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The Allegheny County Child Fatality/Near Fatality Review Team

As mandated by state legislation, Act 33, passed in 2008, Allegheny County developed a core CF/NF Review Team in December 2008. This 24-member team is comprised of DHS staff and community leaders who are well-versed in the field of child abuse. The Allegheny County CF/NF Review Team is chaired by Dr. Mary Carrasco, long-time champion of child abuse prevention and Director of International and Community Health for Pittsburgh Mercy Health System.

pdf.gif Current Allegheny County CFNF Review Team members 

In addition, in Allegheny County core members are always joined by other professionals with particular expertise in the special circumstances surrounding each case.

CFNF Research Report

pdf.gif Improving Systems to Protect Children in Allegheny County: A Report of the Child Fatality/Near Fatality Review Team, 2012
Prepared by: Ebony Robinson, Jean O'Connell Jenkins, LauraEllen Ashcraft, Evelyn Whitehill and Erin Dalton
Published September 2013


The Child Protective Service Law requires that circumstances surrounding cases of suspected child abuse resulting in child fatalities and near fatalities be reviewed at both the state and local levels. To comply with this mandate, the Allegheny County Department of Human Services established a Child Fatality/Near-Fatality (CFNF) review process. The CFNF Review Team examined eight cases of child abuse in 2012 that resulted in three fatalities and five near-fatalities. This report describes the findings and outcomes from these reviews as well as the case practice and system reforms enacted to reduce the likelihood of future child abuse-related incidents.

pdf.gif Improving Systems to Protect Children in Allegheny County: A Report of the Child Fatality/Near Fatality Review Team, 2011
Prepared by: Ebony Robinson, Jean O’Connell Jenkins, Evelyn Whitehill and Erin Dalton
Published November 2012


Act 33 of 2008 requires that circumstances surrounding cases of suspected child abuse resulting in child fatalities and near fatalities be reviewed at both the state and local levels. To comply with this mandate, the Allegheny County Department of Human Services established a Child Fatality/Near Fatality (CFNF) review process. The CFNF Review Team examined 15 cases of child abuse that resulted in eight fatalities and seven near fatalities in 2011. This report describes the findings from these reviews as well as the case practice and system reforms enacted to reduce the likelihood of future child abuse-related incidents.

Background Information

Preparation for review by CFNF Review Team 

Allegheny County convenes the CF/NF Review Team within 31 days of receiving a suspected child abuse report that resulted in a child death or near death. In advance of the review meeting, staff from the DHS Office of Data Analysis, Research and Evaluation (DARE) support the Review Team’s task by researching the case, using a three-part, fact-finding process.

  • Independent, Comprehensive and Critical Review of Case Records 

DHS DARE staff from the Quality Improvement Team thoroughly and critically review past and current CYF case records, while asking the following types of questions: If CYF was involved with the family, what are the details of that involvement? What other DHS offices and systems of care were involved with the child and family? What steps were taken to identify and address known safety factors? Who are the people (family, informal supports, professionals) who have played a role in the life of the child and family? What information can be provided by medical professionals, law enforcement, education professionals and others? 

  • Review of Service Histories for the Child, Family and Caregivers 

By utilizing DHS electronic data systems, DARE staff track the service histories of the child, family and caregivers, including the alleged perpetrator. Information including dates, types of services and providers of services are stored in these confidential, password-protected DHS applications.

  • Interviews with DHS Staff and Providers 

DARE staff interview DHS staff, especially staff from CYF, that have current and past involvement with the child and family. These interviews gather additional information that assists in the review process. These interviews also allow a crosscheck of the information previously gathered with information from professionals directly involved in the case.

Pre-Reporting 

Findings are summarized that tell the story of the child, family and service community, including details surrounding the child’s death or near death.  A smaller pre-review team, comprised of staff from several DHS offices – and facilitated by Dr. Edward Sites, Professor Emeritus from the University of Pittsburgh, School of Social Work – reviews the summarized information, identifies gaps in information and asks the casework staff for clarification of information. This meeting serves to bring all participants to full knowledge about what information, possible questions and recommendations will be presented at the full CF/NF Review Team meeting.

CFNF Review Team Meeting 

When the full CF/NF Review Team convenes, core members and case-specific attendees, including the CYF caseworkers and supervisors as well as professionals from other related disciplines, share what they know about the case in an open and candid way with the rest of the team. The tone of the meetings is non-adversarial, positive, and focused on solutions. Based on all gathered information and subsequent discussions, the Team generates a written report that is approved by the Chair and then sent to the Pennsylvania Department of Human Services. The report includes recommendations for changes at the state and local levels on reducing the likelihood of future child fatalities or near fatalities related to child abuse.

System Improvements resulting from CF/NF recommendations

Action Alert: Safe Sleep 

Related Information
Related Redacted Reports of the CF/NF Review Team

Detailed information about Act 33 of 2008