P2A002: Using Enhanced Death Scene Investigation and Child Death Review to Better Understand and Prevent Drowning Among Children and Youth

Purpose/Objectives: The National Center for Fatality Review and Prevention (National Center) is the data and technical support center for child death review (CDR) across the country. Reviews of drowning deaths are challenging to CDR teams, as key information that informs prevention is often missing in the review due to the lack of a standardized process for investigating drowning deaths.
The Centers for Disease Control and Prevention (CDC) funded the National Center to conduct a pilot project focused on improved drowning death scene investigations (DSI), data collection, and prevention with CDR programs. This session highlights ways the National Center is partnering with pilot jurisdictions to support enhanced DSI in drowning deaths, including early findings from data collection activities, and discusses the role of pediatric providers and medical records in drowning DSI, CDR review, and prevention efforts.

Design/Methods: The National Center has partnered with a national workgroup and investigators across the country to create a standardized Water-Related DSI Protocol that will be released nationally in 2023. A working version of this form has been used to collect enhanced DSI information in pilot jurisdictions. There is significant overlap between the DSI and some electronic medical record information in pediatric drowning, making medical records an important source of information to ensure robust data collection. Data from enhanced reviews using the Water-Related DSI Protocol are collected in a secure national database. This includes rich contextual data on the children’s lives, deaths, risk factors, and their social determinants of health.
The National Center has worked closely with pilot jurisdictions to support partnership with investigators to conduct standardized DSI in drowning deaths to inform effective reviews and prevention recommendations. Pilot sites are provided extensive training, resources, and technical support to help move from case reviews, to high-quality data, and ultimately to prevention. This pilot project is a feasibility study for a national drowning case registry.

Results: Initial findings are based on 30 completed reviews of drowning cases that occurred in 2022. Data collection is ongoing. Most of the deaths are among children who are white (57%), non-Hispanic (53%), male (73%), and aged 1-4 years (60%). More than half of the incidents occurred at a private residence, while one-third occurred in open water. Lack of adequate, undistracted supervision was a significant risk factor in most these deaths.
While the method for collecting the DSI information varies somewhat by jurisdiction, medical records remain a primary source of vital information to ensure a clear understanding of drowning deaths.

Conclusion/Discussion: Standardized DSI and CDR fill a significant gap in knowledge by providing rich data to inform drowning prevention among children and youth. Pediatric providers are well-positioned to support effective data collection, CDR case reviews, and efforts to prevent drowning deaths.