The committee used a combination of case reviews and interviews to gather data on 36 deaths during 1983-85. The committee concluded that half the fatalities could have been prevented, because warning signals existed. The analysis and recommendations focused on reporting, procedures, practice, policy, staffing, training, interagency communication and coordination, resources, legal issues and legislation, and organizational structure. Recommendations included increasing community awareness of indicators of abuse and neglect and reporting procedures, training mandatory reporters, improving communication within and between agencies, changing many procedures to be used by various professionals, adding funding, and amending the State Child Protection Act. Additional recommendations, tables, and instruments, forms, and agency procedure statements are appended.