Issue Brief

Bridging the Gaps: How current law limits the effectiveness of Colorado’s child fatality reviews.

When a child dies in Colorado, there is no consistent and transparent process that guarantees all systems – including law enforcement, schools and hospitals – are notified of their roles. This includes cases in which the child died of abuse and neglect. Conversely, there is no accountability mechanism for ensuring that all systems capable of preventing child maltreatment deaths are improving their practices. There are multiple entities engaged with reviewing child maltreatment deaths. There is not, however, a single entity responsible for implementing standard protocols for notifying agencies of lapses, issuing recommendations for improvements and ensuring those changes are made.

The Office of Colorado’s Child Protection Ombudsman (CPO) received complaints regarding the maltreatment deaths of seven Colorado children. A review of child maltreatment data for six years – 2014 through 2020 – shows that, on average, such information was not disclosed to the public in at least 39 percent of child maltreatment deaths. Despite decades worth of child maltreatment reviews and recommendations, no one can explain why child abuse and neglect deaths in Colorado remain constant, nor what specific actions have been most effective in preventing such deaths. In fact, there is not a definitive number for how many children have died of abuse or neglect during the past six years. This is because the two agencies statutorily charged with reviewing child maltreatment deaths define maltreatment deaths differently. Between 2014 and 2020, anywhere between 206 and 273 children died of abuse and/or neglect in Colorado. While the processes and role of each review team differ, neither team has a process prescribed in statute for disseminating recommendations directly to entities involved with a child prior to their death and monitoring to make sure such recommendations are implemented.

Colorado’s bifurcated system has created a patchwork approach to reviewing child maltreatment deaths that inherently limits information about the systems that served children prior to their deaths. Often the reviews focus on the circumstances surrounding the child’s death and the processes that took place after the child died – instead of the services provided to the child during their lifetime.