25 Feb Child Fatality and Near Fatality External Review Panel Report (2025) 

The 2025 Child Fatality and Near Fatality External Review Panel Report was released this month, summarizing the findings from comprehensive reviews of 248 cases that were determined to be the result of child abuse. Of those cases, 72 were fatalities and 176 were near fatalities with 82% involving children aged four and younger and 44% under the age of one. 

Key Takeaways

Neglect was the most common case categorization, accounting for 57 fatalities and 137 near fatalities, with several different types identified and present in many cases, including: 


— supervisory neglect
— unsafe access to deadly or potentially deadly means
— medical neglect
— neglect resulting from an impaired caregiver
— neglect resulting from unsafe sleep

Additionally, the family characteristics outlined in the report highlight the complexities as well as missed opportunities present in many of the cases:

— 91% of overdose/ingestion cases involved environmental neglect.
— 71% of abusive head trauma cases involved substance abuse by the caregiver.
— 53% of overdose/ingestion cases involved domestic violence.
— 50% of sexual abuse cases involved a medically fragile child.
— 45% of physical abuse cases involved a missed opportunity for bystander intervention.

The Panel determined that 81% of the cases they reviewed were potentially preventable. 

Included below are a few key recommendations developed as a blueprint for decisionmakers, state agencies, and communities to address the contextual factors that continuously contribute to fatalities and near fatalities of children across Kentucky. 

Panel Recommendations 

Overdose/Ingestions 
The Panel classified 98 cases as overdose/ingestions, with 11 fatalities and 87 near fatalities. The average age of the children involved in these cases was three years old. Data shows that the most commonly ingested substances (in decreasing order) were cannabinoids (28%), fentanyl, and methamphetamine, with exposure to cannabinoids increasing by 720% over the last five years. 

The current totals for this category are a record high for the Panel, increasing by more than 100% over the last five years. The Panel recommendations include:

— Amending state regulations to ensure child-resistant packaging is used consistently across all cannabinoid-containing products.
— Creating a robust public safety campaign to educate on the dangers these substances can pose to children.
— Engaging the Office of the Attorney General, law enforcement, and medical professionals to create a comprehensive toolkit focused on testing for, investigating and prosecuting pediatric ingestions.

Physical Abuse
There were 55 cases of physical abuse which accounted for nearly one-quarter of all the cases the Panel reviewed. Of these cases, 42 were near fatalities, 13 resulted in a fatality, and more than half of the cases involved abusive head trauma. 

The Panel recommendation includes:

— Developing and implementing a comprehensive, standardized training curriculum on medical indicators of child physical abuse for case workers and medical professionals.

Department for Community Based Services 

The Panel identified opportunities for improvement in 182 (73%) of the cases reviewed this year and their recommendations include:

— Establishing processes to help address lapses in caseworker services and contacts with families.
— Creating a standardized checklist to assist case workers with consistently assessing for safe firearm storage during home visits.

Medically Complex Children 
The Panel reviewed 43 cases involving children with medical complexities and found that issues related to DCBS, economic hardship, a history of involvement with the child welfare system, and caregivers who experience mental health issues were more prevalent in these cases than in all other cases they reviewed. 

The Panel recommendations include:

— Developing and implementing a comprehensive training curriculum on medically complex children for child welfare case workers.
— Developing a statewide patient registry to support coordinated care and to assist in the early identification of families who are potentially at risk.

Your Role in Prevention

We can all play a role in preventing child abuse and neglect. The Kosair for Kids Face It Movement is a statewide initiative committed to ending child abuse through community engagement and awareness, promoting best practices, and advocating for policies that strengthen the child welfare system and protect children. 

Face It offers resources for families and communities, including Medication Safety in the Home, a practical guide for safely storing medications and preventing accidental ingestions.

The Face It policy team is also tracking proposed state legislation to better protect children from ingesting harmful substances. Senator Danny Carroll has filed Senate Bill 204, which seeks to enhance the penalty when a child under the age of 13 suffers serious physical injury as a result of ingesting or inhaling a controlled substance. It would also require several professions, including law enforcement, child care, medical, and social workers, to complete continuing education training on pediatric ingestions and inhalations every three years, among other items. 

Track the progress of SB 204 on Kentucky Youth Advocates’ Bill Tracker and take action by urging your state Senator to vote YES on SB 204.