2019 System Learning Review Summary Report [New Hampshire].
New Hampshire. Office of the Child Advocate.
Published: October 2019
New Hampshire Office of the Child Advocate
Johnson Hall 107 Pleasant Street
Concord, NH 03301
With support from Casey Family Programs, the New Hampshire Office of the Child Advocate (OCA) engaged in consultation with Collaborative Safety, LLC who developed a Systems Learning Review (SLR) process and accompanying instrument to examine child deaths in the State. The SLR is a process to review critical incidents in a way that appreciates the complexity of multi-system influences on child welfare decision making. The SLR is a collaborative evidence-based review process grounded in safety science. This report includes consideration of all child deaths reported to the OCA from February 2018 through September 2019. In that period, the OCA received notice of 26 child deaths. Of those 26 deaths, 15 children or their families had contact with DCYF prior to or at the time of death and five were examined with the SLR. The death of a parent was also examined with the SLR to test the flexibility of the process. DCYF frontline child protective workers, juvenile probation and parole officers, supervisors, field administrators, and other administrators participated in the six SLRs. Through deep case examination, common features and pressure points that impact case work decision making were identified and analyzed for themes of impact on outcomes for children. Findings indicate: the most common manner in which children died in New Hampshire was by natural causes (n=8) and accidents (n=8); the most common cause of accidental death was asphyxiation, related to safe sleep practices; three children committed suicide and two deaths were classified as homicides; 3 deaths were founded for abuse or neglect; and only one family had an open DCYF case for ongoing services. Findings are then reported in 10 different areas of the safety assessment and key considerations are explored. The report closes with recommendations for improving child welfare services.
New Hampshire; child welfare services; decision making; child welfare reform; statistics; CHILD DEATH REVIEW BOARDS; CHILD FATALITIES; HOMICIDE; child abuse; data analysis; evidence based practice