Oregon Department of Human Services, Child Welfare, is committed to learning from critical incidents to improve safety for children and families. This page highlights prevention efforts and system improvements informed by the Critical Incident Review Teams (CIRT) and structured debriefings.
What we're doing Trends we're tracking What we're learning Stay updated
What we're doing
Critical Incident Review Teams identify system gaps and opportunities to strengthen child safety practice across Oregon. The efforts below highlight
some of the prevention and system improvement work informed by these reviews.
Current efforts focus on four key areas:
1. Strengthening engagement with children and families
These efforts focus on improving how Child Welfare engages families, builds protective relationships, and prevents harm.
Why: Reviews have shown fathers are sometimes not involved early, which can limit safety planning and permanency options for children.
What we're doing: Expanding father engagement through staff training, cross-system collaboration, and policy review. This includes sponsoring a Father’s Advisory Board to provide input on Child Welfare improvements.
Why: Reviews have identified a repeated pattern of infant deaths linked to unsafe sleep environments and products not intended for sleep.
What we're doing: Strengthening safe sleep education for caregivers and caseworkers using harm reduction and culturally responsive approaches. Learn more about infant safe sleep at
OregonSafeSleep.org.
- Reviewing in-home safety plans with a focus on safe sleep practices.
- Promoting the Safe Sleep Self-Study Training with child and family-serving professionals to support safe-sleep practices and consistent messaging.
Why: Domestic violence is a recurring theme across reviews and requires approaches that protect children and support protective caregivers.
What we're doing: Strengthening child-centered, strengths-based practice when supporting families experiencing domestic violence.
2. Behavioral health and substance use supports
These efforts address behavioral health and substance use needs that can affect family functioning and child safety.
Why: Substance use is a common factor identified in many reviews and can affect how a caregiver functions if not identified and addressed early
What we're doing:
- Requiring substance use disorder training for caseworkers.
- Using a six-question screening tool, referred to as UNCOPE, with clear procedural guidance.
- Collaborating with Recovery Support Teams, with specialized training in substance use disorder, to strengthen early intervention, decision making and connection to treatment.
Why: Reviews reinforce that children with complex behavioral health needs often require cross-system coordination and timely access to expertise.
What we're doing: Working with Oregon Health Authority (OHA) to connect staff and families to experts and services for children with complex behavioral health needs
Why: Review findings and broader child death review trends highlight the importance of coordinated prevention and response for youth mental health needs, including suicide risk.
What we're doing: In partnership with OHA and state and local prevention organizations, ODHS is:
- Responding to community mental health and suicide prevention and intervention needs
- Conducting district level practice consultations
- Assessing Child Welfare workforce needs
Learn more at Oregon's Youth Suicide Intervention and Prevention Plan 2026-2030.
3. Cross-system collaboration and accountability
These efforts strengthen coordination between Child Welfare and partner systems responsible for child safety and prevention.
Why: When a child dies unexpectedly, timely information sharing and coordination across agencies supports accountability and prevention learning.
What we're doing: Improving coordination between law enforcement, district attorneys, medical providers, and Child Welfare when an unexpected child death occurs.
Why: Reviews show that shared understanding of Safety Model practices, including in-home safety planning, improves alignment across courts and Child Welfare.
What we're doing: Partnering with the Oregon Judicial Department to strengthen shared understanding of Safety Model practice and the purpose of in-home safety plans.
Why: Consistent application of Karly’s law ensures thorough trauma-informed investigations. Karly’s Law significantly enhances child protection and ensures that suspected abuse is investigated and addressed without delay.
What we're doing: In partnership with multidisciplinary teams, Child Welfare has newly developed Karly’s Law quick reference guide and required advanced training for Child Welfare.
Why: Reviews often identify barriers that cannot be solved by one program or agency; Safe Systems Mapping helps identify root causes and shared solutions.
What we're doing: Bringing together Child Welfare professionals, people with lived experience, Tribal representatives, and community partners to analyze past cases and strengthen practices.
Recent mapping sessions focused on:
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Father Engagement: reducing bias and increasing father involvement (e.g., regional advocates, updated procedures, staff training)
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Parental Substance Abuse: identifying strategies, such as expanding Recovery Support Teams, clarifying guidance, improving caseworker training and strengthening access to community supports
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Youth Substance Abuse: reducing barriers to prevention and treatment, especially related to fentanyl, with youth voice informing the work
4. Workforce and practice improvement
These efforts strengthen how Child Welfare staff identify risk, make decisions, and apply consistent safety practices.
Why: Screening decisions have a major impact on child safety. Reviews reinforce the need to reduce bias and improve consistency at first contact.
What we're doing: Providing training for Oregon Child Abuse Hotline screeners to support equitable decision making. Expansion to all Child Welfare staff is underway.
Why: Reviews frequently highlight the importance of consistent safety management, follow-through and timely course-correction in active cases.
What we're doing: Reinforcing regular case reviews every 90 days to support safety planning, goal progress and family support.
Why: Children with intellectual and developmental disabilities may face unique risk factors and service gaps that require tailored cross-system responses.
What we're doing: Conducting targeted reviews of Critical Incident Review Team cases involving children with intellectual and developmental disabilities to better understand system gaps and strengthen practice. Focus areas include:
- Strengthening cross-system reviews using guidance from the National Center for Fatality Review and Prevention
- Enhancing screening practices and structured decision-making tools
- Improving Child Protective Services and Permanency practices to better identify and respond to the needs of children with Intellectual and Developmental Disabilities
Trends we're tracking
A Critical Incident Review Team Data Overview is in development to share patterns from critical incident data over time, such as:
- Age of children involved in critical incidents
- Number of critical incidents
- Circumstances surrounding the fatalities
These kinds of patterns help the public, policymakers and practitioners understand how risks and system needs may be changing.
Coming soon.
What we're learning
Across multiple reviews, patterns often emerge that point to system-level gaps. These gaps are typically not tied to one office or one worker. Most solutions require collaboration across agencies and with communities. Partnering with families and communities leads to stronger, more equitable improvements.
Stay updated
This page is updated twice a year to reflect lessons learned and progress made. Check back for updates on Oregon’s ongoing efforts to prevent child abuse and strengthen safety for children and families.