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

Army Family Advocacy Program

1 of 30Rich Stagliano/IMWR-FP/DSN 761-0644/[email protected] 301600RJUL2009

Fatality ReviewFatality Review Department of the Army UpdateDepartment of the Army Update

11 August 2009

Mr. Richard F. StaglianoFamily Programs

MWR For All Of Your Life



Fatality ReviewFatality 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



ObjectivesObjectives

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 RequirementsAnnual Report Requirements

An executive summary on An executive summary on eacheach fatality fatality Victim demographics, injuries, autopsy findings, Victim demographics, injuries, autopsy findings,

homicides or suicide methods, weapons, offender homicides or suicide methods, weapons, offender demographics, household information and intervention demographics, household information and intervention timelinestimelines

SJA verified legal disposition involving homicides and SJA verified legal disposition involving homicides and conducted a sufficiency reviewconducted a sufficiency review

System interventions and failuresSystem interventions and failures Analysis of significant findingsAnalysis of significant findings Recommendations for systemic changesRecommendations for systemic changes Services provided to surviving Soldier/Family membersServices provided to surviving Soldier/Family members Signed by Garrison CommanderSigned by Garrison Commander



Fatality Review Committee (FRC)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 NursePediatrician/Family Practice ChaplainMedical Examiner/Pathologist CYS Coordinator Staff Judge Advocate PAO

ASAP Clinical Director ConsultantsCommand Sergeant Major School CounselorProvost Marshal Child Protective Services

CID Local court administratorNPSP/EFMP



Sources of InformationSources of Information

ACR and COPS databasesACR and COPS databases Request information earlyRequest information early Preliminary data from Army Records Center indicated a significant Preliminary data from Army Records Center indicated a significant

number of cases met the death investigation criteria for fatality number of cases met the death investigation criteria for fatality review but were not reviewed by local FRCsreview but were not reviewed by local FRCs

Autopsy Report (summary section)/Final CID Report Autopsy Report (summary section)/Final CID Report SummarySummary Used to complete the EXSUM – Spells out the Who, What, Where, Used to complete the EXSUM – Spells out the Who, What, Where,

When, Why and How regarding the fatalityWhen, Why and How regarding the fatality Used to construct the intervention timelinesUsed to construct the intervention timelines Note: Explain if there are differences between information Note: Explain if there are differences between information

contained in these or other documentscontained in these or other documents



Case Summary - ChildCase Summary - Child

The decedent was a two month old dependent son African-American) of a 21yr old female PFC assigned to Fort ____ with her 22 yr old dependenthusband (African American). The Family lived off post. On 8 Apr 06, theinfant was taken to MTF via ambulance with no respiration. The civilian fatherreported to EMS that while feeding the infant, he became apneic, turning blueon the lips. The infant was life-flighted to MEDCEN for further care. The infantreceived a full non-accidental trauma exam which revealed further injuries toinclude brain injury, retinal damage to both eyes and died as a result of hisinjuries. Medical personnel at MEDCEN stated that the injuries wereconsistent with Shaken Baby Syndrome. The child died on 17 Apr 06. A jointinvestigation was conducted between CID and the local police. The motherand father were charged with murder. The mother was charged with 1st

degree criminal abuse and murder because she allowed her husband to watchher child even though she had an active protection order against him fordomestic violence.



Case Summary - DVCase Summary - DVThe 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 wifeadmitted to stabbing and killing her husband. She stated the incident was dueto an argument with her husband. It was reported that the Soldier overheardhis wife on the phone with another man and an argument ensued. As theSoldier came towards his wife, she grabbed a kitchen knife off the counter andstabbed him once in the chest according to police. The Soldier wasintoxicated at the time of the incident. The victim died on 11 Dec 05. Themanner of death was homicide. The children were initially place in the careand custody of the _____ county Social Services Department and then in thecare of the paternal grandmother. The children received counseling from acivilian provider. The Soldier was being treated for PTSD and conversiondisorder. He was also participating in ASAP. There was FAP involvement dueto DV. Multiple FAP providers were involved in the case. Although advocacyand counseling services were offered to the wife, she declined. The wifereceived a 10 year confinement sentence which was suspended; she wasplaced on probation for five years.



Case Summary - H/SCase Summary - H/SOn 5 Nov 05, a retired Army SM (Hispanic), age 44, fatally injured his 36 yearold Active Army SFC spouse (Caucasian) with a gunshot wound to the head. The husband committed suicide with a self-inflicted gunshot to the head. Theweapon was owned by the husband. The Family lived off post. Thehomicide/suicide was witnessed by the couples 13 year old daughter. Thedaughter contacted 911 and prevented her 8 year old sister from viewing thecrime scene. The AD spouse redeployed from Iraq, completed block leaveprior to the homicide. The AD spouse had petitioned for divorce (19 yrmarriage) precipitated by spousal’s infidelity. The husband would be grantedthe home, the AD spouse would be granted custody of the children. Theincident occurred while the AD spouse was relocating. The autopsy findingsreported the husband’s blood alcohol was negligible (wine). The command and neighbors reported no red flags for the couple. The victim hadcompleted deployment to Iraq and block leave. The retired SGM participatedin approximately 4 deployments prior to retirement. The daughters wereprovided counseling following the death of their parents and relocated toreside with the paternal grandparents in __________.



Fatality Review – Allows the Army to identifyFatality Review – Allows the Army to identify systemic problems and formulate lessons learned systemic problems and formulate lessons learned

Fatality Review – Allows the Army to identifyFatality Review – Allows the Army to identify systemic problems and formulate lessons learned systemic problems and formulate lessons learned

FY03 FY04 FY05 FY06 FY07 Significant Findings – Child Abuse

6/18 3/13 8/18 2/12 6/14 # of child abuse fatalities that occurred while the Soldier was deployed

56 % 54% 39% 67% 71% % of adults involved in child abuse fatalities who had active substance abuse/ mental health issues

76% 62% 83% 83% 78% % of all child deaths when children were under the age of four

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

FY03 FY04 FY05 FY06 FY07 Significant Findings – Spouse Abuse

none none none none none There was no direct evidence that domestic violence fatalities occurred as a result of deployment**

N/A 80% 63% 40% 50% % of domestic violence fatalities where the couples were separated as a result of severe marital discord

2/8 3/5 4/16 6/15 2/10 # of domestic violence fatalities where there was no indication of risk or involvement with the FAP



FY07 CAN FatalitiesFY07 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 DV FatalitiesFY07 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



The The Cycle ofCycle of

ImprovementImprovementCommunityCommunity

ActionAction

DataDataGatheringGathering

Case Case ReviewReview

Changes inChanges inCommunity SystemsCommunity Systems

ParadigmParadigm



State Agency that Leads State Agency that Leads Coordination of CDR ProgramCoordination of CDR Program

Source: The National Center for Child Death Review State Profile Database: Reports from State CDR Program Coordinators, May 2009

Agency Lead Number of States

Health Department 24

Social Services 10

Medical Examiner 5

Attorney General, DOJ 3

Other 8



Types of Death Reviews Types of Death Reviews by State CDR Teamsby State CDR Teams

Source: The National Center for Child Death Review State Profile Database: Reports from State CDR Program Coordinators, May 2009

Types Number of States

Natural Deaths, Infants under 1 17

SIDS 27

Natural Deaths, aged 1 and older 18

Homicide 27

Suicide 27

Abuse and Neglect 29

Current or History contact with Social Services 26



Leading Causes and Total 5-Year Incidence Leading Causes and Total 5-Year Incidence of Injury Deaths by Age Group, The United of Injury Deaths by Age Group, The United

States, 2000-2004States, 2000-2004

Source: Children’s Safety Network, United States Fact Sheet, 2008

Ages < 1 Number of Deaths

Unintentional – Suffocation 3,120

Unintentional – Motor Vehicle Traffic 704

Homicide Unspecified 622

Homicide Other Specified/Classifiable 545

Unintentional – Drowning 326



Leading Causes and Total 5-Year Incidence Leading Causes and Total 5-Year Incidence of Injury Deaths by Age Group, The United of Injury Deaths by Age Group, The United

States, 2000-2004States, 2000-2004

Source: Children’s Safety Network, United States Fact Sheet, 2008

Ages 1 - 4 Number of Deaths

Unintentional – Motor Vehicle Traffic 2,676

Unintentional – Drowning 2,291

Unintentional – Fire/Burn 1,210

Homicide Unspecified 738

Unintentional – Suffocation 712



DoD Fatality Review SummitDoD Fatality Review SummitFY06 ResultsFY06 Results

OSD stated that the Services can collect fatality OSD stated that the Services can collect fatality review data as close to the death as possible, within review data as close to the death as possible, within the limits of the lawthe limits of the law

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

Marital discord is a predominate factorMarital discord is a predominate factor Divorce is a high stressorDivorce is a high stressor Threats of homicide and/or suicidal comments should Threats of homicide and/or suicidal comments should

be taken seriously and immediately reported to be taken seriously and immediately reported to command and/or appropriate agenciescommand and/or appropriate agencies



DoD Fatality Review Summit DoD Fatality Review Summit FY06 ResultsFY06 Results

DVDV Gunshots were cited as the most common method of death by Gunshots were cited as the most common method of death by

all Servicesall Services 53% of the victims were active duty members53% of the victims were active duty members Alleged offender factors – low marital satisfaction, conflict with Alleged offender factors – low marital satisfaction, conflict with

partners, reported anger problems and separation from partnerpartners, reported anger problems and separation from partner CANCAN

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

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

OSD adopted 4 Army recommendationsOSD adopted 4 Army recommendations Recommendations need to be agency specificRecommendations need to be agency specific



DoD Fatality Review Summit DoD Fatality Review Summit FY06 ResultsFY06 Results

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



Keys to Success 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 Success

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 by1 May 10



ReferencesReferences 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, www.childdeathreview.org

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’dReferences Cont’d CDC’s Violence Prevention Resources – www.cdc.gov/injury, call 1-800-CDC-INFO Home Fire Safety: Be Safe and Sound, Home Safety Council -

www.homesafetycouncil.org Suicide Prevention Resource Center – www.sprc.org, 877-GET-SPRC (877-438-

7772) Sudden Unexplained Death in Childhood Program – www.sudc.org, 1-800-620-SUDC Stop Bullying Now, Activities Guide – www.stopbullyingnow.hrsa.gov 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 – www.childdeathreview.org, National Center for Child Death Review, 1-800-656-2434

Children’s Safety Network – www.ChildrensSafetyNetwork.org, National Injury and Violence Prevention Resource Center



Questions?



Back-up Slides



Laws, Directives, Instructions, Laws, Directives, Instructions, and Regulationsand Regulations

PUBLIC LAW 97-291, VICTIM WITNESS PROTECTION ACT OF 1982PUBLIC LAW 97-291, VICTIM WITNESS PROTECTION ACT OF 1982

DoD DIRECTIVE 1030.1, VICTIM AND WITNESS ASSISTANCE, 1984DoD DIRECTIVE 1030.1, VICTIM AND WITNESS ASSISTANCE, 1984

DoD DIRECTIVE 6400.1, FAMILY ADVOCACY PROGRAM, 2004DoD DIRECTIVE 6400.1, FAMILY ADVOCACY PROGRAM, 2004

DoD MANUAL 6400.1M, FAMILY ADVOCACY QUALITY ASSURANCE STANDARDSDoD MANUAL 6400.1M, FAMILY ADVOCACY QUALITY ASSURANCE STANDARDS

DoD INSTRUCTION 6400.3, FAMILY ADVOCACY COMMAND ASSISTANCE TEAMDoD INSTRUCTION 6400.3, FAMILY ADVOCACY COMMAND ASSISTANCE TEAM

DoD INSTRUCTION 6400.06, DOMESTIC ABUSE INVOLVING DoD MILITARY AND DoD INSTRUCTION 6400.06, DOMESTIC ABUSE INVOLVING DoD MILITARY AND CERTAIN AFFILIATED PERSONNEL, 2007CERTAIN AFFILIATED PERSONNEL, 2007

PUBLIC LAW 103-160, NATIONAL DEFENSE AUTHORIZATION ACTS, 1994PUBLIC LAW 103-160, NATIONAL DEFENSE AUTHORIZATION ACTS, 1994

PUBLIC LAW 107-311, ARMED FORCES DOMESTIC SECURITY ACT, 2002PUBLIC LAW 107-311, ARMED FORCES DOMESTIC SECURITY ACT, 2002

ARMY REGULATION 608-18, FAMILY ADVOCACY PROGRAM, 2006ARMY REGULATION 608-18, FAMILY ADVOCACY PROGRAM, 2006

ARMY REGULATION 608-1, ARMY COMMUNITY SERVICE, 2007ARMY REGULATION 608-1, ARMY COMMUNITY SERVICE, 2007



DoD DefinitionsDoD 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.



Data from Army Central Registry, 6 Feb 09

2470 2506 2704 2830 3081 2551 2545 2561 2596

4196 4123 4655 4558 45733951 3911

51663700

0

2000

4000

6000

8000

10000

FY 00 FY01 FY02 FY03 FY04 FY05 FY06 FY07 FY08

Substantiated Unsubstantiated

Army Child Abuse Cases Army Child Abuse Cases

FY 2000-2008FY 2000-2008



Army Spouse Abuse CasesArmy Spouse Abuse CasesFY 2000-2008FY 2000-2008

4030 3944 3852 3430 3093 2998 2780 2747 2573

3549 3745 3953

32333153 3586

34314291 4203

0100020003000400050006000700080009000

FY 00FY01 FY02 FY03 FY04 FY05 FY06 FY07 FY08

Substantiated Unsubstantiated

Data from Army Central Registry, 6 Feb 09

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

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