Sutter County
Child Death Review Team
2000-2013 Report
by
Judy Mikesell, RN, BSN, PHN
Sutter County Child Death Review Team Coordinator; Co-Chair
Director of Public Health Nursing
Sutter County Human Services-Health Division
Foreword
Reviewing the circumstances surrounding the death of a child is never easy.
Children, whether infants, young children, or adolescents, should be happy,
loved, and busy learning about the world around them. To keep children safe
requires that parents and caregivers be aware of the inherent risks at
different ages, from the complete dependence of an infant, to the insatiable
curiosity of a young child, to the risk-taking and feeling of invulnerability of
an adolescent. Whenever the life of a child is cut short, whether from a
natural cause, a preventable injury or a homicide, the family and friends who
loved the child are devastated.
The Child Death Review Team members, many of us parents ourselves, never
take these deaths lightly. We try to serve these children by ensuring that no
child abuse or neglect death is unidentified, and by learning from preventable
injury fatalities, so that future deaths and injuries from the same causes can
avoided. Not every illness, injury, or death can be prevented. But we all do a
serious disservice to the children and families in our community if we fail to
do our best to prevent those injuries and deaths that we can. To this end,
many agencies, organizations, and individuals in the community work
diligently to educate parents, caregivers, children, and the general public
about injury prevention and health issues. Avoiding a preventable death is by
far preferable to having to live forever with the heartbreak of, “If only…”
~ Judy Mikesell, RN, BSN, PHN
Sutter County Child Death Review Team Coordinator
Director of Public Health Nursing
“There’s no tragedy in life like the death of a child. Things never get back to the way
they were.”
-Dwight D. Eisenhower
(Who lost his 4 year old son to scarlet fever)
In Appreciation
Sutter County Child Death Review Team
The Sutter County Child Death Review Team could not do the difficult work that it must do without
the ongoing dedication and professional expertise that the representatives from the following
agencies provide. Many of the team members are parents themselves, so reviewing the
circumstances surrounding the deaths of these children who die too young hits close to home.
Heartfelt thanks go to these agencies and individuals for their concern and care for the children
whose deaths are reviewed, and those they strive to protect by learning how to avoid future similar
tragedies.

Bi-County Ambulance

California Highway Patrol, Yuba-Sutter

Compassionate Friends

Rideout Medical Group-Emergency Department

Sutter County Child Development Behavior Specialist

Sutter County Child Protective Services

Sutter County District Attorney’s Office

Sutter County Fire Department

Sutter County Human Services

Sutter County Office of Education

Sutter County Probation

Sutter County Public Health

Sutter County Sheriff-Coroner’s Office

Sutter County Welfare & Social Services

Sutter-Yuba Mental Health

Trauma Intervention Program (TIP)

Yuba City Fire Department

Yuba City Police Department

Yuba City Unified School District
 Yuba County Sheriff’s Department
TABLE OF CONTENTS
Executive Summary
Background of Child Death Review Teams
Sutter County Child Death Review Team
Notes Regarding 2000-2013 CDRT Report
Child Death Case Review Summary Data 2000-2013
Total Child Deaths
Category
Age Groups
Gender: Gender & Category; Gender & Age Group
Ethnicity; Ethnicity & Category
Category & Mode by Age Group
Under 1 Month of Age
1-11 Months
1-3 Years
4-5 Years
6-7 Years
8-9 Years
10-13 Years
14-15 Years
16-17 Years
Natural Deaths
Type
Year
Undetermined Deaths
Underlying Issues
Unintentional Suffocation
By Year
Intentional Deaths
Mode
Homicides by Year
Child Abuse or Neglect Deaths
Percentage of Total Child Deaths
Deaths by Year
Age at Occurrence
Suicides by Age Group; by Year
Unintentional Deaths
Mode
Deaths by Year
Drowning Deaths
Age Group
Location
Motor Vehicle-Related Deaths
Deaths by Year
Single vs. Multiple Vehicle Crashes
Victim as Driver, Passenger, or Other
Relationship of Driver to Victim
Driver by Gender; Victim by Gender
Diver by Age Group; Victim by Age Group
Vehicle-related Drownings
Number of Vehicles-Occupants-Fatalities
Day of the Week
Time of Day
Excessive Speed; Alcohol or Drugs Involved
Use of Seatbelts or Car Seats
Factors Involved
Child Deaths: Other Information
Month of Year
Month of Year by Category
Preventable Deaths
Percentage of Total Deaths
By Year
Recommendations and Community Interventions
Appendix A: 2013-2014 Child Death Review Team Members
Appendix B: On-Line Resources
EXECUTIVE SUMMARY
This report describes the results of Sutter County Child Death Review Team (CDRT) reviews
of the 132 children and adolescents aged birth through 17 who died between the last half of
2000 and the end of 2013. These deaths included 69 (52% of the total) due to natural causes,
35 (27%) due to unintentional (accidental) injuries, 13 (10%) due to homicides, and 3 (2%) due
to suicides. There is 1 case (1%) case from 2013 still pending completion of the investigation
at the time of this report. The exact cause of 11 of the deaths (8%) could not be definitively
determined, although 7 were most likely due to unintentional asphyxiation by parent overlay
while co-sleeping in an adult bed, and 1 from unintentional asphyxiation from sleeping on soft
bedding. It could not be determined if one death was an accidental or suicidal death from a
drug overdose. The cause of one infant and one teen sudden death could not be determined.
In this report is also information regarding the child deaths by year, gender, ethnicity, age
group, and type of deaths within categories,
The primary goal of child death review teams is to ensure that all deaths due to child abuse or
neglect are identified as such. Of the total 132 deaths, 122 (95%) were not caused by child
abuse or neglect. Five (4%) of the deaths were directly due to child abuse, and one death (1%)
was due to neglect. Three of the five deaths due to child abuse occurred when an out-of-State
parent came to Sutter County the day before committing a quadruple homicide/suicide. The
other 2 were children who died from late effects of Shaken Baby Syndrome (SBS). Fortunately,
there have been no more SBS fatalities since 2002.
Since a major focus for child death review teams is to try to prevent future child and adolescent
deaths, CDRT’s attempt to determine if each death was potentially preventable. Of the 132
deaths reviewed, 39% were considered definitely preventable, 7% were possibly preventable,
and 51%, primarily the natural deaths, were deemed not preventable. In 3% of the deaths, it
could not be determined if the death was preventable. 1 case is still pending. The significance
is that 60 (46%) of these children, did not, or probably did not, need to die.
Some patterns have emerged. For example, motor vehicle crashes comprise the largest
segment of unintentional deaths, and in these, certain issues are consistent. Excessive speed
was a major factor in 65% of the motor vehicle-related deaths. The person who died was the
passenger rather than the driver in 76% of the fatal crashes. Males were the drivers in 65% of
the crashes, and were the victims in 60%. The 16-17 year age group had the highest number
of drivers causing the crashes and the highest number of victims.
An ongoing concern is drownings, both of young children and adolescents. There were one or
more drownings in 10 of the 14 years in which child deaths were reviewed. Lack of adequate
adult supervision was a common factor in many of the unintentional child deaths, especially
those of young to pre-teen children.
Positive trends have been seen over this report period of mid-2000 through 2013, including:
 The last child abuse death occurred in 2002.
 The last fatal drug overdose occurred in 2006.
 The only child neglect case occurred in 2007.
 The last homicide occurred in 2008.
1

There were no deaths from fires, burns, falls, suffocation due to choking on objects, or
ingestion of poisonous substances.

Another striking change over time has been the significant decrease in motor vehicle
deaths in this age group. In the 5 ½ year period between the last half of 2000 and the
end of 2005, there were 17 motor vehicle-related deaths in this age group, but in the 8
year report period between 2006 and 2013, there were only 3. The last motor vehiclerelated death, which occurred in 2010, was a Sutter County child who died while out of
the country.

Unintentional deaths due to any cause have decreased significantly over this time
period, from multiple deaths all years but one from 2000-2008, down to a single
unintentional death each year from 2009 to 2013.
Recommendations resulting from the child death cases reviewed included agency and
community involvement in prevention events such as the “Every 15 Minutes” impaired driving
prevention program for high school students; the “Drug Store” drug awareness program for
students; parenting classes; public and professional education regarding injury prevention
issues such as safe driving, child car seat safety; water safety, fire prevention, Shaken Baby
Syndrome, and safe sleeping practices for infants, as well as increased awareness regarding
the presence of gangs in the community. It is probable that increased focus regarding these
issues by parents and agencies, as well as the many prevention campaigns and activities in
the community have had a positive effect in lowering the frequency of these child deaths.
Smaller jurisdictions such as Sutter County deal with a statistically small sample of numbers of
child deaths, and variances of just a few cases appear to show major changes in occurrence.
This does not lessen the importance of each case to the family and friends who loved the child,
or to the community who is concerned about the loss, but it does make it more difficult to draw
accurate conclusions from the available data. Continuing to review the deaths and compile
data will assist in formulating strategies to decrease the number of child deaths that are
preventable. And since the deaths are just “the tip of the iceberg” of children who sustain
injuries or illness that may significantly affect their lives, the information gained in the child
death review process can have an impact far beyond that of child fatalities. It is very important
to note that looking at causative factors that were involved in the deaths is not meant to cause
pain to any of those who cared about these children. But if we do not look at these details and
learn from them, we have no hope of preventing the same type of deaths from reoccurring.
2
BACKGROUND OF CHILD DEATH REVIEW TEAMS
Child death review teams (CDRT’s) originally formed as a response to the need to better
identify child abuse and neglect deaths. While this remains an extremely important component
of CDRT’s, most teams have expanded their protocols to incorporate the review of all child
deaths, with an emphasis on understanding the causes of all avoidable child deaths, whether
intentional or unintentional. Since many times more children die of unintentional injuries as do
of intentional injuries, the only way to have a significant impact on reducing child fatalities is to
also address unintentional deaths. It has also been learned than even some natural deaths
can be prevented (for example, SIDS death rates have been cut in half by a few simple
strategies, primarily that of simply by placing young infants on their backs, rather than on their
stomachs, while sleeping).
Analyzing the circumstances surrounding all of these deaths leads to recommendations for
possible interventions that can lower the incidence of future similar fatalities. Thorough
reviews also allow identification of system changes, within and between agencies, that may be
needed for more effective interagency communication and handling of child deaths .
California passed legislation in 1988 that allowed counties to establish official interagency
CDRT’s with the legal authority to exchange confidential information relating to child death
cases. Penal Code sections 11166.7 – 11166.9, 11167.5, and Welfare and Institutions Code
18951 subdivision (d) cover interagency child death teams and multidisciplinary personnel
teams. Core team membership includes representatives from agencies including law
enforcement, public health, child protective and social services, district attorney’s office,
schools, first responders, emergency rooms, probation, and mental health. (See Appendix A:
Sutter County Child Death Review Team 2013-2014 Member Roster.)
Counties are required to submit Fatal Child Abuse and Neglect Surveillance (FCANS) forms to
the State if a child’s death was due to child abuse or neglect, or if there was any history or
suspicion of child abuse or neglect in the child’s life. A primary purpose of these forms is to
compile a database to help determine how much this type of history increases a child’s risk of
premature death, even if the death was not directly attributable to abuse or neglect. An annual
FCANS reconciliation audit compares child abuse or neglect reports from the FBI, Child
Welfare and Social Services, and county child death review teams, to obtain the most accurate
data regarding the true incidence of child abuse and neglect fatalities in California.
In addition to local CDRT’s, California enacted legislation to establish the State Child Death
Review Council (SCDRC) under the Office of the Attorney General. The State Council
provided support, technical assistance, and training to local teams. Designated council
members represented specific state agencies and professional associations that deal with
child fatalities. This was a successful collaboration of agencies for several years, until funding
was no longer available and the Council was disbanded.
Some valuable resources aid local CDRT’s. One is the U.S. Department of Health & Human
Services: Administration for Children & Families- Child Death Review Teams. Among others
are the California Department of Public Health: EpiCenter-California Injury Data Online, and
the Los Angeles County Interagency Council on Child Abuse and Neglect.
3
SUTTER COUNTY CHILD DEATH REVIEW TEAM
Sutter County reactivated the Child Death Review Team (CDRT) in 2001. Prior to this time, a
team had met infrequently because CDRT’s historically only reviewed child abuse and neglect
cases, and fortunately these had been rare in Sutter County. Team reactivation was spurred
by a national and state emphasis on reviewing all child deaths, not just abuse and neglect
deaths, if there was to be any chance of lowering child mortality.
The Sutter County CDRT reviews all deaths of children from birth through age 17 that occur
within the county, other than natural deaths of newborns in the hospital, if that family resides in
another county. The team also reviews deaths of children who are Sutter County residents,
even if the death occurs outside the county, since the dynamics that contribute to the death
often begin in the home environment, or the death is that of a critically ill or injured child
transported to an out-of-county hospital prior to dying.
The CDRT has been coordinated by the Public Health Maternal, Child and Adolescent Health
Director, who continued as Coordinator when she became Director of Public Health Nursing.
She also co-chaired, with a detective, (6 over the years, as their assignments changed) from
Sutter County Sheriff-Coroner’s Office. From 2001-2007 she also served as a member of, and
for one year as Co-Chair of, the California State Child Death Review Council, which was under
the authority of the Attorney General’s Office until loss of funding caused the Council to be
discontinued. This was beneficial since it gave a voice for the smaller county perspective.
Sutter County CDRT meets quarterly if there are cases to be reviewed, and consists of
professionals from a wide range of agencies that can provide valuable information into the
circumstances surrounding each death. Meetings adhere to the strict legal confidentiality
guidelines of multi-disciplinary teams as regulated by the California Penal Code and the
California Welfare and Institutions code. Each member signs a confidentiality agreement and
the sign-in sheet for each meeting also contains the wording of that agreement.
The primary objectives of the child death review process are to identify deaths caused by child
abuse or neglect; to increase knowledge surrounding preventable deaths and to formulate
prevention strategies; to analyze trends in County child mortality; and to strengthen
interagency communication regarding responses to child deaths. The team looks at trends and
commonalities in causes and details of death, and looks at strategies that can help prevent
future child deaths that might occur from circumstances similar to deaths that have been
reviewed. The team also discusses “close calls”, which are situations in which the child
avoided death, but which easily could have ended in a fatality. The team members and
member agencies share the common goal of preventing those child and adolescent deaths
that do not need to occur.
Meetings also serve as a forum in which team members can share information pertinent to any
issue involving child deaths, death and injury prevention, or agency procedures and
communications regarding child deaths and the ensuing investigations. The discussions and
knowledge base gained have assisted participants in understanding the operations and
systems of the other agencies, and how best to overcome possible obstacles in
communicating with one another when child deaths are involved.
4
NOTES REGARDING 2000-2013 CDRT REPORT
For simplicity’s sake, groupings used in this report are somewhat different than those on the
California death certificate. The terms “category” and “mode” are used as follows. “Category”
refers to the intent or lack of intent of the death, whether intentional (homicide or suicide),
unintentional, natural, or undetermined (“could not be determined”). This correlates to the
“manner of death” section on the death certificate. “Mode” gives more information within each
category, and refers to the event leading to the death. For example, the “category” of a death
may be “unintentional” but the “mechanism” may be motor vehicle crash, drowning, etc. This
report will not go into specific legal “cause” of death as shown on death certificates, since that
section delves further into the specific physical condition, such as “asphyxia due to drowning”
or “cardiac arrest due organic brain dysfunction”. The importance for child death review is to
determine what occurrence laid the groundwork for the death.
When looking at categories of death, “natural” includes diseases, birth defects, perinatal
factors resulting in the death of the newborn, and other biological conditions. “Unintentional” is
replacing the terminology “accidental” in the injury prevention community, meaning that there
was no intent to cause the injury or death, but that it was not just a random act over which no
potential preventive action could have been taken to keep the injury or death from occurring.
However, on California death certificates, the term “Accidental” still serves as the term for that
manner of death category.
“Undetermined” and “Could Not be Determined” describe the cause of death and the manner
of death, respectively. These terms mean that there was not sufficient physical evidence for
the forensic pathologist or coroner to determine with certainty whether the death was caused
intentionally, unintentionally, or was a natural death. There will sometimes be notes in the
death report that gives an indication of the likely cause, such as “probably soft mechanical
asphyxiation”, even though the formal cause and manner of death are “Undetermined”/”Could
Not Be Determined”. In some cases even the cause of death may be undetermined, meaning
that even the physical cause of death cannot be definitively determined. The great majority of
undetermined deaths are infants under 1 year of age.
5
TOTAL CHILD DEATHS
Ages Birth – 17 Years
2000-2013
Total Child Deaths
2000-2013
n = 132
Note: Partial year's data for 2000 & 2001
25
20
15
10
5
0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Although the Sutter County population of children in the 1-17 year age range increased
approximately 10.6% between 2000 and 2013, the child deaths have actually decreased, most
markedly in motor vehicle-related deaths and homicides, including both child abuse and gangrelated deaths. This seems to be a positive trend, and likely speaks to the many efforts made
in the community to reduce the instances of preventable deaths. However, it must be noted
that when dealing with statistically small numbers of events, such as child deaths in smaller
sized jurisdictions such as ours, the fluctuations of only a few cases can look as though there
are major changes, when the numbers may not really be statistically significant. The fact that
those types of deaths mentioned, though small in number, have shown a consistent decrease
over a period of years does indicate a positive trend.
The following sections give more details regarding the deaths during this review period.
6
CHILD DEATHS BY CATEGORY
Child Deaths by Category
2000-2013
n = 132
80
70
60
50
40
30
20
10
0
Natural
Unintentional
Homicide
Suicide
Undetermined
Natural deaths, which include prematurity, birth defects, cancers, Sudden Infant Death
Syndrome (SIDS) and other illnesses, generally are the largest component of the child death
picture, most markedly in infants. Unintentional (“accidental”) deaths are almost always the
next most frequent cause of death in children. More information will be detailed in the sections
pertaining to each category of death.
CHILD DEATHS BY AGE GROUP
Child Deaths by Age Group
2000-2013
n = 132
50
40
30
20
10
0
< 1 Mo 1-11 Mo 1-3 Yrs
4-5 Yrs
6-7 Yrs
8-9 Yrs 10-13 yrs 14-15
16-17
The breakdowns by age have remained mainly consistent over the years, since there are
some fairly predictable age-related patterns. The youngest, newborns under 1 month are
primarily those who succumbed to prematurity and/or birth defects. This continues in the 1-11
month age range, which also includes SIDS deaths and other conditions or illnesses such as
cancer. The 1-3 year olds primarily are lost due to unintentional deaths, The lowest numbers of
deaths are in the 4-9 year olds who are mainly past the effects of newborn conditions but
remain under closer adult supervision than do the 10-17 year olds who exert more
independence, but do not have the experience or judgment to recognize and avoid risks.
7
CHILD DEATHS: GENDER
Child Deaths by Gender
2000-2013
N = 132
Female
36%
Male
64%
GENDER & CATEGORY
Child Deaths by Gender and Category
2000-2013
n = 132
40
35
30
Male
25
Female
20
15
10
5
0
Natural
Unintent. Homicide
Suicide
Undeterm
Pending
The Sutter County population of 0-17 year olds has consistently been between 51.1-51.8%
male to 48.2-48.9% female from 2000-2013 (California Vital Statistics Master File). Boys are
consistently over-represented in every primary category of child death during this report period.
Within these categories, girls were slightly over-represented in birth defect deaths (14:12),
accidental overdose (1:0), and other conditions/illness (5:4). The only kidnap victim was a
Sacramento girl, taken in Sacramento, but driven to Sutter County before being killed. Most
significant areas of higher rates for boys were homicides (12:1), prematurity (14:9), vehiclerelated (12:8), suicides (3:0), and included all 5 child abuse deaths and all 7 gang/probable
gang-related deaths.
8
CHILD DEATHS: GENDER & AGE GROUP
Child Deaths by Gender and Age Group
2000-2013
n = 132
25
20
15
Male
10
Female
5
0
< 1 Mo 1-11
Mo
1-3
Yrs
4-5
Yrs
6-7
Yrs
8-9
Yrs
10-13 14-15 16-17
Yrs
Yrs
Yrs
Boys were slightly to significantly over-represented in every age group except 6-7 year olds.
9
CHILD DEATHS: ETHNICITY
Child Deaths by Ethnicity
2000-2013
n = 132
Afr-Amer Native Amer
1%
7%
Asian
12%
White
44%
Hispanic
36%
2014 population estimates of the 0-17 years of age population in Sutter County is
approximately 38.6% White; 40.4% Hispanic; 1.6% Black; 13.0% Asian; 1.0% Native
American; and 5.2% stating 2 or more ethnicities. Some of these percentages changed fairly
significantly during this 2000-2013 report period. But using the 2014 data, Whites are slightly
over-represented in overall child deaths, Blacks are significantly over-represented; and
Hispanics and Asians are under-represented in the overall numbers.
CHILD DEATHS: ETHNICITY & CATEGORY
Child Deaths by Ethnicity & Category
2000-2013
n - 132
35
Natural
30
Unintent.
25
Homicide
20
Suicide
15
Undeterm.
10
Pending
5
0
White
Hispanic
Asian
Afr-Amer Native Am
The ethnic proportion in most categories is roughly that of the community ethnic breakdown of
0-17 year olds. However, Hispanics and Asians are significantly over-represented in
Homicides, and Whites are over-represented in unintentional deaths.
10
UNDER 1 MONTH OF AGE
Child Deaths
Category by Age Group: Under 1 Month
2000-2013
n = 41
Undeterm, 2
Natural, 39
Child Deaths
Mode by Age Group: Under 1 Month
2000-2013
n = 41
25
20
15
10
5
0
Premature
Birth Defect
Illness
Undeterm
Per the Centers for Disease Control (CDC), the most common causes of death in infants are
birth defects (congenital malformations) or chromosome abnormalities; prematurity with low
birth weight; and Sudden Infant Death Syndrome (SIDS). It is rare that newborns under 1
month die of SIDS. Prematurity can occur along with birth defects, or can be due to maternal
issues, such as diabetes, hypertension, incompetent cervix, infections, or other medical
conditions or injuries that affect the ability to maintain a pregnancy to full term. Birth defects
may allow a live or even full-term birth, but be of such an extreme and overwhelming nature
that the baby is not able to survive, regardless of medical interventions. The two
“undetermined” deaths were deemed to be likely unintentional soft suffocations, since both
infants were co-sleeping with adults at the time of death. In the California Department of Public
Health’s County Health Status Profiles 2014, Sutter County’s infant mortality rate, 2009-2011,
was 4.6 per 1,000 live births. This was better than both the State rate of 4.9 and the Healthy
People 2020 National Objective of 6.0.
11
1-11 MONTHS OF AGE
Child Deaths
Category by Age Group: 1-11 Months
2000-2013
n = 24
Unintent., 2
Pending, 1
Undeterm, 5
Natural, 16
Child Deaths
Mode by Age Group: 1-11 Months
10
2000-2013
n = 24
8
6
4
2
0
The most common causes of death of infants from 1-11 months are birth defects or
chromosomal & metabolic disorders. An exact cause for Sudden Infant Death Syndrome
(SIDS) is not known. It can occur up to one year of age, though most occur from 2-4 months.
Strategies including putting infants on their backs, not their stomachs, to sleep; not keeping
them too warmly dressed or in overheated rooms; and putting them to sleep on safe bedding
can lower the risk of SIDS by about half. However, it is still not known how to prevent the other
half of SIDS deaths. SIDS is one condition within the broader term, “Sudden Unexplained
Infant Deaths”, (SUIDS). SIDS is a diagnosis of exclusion, meaning that all other reasonable
causes of death have been ruled out. The broader SUIDS term includes deaths for which there
isn’t a clear-cut reason for the death, but for which things were identified which might have
contributed to the infant’s death. Please see the note in the “Under 1 Month” section above
regarding County rates, since it also applies to this 1-11 month age range. The “Undetermined”
deaths were deemed likely due to unintentional suffocation, since 4 of the infants were cosleeping with adults at the time of death, and the other had been sleeping alone, but had rolled
over and was found face down on an adult bed that was covered with very soft bedding.
12
1-3 YEARS OF AGE
Child Deaths
Category by Age Group: 1-3 Years
2000-2013
n = 14
Homicide, 2
Natural, 3
Unintent., 9
Child Deaths
Mode by Age Group: 1-3 Years
2000-2013
n = 14
5
4
3
2
1
0
Birth Defect Vehicle
Ch.Abuse Drowning Acc. Gun
Illness
Other
Unintentional deaths accounted for 64% of the fatalities in this age group, with vehicle-related
being the most frequent with 4 deaths. Two deaths occurred when the vehicle in which 3 year
old twin boys were passengers slid off the road in poor weather, landing upside down in a
canal. They were properly restrained in car seats, but could not be rescued in time to save
them from drowning. One infant died due to a low-speed crash, when the improperly installed
car seat was impacted by the car’s airbag, causing a fatal injury. One child died in Mexico, in
an accident when a flat tire caused the vehicle to go out of control and down a cliff, killing the
two-year old, her parents, and 3 other relatives. Two siblings, also Sutter County residents,
were injured in the crash. Two of the three non-vehicle-related drowning deaths were in
residential pools, one of which was ruled a child neglect case, since the family member was
aware that the child was inadequately supervised while by the pool. The other drowning
occurred in an out-of-county pond, when the 2 year old fell out of an inflatable boat he was
riding in with his father. The father also died, trying to save the toddler. The two child abuse
deaths were both from effects of Shaken Baby Syndrome injuries they sustained as younger
infants at the hands of family members. The unintentional gunshot fatality was self-inflicted.
The “Other” unintentional fatality was a child who was hit by a speeding watercraft while she
and a parent were walking in very shallow water at the edge of the river.
13
4-5 YEARS OF AGE
Child Deaths
Category by Age Group: 4-5 Years
2000-2013
n=3
Homicide, 1
Unintent, 2
Child Deaths
Mode by Age Group: 4-5 Years
2000-2013
n=3
3
2
1
0
Child Abuse
Drowning
The child abuse death was a 5 year old boy who was shot, along with his mother and 9 year
old twin brothers, by his father. The homicides occurred during a custody dispute, when the
father came from where he lived out of state the night before the deaths to return the 3 boys to
his estranged wife who had recently come to this county to stay with relatives. He killed the 3
boys, his wife, and then himself. Two of the boys’ sisters were in another room, and they and
other relatives were unharmed. Since the perpetrator was a parent, this was categorized as a
child abuse death. One of the drownings occurred in water at a golf course in the Bay Area,
and the other happened in a residential pool during a large party.
14
6-7 YEARS OF AGE
Child Deaths
Category by Age Group: 6-7 Years
2000-2013
n=3
Natural
3
Child Deaths
Mode by Age Group: 6-7 Years
2000-2013
n=3
Illness, 1
Birth Defect,
3
The 6-7 year old group is generally an age at which the child is somewhat more independent
and understands some risks that younger children do not, but is still under adult supervision,
so unintentional injuries are much less frequent than in younger and older age groups.
15
8-9 YEARS OF AGE
Child Deaths
Category by Age Group: 8-9 Years
2000-2013
n=3
Natural, 1
Homicide, 2
Child Deaths
Mode by Age Group: 8-9 Years
2000-2013
n=3
Birth Defects,
1
Child Abuse, 2
The 8-9 year old age group generally has few unintentional deaths for the same reasons
stated above for the 6-7 year old age group. The child abuse victims were the nine year old
twin siblings who were killed along with their five year brother and their mother, as was
described in the “4-5 Year Old” section above. The one natural death was from late effects of
conditions caused by congenital (birth) defects.
16
10-13 YEARS OF AGE
Child Deaths
Category by Age Group: 10-13 Years
2000-2013
n = 11
Suicide 2
Homicide, 1
Unintent
5
Natural
3
Child Deaths
Mode by Age Group: 10-13 Years
2000-2013
n = 11
4
3
2
1
0
Cancer
Vehicle
Drowning
Suicide
Unint. Gun Kidnap/Hom
Both of the drowning victims were 10 year olds, one of whom died in a residential pool; the
other of whom died in a lake in Yuba County. In both cases, the adults had temporarily left the
immediate vicinity where the child was in the water. One of the vehicle-related deaths was a 10
year old who was wearing a seat belt, and who was ejected from the family vehicle during a
crash. The other was a bicycle vs. vehicle death of a 10 year old boy who was riding a bike,
unsupervised on a 2-lane, 55 mph road. He veered into the path of a car, sustaining nonsurvivable injuries. Both of the suicides were boys, particularly sad due to their young ages.
One was a hanging death and the other was a self-inflicted gunshot death. The unintentional
gunshot death was a 13 year old boy who was playing with a loaded gun while alone in the
family car. The homicide was a 13 year old Sacramento girl, kidnapped in Sacramento, and
then driven to Sutter County before being sexually attacked and strangled on a riverbank. The
three natural deaths were all due to cancer.
17
14-15 YEARS OF AGE
Child Deaths
Category by Age Group: 14-15 Years
2000-2013
n = 11
Homicide, 1
Natural, 3
Unintentional,
7
Child Deaths
Mode by Age Group: 14-15 Years
2000-2013
n = 11
6
5
4
3
2
1
0
Vehicle
Drowning
Birth Def
Gun/Gang
Cancer
Five of the seven unintentional deaths were vehicle-related. All of the victims were passengers. The
drivers in 4 of the 5 crashes were male friends or boyfriends of the victims and the fifth driver was an
unlicensed female relative. Factors involved in one or more crashes included alcohol, improper seatbelt
use (shoulder belt fastened but lap belt not fastened), ‘road rage”, racing, a stolen vehicle, and failure to
call for help after a crash occurred, in spite of injuries to the victim. The last two factors were involved
when three Sacramento County teen boys stole a car there, were joyriding on Sutter County levees,
and crashed. After the crash, the victim was alive, though he had sustained major injuries. Rather than
calling for medical aid, one of the other boys called his father, who told them not to call for help, saying
he would come to them. During the nearly 3 hour wait for his arrival, the uninjured boys turned off
vehicle lights and concealed the car from being seen by passing vehicles. During this time, the victim
died. The other boy’s father and a friend then drove the boy’s body back to Sacramento County, put it
in a drainage ditch and did not report the crash. There were five arrests and convictions in this case.
The two drownings were 14 and 15 year old boys who died while swimming in the river in unrelated
incidents. The homicide was a gang-related drive-by shooting. Two of the natural deaths were due to
conditions due to birth defects and the third child died of cancer.
18
16-17 YEARS OF AGE
Child Deaths
Category by Age Group: 16-17 Years
2000-2013
n = 22
12
10
8
6
4
2
0
Unintent.
Homicide
Natural
Suicide
Undeterm
Child Deaths
Mode by Age Group: 16-17 Years
10
2000-2013
n = 22
8
6
4
2
0
Sixteen to seventeen year-olds are at risk for a number of reasons. They and their friends are
driving, often feel that they are more skilled than they actually are, and any kind of distraction
is more dangerous than with more experience drivers. Risk-taking is common, particularly for
boys in this age group, and they often lack the emotional maturity to make sound judgments
when involved in such activities. To compound this, teens tend to have an unrealistic sense of
invulnerability, which can put them in harm’s way.
Nine of the deaths in this age range were vehicle-related, and included those of 7 boys and 2
girls. Two of the crashes involved two vehicles. The other seven involved a single vehicle. Four
of the victims were drivers, three were passengers, and the status of one could not be
19
determined. The ninth victim was pedestrian wearing dark clothing at night while walking along
the side of the road in a rural area. He was stuck by a vehicle whose driver did not see him in
the dark.
Other factors leading to the fatalities included a crash by an unlicensed driver; lack of use of
seat belts; a teen boy standing in the bed of a pickup truck, then falling out as it sped off after
an altercation with other youths; and drivers of two vehicles racing one another. One incident,
in which a 17 year old and two others were killed was the result of speed, lack of use of
headlights at night, and running a stop sign, which resulted in impact with and being run over
by a trailer-tractor rig.
The incident in which it could not be determined if the victim was the driver or passenger was
one in which three Sacramento boys had been observed partying and driving an SUV at night
at a river beach in Sutter County, and ended up driving a vehicle into the river. All three youths
drowned, though only one of the deaths was reviewed by this CDRT.
Another death was caused by a head-on dirt bike crash at night. Neither helmets nor the
required headlights were being used at the time of the crash. One boy died and the other
sustained significant injuries.
A private plane crash took the lives of a 17 year old boy and adult male pilot from Sacramento,
when the plane reportedly fell apart in the sky and crashed in Sutter County. The National
Transportation Safety Board (NTSB) report stated that there was marijuana in the systems of
both the teen and the pilot.
There were two drug overdoses; one of which was a 17 year old girl who unintentionally
overdosed on the drug Ecstasy at a party. This incident was particularly troubling because
apparently others who were present did not summon medical aid in time to save her life. The
other drug overdose was ruled, “Undetermined” because evidence made it impossible for the
coroner to determine if the death was accidental or a suicide.
All of the homicide victims were male. Five of the six homicides were apparently gang-related
shootings. The sixth was due to a stabbing that occurred during an altercation amidst a mob
scene at a large party. The suicide was a 17 year old boy who took his life with a shotgun.
One of the two natural deaths was due to cancer, and the other due to conditions due to birth
defects. The second “Undetermined” death was a 16 year old boy who collapsed at school,
having medical conditions which may have caused his death but for which tests were
inconclusive.
20
NATURAL CHILD DEATHS
Natural Child Deaths by Type
2000-2013
n = 69
SIDS, 3
Cancer, 8
Premature, 23
Illness, 9
Birth Defect, 26
Prematurity and birth defects (congenital conditions) can be co-existing issues. The type noted
above is the primary cause of death shown on the death certificate, although birth defect(s)
may be shown as conditions contributing to the death.
Natural Child Deaths by Year
2000-2013
n = 69
10
9
8
7
6
5
4
3
2
1
0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Natural deaths include those from preterm birth, birth (congenital) defects, SIDS, illness, and
conditions such as cancer. Although these look like large spikes or drops in occurrence, these
are still small numbers, making the difference in just a few cases look as though there is a
large positive or negative trend, when it may in fact, not be statistically significant.
21
UNDETERMINED CHILD DEATHS
UNDERLYING ISSUES
Undetermined Child Deaths
Underlying Issues
2000-2013
9
8
7
6
5
4
3
2
1
0
Unint. Suffocation
Medical Cond.
Unint. vs. suicide O.D.
PROBABLE UNINTENTIONAL SUFFOCATION
8
6
Infant Sleep-Related
Probable Unintentional Suffocation
Deaths
2000-2013
n=8
4
2
0
Co-Sleep with Adult
Soft Bedding
The issue of unintentional suffocation of infants is an emotional one. The desire to have one’s
infant close to you is a natural instinct. The unfortunate fact is that young infants can easily
suffocate because their face is soft and pliable, and they often cannot move themselves out of
a suffocating situation. Co-sleeping with an adult or in bedding that is soft and can easily
surround the pliable nose and mouth of an infant is a dangerous practice. Breastfeeding and
cuddling are extremely beneficial to both the baby and the parents, but the safest thing that a
parent or caregiver can do for the child is to then put them in a separate, safe, nearby crib to
sleep. It used to be thought that only an intoxicated parent was at risk of rolling over onto an
infant or unknowingly smothering them with an arm or bedding. But it is now understood that a
fatigued parent, as most parents of newborns are, can have these same things happen, only to
wake up to an infant who has been unintentionally suffocated. This heaps feelings of guilt as
well as intense sorrow on the parent, since their baby was usually otherwise healthy and didn’t
need to die. This heartbreak can be avoided by loving your child intensely, but safely.
22
UNDETERMINED CHILD DEATHS BY YEAR
Undetermined Child Deaths by Year
2000-2013
n = 11
3
2
1
0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
23
INTENTIONAL CHILD DEATHS
Intentional Child Deaths by Mode
2000-2013
n = 16
7
6
5
4
3
2
1
0
Gang/Prob Gang Abuse/Neglect
Suicide
Kidnap
Other Alterca.
Homicide Child Deaths by Year
2000-2013
n = 13
5
4
3
2
1
0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Though the numbers were low most years, any homicide deaths are too many. The trending
shown over the years from 2000 to 2013 has progressed in a positive direction. Much work has
been done in the community by law enforcement, probation, schools, other agencies and
individuals to try to reduce gang-related fatalities. In this age group, those efforts seem to be
showing definite improvement in accomplishing that goal.
24
CHILD DEATHS DUE TO ABUSE OR NEGLECT
Percentage of all
Child Deaths Due to Abuse or Neglect
2000-2013
n = 132 total deaths
Abuse/Neglect
5%
Not
Abuse/Neglect
95%
Any death due to child abuse or neglect is particularly disturbing, because those deaths are
caused not by strangers, but by the very people, family members or caregivers, who are
supposed to care for and protect these children. Two of these abuse deaths were due to
Shaken Baby and Shaken-Impact Syndrome abuse. These two baby boys had been severely
injured as very young infants, but each lived over a year with massive neurological damage,
and then died as a result of the original injuries.
Even the small numbers of abuse or neglect deaths shown are artificially inflated in relation to
the norm in Sutter County, since the other three abuse deaths were those of the 5 year old and
his two 9 year old brothers at the hands of their father who brought them from out-of-state the
day before committing the quadruple homicide/suicide described earlier in this report. The
neglect case was the toddler who drowned in a residential pool while being inadequately
supervised by a family member.
25
Child Abuse or Neglect Deaths by Year
2000-2013
n=6
5
4
3
2
1
0
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
The last abuse death occurred in 2002, and the only neglect death was in 2007. The spike in
2002 was due to the three boys killed by their father as described in the previous section.
Child Abuse or Neglect Deaths
Age at Time of Occurance
2000-2013
n=6
9 Years
2
1 Month
1
2 Months
1
5 Years
1
The one month old and two month old were the baby boys who died several months later due
the massive injuries caused by Shaken Baby/Shaken Impact Syndrome. The five year old and
the 2 nine year olds were the sibling boys killed along with their mother by their out-of-state
father in the quadruple homicide/suicide described earlier in this report.
26
SUICIDE
Child Suicide Deaths by Age Group
2000-2013
n=3
16-17 Years, 1
10-13 Years, 2
Suicide Child Deaths by Year
2000-2013
n= 3
3
2
1
0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Suicides are incredibly heartbreaking for the loved ones of the person who died, particularly
when the death is of a child or adolescent. It is impossible for those left behind not to wonder if
they could have done something to stop the death, though this is not always possible. The pain
is intensified if there are siblings who must try to understand and cope with the death. YubaSutter Mental Health and the Network of Care, along with other agencies are actively providing
public education and training sessions, such as “Mental Health First Aid” and “Applied Suicide
Intervention Training (ASIST)” regarding recognizing signs of someone who may be at risk of
suicide, as well as skills for dealing with the situation. The Mental Health Crisis Line and other
counseling services can work with those who feel they in danger of committing suicide.
Schools, mental health, law enforcement and other agencies are working on anti-bullying
prevention, since being bullied may put youth at higher risk of suicide.
27
UNINTENTIONAL CHILD DEATHS
Unintentional Child Deaths by Mode
2000-2013
n = 35
20
15
10
5
0
Vehicle
Drowning
O.D.
Plane
Gunshot
Other
The term “unintentional” has been replacing the term “accidental” in the injury prevention
community, although death certificates in California still use “Accident” as the term for Manner
of Death. The reason for the change is that although these deaths were certainly not
intentional, the large majority of them were preventable. The most common cause (49%) of
unintentional deaths of 0-17 year olds in Sutter County from 2000-2013 was vehicle-related
fatal injury, followed by drowning (34%). The three instances in which the children drowned
due to vehicles going into bodies of water are shown in the “Vehicle” category, since the event
which precipitated the drowning was the vehicle incident.
Unintentional Child Deaths by Year
2000-2013
n = 35
8
7
6
5
4
3
2
1
0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
The downward trend, and the fact that there has only been a single unintentional death each
year from 2009-2013 is primarily due to the significant decrease in child deaths due to motor
vehicle crashes.
28
CHILD DEATHS BY DROWNING
Child Drowning Deaths
by Age Group
2000-2013
n=9
4
3
2
1
0
1-3 Years
4-5 Years
6-7 Years
8-9 Years 10-13 Years 14-15 Years 16-17 Years
The total of these drowning deaths excludes three drownings that were directly caused by
vehicles crashing into bodies of water. Those fatalities are shown in the “Vehicle-related
Deaths” section, since the events that caused the deaths were the vehicle crashes.
Child Drowning Deaths
by Location
2000-2013
n=9
5
4
3
2
1
0
Res. Pool
River
Lake
Pond
Golf Course
The locations of the vehicle-related drownings are included in the “Vehicle-related Deaths”
section.
29
Child Drowning Deaths
by Year
3
2000-2013
n=9
2
1
0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Although these are statistically small numbers, any drowning is a drowning too many, since
they are almost always preventable. Though the numbers have gone up and down over the
years, we have not yet been able to stop children from dying by drowning, despite public
awareness information from numerous local, state and national agencies and organizations.
Unfortunately, the single most consistent underlying cause in the great majority of child
drowning deaths is the lack of adequate adult supervision. Parents must remain within arm’s
reach and direct visual contact of young children who are in or near water, not just be in the
nearby vicinity or be distracted by other activities. Anyone caring for children must always be
aware of how curious children are; how quickly they move; and how silently they drown.
Parents also need to talk to their teenagers about the dangers of swimming in the river, due to
lack of visibility, currents, and dangerous outcroppings and snags, as well as extremely cold
temperatures during several months of the year.
30
MOTOR VEHICLE-RELATED DEATHS
Motor Vehicle-Related Child Deaths by Year
2000-2013
n = 20
6
5
4
3
2
1
0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
These numbers include three drowning deaths that were directly caused by vehicles crashing into
bodies of water. The last vehicle-related death was in 2010, and was a Sutter County child who died in
a multiple fatality crash outside of the country. Graduated driver’s licenses in California limit who a new
teen driver can have in the car with them to reduce distractions that a new driver faces, and limits the
hours that they can drive. The law also requires additional adult supervision during the initial period,
and seems to have had a major effect on reducing the fatal crashes involving 16-17 year olds. This,
coupled with ongoing local student and public awareness campaigns and events, seems to have had a
large positive effect on the frequency of teen vehicle crashes.
Single vs. Multiple Vehicle Crashes
Motor Vehicle-Related Child Deaths 2000-2013
n = 20 Crashes
(excludes bike vs. vehicle, and pedestrian vs. vehicle)
Multiple, 4
Single, 16
The fact is that 80% of these fatalities occurred in single-vehicle crashes, not from someone in
another vehicle causing the fatal crash. The most common scenario involved the driver losing
control of the vehicle, resulting in it leaving the road and rolling over or impacting an object
such as a tree, utility pole or bridge abutment. Three of the fatalities were the result of the two
incidents in which the driver lost control of the vehicle, which then went into a body of water,
resulting in drowning deaths.
31
Victim as Driver, Passenger, Other
Motor Vehicle-Related Child Deaths
2000-2013
n = 20
Pedestrian, 1
Unknown, 1
Bicycle, 1
Driver, 4
Passenger, 13
The majority (65%) of the victims were passengers, not drivers. Some of these were young
children being driven by family members; other victims were passengers in vehicles driven by
friends or family. Three of the four drivers who were victims were the only occupants in the
vehicle. The fourth was the boy was one of the drivers in a head-one dirt bike crash. This
emphasizes that adults must take great care when they have children as passengers in their
vehicle. It also draws strong attention to the fact that parents must not only talk with their teens
about the manner in which they themselves drive, but must also be aware of who their teens
are with and discuss with them choices about with whom they get into a car, and safe
behaviors of both the driver and the passengers.
RELATIONSHIP: DRIVER TO VICTIM
Relationship of Driver to Victim
Motor Vehicle-Related Child Deaths
2000-2013
n = 20 Victims
Unknown, 1
Stranger, 2
Self, 4
Other Relative,
3
Friend, 7
Parent, 3
32
Drivers by Gender
Motor Vehicle-Related Child Deaths
2000-2013
n = 20
Unknown
5%
Female
30%
Male
65%
Victims by Gender
Motor Vehicle-Related Child Deaths
2000-2013
n = 20
Female
40%
Male
60%
Males are over-represented as both drivers and victims. Two of the female drivers were
themselves the victims, and three were family members (one mother and two sisters) of the
child who died. Two of the female drivers fell into the “Stranger” category. One of these struck
a ten year old bicyclist who veered into the path of the car, and the other struck a pedestrian
who was wearing dark clothing and walking along the rural roadside after dark. Three of the
males who were drivers were also the victims. Eleven of the male drivers were friends,
boyfriends, or family members of the victims. It could not be definitively determined which of
the boys was driving the vehicle in the incident wherein the vehicle ended up in the river.
33
DRIVER & VICTIM BY AGE GROUP
Driver by Age Group
Motor Vehicle-Related Child Deaths
2000-2013
N = 19 Drivers
6
5
4
3
2
1
0
15 Yrs
16-17
18-19
20-24
25-30
31-35
36-39
Over 40
Victim by Age Group
Motor Vehicle-Related Child Deaths
2000-2013
N = 20 Victims
10
9
8
7
6
5
4
3
2
1
0
Under 1
1 - 3 Yrs
4-6 Yrs
7-9 Yrs
10 12 Yrs 13-15 Yrs 16-17 Yrs
The 16-17 year age group had the highest number of both drivers involved in these deaths,
and the highest number of victims. Reasons for this and the effect of the California graduated
driver’s license are discussed in the graph above regarding motor vehicle fatalities by year.
34
VEHICLE-RELATED DROWNINGS
Vehicle Crash-Related Child Drownings
Percentage of Drownings that were Vehicle-Related
2000-2013
n = 12 Total Drownings
Yes
25%
No
75%
Three of the twelve total drownings during this report period were directly due to drivers of
vehicles losing control, resulting in the vehicle going into a body of water. Two of these were
twin boys in the same vehicle that went into a water canal. The third was a teen who, with
other boys reportedly partying along the river, drowned after their vehicle went into the river.
NUMBER OF VEHICLES, OCCUPANTS & FATALITIES
Vehicles-Occupants-Fatalities
Motor-Vehicle Related Child Deaths
2000-2013
64
70
60
50
40
30
20
29
19
10
0
# of Vehicles
# of Occupants
# of Fatalities
The total of 29 fatalities is higher than the 20 child deaths shown in previous graphs, since
there were also adult and other teen fatalities to be represented. The loss of a child or
adolescent life is extremely difficult, but the number of fatalities could have been even worse.
The number of occupants involved in the crashes resulting in fatalities is 2.2 times the number
of fatalities. The average number of occupants was 3.4 per vehicle, but there was a wide range
of number of occupants, from a single driver/occupant, to the one unusual out-of-country case
with 13 occupants in the vehicle, 6 of whom died.
35
DAY OF THE WEEK
Day of Week
Motor Vehicle-Related Child Deaths
2000-2013
n = 20
5
4
3
2
1
0
Sunday
Monday
Tuesday
Wed.
Thursday
Friday
Saturday
With small numbers such as these, there is no statistically significant difference in the day of
the week on which these fatalities occurred.
TIME OF DAY
Time of Day
Motor Vehicle-Related Child Deaths
2000-2013
n=20
12
10
8
6
4
2
0
1-5 a.m.
6-12 a.m.
1-5 p.m.
6-12 p.m.
Unknown
As can be seen, the time period of 6 p.m. to midnight is significantly over-represented. This
correlates with times that children and adolescents are not in school and may have less
supervision that at other times of day.
36
EXCESSIVE SPEED
Excessive Speed Involved
Motor Vehicle-Related Child Deaths
2000-2013
Unknown
15%
No
20%
Yes
65%
Excessive speed, or speed excessive for road conditions, was a factor in majority of these
deaths. The result was a loss of control of the vehicle, resulting in it leaving the roadway,
impacting an object, overturning, or submerging in water. In younger drivers, inexperience,
distractions, and overestimation of their driving ability is often involved in vehicle crashes.
ALCOHOL OR DRUGS
Alcohol or Drugs in Driver
Motor Vehicle-Related Child Deaths
Unknown
16%
2000-2013
Yes
10%
No
74%
While a small percentage of the drivers were shown to have drugs or alcohol in their system,
these substances also contribute to non-fatal crashes.
For years, multiple agencies in the community have worked together to present the simulated
crash “Every 15 Minutes” drunken driving prevention program at local high schools. Prevention
is always difficult to measure, but the fact that there were not more fatal crashes due to
substance use in this age group may demonstrate effectiveness in reaching high school
students. However, since teens tend to have a sense of invulnerability, it will take continued
efforts on many fronts, including programs such as these, enforcement of “sales to minors’
violations, encouraging positive peer pressure, and effective parental supervision and
guidance to effectively prevent both fatal and nonfatal youth crashes due to alcohol or drugs.
37
SEAT BELT USE
Victims Use of Seatbelt or Car Seat
Yes or No/Incorrect Usage
Motor Vehicle-Related Child Deaths
n = 20
12
10
8
6
4
2
0
Yes
No/Incorrect
Unknown
Of the six, “No/Incorrect” seatbelt use, four had no seatbelt on at the time of the crash. One
was due to an incorrectly installed and placed infant car seat which resulted in the airbag
hitting the car seat in a slow-speed crash, causing fatal injury to the baby. The other was due
to a 2-piece seatbelt being incorrectly used; with the shoulder strap being fastened, but the lap
belt not being fastened.
FACTORS INVOLVED

















Excessive speed or speed excessive for road conditions
Lack of, or improper use of seatbelts, car seat
Racing another vehicle
Road Rage
Unsafe passing
Unlicensed driver
Running stoplight or stop sign
No headlights at night
Unsafe turn
Stolen vehicle
Victim standing in back bed of moving truck
Pedestrian at edge of road, wearing dark clothing at night
Did not seek medical aid for injured party
Unsupervised bike riding of young boy on high-speed road
No headlight or helmet at night in dirt bike crash
Alcohol or drugs
Distractions from others in vehicle
38
CHILD DEATHS BY MONTH OF THE YEAR
Total Child Deaths by Month of Year
2000-2013
n = 132
16
14
12
10
8
6
4
2
0
Natural Child Deaths by Month of Year
2000-2013
n = 69
12
10
8
6
4
2
0
Jan.
Feb. March April May
June
39
July
Aug. Sept. Oct.
Nov.
Dec.
HOMICIDE DEATHS BY MONTH
Homicide Child Deaths by Month of Year
2000-2013
n = 13
7
6
5
4
3
2
1
0
Jan.
Feb. March April
May
June
July
Aug. Sept.
Oct.
Nov.
Dec.
SUICIDE DEATHS BY MONTH
Suicide Child Deaths by Month of Year
2000-2013
n = 13
2
1
0
Jan.
Feb. March April May June
40
July
Aug. Sept. Oct.
Nov. Dec.
UNINTENTIONAL DEATHS BY MONTH
Unintentional Child Deaths by Month of Year
2000-2013
n = 35
8
7
6
5
4
3
2
1
0
Jan.
Feb. March April May
June
July
Aug. Sept. Oct.
Nov.
Dec.
The increase in unintentional deaths during the summer months coincides with school being
out resulting in children and youth having more time to be involved in outdoor activities.
UNDETERMINED DEATHS BY MONTH
Undetermined Child Deaths by Month of Year
2000-2013
n = 11
3
2
1
0
Jan.
Feb. March April
May
June
41
July
Aug. Sept.
Oct.
Nov.
Dec.
PREVENTABLE CHILD DEATHS
Preventable Child Deaths
2000-2013
n = 132
80
70
60
50
40
30
20
10
0
67
52
9
Preventable
4
Poss Prev
Not Prev
Can't Determ
Percent of Child Deaths Preventable-by Year
2000-2013
n = 132
80
70
60
50
40
30
20
10
0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
The improved trend shown here reflects in large part the significant decline in motor vehicle
fatalities and homicides discussed in earlier sections of this report. This is important data,
because natural deaths cannot be often greatly impacted, other ensuring adequate prenatal
care, eliminating vaccine-preventable illnesses and ensuring that infants sleep in safe
environments to lower SIDS deaths. But reducing, or ideally, eliminating preventable deaths is
what can actually have a significant impact on the number of children who unnecessarily die. It
also relieves parents and families of the emotional toll of knowing that they may not have had
to have lost their child.
42
RECOMMENDATIONS & COMMUNITY INTERVENTIONS
BICYCLE SAFETY

Multiple agencies, including law enforcement and Public Health, promote bicycle safety
and skills through education and training at health fairs and bicycle safety “rodeos.

Parents must be responsible for ensuring that their children have the skills they need to
bike safely and must ensure that their child wears securely fastened, correctly fitted
helmets at all times when riding. Educational talks by numerous agencies emphasize
this to parents.
FAMILY VIOLENCE

The Sutter County Domestic Violence Council & Child Abuse Prevention Council will
continue to meet quarterly to address issues in the area of family violence.

The community will continue to hold to a “no tolerance” position towards family violence.

Events sponsored by Casa de Esperanza and other agencies, such as “Hands Across
the Bridge” during Child Abuse Prevention Month in April, and the “Candlelight Vigil”
during Domestic Violence Awareness Month in October involved the community as a
whole in the awareness and prevention of family violence.

At-risk parents are to be referred to community resources for parenting classes.

The Sutter County Child Death Review Team’s Shaken Baby Syndrome Prevention
Project promoted awareness of the dangers of SBS with outreach efforts funded by a
mini-grant from the Sutter County Children and Families Commission, and donations
from Sutter County Sheriff’s Department and other community organizations. Since
young males cause 70-80% of Shaken Baby and Shaken-Impact injuries, the project,
started in 2003, developed a billboard showing local young men in various sports and
occupations holding babies, with the title, “Real Men Know When to be Gentle....
NEVER SHAKE A BABY”.
This project also included posters, pamphlets, movie theater on-screen ads;
educational presentations at numerous parent, student, professional, and community
venues; public access television educational spots; and “Fragile: Never Shake a Baby”
window and mirror clings in local businesses and restaurants. The pamphlets were
produced in English, Spanish and Punjabi. These can be downloaded at the Sutter
County Human Services-Public Health section on the county web page at
http://www.co.sutter.ca.us/doc/government/depts/hs/ph/hs_public_health. Posters were
distributed to numerous agencies and organizations both within Sutter County and
to other counties and states.
43
GANGS

Law enforcement agency efforts, including the multi-agency Yuba-Sutter Anti-Gang
Enforcement (YSAGE), have the mission to reduce gang violence in Yuba and Sutter
Counties through proactive enforcement efforts, intelligence gathering, and improved
communication. The collaborative allows the pooling of resources, so two or more times
per month they can saturate the region with 30-40 officers with the specific aim of
targeted gang enforcement and conducting associated investigative follow-up.
MOTOR VEHICLE SAFETY

Multiple agencies continue to provide community programs such as “Every 15 Minutes”
high school drunk driving prevention program.

Multiple agencies, with law enforcement as lead, will continue to provide safe driving
educational messages and outreach regarding areas such as child safety restraints,
seatbelt use, drunk and drugged driving, aggressive driving and unsafe passing, driving
safety around schools and school buses, and young drivers.

Sutter County Public Health, law enforcement, and the local Keeping Kids Safe program
have conduct child car seat safety checks, and have provided low-cost car seats and
parent education. Information regarding the required car seats for newborns is given at
Fremont Hospital, by Sutter County Public Health Nurses, by obstetrician offices, and at
outreach events for parents.

DUI check-points continue to be utilized by the law enforcement agencies in the county,
including California Highway Patrol, Sutter County Sheriff’s Department and Yuba City
Police Department.

The widening of Highway 99 between Yuba City and Sacramento over the past several
years has changed the large majority of the road into four lanes. This has provided
drivers with a safer option for passing slower vehicles, without needing to enter a lane of
oncoming traffic.
44
PARENTAL & CAREGIVER SUPERVISION
OF CHILDREN

Sutter County Children & Families Commission funds a Child Development Behavioral
Specialist, who works with parents regarding parenting skills and child behavior.

Sutter County Public Health Nurses, Friday Night Live, Children’s Home Society, Family
Soup, Head Start and Migrant Head Start, First Steps, Casa de Esperanza, Child
Protective Services, Bright Futures, Parent Network, schools, and others have provided
parenting education during this report period. Included in parts of these educational
presentations is the need for adequate, consistent adult supervision of children.
SIDS PREVENTION & SAFE SLEEP ENVIRONMENTS FOR BABIES

“Safe Sleep” for infants encompasses both Sudden Infant Death Syndrome (SIDS)
prevention, such as the “Back to Sleep” Campaign, and safe sleeping environments for
infants to avoid deaths by unintentional suffocation.

Public Health Nurse have provided SIDS and Safe Sleeping Environment educational
presentations to groups such as Cal Works, Teen Health Focus at Friday Night Live,
First Steps Perinatal Substance Treatment Program, Casa de Esperanza, prenatal
classes, health fairs; and during Public Health Nurse home visits and newborn hospital
rounds for parents of Medi-Cal qualified babies. Others educating parents on this topic
are Fremont Hospital and obstetrician and pediatrician’s offices.
SUICIDE PREVENTION

Sutter-Yuba Mental Health and the Network of Care, along with other agencies, are
actively providing public education regarding recognizing signs of someone who may
be at risk of suicide, as well as skills for dealing with the situation. Trainings include,
“Mental Health First Aid” and “Applied Suicide Intervention Training (ASIST)”.

The Mental Health Crisis Line at (530) 673-8255, and other counseling services can
work with those who feel they are in danger of committing suicide.

Schools, Mental Health, law enforcement and other agencies are working on antibullying prevention, since being bullied may put youth at higher risk of suicide.

With Yuba-Sutter Mental Health as a lead, the community is working to destigmatize
mental health issues, both to improve how those with mental illness are treated by
others, and to remove barriers for those who need help, but who may avoid
accessing assistance due fear of being identified as mentally ill.
45
SUBSTANCE ABUSE

Numerous community agencies participated in the “Drug Store” program, which was
held for several years during this report period. The annual events took approximately
2,500 middle school students through a series of eight performed vignettes depicting
events leading up to the “fatal” overdose of a student, and the effects upon the family in
the emergency room and at the student’s funeral.
NOTE: The “Drug Store” event was held until 2004, but had to be cancelled as of
2005. Although this was a valuable tool, producing this 4-5 day event required an
incredible amount of time and staffing on the parts of the agencies involved. As
agency budgets became tightened and personnel became less available, it was no
longer feasible to hold the program.

Law enforcement continues to provide drug violation enforcement in the community,

Mental Health, schools, and other agencies continue to provide community education
regarding substance abuse in any form to professionals, parents, pregnant women,
students, and other adults regarding the dangers of substance abuse in any form.

Agencies will work to link substance abusing individuals with treatment programs and/or
support groups, to increase their potential for abuse cessation.
WATER SAFETY

Water safety awareness and education regarding all types of water safety (rivers,
swimming pools, large buckets, swimming lessons, adequate adult supervision, etc.)
are addressed many agencies, including Sutter County Sheriff’s Boat Patrol, other law
enforcement and fire personnel, schools, Public Health staff, American Red Cross,
Yuba City Parks and Recreation Department, the YMCA, Gauche Aquatic Park.

Note: The CDRT was unable to enact a recommendation made for water safety
prevention in 2002 and followed up in 2003. The suggestion had been made to put
cautionary signage at various points near the river, regarding the dangers of swimming
in the river. Due to legal issues, that was not deemed possible to implement.
46
SYSTEM RECOMMENDATIONS

Child protective services will notify the Sheriff-Coroner’s office of name changes, as
happens when a child is adopted, if the child had been victim of, but survived, severe
child abuse injuries. This will facilitate linkage of facts regarding the original injuries if
the child later dies of the effects of those injuries, such as can occur with Shaken Baby
Syndrome. In these types of cases, without the name change information, the true
underlying cause of the death would be more difficult to determine, or the adoptive
parents might inadvertently be suspected of causing the injuries.

Sutter County Child Death Review Team will continue to work with other county child
death review teams to facilitate cross-jurisdictional information exchange for child death
cases when county of residence, and/or death differ, and to share information for
interventions that can lower the incidence of child deaths.
47
CONCLUSIONS
Although 132 child deaths from 2000-2013 were reviewed, there are limitations to the
conclusions that can be drawn. As was mentioned early in the report, within different
categories of deaths these are still small numbers, and small fluctuations can seem to show
changes in trends that may not actually be statistically significant. Not including 2000, for
which reviews were done only for the last half of the year, there was an average of 12.5 deaths
per year. However, the numbers of deaths in a year varied from a low of 4 to a high of 20.
Because some types of child fatalities, such as suicide, SIDS, and child abuse deaths, occur
relatively rarely in Sutter County, a pattern cannot be reliably identified. A spike in child abuse
deaths showed up in 2002, but was mainly due to 3 deaths in one incident in which the
perpetrator came from an out-of-state residence the night prior to the incident. So although this
was horrifying and dramatic, it did not portend a trend.
There have been no suicides or child abuse deaths in the age group covered by the CDRT
since 2002. There was one child neglect case in 2007, which was the residential pool drowning
of an inadequately supervised toddler. However, fatalities represent only the tip of the
intentional or unintentional injury “iceberg”. For each fatality, there are many more injuries,
from mild to severe. Even some “Natural” deaths may be preventable. Therefore, to ignore
prevention aspects would be doing a major disservice to our children.
There are some consistencies to be seen throughout the years. Boys died more frequently
than girls, at all ages, and of all causes other than birth defects. Newborns die most often from
prematurity, followed by birth defects. In the “Unintentional” category, vehicle-related deaths
far outnumber deaths by all other causes. The passenger, rather than the driver was the victim
the majority of the time. The driver was a friend of the victim in almost half of the deaths. In the
vehicle-related incidents, excessive speed was by far the most common factor. When looking
at all of the unintentional deaths, inadequate adult supervision was the underlying cause the
largest number of the deaths, particularly those of children under the age of thirteen. All of the
homicide victims, including those dying of child abuse, during this time period were boys.
These findings are all fairly consistent with state and national statistics.
We as parents, relatives, friends, caregivers, educators, professionals, and the community at
large need to continue to look at prevention strategies that will help keep our children safe and
healthy. No child should die an early death if that death was preventable.
48
APPENDIX A
SUTTER COUNTY CHILD DEATH REVIEW TEAM
2013-2014 MEMBER ROSTER
JUDY MIKESELL, DIRECTOR OF PH NURSING
CDRT Coordinator, Co-Chair
Sutter County Public Health
JOSEFINA ARANA, DETECTIVE
CDRT Co-Chair
Sutter County Sheriff-Coroner’s Office
* BRIAN BAKER, SGT., Yuba City Police Department
* BRANDON BARNES, LT., Yuba County Sheriff’s Department
* JODIE BECK, PUBLIC INFORMATION OFFICER, California Highway Patrol, Yuba-Sutter
* LOU BINNINGER, Trauma Intervention Program (TIP)
* AMERJIT BHATTAL, ASSISTANT DIRECTOR, Sutter County Human Services-Health
* JACKIE BOISA, Compassionate Friends
* JAMES CASNER, CHIEF DEPUTY CORONER, Sutter County Sheriff-Coroner’s Office
* BILL COCHRAN, CAPT., Sutter County Fire Services
* LOU ANNE CUMMINGS, M.D., Sutter County Health Officer
* PETE DAILEY, CHIEF, Yuba City Fire Department
* GRACE ESPINDOLA, Sutter County Office of Education
* LORI HARRAH, ASSIST. DIRECTOR, Sutter County Human Svcs-Welfare & Social Svcs
*TONY HOBSON, ASSIST. DIRECTOR, Sutter County Human Svcs-Mental Health
* BILL KELLOGG, CHIEF INVESTIGATOR, Sutter County District Attorney’s Office
* PAULA KEARNS, MANAGER, Sutter County Social Services
* ROB LANDON, CHIEF, Yuba City Police Department
* BRUCE MORTON, DIR. STUDENT WELFARE/ATTENDANCE, Yuba City Unified Schools
* ANDRES ORNELAS, COMMANDER, California Highway Patrol, Yuba-Sutter
* LETICIA PARAS-TOPETE, CHIEF PROBATION OFFICER, Sutter County Probation
* J. PAUL PARKER, SHERIFF-CORONER, Sutter County Sheriff-Coroner’s Office
* TOM SHERRY, DIRECTOR, Sutter County Human Services
* TRACY SISEMORE, RN, SUPERVISOR, Rideout Hospital Emergency Department
* LISA SOTO, DEPUTY DIRECTOR, Sutter County Welfare & Social Services
* LISA SUAREZ, Sutter County Child Development Behavior Specialist
* RON WELCH, Bi-County Ambulance
* ALICE WILLIAMS-ROOT, SUPV. PHN, Sutter County Public Health
* JANA WOODARD, SUPERVISOR, Sutter County Child Protective Services
* DAN YAGER, FIRE SERVICES MANAGER, Sutter County Fire Services
49
APPENDIX B
ON-LINE RESOURCES
There are countless resources available, many on-line. The following is just a sampling of
reputable web sites with information on some of the topics covered in this report.
NOTE: Please use caution when going to web sites in general. Many exist that purport to be
experts in a particular area, but may not have objective or legitimate information, especially
concerning sensitive areas such as child injuries and deaths.
CHILD DEATH REVIEW
National MCH Center for Child Death Review http://www.childdeathreview.org/
Inter-Agency Council on Child Abuse & Neglect http://ican4kids.org/
State of California Child Death Review Enabling Rules
www.childdeathreview.org/Legislation/CAleg.pdf
CHILD SAFETY: GENERAL INFORMATION
Center for Injury Prevention Policy & Practice http://www.cippp.org/
Harborview Injury Prevention & Research Center http://depts.washington.edu/hiprc/
Safe Kids http://www.safekids.org/
Sutter County Children & Families Commission
http://www.co.sutter.ca.us/doc/government/depts/hs/cfc/cfchome
Sutter County Human Services: Public Health
http://www.co.sutter.ca.us/doc/government/depts/hs/ph/hs_public_health
Sutter County Human Services: Welfare & Social Services
http://co.sutter.ca.us/doc/government/depts/hs/wss/hs_welfare_social_services
Sutter County Sheriff
http://suttersheriff.org/
Sutter County Fire Services
http://www.co.sutter.ca.us/doc/government/depts/cs/cs_fire_services
U.S. Army Corps of Engineers: Water Safety http://watersafety.usace.army.mil/
U.S. Consumer Product Safety Commission http://www.cpsc.gov/cpscpub/pubs/chld_sfy.html
Yuba City Fire Department http://www.yubacityfire.org/
Yuba City Police Department: http://www.ycpd.org/
50
CHILDREN & CANCER
National Cancer Institute: Childhood Cancers
http://www.nci.nih.gov/cancertopics/types/childhoodcancers
DATA
California Highway Patrol-Statewide Integrated Traffic Records System (SWITRS)
http://iswitrs.chp.ca.gov/Reports/jsp/CollisionReports.jsp
California County Health Status Profiles
http://www.cdph.ca.gov/pubsforms/Pubs/OHIRProfiles2013.pdf
California Department of Health Services, Epidemiology & Prevention
http://www.applications.dhs.ca.gov/epicdata/default.htm
Centers for Disease Control (CDC) Childhood Injury Report: - Centers for Disease Control
www.cdc.gov/safec
Centers for Disease Control (CDC) Statistics http://www.cdc.gov/ncipc/wisqars/ and
http://www.cdc.gov/search.do?action=search&page=2&queryText=10+leading+causes+of+dea
th+chart
Child Trends http://www.childtrends.org/
Children Now http://www.childrennow.org/
U.S. Census: Sutter County http://quickfacts.census.gov/qfd/states/06/06101.html
GRIEF & MOURNING
Compassionate Friends http://www.compassionatefriends.org/
Trauma Intervention Program (TIP) of Yuba-Sutter Counties http://www.yubasuttertip.org/
MOTOR VEHICLE INJURY INFORMATION & PREVENTION
California Highway Patrol http://www.chp.ca.gov/
Kids and Cars http://www.kidsandcars.org/
National Highway Transportation Safety Administration(NHTSA) http://www.nhtsa.gov/
PREMATURITY & BIRTH DEFECTS
March of Dimes http://www.marchofdimes.com/
51
SHAKEN BABY SYNDROME
National Center on Shaken Baby Syndrome http://www.dontshake.com/
National Institute on Neurological Disorders
http://www.ninds.nih.gov/disorders/shakenbaby/shakenbaby.htm
SUDDEN INFANT DEATH SYNDROME (SIDS) & SAFE INFANT SLEEP ENVIRONMENTS
California SIDS Program: http://californiasids.cdph.ca.gov/Universal/HomePage.html
Safe to Sleep® Public Education Campaign - NICHD
http://www.nichd.nih.gov/sts/Pages/default.aspx
U.S. Consumer Product Safety Commission: Crib Safety & SIDS Prevention
http://www.cpsc.gov/cpscpub/pubs/cribsafe.html
SUICIDE-YOUTH
Sutter-Yuba Mental Health
http://www.co.sutter.ca.us/doc/government/depts/hs/mh/hs_mental_health
Sutter-Yuba Network of Care
http://sutter.networkofcare.org/mh/services/subcategory.aspx?tax=RR-5150.5000-800
Center for Suicide Prevention http://www.suicideinfo.ca/youthatrisk/
VIOLENCE & CHILDREN/YOUTH
Centers for Disease Control (CDC) Best Practices for Youth Violence Prevention
http://www.cdc.gov/ncipc/dvp/bestpractices.htm
National Council on Child Abuse and Family Violence http://nccafv.org/
Prevent Child Abuse America http://www.preventchildabuse.org/index.shtml
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52