Fatality Review Department of the Army Update 11 August 2009 Mr. Richard F. Stagliano
description
Transcript of 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
Army Family Advocacy Program
2 of 30Rich Stagliano/IMWR-FP/DSN 761-0644/[email protected] 301600RJUL2009
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
Army Family Advocacy Program
3 of 30Rich Stagliano/IMWR-FP/DSN 761-0644/[email protected] 301600RJUL2009
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
Army Family Advocacy Program
4 of 30Rich Stagliano/IMWR-FP/DSN 761-0644/[email protected] 301600RJUL2009
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
Army Family Advocacy Program
5 of 30Rich Stagliano/IMWR-FP/DSN 761-0644/[email protected] 301600RJUL2009
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
Army Family Advocacy Program
6 of 30Rich Stagliano/IMWR-FP/DSN 761-0644/[email protected] 301600RJUL2009
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
Army Family Advocacy Program
7 of 30Rich Stagliano/IMWR-FP/DSN 761-0644/[email protected] 301600RJUL2009
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.
Army Family Advocacy Program
8 of 30Rich Stagliano/IMWR-FP/DSN 761-0644/[email protected] 301600RJUL2009
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.
Army Family Advocacy Program
9 of 30Rich Stagliano/IMWR-FP/DSN 761-0644/[email protected] 301600RJUL2009
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 __________.
Army Family Advocacy Program
10 of 30Rich Stagliano/IMWR-FP/DSN 761-0644/[email protected] 301600RJUL2009
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
Army Family Advocacy Program
11 of 30Rich Stagliano/IMWR-FP/DSN 761-0644/[email protected] 301600RJUL2009
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
Army Family Advocacy Program
12 of 30Rich Stagliano/IMWR-FP/DSN 761-0644/[email protected] 301600RJUL2009
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
Army Family Advocacy Program
13 of 30Rich Stagliano/IMWR-FP/DSN 761-0644/[email protected] 301600RJUL2009
The The Cycle ofCycle of
ImprovementImprovementCommunityCommunity
ActionAction
DataDataGatheringGathering
Case Case ReviewReview
Changes inChanges inCommunity SystemsCommunity Systems
ParadigmParadigm
Army Family Advocacy Program
14 of 30Rich Stagliano/IMWR-FP/DSN 761-0644/[email protected] 301600RJUL2009
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
Army Family Advocacy Program
15 of 30Rich Stagliano/IMWR-FP/DSN 761-0644/[email protected] 301600RJUL2009
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
Army Family Advocacy Program
16 of 30Rich Stagliano/IMWR-FP/DSN 761-0644/[email protected] 301600RJUL2009
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
Army Family Advocacy Program
17 of 30Rich Stagliano/IMWR-FP/DSN 761-0644/[email protected] 301600RJUL2009
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
Army Family Advocacy Program
18 of 30Rich Stagliano/IMWR-FP/DSN 761-0644/[email protected] 301600RJUL2009
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
Army Family Advocacy Program
19 of 30Rich Stagliano/IMWR-FP/DSN 761-0644/[email protected] 301600RJUL2009
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
Army Family Advocacy Program
20 of 30Rich Stagliano/IMWR-FP/DSN 761-0644/[email protected] 301600RJUL2009
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
Army Family Advocacy Program
21 of 30Rich Stagliano/IMWR-FP/DSN 761-0644/[email protected] 301600RJUL2009
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)
Army Family Advocacy Program
22 of 30Rich Stagliano/IMWR-FP/DSN 761-0644/[email protected] 301600RJUL2009
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
Army Family Advocacy Program
23 of 30Rich Stagliano/IMWR-FP/DSN 761-0644/[email protected] 301600RJUL2009
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
Army Family Advocacy Program
24 of 30Rich Stagliano/IMWR-FP/DSN 761-0644/[email protected] 301600RJUL2009
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
Army Family Advocacy Program
25 of 30Rich Stagliano/IMWR-FP/DSN 761-0644/[email protected] 301600RJUL2009
Questions?
Army Family Advocacy Program
26 of 30Rich Stagliano/IMWR-FP/DSN 761-0644/[email protected] 301600RJUL2009
Back-up Slides
Army Family Advocacy Program
27 of 30Rich Stagliano/IMWR-FP/DSN 761-0644/[email protected] 301600RJUL2009
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
Army Family Advocacy Program
28 of 30Rich Stagliano/IMWR-FP/DSN 761-0644/[email protected] 301600RJUL2009
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.
Army Family Advocacy Program
29 of 30Rich Stagliano/IMWR-FP/DSN 761-0644/[email protected] 301600RJUL2009
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 Family Advocacy Program
30 of 30Rich Stagliano/IMWR-FP/DSN 761-0644/[email protected] 301600RJUL2009
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