Broome County Child Fatality Review Team Issues Report June 20, 2017

Broome County Child Fatality Review Team Issues Report

Top Priority: Safe Sleep Practices for Infants


(BINGHAMTON, NY) – The Broome County Child Fatality Review Team (BC CFRT) released a report today summarizing findings and recommendations to help prevent future child deaths and to promote the safety of children in Broome County.

The report comes after the Team closely examined 83 cases involving children aged 0-17 who died during years 2007-2016. The BC CFRT does not review all child deaths. The Team has been reviewing cases since March of 2009. Approximately 10 cases are reviewed each year.

The Team, comprised of professionals from multiple disciplines including medicine, law enforcement, child welfare, public health and behavioral health, is authorized by New York State Social Services Law (SSL) to review the death of any child under the age of 18 whose death is unexpected or unexplained.   Priority is given to review cases with Department of Social Services involvement.

“The death of any child is tragic. The BC CFRT works to develop an understanding of how and why children die, and to take the steps necessary to improve their health, safety and protection,” said Dr. Christopher Ryan, Medical Director at the Broome County Health Department.

The Team’s findings in this report indicate that 28 percent of the child deaths that occurred were due to natural causes, involving acute illnesses or conditions suffered by children with chronic medical concerns, or undiagnosed congenital conditions or illnesses of unknown origin.

Forty-eight percent were certified as accidental deaths. These cases included accidental asphyxiation, drowning, allergic reactions, smoke inhalation, injuries due to a fall, prescription drug overdose, and transportation-related deaths.

The remaining 24 percent were homicide, suicide or undetermined.  The cases deemed “undetermined” involved a manner of death that could not be determined by a coroner or pathologist after an investigation was completed.


The examination of these cases has helped the BC CFRT identify patterns and behaviors that, if changed, can possibly help prevent child deaths in the future.

A major theme that has emerged from reviewing cases over the course of several years is the role of safe sleep practices in reducing sudden unexplained infant death (SUID). The BC CFRT found that sleep environment is a very important element to be considering in understanding how and why some infants die.

Of the cases reviewed by the BC CFRT, regardless of death certification, the Team determined 28 cases (33%) involved hazardous sleep environments. Hazardous sleep environments involve infants placed to sleep in environments that place them at significant risk of suffocation or asphyxiation. Such environments include the presence of pillows, cushions, blankets, comforters, stuffed animals, pets, siblings and include instances in which a child is placed to sleep on their stomach.

Most notable, in 14 cases an infant was co-sleeping with or sharing a sleep surface with at least one adult. At some point during the sleep episode the adult(s) and/or the bedding created a situation in which the infant was asphyxiated or suffocated. All of these co-sleeping deaths may have been preventable.

The Team recommends caregivers follow the American Academy of Pediatrics’ guidelines for infant sleep safety.  Infants should be placed alone, on their back, in an empty crib.  The crib should meet current safety standards and have a firm mattress sized appropriately for the crib, with a tight-fitting sheet.  The crib should be free of bumper pads, pillows, blankets, stuffed animals, etc.  In addition, if possible, the crib should be in the same room as the parents.  Your baby should not sleep in an adult bed, or a couch, or on a chair alone, with you, or with anyone else.

The BC CFRT recommends the community continue to invest in educating all types of caregivers regarding the safe sleep of infants, including: parents, grandparents, intimate partners, daycare providers, and babysitters.

In addition, the BC CFRT also has issued community recommendations that include Substance Use/Abuse, Consumer Product Safety and Reducing Risk – Use Well Established Safety Devices/Procedures.

A copy of the full report can be found on the Broome County Health Department’s website at



06/20/2017 - 3:14pm