OCA Fatality Reports

Fatality Investigations

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Pursuant to Connecticut General §§46a-13l(b) and (c), the State Child Fatality Review Panel is mandated to review the circumstances of the death of any child who has received services from a state department or agency addressing child welfare, social or human services or juvenile justice.

The Child Fatality Review Panel's reports of its investigations of child fatalities are public documents and can be obtained from the Office of the Child Advocate upon request. You may also view these reports online using the hyperlink to individual reports listed below.

• Executive Summary of Addendum to Fatality Review Investigative Report: Addendum To Fatality Investigation Findings & Recommendations Reports Regarding the Deaths of LR & MM (December 17, 2024)
• Addendum to Fatality Review Investigative Report: Addendum To Fatality Investigation Findings & Recommendations Reports Regarding the Deaths of LR & MM (December 17, 2024)
• Fatality Data: Examination of Preventable Deaths of Individuals 18 to 21 years in Connecticut
• Executive Summary of Fatality Review Investigative Report: OCA Executive Summary Marcello M. Fatality Report (Feb 20, 2024)
• Fatality Review Investigative Report: OCA Marcello M. Fatality Report (Feb 20, 2024)
• Executive Summary of Fatality Review Investigative Report: OCA Executive Summary Liam R. Fatality Report (October 24, 2023)
• Fatality Review Investigative Report: OCA Liam R. Fatality Report (October 24,2023)
• Fatality Review Investigative Report: OCA Infant Toddler Fatality Report (July 25,2023)
• Fatality Investigation Review Findings and Recommendations Letter: OCA Public Findings Letter on Child Fatalities (Feb 23,2023)
• Fatality Investigation Review Findings and Recommendations Letter: OCA Findings Letter Alex M. (March 7,2022)
• Fatality Review Investigative Report: The Deaths of Nine Children in Unlicensed and Licensed Day Care Settings 2016-2017 (December 18, 2018)
• Legislative Hearing Report: OCA Solnit Center South Report (September 26, 2018) - OCA's review of the circumstances leading to the death of Destiny G.
• Fatality Review Investigative Report: Matthew Tirado (December 12, 2017)
• Report: Five Year Fatality Report 2011-2015
• Report Insert: Londyn Report Clarifying Insert (February 26, 2016)
• Fatality Review Investigative Report: Londyn Report (December 22, 2015)
• Report: Shooting at Sandy Hook Elementary School (November 21, 2014)
• Report: Children Birth to Three 2013 (July 31, 2014)
• Public Information Bulletin: Child Fatality Review (June 3, 2014)
• Joint OCA-CCADV Investigative Report: Joint Investigative Report on the Death of Zaniyah Z (September 2015)
• Report: 12 Years of Child Gun Deaths in CT (January 28, 2013)
• "An Examination of Connecticut Child Fatalities: A Ten Year Review January 1, 2001 to January 1, 2011" - A data and information report released by the Child Fatality Review Panel on December 14, 2011.
• Jayden R. - Excerpts from a report produced by the Department of Children and Families, Probate Court and the Office of the Child Advocate/Child Fatality Review Panel regarding the circumstances surrounding the death of a three-year old who fell out of a window, April 2011.
• Michael B. - Excerpted Special Public Report, Findings and Recommendations, Fatality Review of Baby Michael, May 2010.
• Michael B. - Press release/executive summary released May 6, 2009.
• Makayla K. - Released February 18, 2004 - This report discusses the circumstances surrounding the death of a teenage girl who died three days after she had been drinking alcohol at a party and took the drug known as Ecstasy.
• Child Fatality Investigations of DCF: 1996-2003 - This report summarizes investigatory findings and recommendations specifically related to the Department of Children and Families.
• Joseph Daniel S. - Released January 2003 - This report discusses the circumstances surrounding the death of a troubled twelve year old who hung himself in a closet at his home and whether there were inadequacies in the protection and support provided by the "systems" to which he was known.
• Ezramicah H. - Released May 2002 - This report discusses the homicide of a six and a half month old infant while under the protective supervision of the Department of Children and Families, removed twice from his family and returned twice with multiple service providers.
• Falan F. - Released December 19, 2001 - This report discusses the circumstances surrounding the death of a teenager who committed suicide while incarcerated in an isolated adult prison cell shortly after two and one half years of protective custody and court involvement.
• Alex B. - Released March 21, 2001 - This report discusses the homicide of a three year old in the custody of the Department of Children and Families who was placed in the care of a Florida couple and died at the hands of the prospective adoptive father.
• Aquan S. - Released September 13, 1999 - This report discusses the examination into the State's delivery of services of a child who died at the hands of police.
• Summary Review of Connecticut's 1998 Fatalities of Children Who Received Services From State Agencies - This report provides a review of the circumstances of the death of any child who has received services from a state department or agency addressing child welfare, social or human services, or juvenile justice.
• The Child Advocate's Follow-Up Report, - Released April 16, 1999 - This report provides a detailed summary of follow-up agency responses and findings to the recommendations made by the Panel in each of the four child fatalities reviewed in 1998 - Andrew M. Shanice M., Ryan K., and Tabatha B.
• Tabatha B. - Released November 30, 1998 - Part I, "Child Welfare Management" discusses the child protection case management of a child who committed suicide while incarcerated at Long Lane School. Part II, "Long Lane School" describes the physical conditions, staffing and programming at the state's only juvenile correctional facility.
• Ryan K. - Released September 17, 1998 - This report analyzes the child protection case management of a child who died in the home of relatives who had obtained guardianship through Probate Court.
• Shanice M. - Released July 22, 1998 - "Child Welfare Case Management of Medically Fragile Children" discusses child protection practices within the context of the life of a child who died from asthma.
• Andrew M., Part I - Released May 7, 1998 - "The Immediate Circumstances" examines the events immediately prior to Andrew's death while being physically restrained at a psychiatric hospital. Andrew M., Part II - Released June 19, 1998, "Child Welfare Case Management" examines the quality of services Andrew received from the State of Connecticut beginning in infancy.
• Emily H. - Released April 26,1995 - This report discusses multi-system failures and the circumstances surrounding the death of a nine month old infant - the youngest in a family known by the Department of Children and Families - and identifies several points at which the extreme danger to children in her family might have been recognized and averted.