Medical, social service and coroner reports were reviewed for 14 cases of fatal child abuse and neglect identified at a children's hospital from 1988-1992. Twelve cases involved physical abuse and two neglect. The median age was 6.5 months (range 24 days to 3 years). Six families (43%) had prior protective service involvement; however, four of the referrals involved a sibling. Only two of 12 physical abuse victims had a history of a prior suspicious injury. Clinical and postmortem findings are presented. The cause of death in all physically abused patients was blunt impact head injury; one also had contributing intraabdominal injuries. Ten cases were ruled due to homicide; 12 have come to legal closure resulting in nine felony convictions. These findings emphasize the role of blunt impact brain injury in fatal child abuse cases. Two findings have significant implications for prevention: (a) the paucity of injuries recognized prior to the fatal event, and (b) among families known to child protection agencies the focus was not the fatally injured child.