2% (8 of 413)

The average child death rate decreased from 44.58 (2007-2009) to 37.79 per 100,000 children (2010-2012). The child and abuse and neglect (CAN) homicide rate also decreased from 1.82 deaths (2007-2009) to 1.02 deaths per 100,000 (2010-2012).

During this report period, 11 of the injury related deaths (14%) were the result of a CAN homicide.

Half of the injury related deaths (40 of 80) were youth 10 to 17 years of age. Of these, 19 deaths were third party homicides, two were CAN homicides and 10 were suicides.

Other major findings include:

  • Nearly one-fifth of child deaths were injury-related and preventable.
  • The majority of perpetrators of CAN homicides in Sacramento County are biological parents.
  • Nearly half of CAN homicide perpetrators have a known history of involvement with Child Protective Services as children.
  • Three-fourths of child maltreatment deaths occurred in children five years of age or under.
  • African-American children died at a rate more than two times higher than that of all children in Sacramento County.
  • The number of infant sleep-related deaths has decreased.
  • There is a statistically significant correlation between infant sleep-related deaths and CPS referrals.
  • Families of decedents are more likely to be enrolled in government aid programs.
  • Since 2007 the number of youth deaths due to motor vehicle collisions decreased by 85%
  • The number of injury-related youth deaths decreased by half.
  • Half of youth suicide decedents had a family history of mental health issues.

The 2010-2012 Annual CDRT Report findings and related recommendations were developed with an awareness of the complexity of problems facing Sacramento County’s children and their families.  With that in mind, the prevention strategies recommended not only focus on preventing child deaths, but are also aimed at protecting Sacramento County’s children from disease, disfigurement, disability, emotional damage and other long-range effects of child abuse, accidental injury and poor health. The following are the recommendations included in the report:

  • Expand prevention and early intervention programs to target parents of children older than six years of age, aimed at reducing Child Abuse and Neglect (CAN) homicides in Sacramento County.
  • Continue public education and targeted interventions aimed at modifiable adult behaviors and risk factors contributing to preventable deaths.
  • Sacramento County’s Child Protective Services (CPS) should consider all prior CPS history, specifically that of parents and/or caregivers, in their risk and safety assessments.
  • Sacramento County’s Child Protective Services (CPS) should continue to partner with, and funding should be dedicated to, community-based prevention programs to ensure that the safety and well-being of the child remains central, specifically after a CPS case has been closed.
  • Expand training and education efforts involving infants with Child Protective Services (CPS) referrals to reduce the prevalence of infant sleep-related deaths.
  • Continue the work of the Sacramento County Blue Ribbon Commission to implement and monitor targeted, coordinated efforts to reduce the disproportionate African American child death rates.
  • Sacramento County agencies who serve families enrolled in government aid programs, and their community partners, should expand resources and referrals to include child health and safety.
  • Encourage the continuation of comprehensive child passenger safety programs and car safety programs targeted at youth and their parents.
  • Develop prevention strategies targeting the most at-risk youth, those with a family or individual history of crime, domestic violence, or gang involvement.
  • Ensure there is a coordinated strategy for early identification and intervention of mental health issues among youth.