Arizona Child Fatality Review Team: Twenty-Ninth Annual Report
Twenty-Ninth Annual Report
November 15, 2022
The Arizona Child Fatality Review Program’s (CFRP) goal is to reduce child deaths in Arizona by
conducting a comprehensive review of all child deaths to determine what steps could have
been taken, if any, to prevent each child’s death. In 2021, 863 children died in Arizona, an
increase from 838 deaths in 2020. The leading causes of death were prematurity, congenital
anomalies, motor vehicle crashes, firearm injuries, and suffocation. Prematurity was the most
common cause of death for neonates (infants less than 28 days old) while suffocation was the
common cause of death among infants 28 days to less than 1 year of age. Drowning was the
most common cause of death in children 1-4 years of age as 68% of the 44 drowning deaths
occurred in this age group. The drowning death rate doubled from 2020 to 2021.
Of the 863 deaths, 410 (48%) were determined to be preventable by the local review teams.
The three most common causes of preventable death were motor vehicle crashes, firearm
injuries, and suffocation. In 43% of the preventable deaths, substance use was a contributing
factor, and in 33% of these deaths, poverty was a risk factor.
There were 44 suicide deaths in 2021. In 68% of these deaths, recent warning signs for suicide
were the most common risk factor, and 17 suicide deaths were due to firearm injury. In 2021,
56 children died from a firearm injury, and 100% of these deaths were determined to be
preventable.
Sudden Unexpected Infant Death (SUID) is the death of a healthy infant who is not initially
found to have any underlying medical condition that could have caused their death. Most of
the SUIDs are due to suffocation and unsafe sleep environments. There were 65 SUIDs in 2021.
An unsafe sleep environment was a factor in 95% of these deaths and bedsharing in 58% of
the deaths.
Arizona’s abuse/neglect mortality rate increased 36.2% from 5.8 in 2020 to 7.9 in 2021. Of the
128 children who died in 2021 from abuse/neglect, substance use was a contributing factor in
59% of the deaths, and the child’s families had prior involvement with a CPS agency in 46% of
the deaths.
In 2021, 31 Arizona children died from COVID-19 and 61% of these children were less than 12
years old. There were also 27 deaths where COVID-19 indirectly caused or contributed to the
child’s death, and 56% of these children were less than 12 years old. The fatality review team
recognizes that COVID-19 is indirectly related to other child deaths and may have been a
factor in child deaths due to suffocation, poisoning, strangulation, and firearm injuries included
in this report.
Arizona Child Fatality Review Program | Twenty-Ninth Annual Report
• • •
I would like to thank all our volunteers for their support of the CFR program and its mission to
prevent child deaths in Arizona. Five of us have participated in the CFR program for over 25
years: Susan Newberry, MEd (Maricopa Team), Kathy Bowen, MD and Lori Groenewold (Pima
Team), and Patti Perry, MD (Yuma Team). The ongoing support of the Arizona Department of
Health Services and the Arizona Chapter of the American Academy of Pediatrics is greatly
appreciated.
Sincerely,
Mary Ellen Rimsza, MD FAAP
Chair, Arizona Child Fatality State Team
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