“Today marks an important step in our efforts to prevent child abuse. Madam President, today also marks the important work and collaboration in this General Assembly by our Members who are committed to keeping our children safe, and when we fail, we make sure of what we can do the next time to prevent the abuse from happening in the future.”[i]
Those words were spoken on the floor of the Pennsylvania Senate on June 29, 2008, just before lawmakers unanimously approved legislation requiring “uniform standards” for reviewing and reporting “child fatalities and near fatalities resulting from child abuse.”
That bill – Senate Bill 1147, later enacted as Act 33 of 2008,[ii] secured broad, bipartisan support in both chambers of the General Assembly. Lawmakers emphasized that mandating county-level child fatality review teams – intended to be “broadly representative of the county” – would bring multidisciplinary expertise to elevate prevention, transparency, systems improvement and accountability. The General Assembly’s intent was clear: Learn from these tragedies and “take immediate steps to prevent future harm to our children.”[iii]
By the Numbers: A Grim Trajectory
In 2008, the year Act 33 was enacted, the Pennsylvania Department of Human Services (PA DHS) reported 47 child deaths were substantiated as child abuse or neglect (CAN). In 2023, that number had risen to 57.[iv].
But these numbers are like a canary in a coal mine.
In a 2024 memo, Deputy Secretary for PA DHS’ Office of Children, Youth and Families (OCFY), Laval Miller-Wilson warned 2023 marked an “all time high” of child fatalities and near fatalities reported to ChildLine -346 total reports required the statutory review process outlined in Act 33 (many more incidents will be reviewed than are eventually substantiated as CAN).
Miller-Wilson included a six-year trendline (2018-2023) showing the steady increase in reports made to ChildLine. In 2018, 236 cases (88 fatalities, 148 near fatalities) were reported due to someone having reasonable cause to suspect CAN was a factor in the fatality or near fatality. By 2023, the number jumped to 346 (99 fatalities, 247 near fatalities).
Though there was a small year-over-year decline in substantiated CAN fatalities between 2022 (n=60) and 2023 (n=57), each of the past five years exceeded the total from 2018. Near fatalities substantiated as CAN rose annually, peaking in 2022 (n=138) before declining in 2023 (n=119).
A Call for Dedicated Leadership within PA DHS
To address these troubling trends, Miller-Wilson has urged PA DHS Secretary Val Arkoosh to create “a time-limited special position to advance and coordinate strategies that eliminate (or at least substantially reduce) child fatalities and near fatalities in the Commonwealth.”[v] He assured that this new position would work collaboratively with OCYF’s new Medical Director hired in July 2024. By October 2024, at Secretary Arkooh’s request, the Medical Director had identified potential candidates for the Special Advisor role.[vi]
The proposed “duties and responsibilities” of this Special Advisor would include:
Miller-Wilson’s memo was candid: despite 17 years of Act 33 being in effect and hundreds – if not thousands – of developed recommendations, many “have not been carried out”.
Fractured Collaboration and Silenced Stakeholders
In March 2025, Arkoosh authored a guest opinion published in the Philadelphia Inquirer defending the Shapiro Administration’s child protection priorities.[vii] She previewed that the Administration would soon “launch a Child Fatality and Near Fatality Workgroup comprised of six state agencies to coordinate prevention strategies and champion lessons learned from post-incident reviews.” Arkoosh stressed preventing fatalities and near-fatalities requires “further partnership”, especially with parents, schools, health providers, substance abuse treatment providers and other stakeholders.
Yet these words ring hollow against the reality of the Shapiro Administration’s insularity.
Documents cited in this report, including Miller-Wilson’s memo among them – only surfaced because the Center for Children’s Justice (C4CJ) has begun to leverage Pennsylvania’s Right to Know Law (RTKL) as a tool to promote and prioritize child protection.
RTKL requests have become a frequent necessity under an administration whose child protection priorities are obscured, in part, due to curtailed collaboration, dismantled stakeholder tables, and diminishment of meaningful engagement with those with lived experiences and/or (non-government) interdisciplinary voices. The administration tends to seek partners who are inside state or county government or are the preferred contractors of local or state government.
Long-standing forums, while not always ideal, like the Child Welfare Council, Multidisciplinary Workgroup on Infants with Substance Exposure, Fatality and Near Fatality Trend Analysis Team – have quietly disappeared.
Meanwhile, the Commonwealth’s state paid Child Advocate, who had been embedded in Governor Shapiro’s Office over the last two years, resigned in January 2025 citing resistance from PA DHS leadership and inconsistent backing from the Shapiro Administration and the Pennsylvania General Assembly.
Transparency Promised, But Not Delivered
C4CJ tested Act 33 implementation at the county level through RTKL filings with Berks, Blair and Lancaster Counties, requesting:
The responses were disconcerting.
Berks and Blair claimed they had no written protocol. Blair had a number of convoluted responses eventually leading to an assertion that it wasn’t certain who convenes or serves on its Act 33 team.
C4CJ’s intent was to secure this information from all 67 counties. However, after filing in just three counties, it was clear there was widespread confusion and/or significant resistance, ultimately leading to protracted appeals before the Office of Open Records (OOR).
Lancaster County expressed concern that sharing its protocol would allow the public to understand the “process by which” such incidents are investigated “and what could be corrected in the future to prevent similar situations.” The county also refused to provide its Act 33 team members.
Lancaster County cited Section 780(b)(2) of Pennsylvania’s RTK Law, claiming the protocol and team members were exempted from public access, because release could jeopardize public safety (“maintained by an agency in connection with the military, homeland security, national defense, law enforcement or other public safety activity that, if disclosed, would be reasonably likely to jeopardize or threaten public safety or preparedness or public protection activity or a record that is designated classified by an appropriate Federal or State military authority.”).
C4CJ challenged this at OOR demonstrating how the Act 33 review is distinct from the county’s responsibilities (outlined in Title 23 §6362), related to the actual investigation and decision to substantiate (or not) abuse or neglect. Act 33 reviews are understood as about systems learning, not case adjudication. PA DHS reinforced this in a 2015 policy bulletin:
“By completing detailed reviews of child fatalities and near fatalities and conducting an analysis of related trends, we are better able to ascertain the strengths and challenges of public, private and community services and to identify solutions to address the service needs of the children and families served within, but also beyond, the child welfare system. These reviews and subsequent analyses become the foundation for determining the contributing factors and symptoms of abuse and responses that may prevent similar future occurrences. These reviews seek to identify areas that require systemic change in order to improve the delivery of services to children and families, which ultimately enhance our ability to protect children.”
Under Title 23 §6365, the law is explicit: the Act 33 review team must be “broadly representative of the county” and include individuals with “expertise in prevention and treatment of child abuse.” The Act 33 Team should include perspectives as needed based on the “circumstances of each case” but the law has specific guidance of what “broadly representative” of the community looks like including, a health care professional, a representative of a local school, educational program or child care or early childhood development program, a representative of law enforcement or the District Attorney, an attorney or Court Appointed Special Advocate (CASA) who represents or advocates for children, a representative of a local domestic violence program, a representative of a local drug and alcohol, attorneys who represent parents.
The 2015 bulletin addresses “Team Structure” stipulating, “The county agency, in accordance with the protocol and in consultation with the county review team, is also responsible for appointing a person to chair the county review team.” The chair “cannot be a county agency employee.”
C4CJ argued that failure to identify team members makes it impossible to see the degree to which the county has enlisted “objective expertise”.
In its May 23, 2025 decision, OOR determined that Lancaster County did not “clearly demonstrate” that releasing the Act 33 team protocol “would disrupt the County’s protection activities” or that releasing the membership of the Act 33 team would “endanger” the team’s work – collectively or create a reasonable likelihood of danger to team members.
A Sea of Black Ink: Redactions Undermine Transparency
The reports provided by Lancaster County were so heavily redacted they were rendered nearly meaningless – pages overwhelmed by black ink was among the catalysts to C4CJ filing an appeal with OOR.
In cases involving near fatalities (by law the child’s name cannot be released), the county redacted even the most basic data: the child’s birth date, date of the incident, and date of notification to ChildLine. Also withheld were any references to the types of documents reviewed, the tasks undertaken by the team, and the team’s identified systems’ strengths, deficiencies, and recommendations.
Yet back in 2015, PA DHS clearly stated in its Bulletin 3490-15-01: “The release of child fatality and near fatality information to the general public is necessary to provide a broader perspective on the accomplishments and challenges related to the protection of children in Pennsylvania. Release of this information leads to greater system transparency and accountability.”
C4CJ argued that Lancaster County’s redactions directly contradicted both the spirit and specific requirements of Act 33. However, OOR accepted Lancaster’s attestation that reports “contain identifying information regarding the child, family, and often includes medical information and diagnoses.” OOR noted that the attestation itself was “sufficient evidence to demonstrate that a record is not public under RTKL”.
Despite OOR admitting that it was not “possible to discern from the face of the redacted reports alone what type of information every redaction covers,” OOR concluded from “a cursory review that much of the information was redacted to ensure that no other person was identified, or that their roles in underlying incidents were not identified.”
As part of its appeal to OOR, C4CJ cited PA DHS’ own Tip Sheet, which expressly states that the date of birth or age for a child victim is permitted in the public report. OOR directed Lancaster County to disclose the birth date or age of children in fatality cases (a child’s name is released if there is a fatality), but upheld redactions of this information for near fatalities (a child’s name is not released) writing that the that the “statute does appear to provide the County the authority to redact them.”
On one of the most critical issues – the redaction of team findings and recommendations – OOR noted it was “sympathetic” to C4CJ’s concern that the redactions make “the documents useless for the intended purposes.” Ultimately, however, OOR deferred to the county’s claim that disclosure could result in the identification of living individuals, and upheld the significant redactions that render the reports nearly useless.
Seventeen Years Later: Oversight and Accountability are Lacking as Children Keep Dying or Nearly Dying
Act 33 was enacted with a solemn commitment: that Pennsylvania would learn from and urgently work to prevent child abuse and neglect.
Seventeen years later, more children are dying or nearly dying from abuse and neglect. Despite thousands of reviews and hundreds (likely thousands) of recommendations, few have been meaningfully implemented. Transparency remains elusive. The systems meant to protect children—child welfare, education, healthcare, community organizations, and faith-based partners—are uncertain their role or often underutilized and most always siloed. What was promised as a mechanism for learning and prevention has become a bureaucratic exercise consuming far too many resources (human and fiscal), with leaders too often failing to act to close systemic gaps and redacting reports into oblivion.
To date, Act 33 has fallen short of its promise, failing to spur meaningful prevention or reform. Instead, it highlights the ongoing need for those entrusted with the authority to protect Pennsylvania’s children to remain vigilant—and to summon the courage to lead, advancing bold policies and lasting investments that can truly safeguard the Commonwealth’s future – its children – before their lives are cut short or irreparably harmed.