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DCF Does Not Complete Its Fatality Review Reports and Submit Them to OCA Within the Established Timeframe.

Audit encourages DCF to review its processes, and identify opportunities to more effectively complete and submit fatality review reports to the Office of the Child Advocate.

Table of Contents


Of the 73 fatality investigations performed by DCF during our audit period, none was completed and submitted to OCA within the established 30- or 60-day timeframe. Specifically, the reports for 68 of these 73 investigations had not been completed and submitted to OCA; 31 (46%) of the 68 were instances where DCF had been aware of a child’s death for more than 365 days. Two of the remaining five reports were completed an average of 316 days late.8 These five reports were ultimately submitted to OCA for review.

OCA evaluates the effectiveness of DCF’s work on cases; assesses implications for DCF policies, regulations, training, and contracted services; and determines whether case management and other services provided are adequate, appropriate, and compliant with DCF’s own policies and regulations. Without timely fatality review reports from DCF, OCA cannot properly perform this function.

Authoritative Guidance

According to 110 CMR 13.02(4), DCF is required to finalize its fatality review report within 30 days after receiving notification of an unnatural death or 60 days after receiving notification of a natural one. The regulation also states that the report must be approved by the DCF commissioner. Internal DCF policies state that a fatality review report is considered “complete” and available for dissemination when it is signed and approved by the commissioner.

Reasons for Noncompliance

Management told us that the process that DCF has established to approve and submit these completed review reports is too complex; it includes internal and external investigations and no fewer than six departments and/or personnel within DCF to discuss, review, and update the report.


DCF should take the measures necessary to ensure that all fatality review reports are completed and submitted to OCA within the established timeframe. Specifically, DCF should evaluate its current processes, identify opportunities to make them more efficient and less complicated, and update its policies to reflect these changes.

Auditee’s Response

Given the complexity of the issues that may be involved in a child death and the time needed to gather the relevant materials, the current regulations may need to be amended to allow for a more reasonable timeframe. In any event, DCF agrees with the OSA’s recommendations regarding streamlining our fatality investigation report process to ensure more timely completion and submission to the Office of the Child Advocate. DCF is working with the Office of the Child Advocate to develop a process that best meets this need and will take appropriate actions which may include reviewing and/or revising our regulations, updating the format of the report, and updating our policy. DCF is committed to modifying our process to ensure these reports will be completed and submitted in a timely manner and so that the Department can utilize them as a continuous quality improvement (CQI) tool. All of the fatality investigation reports for the period under audit and requested by the current Office of the Child Advocate have been submitted.

8. Three of the five reports were not dated, so we could not determine their report completion dates or calculate their average number of days late.

Date published: December 7, 2017