State resumes reviews of child fatalities

For a few years, Hawaii had the dubious distinction of being the only state — or possibly one of two — that did not regularly review child deaths.

The other states analyzed such fatalities to look for risk factors and patterns, using that knowledge to develop initiatives to try to reduce the incidence of preventable deaths.

Hawaii no longer is an outlier.

Thanks to legislation passed last year, the state Department of Health has resumed a multidisciplinary, multi-agency review of deaths involving people under 18.

The legislation also authorized the agency to start a similar program examining the deaths of pregnant women and of women who gave birth within a year. Until launching that effort in July, Hawaii was one of only 13 states not conducting maternal death reviews.

“We want to know what’s going on,” said Lisa Kimura, executive director of the Healthy Mothers Healthy Babies Coalition of Hawaii, a nonprofit that supported the 2016 legislation. “The best way you do that is by reviewing these deaths.”

The Health Department stopped doing child death reviews in 2013 because of a lack of resources, according to Matthew Shim, chief of its Family Health Services Division.

The examinations are separate from any law enforcement or child welfare investigations that may be conducted immediately after a death.

“The goal of the reviews is to identify means of prevention and has led to recommendations to prevent future deaths and keep children safe and healthy,” Shim wrote in an email to the Honolulu Star-Advertiser.

The reviews are supposed to be the basis of regular reports to the Legislature, but the last one submitted was in December 2011, when DOH provided an analysis of roughly 1,000 child deaths from 2001 to 2006. About 370 of those cases were extensively reviewed.

MANY PREVENTABLE DEATHS

Nearly 75 percent of the closely examined deaths were found to have been preventable, according to the report, which recommended such initiatives as mandating lifeguards or adult supervision at hotel pools and providing best-practices training on infant autopsy and investigations to coroners, first responders, medical providers and others.

The Legislature last year appropriated $150,000 to resume the child fatality examinations and implement a maternal review program.

Among those who supported the legislation was Maui resident Lauren Wilson, a licensed clinical social worker whose daughter was born prematurely in 2008 and died as the infant was about to be transported to a Honolulu hospital.

Wilson said in an email to the Star-Advertiser that resuming the death reviews is important.

“So many child and maternal deaths are preventable,” Wilson wrote. “It can cause extra anguish for a family to know that information was available to prevent a death but wasn’t being used or tracked by anyone.”

Lin Joseph, maternal and child health director for the March of Dimes, which strives to improve the health of babies by preventing birth defects, premature birth and infant mortality, also applauded the resumption of reviews. She said the death of a child or pregnant woman is a sentinel event that requires proper investigation to understand underlying causes and opportunities for prevention.

Joseph spoke of the need to improve Hawaii’s infant mortality rate, which reflects deaths of babies under 1.

The state’s rate jumped to 5.9 deaths per 1,000 live births in 2015 from 4.4 in the prior year, according to the most recent data from the National Center for Fatality Review and Prevention. The rate fluctuated between 5.2 and 6.6 from 2010 to 2013.

SURGE IN CHILD DEATHS

Hawaii’s child fatality rate, which measures deaths per 100,000 population, has had similar fluctuations.

It surged to 51.1 in 2015, from 41.1 the prior year, but hit 58 in 2013, the highest in the past six years, according to the national center’s data.

In testimony on the 2016 bill, officials of the Kapiolani Child Protection Center, an affiliate of Hawaii Pacific Health, credited death reviews with contributing to such successful initiatives as safe sleep requirements for licensed child-care providers and assisting in development of a state suicide prevention plan.

The center noted that Hawaii was the only state at the time that was not conducting child death reviews on a regular basis to identify preventable cases.

Other organizations testifying on the bill noted that Hawaii was one of only two states not doing the reviews.

A Kapiolani spokeswoman said Friday that the center’s information came from a Health Department group, which could not be reached for clarification because of the state holiday.

Wilson, the Maui woman, said the loss of her child has shaped her advocacy.

“I think all (who) have lost someone dear search for meaning in that death,” she wrote. “When your child dies, your love continues and it searches for a place to put that love into action. For me, parenting the memory of my daughter means doing all I can to ensure no other family has to go through what we went through. Like all parents I want my daughter’s life, although short, to leave a positive legacy in the world. If through our experience and her life we can prevent even one other infant and child death, I think we will have succeeded.”

While she was pregnant with her daughter in 2008, Wilson said she was medevaced to Oahu because of pre-labor problems. After a few days, she was sent back to Maui for the remainder of her pregnancy – “an ultimately fatal mistake for my daughter” and one that had an impact on her health-care providers who recognized a broader problem that needed fixing, she wrote.

Up until 2008, the number of neighbor island pregnant women who were brought to Oahu for medical reasons but then sent back to their home islands was high, according to Wilson.

“From 2009 and on, the number of neighbor island women sent back decreased,” she said. “This change saves lives.”

Wilson is the mother of three children – “two who run here with me and one who soars,” she wrote. Her two other children were born on Oahu after complicated pregnancies.