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Fatality Review Department of the Army Update 11 August 2009 Mr. Richard F. Stagliano Family Programs. MWR For All Of Your Life. P.L. 108-136, Sec. 576 Each fatality (implicitly includes suicides)

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Fatality Review Department of the Army Update 11 August 2009 Mr. Richard F. Stagliano Family Programs

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Fatality Review

Department of the Army Update

11 August 2009

Mr. Richard F. Stagliano

Family Programs

MWR For All Of Your Life

fatality review
P.L. 108-136, Sec. 576

Each fatality (implicitly includes suicides)

Known or suspected to have resulted from domestic violence or child abuse against any of the following:

A member of the Army on active duty

A current or former dependent of a member of the Army on active duty

A current or former intimate partner who has a child in common or has shared a common domicile with a member of the Army on active duty

Fatality Review
Fatality reviews are a critical part of the effort to formulate lessons learned and identify trends and patterns that assist in developing policy recommendations for early/effective intervention

Garrison Commanders or their designees have responsibility for conducting fatality reviews (dv, can and suicide related to an act of dv or can), approving and forwarding an annual report through IMCOM to FMWRC – Suspense: 1 May 10

Installation reports are due 24 months following the end of the fiscal year in which fatalities occurred

annual report requirements
An executive summary on each fatality

Victim demographics, injuries, autopsy findings, homicides or suicide methods, weapons, offender demographics, household information and intervention timelines

SJA verified legal disposition involving homicides and conducted a sufficiency review

System interventions and failures

Analysis of significant findings

Recommendations for systemic changes

Services provided to surviving Soldier/Family members

Signed by Garrison Commander

Annual Report Requirements
fatality review committee frc
Chair, Garrison Commander or designee

Meets quarterly

Multidisciplinary and impartial

Members – Core Additional Members

Chief, SWS/CRC Chairperson Dental Activity Commander

FAPM (coordinator) Public Health Nurse

Pediatrician/Family Practice Chaplain

Medical Examiner/Pathologist CYS Coordinator

Staff Judge Advocate PAO

ASAP Clinical Director Consultants

Command Sergeant Major School Counselor

Provost Marshal Child Protective Services

CID Local court administrator


Fatality Review Committee (FRC)
sources of information
ACR and COPS databases

Request information early

Preliminary data from Army Records Center indicated a significant number of cases met the death investigation criteria for fatality review but were not reviewed by local FRCs

Autopsy Report (summary section)/Final CID Report Summary

Used to complete the EXSUM – Spells out the Who, What, Where, When, Why and How regarding the fatality

Used to construct the intervention timelines

Note: Explain if there are differences between information contained in these or other documents

Sources of Information
case summary child
The decedent was a two month old dependent son African-American) of a 21

yr old female PFC assigned to Fort ____ with her 22 yr old dependent

husband (African American). The Family lived off post. On 8 Apr 06, the

infant was taken to MTF via ambulance with no respiration. The civilian father

reported to EMS that while feeding the infant, he became apneic, turning blue

on the lips. The infant was life-flighted to MEDCEN for further care. The infant

received a full non-accidental trauma exam which revealed further injuries to

include brain injury, retinal damage to both eyes and died as a result of his

injuries. Medical personnel at MEDCEN stated that the injuries were

consistent with Shaken Baby Syndrome. The child died on 17 Apr 06. A joint

investigation was conducted between CID and the local police. The mother

and father were charged with murder. The mother was charged with 1st

degree criminal abuse and murder because she allowed her husband to watch

her child even though she had an active protection order against him for

domestic violence.

Case Summary - Child
case summary dv
The decedent was a 22 year old Active Army Specialist African-American)

assigned to _____ with his civilian spouse (Caucasian) and three children.

The Family lived off post. On 11 Dec 05, the 24 year old dependent wife

admitted to stabbing and killing her husband. She stated the incident was due

to an argument with her husband. It was reported that the Soldier overheard

his wife on the phone with another man and an argument ensued. As the

Soldier came towards his wife, she grabbed a kitchen knife off the counter and

stabbed him once in the chest according to police. The Soldier was

intoxicated at the time of the incident. The victim died on 11 Dec 05. The

manner of death was homicide. The children were initially place in the care

and custody of the _____ county Social Services Department and then in the

care of the paternal grandmother. The children received counseling from a

civilian provider. The Soldier was being treated for PTSD and conversion

disorder. He was also participating in ASAP. There was FAP involvement due

to DV. Multiple FAP providers were involved in the case. Although advocacy

and counseling services were offered to the wife, she declined. The wife

received a 10 year confinement sentence which was suspended; she was

placed on probation for five years.

Case Summary - DV
case summary h s
On 5 Nov 05, a retired Army SM (Hispanic), age 44, fatally injured his 36 year

old Active Army SFC spouse (Caucasian) with a gunshot wound to the head.

The husband committed suicide with a self-inflicted gunshot to the head. The

weapon was owned by the husband. The Family lived off post. The

homicide/suicide was witnessed by the couples 13 year old daughter. The

daughter contacted 911 and prevented her 8 year old sister from viewing the

crime scene. The AD spouse redeployed from Iraq, completed block leave

prior to the homicide. The AD spouse had petitioned for divorce (19 yr

marriage) precipitated by spousal’s infidelity. The husband would be granted

the home, the AD spouse would be granted custody of the children. The

incident occurred while the AD spouse was relocating. The autopsy findings

reported the husband’s blood alcohol was negligible (wine). The command

and neighbors reported no red flags for the couple. The victim had

completed deployment to Iraq and block leave. The retired SGM participated

in approximately 4 deployments prior to retirement. The daughters were

provided counseling following the death of their parents and relocated to

reside with the paternal grandparents in __________.

Case Summary - H/S
fatality review allows the army to identify systemic problems and formulate lessons learned
Fatality Review – Allows the Army to identify systemic problems and formulate lessons learned

** Note: Army Criteria: Soldier deployed, re-deployed OIF/OEF within 6 months prior to fatality

fy07 can fatalities
14 Child Abuse and Neglect Fatalities

4 (29%) victims were male; 10 (71%) were female

14 (100%) had more than one risk factor

8 (57%) were unknown to FAP

6 (43%) occurred while Soldier was deployed

10 (71%) involved substance abuse/behavioral health issues

11 (78%) were under the age of four; 8 (57%) < one

6 (43%) were neglect; 4 (29%) drowning; 1 (7%) starvation and 1 (7%) smoke inhalation

3 (22%) were accidental deaths, 9 (64%) homicides and 2 (14%) undetermined

4 (44%) offenders were fathers/step-fathers; 4 (44%) were mothers and 1 (12%) was a sibling

2 (14%) had known co-occurrence of domestic abuse

8 (57%) occurred on base; 6 (43%) off base

FY07 CAN Fatalities
fy07 dv fatalities
10 Domestic Violence Fatalities

6 (60%) were suicides, 4 (40%) homicides

4 (40%) had a history of substance abuse

5 (50%) involved firearms

1 (10%) occurred within 6 mos of deployment/re-deployment

5 (50%) couples were separated as a result of severe marital discord

4 (40%) involved allegations of marital infidelity

4 (40%) occurred on base; 6 (60%) off base

FY07 DV Fatalities

Changes in

Community Systems




Cycle of






state agency that leads coordination of cdr program
Source: The National Center for Child Death Review State Profile Database: Reports from State CDR Program Coordinators, May 2009State Agency that Leads Coordination of CDR Program
types of death reviews by state cdr teams
Source: The National Center for Child Death Review State Profile Database: Reports from State CDR Program Coordinators, May 2009Types of Death Reviews by State CDR Teams
dod fatality review summit fy06 results
OSD stated that the Services can collect fatality review data as close to the death as possible, within the limits of the law

Look out for suicides when there is volatility – guns in the home

Marital discord is a predominate factor

Divorce is a high stressor

Threats of homicide and/or suicidal comments should be taken seriously and immediately reported to command and/or appropriate agencies

DoD Fatality Review SummitFY06 Results
dod fatality review summit fy06 results19

Gunshots were cited as the most common method of death by all Services

53% of the victims were active duty members

Alleged offender factors – low marital satisfaction, conflict with partners, reported anger problems and separation from partner


Army and Navy cited blunt force trauma as the leading cause of death; Air Force cited asphyxiation

Approximately half of offenders were active duty service members, and most were male

OSD adopted 4 Army recommendations

Recommendations need to be agency specific

DoD Fatality Review Summit FY06 Results
dod fatality review summit fy06 results20
DHHS agreed to collaborate with DoD in improving access to medical and law enforcement records or death review reports concerning deaths related to child abuse/neglect

DoD will explore whether DOJ grants to states under the Violence Against Women Act could improve similar access to records concerning dv-related deaths

Some child death investigations in the civilian community were more likely to be classified as SIDS because of inadequate law enforcement training

DoD Fatality Review Summit FY06 Results
keys to success
Initiate and support collaboration with other military and civilian agencies

Conduct fatality reviews early

Request data from ACR/CID

Request law enforcement personnel’s assistance in collecting medical records/medical examiner’s information

Utilize the FRC to construct timelines, analyze significant findings/systemic issues, track services to survivors and recommend solutions

Complete specified Data Sheet(s)

Keys to Success
keys to success22
Explain the reason(s) if the requested information in operational guidance cannot be provided

Challenge accidental, SIDS or natural death initial findings

Target high risk populations with effective prevention and education programs

Obtain legal sufficiency review

Ensure installation annual report is signed by the Garrison Commander and received by FMWRC by

1 May 10

Keys to Success
DA Domestic Violence and Child Abuse Fatality Review, Fourth Annual Report, FMWRC, September 2008

HQDA Operational Procedures, 5 Jun 08

Para 2d (1)–(7) through 2g

Para 10, lessons learned

OTSG/MEDCOM Policy Memo 08-033, 22 Jul 08, Mandatory Briefings on Shaken Baby Syndrome

A Program Manual for Child Death Review, National Center for Child Death Review,

Guides to Effective Child Death Reviews, The National MCH Center for Child Death Review

The Status of Child Death Review in the United States in 2008, Updated May 2009, The National Center for Child Death Review State Profile Database

OJJDP Fact Sheet, The National Center on Child Death Review, April 2001, # 12

references cont d
CDC’s Violence Prevention Resources –,

call 1-800-CDC-INFO

Home Fire Safety: Be Safe and Sound, Home Safety Council -

Suicide Prevention Resource Center –, 877-GET-SPRC (877-438-7772)

Sudden Unexplained Death in Childhood Program –,


Stop Bullying Now, Activities Guide –

NFIMR Bulletin: A Publication of the National Fetal-Infant Mortality Review Program, Jan 2000, Fatal and Infant Mortality Review and Child Fatality Review: Opportunities for Local Collaboration

Fact Sheet –, National Center for Child Death Review, 1-800-656-2434

Children’s Safety Network –, National Injury and Violence Prevention Resource Center

References Cont’d
laws directives instructions and regulations
Laws, Directives, Instructions, and Regulations
dod definitions
Child Abuse – The physical or mental injury, sexual abuse or exploitation, or negligent treatment of a child. It does not include discipline administered by a parent or legal guardian to his or her child provided it is reasonable in manner and moderate in degree and otherwise does not constitute cruelty.

Domestic Violence – is an offense under the United States Code, the Uniform Code of Military Justice, or state law that involves the use, attempted use, or threatened use of force or violence against a person of the opposite sex, or a violation of a lawful order issued for the protection of a person of the opposite sex, who is (a) a current or former spouse; (b) a person with whom the abuser shares a child in common; or (c) a current or former intimate partner with whom the abuser shares or has shared a common domicile.

DoD Definitions
army child abuse cases fy 2000 2008
Army Child Abuse Cases FY 2000-2008

Data from Army Central Registry, 6 Feb 09

army spouse abuse cases fy 2000 2008
Army Spouse Abuse CasesFY 2000-2008

Data from Army Central Registry, 6 Feb 09