Standards for public agencies

2020 Edition

Risk Prevention and Management (PA-RPM) 3: Child Fatality and Near Fatality Review

The agency is accountable to the public and manages risk associated with child maltreatment and fatalities.
NA The agency does not provide child and family services
2020 Edition




Proactive, comprehensive, and systematic risk prevention and management practices sustain the agency’s ability to positively impact the communities and people it serves by reducing its risk, loss, and liability exposure.
Full Implementation, Outstanding Performance
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.  
  • All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance. 
Substantial Implementation, Good Performance
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
  • The majority of the standards requirements have been met and the basic framework required by the standard has been implemented. 
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.

Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.  

  • The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.  
  • Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.  
  • Service quality or agency functioning may be compromised.  
  • Capacity is at a basic level.
Unsatisfactory Implementation or Performance
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.  
  • The agency’s observed administration and management infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
Self-Study EvidenceOn-Site EvidenceOn-Site Activities
County/Municipality Administered Agency, State Administered Agency (Central Office), or other Public Entity
  • Procedures for participation on and coordination with child fatality/near fatality review team
  • Public Disclosure law/policy regarding child fatalities and near fatalities 
State Administered Agency (Regional Office)
  • Procedures for participation on and coordination with the local child fatality/near fatality review team, as applicable
All Agencies
  • Reports for the previous year from:
  1. Child fatality/near fatality review team 
  2. Administrative reviews following child fatalities/near fatalities
  • Child fatality/near fatality review team meeting minutes for the previous six months 
  • Documentation of improvement/prevention activities related to any child fatalities or near fatalities in the current long-term planning period
County/Municipality Administered Agency, State Administered Agency (Central Office), or other Public Entity
  • Interviews may include: 
    1. Agency leadership
    2. In-house counsel
    3. Risk management personnel
State Administered Agency (Regional Office)
  • Interviews may include: 
    1. Regional Director

Fundamental Practice

PA-RPM 3.01

The agency increases accountability to the public, promotes safety, and manages risk by:
  1. aggregating information on fatalities and near fatalities from multiple data sources;
  2. actively participating on a multi-disciplinary child fatality and near fatality review team;
  3. participating in investigations of child fatalities and near fatalities, as appropriate, including assessing the safety of surviving children in the home; and
  4. ensuring adherence to the public disclosure policy, which reflects federal statute.

Fundamental Practice

PA-RPM 3.02

The agency incorporates recommendations from the child fatality and near fatality review team into its risk prevention, quality improvement, and long-term planning activities by:
  1. developing a customized improvement plan to implement recommendations;
  2. tracking progress toward plan implementation; and
  3. monitoring and periodically reporting back to the review team on the status of planned improvements.

Fundamental Practice

PA-RPM 3.03

The agency conducts internal administrative reviews following a fatality or near fatality of any child known to the agency to:
  1. assess the agency’s internal operations including adherence to policies and procedures; and 
  2. identify and respond to the social and emotional support needs of staff. 


Conducting administrative reviews of fatalities or near fatalities of “any child known to the agency” means an open case is not required in order to pursue an internal investigation. Agencies should follow state definitions regarding what it means to be “known to the agency” (e.g. how long ago contact was last was made, the type of contact, etc.).
Note: The agency should also conduct aggregate reviews of child fatalities or near fatalities to identify trends or patterns of concern as part of the quarterly review process in PA-RPM 2.03. See PA-RPM 2.04 for additional incident review requirements, including requirements for corrective action.