By Rose Hoban
It’s difficult enough for a parent to cope with the loss of a child to suicide. It’s even harder when those deaths leave unanswered questions because the state does not have the capacity to delve deep for certain clues that might offer a fuller picture.
Sandra Bishop-Freeman, the interim chief toxicologist at the Office of the State Medical Examiner, described such a situation recently during a meeting of a legislative task force. She illustrated the problem using the case of a boy with a history of anxiety, social depression, attention-deficit hyperactivity disorder (ADHD) and panic attacks who died by suicide.
After his death, the medical examiner’s office performed an examination, but their analysis was incomplete, Bishop-Freeman told the Intentional Death Prevention Committee of the Child Fatality Task Force during a Nov. 14 presentation.
“This student was taking multiple psychotropic meds that we did not test for because we do not have that within the scope of our analysis,” Bishop-Freeman told task force members. “These antipsychotic or antidepressant medications could often cause increased risk of suicidality.”
The medical examiner’s office is limited by the types of drug screening they can perform. If there’s a known cause of death, pathologists in the office can only perform tests for the presence of alcohol, not for other drugs.
Chief Medical Examiner Michelle Aurelius noted that reports in these cases will just say, “‘no ethanol detected,’ meaning no drinking alcohol detected.”
“The community and those monitoring public health trends don’t realize that we are not testing for additional substances,” Aurelius said. “We’re the only state that we know of that provides limited testing just to volatiles. When we look at other states, they provide expanded testing, at least on a limited basis.”
Other states use sophisticated blood testing to detect common drugs of abuse and prescription drugs. Aurelius said this type of information translates into more messages and actions that could prevent future deaths. Even as technology exists to answer these questions, North Carolina policy hasn’t been updated to embrace these changes. Without more funding, the state Department of Health and Human Services can’t streamline the data and ramp up child death prevention activities.
“When a mom wants to know whether their child was on their ADHD medication or not, if they had an accidental interaction with a firearm that led to death, we can’t answer that question,” Aurelius told the task force. “When families or the community wants to know, for a hanging suicide was this individual on illicit drugs at the time, and that’s why they potentially made this choice? We can’t answer that question.”
Sometimes those answers come in the form of a “black box warning” on a medication, cautioning patients about certain medications.
The task force is asking the General Assembly for about $650,000 from state coffers and a green light to move ahead with this type of testing. They’re making this request again after a similar proposal to strengthen the child death tracking system was denied in the previous two-year budget cycle.
Streamlining the process
Since the creation of the Child Fatality Task Force in 1991, the rate of child deaths has fallen by about half, but there still are more than a thousand child deaths each year in North Carolina. Most are from natural causes, but several hundred child deaths each year occur as the result of homicide, suicide, motor vehicle accidents and other unintentional injuries.
After several high-profile deaths in the child welfare system during the past decade, lawmakers ordered an independent review of the system that was delivered in 2019. In it, the reviewers looked at the child fatality review process and concluded that it needed to be simplified.
“North Carolina may have the most complicated system in the country. Not the worst, not the best, but the most complicated,” task force head and DHHS employee Kella Hatcher told the group.
Hatcher explained that federal law requires three citizen panels to review child deaths in each state; in North Carolina, policy dictates that community child protection teams in each of the state’s 100 counties plus an advisory board review each child death in their county. Even though the state has grown to be the nation’s ninth largest, North Carolina is one of “very few” states trying to review all cases.
“Yet we give almost no resources to our local teams right now to do that,” Hatcher added.
On top of that, the flow of information and data can be complicated. Between that and the multiple layers of data collection and reporting, the state is losing the opportunity to find trends in the data that could help prevent future deaths.
“We don’t use the National Fatality Review Case Reporting System as 48 other states do, even though it’s free to use, and it’s web-based,” Hatcher said. “It’s based on national best practice in the kinds of questions we need to be asking in these reviews. And partly because we don’t use that system and because of the way we’re structured, we have somewhat weak connections between what’s happening at the local level and what’s happening with our state-level groups.”
Finally, there’s no one state agency to coordinate all the data, simplify workflows and reduce redundancies.
“A lot of states have a team of people who are assisting with their child death review system in their state, ours is fragmented into different places in DHHS, without a singular office who’s working as a cohesive team,” Hatcher said.
In 2019, the task force asked the legislature for $550,000 in annual funding to centralize some of these functions and data collection, reduce the number of child death reviews , and streamline the entire system. The proposal was included in the 2019 budget that was vetoed by Democratic Gov. Roy Cooper as he tussled with the Republican-led legislature over Medicaid expansion.
So the proposal went nowhere.
Better coordination needed
Hatcher made the point that there are many strengths in the state’s child death reporting system. For one thing, with 100 community child protection teams and their advisory boards around the state, there’s a lot of expertise about the problems and getting local resources to create harm prevention initiatives.
North Carolina is unique in how the state medical examiner has staff dedicated to child safety issues.
But the lack of streamlined data is a real Achilles’ heel that prevents better coordination between state and local initiatives.
“We want to add accountability and follow through so that we can make sure that the review efforts lead to meaningful change that ends up saving lives and promoting child well-being,” Hatcher said.
Christy Malott, who chairs the community child protection team in Durham, talked about how their team has been able to identify patterns over time and make recommendations on further prevention efforts.
“But it’s important that those recommendations really are going somewhere that someone at the state level is hearing them and can help us implement some of the things that we recommended,” Malott said.
“We can only accomplish these changes through legislation that would change existing laws,” Hatcher concluded.