Jim Holler, Jr. Chief of Police, Liberty Township Police Department (717)752-4219 Email: email@example.com www.hollertraining.com Child Death Investigations Course Outline Cop Suicide The numbers of deaths due to suicide are 2 to 3 times the number of line of duty deaths among law enforcement agencies and emergency workers Nationally, twice as many cops - about 300 annually - commit suicide as are killed in the line of duty, according to a study by the National Association of Police Chiefs Four Types of Child Fatalities Natural Deaths Accidental/Unintentional Deaths Suicides Homicides Natural Deaths Two thirds of natural deaths occur within the first 28 days of life Pre-maturity SIDS – Most occur between 2 and 4 months of age Maternal complications Diseases Congenital anomalies Sudden Unexplained Infant Death (SUID) “Sudden and unexpected death of an infant due to natural or unnatural causes.” “Sudden death of an infant under one year of age which remains unexplained after a thorough case investigation, including performance of a complete forensic autopsy, examination of the death scene, and review of the clinical history.” SIDS is the leading cause of death among infants who are 1 month to 1 year old, and claims the lives of about 2,500 infants each year in the United States Sudden Unexplained Infant Death claimed the lives of 4,600 infants each year Accidental suffocation & strangulation has doubled in the last decade Most SIDS deaths are associated with sleep (hence the common reference to "crib death"), and infants who die of SIDS show no signs of suffering While most conditions or diseases usually are diagnosed by the presence of specific symptoms, most SIDS diagnoses come only after all other possible causes of death have been ruled out through a review of the infant's medical history and environment Importance of Investigating Sudden Unexplained Infant Death Without a complete death scene investigation It is difficult to determine cause and manner-of-death Disadvantage for pathologist conducting autopsy Disadvantage for those trying court cases Hinders prevention efforts Types of Sudden Unexplained Infant Death SIDS Suffocation Metabolic Error Injury or Trauma Unknown or Unclassified Several studies show that SIDS and other SUID are more accurately diagnosed when information from a death scene investigation is used to make the diagnosis The Importance of SUID Data Collection A form developed by workgroup comprised of medical examiners, coroners, death scene investigators, law enforcement, infant death researchers, and SIDS parents organizations. Body design EMS interview Hospital interview Immunization record Infant exposure history Informant contacts Law enforcement interview Materials collection log Non-professional responder interview Parental information Primary residence information Scene diagram Accidental /Unintentional Deaths Ranked number 1 in children 1 to 4 Crashes, drowning, poisoning, firearms, fires, window covering cords & cribs A study released by the American Academy of Pediatrics shows that black and American Indian children were more likely than others to die in accidents involving fire, suffocation, poisoning, falls, vehicle collisions and firearms. The data show 13.7 per 100,000 children up to age 4 died in accidents in 2003. For American Indian children, the rate was 28 per 100,000. For blacks, it was 20.6. The rate was 13 for Latinos, 11.1 for whites and 5.9 for Asians. Suicidal Deaths Third leading cause of death in children from ages 10-19 o Autoerotic Asphyxiation – Suicide or Accidental? A sexual partner may or may not be involved in the act, however, if one is excluded the practice can be referred to as autoerotic asphyxiation, Various methods are used to achieve the level of oxygen depletion needed such as a plastic bag over the head or self-strangulation, typically by the use of a ligature (scarfing). The increased pleasure results from the body producing more endorphins as it approaches the state of asphyxia. Pleasurable or not, it is an extremely dangerous practice that results in many accidental deaths each year. In most cases, people strangulate themselves by using a ligature such as a rope with which they have made a noose or slip-knot around the neck. Most people have built-in safety or rescue methods. In nearly all fatal cases, people did indeed have safety mechanisms, but these had failed. The Choking Game achieves a brief high or euphoric state by stopping the flow of oxygen containing blood to the brain Sometimes children choke each other until the person being choked passes out. The pressure on the arteries is then released and blood flow to the brain resumes causing a "rush" as consciousness returns There are variations of this activity which involve hyper- ventilating until the participant loses consciousness The danger becomes even greater when a ligature is used and the activity is performed by a lone child. If the child loses consciousness and there is no one there to IMMEDIATELY release the pressure, he is unable to help himself. The child will suffer brain damage and death certainly after three minutes. Some of those who have died were alone for as little as 15 minutes before someone found them and it was already too late. Homicides Ranked number 4 in children 1 to 14 years The National Child Abuse and Neglect Data System (NCANDS) reported an estimated 1,490 child fatalities in 2004. This translates to a rate of 2.03 children per 100,000 children in the general population. "child fatality" as the death of a child caused by an injury resulting from abuse or neglect, or where abuse or neglect was a contributing factor. Perpetrators are, by definition, individuals responsible for the care and supervision of their victims. In 2004, one or both parents were involved in 78.9 percent of child abuse or neglect fatalities. Of the other 21.1 percent of fatalities, 10.7 percent were the result of maltreatment by nonparent caretakers, and 10.4 percent represent unknown or missing information. There is no single profile of a perpetrator of fatal child abuse, although certain characteristics reappear in many studies. Frequently, the perpetrator is a young adult in his or her mid-20s, without a high school diploma, living at or below the poverty level, depressed, and who may have difficulty coping with stressful situations. In many instances, the perpetrator has experienced violence first-hand. Most fatalities from physical abuse are caused by fathers and other male caretakers. Mothers are most often responsible for deaths resulting from child neglect. Faulty Statistics Child’s disappearance my not be known Missing child’s body never found Parents may fabricate a story of a child’s abduction Improper death investigations No autopsy Timeliness of the investigation Crime scene investigation Witness and caretaker information Background of the child and family What is a Child Death Review Team? The death of a child is a community responsibility. A child’s death is a sentinel event that should urge communities to identify other children at risk for illness or injury. A death review requires multidisciplinary participation from the community. Operating Principles of Child Death Review A review of case information should be comprehensive and broad. A review should lead to an understanding of risk factors. A review should focus on prevention and should lead to effective recommendations and actions to prevent deaths and to keep children healthy, safe and protected. Results of these reviews may be used to improve services, advocate for change, and conduct public awareness activities, ultimately for the purpose of preventing future child maltreatment deaths Looking beyond the risk factors……Using the team to help determine the cause of death 10 Objectives of Child Death Review 1) Ensure the accurate identification and uniform, consistent reporting of the cause and manner of every child Reviews ensure team members are informed of all deaths and thus they are more likely to take actions for investigation, services and prevention More complete information may help to identify cause and manner Reviews can lead to modifications of death certificates death 2) Improve communication and linkages among local and state agencies and enhance coordination of efforts Meeting regularly can improve interagency cooperation and coordination The benefits of sharing information and clearly understanding agency responsibilities can make the CDR process worthwhile in and of itself Reviews facilitate valuable cross discipline learning and strategizing Reviews improve interagency coordination beyond the review meetings 3) Improve agency responses in the investigation of child deaths Reviews promote early and more efficient notification of child deaths, facilitating more timely investigations Sharing information on the type of investigation conducted leads to improved investigation standards Reviews can identify ways to better conduct and coordinate investigations and resources 4) Improve agency response to protect siblings and other children in the homes of deceased children Reviews can often alert other agencies, such as social services, that other children may be at risk of harm; and they identify gaps in policies that may have prevented the earlier notification to these agencies 5) Improve criminal investigations and the prosecution of child homicides Reviews can provide new case information to aid in better identifying intentional acts of violence against children Reviews may bring a multidisciplinary approach to assist in building a case for adjudication Reviews can provide a forum for professional education on current findings and trends related to child homicides 6) Improve delivery of services to children, families, providers and community members Reviews can identify the need for delivery of services to families and others in a community following a child death Reviews can facilitate interagency referral protocols to ensure service delivery 7) Identify specific barriers and system issues involved in the deaths of children Team members can help agencies identify improvements to policies and practices that may better protect children from harm 8) Identify significant risk factors and trends in child deaths Reviews bring a broad ecological perspective to the deaths, thus medical, social, behavioral and environmental risks are identified and more easily addressed 9) Identify and advocate for needed changes in legislation, policy and practices and expanded efforts in child health and safety to prevent child deaths Every review should conclude with a discussion of how to prevent a similar death in the future Reviews are intended to be a catalyst for community action Teams are not expected to always take the lead, but should identify where and to whom to direct recommendations, then follow-up to ensure they are being implemented. 10) Increase public awareness and advocacy for the issues that affect the health and safety of children When review findings on the risks involved in the deaths of children are presented to the public, opportunities can be identified for education and advocacy The Child Abuse Problem More than 2,000 children die of child abuse each year in the US Most child deaths result from physical abuse, head injuries in particular The next most common cause of physical abuse deaths is punches or kicks to the abdomen Other forms of fatal physical abuse include immersion into hot water, drowning and smothering Many times these injuries occur when a child’s head is slammed against a surface, is severely struck or when a child is violently shaken The Crime Scene Work from scene back – When discovered to before death Listening to the caregivers story The Important 911 Call ALWAYS OBTAIN A COPY OF 911 TAPE The care giver’s statements on the 911 call should be compared to subsequent care giver statements Are there other voices or other background noises in the tape? Does this information differ from the care givers original account? Retinal Hemorrhages after CPR 6 out of 54 children had retinal hemorrhages after CPR (55% <2y/o) 4 children with head injury from abuse 1 child with head injury following MVA 1 child with severe hypertension Very unusual after accidental head injury CPR may RARELY cause small punctuate hemorrhages Other conditions may cause RH but ABUSE is most likely if head injury is also present Accidental verses Inflicted Injuries The importance of preliminary questioning You want to LOCK the caretaker into a story as soon a possible! Should be done in a non-intrusive and non-threatening manner Initiate questioning of caregiver by asking him or her “how it happened” Do not make threats or accusations A lack of detail and/or any contradictory or unconvincing explanations may provided important clues about whether an injury was accidental or a result of abuse Case Information Demographics o Infant o Mother o Caretaker (if not mom) o Household residents Diet Recent hospitalization Previous medical diagnosis History of medical care without diagnosis Recent fall or other injury Use of religious remedies Arriving on the Scene The Importance of Law Enforcement Responding as FIRST RESPONDERS Preserve life is first priority Call EMS if needed Survey the crime scene TALK to first responders TALK to first officer on the scene WHAT did they see, hear, and smell? What was the scene temperature? Establish scene boundaries What did EMS move to get to the body? Conditions upon arrival? What did family members/witnesses say or do? Don’t be blinded about “where” the house is located and the neighborhood that you are in The IMPORTANCE of DEATH SCENE PACKETS or CHECK LISTS You usually have only ONE opportunity to view the scene and surrounding areas Scene Assessments – Perimeters and Boundaries Where are the boundaries? Set clear boundaries so they can be controlled Start large and reduce if needed May not have a good understanding of witnesses and family members Who is suspect and what is their relationship to the child Be cautious of curious neighbors being too helpful Scene Assessments – Outside Areas Open fields Wooded areas Parking lots Playgrounds Closest house? Type of neighborhood? Containment of area? Scene Assessments – Night Scenes Lighting Determining crime scene Weather conditions Public view Traffic areas Should always be conducted during daylight if possible Fragile evidence will be found more often Scene Assessments Watch out for tunnel vision , keep an open mind Make mental notes of key evidence and write down or relay to others Scene Preservation Note conditions of crime (scene, clean, cluttered) Note dust patterns Don’t use or flush the commode Don’t turn on the water in the sink Don’t open widows until photographed Photography Documentation Take pictures of the crowd, EMS, scene and vehicles Scene Control Careful consideration must be given to scene control, which necessitates several officers. There may be multiple scenes (e.g., the dwelling and an outdoor swing set); multiple care givers; visits from family and significant others; siblings and other children; and media presence. Maximum scene control means minimal scene contamination. The scene is very likely to have been altered prior to the arrival of the investigator. Care givers may have attempted resuscitation efforts, moved items, or in the worse case scenario, attempted to stage the scene. EMT personnel, other investigators, or the coroner/medical examiner may have had contact with the victim and/or moved items. Careful interviewing will assist in the best possible reconstruction of the scene. Finding the Body DO NOT MOVE UNLESS RESCUE EFFORTS WARRANT MOVING Contact the coroner Photograph the body in place Photograph everything around the body What you first see may not tell you the real story Bite marks/other bruises Color of injury may indicate time table of events Animal vs child/adult bites Foot, shoe, tire impressions Special emphasis should be placed on areas/items involved in impacts. If the accidental fall explanation is provided Measure the distance between the surfaces from which the child fell to the floor. Note any carpet, carpet padding, etc. where the child was alleged to have fallen and obtain samples of same What you first see may or may not tell you the real story Children are rarely severely abused or killed in a single incident where there is no evidence of a pattern of prior conduct, often evidenced by pre-existing injuries, such as rib fractures, skull fractures, older bleeding within the skull, bruises, or simply changes in the baby's behavior with no apparent cause. The Body Lividity – State of Decay Postmortem Changes - Livor Mortis/Rigor Mortis Livor Mortis o Blanchable or Fixed o Push against the skin – if blanchable, there will be a mark – if fixed, there will not be a mark left o Generally fixed at 8-12 hours; may take longer o Difficult to see in dark skinned individuals o Difficult to see in massive blood loss o Difficult to see in chronic anemia Rigor Mortis o The body muscles will normally be in a relaxed state for the first 3 hours after death o Muscles will stiffen between 3 hours and 36 hours and then becoming relaxed again o There is some uncertainty in estimates derived from rigor mortis because the time of onset is highly dependant on the amount of work the muscles had done immediately before death If body is warm, Not dead more than a but not stiff couple of hours Dead between a couple If body is warm hours and half of day. and stiff If body is cold Dead between a half day and stiff and two days If body is cold, Dead more than but not stiff two days Accidental versus Inflicted Injuries Injuries to the buttocks, genitalia, abdomen, back, and lateral area of the body, especially the sides of the face, frequently indicate abuse Contusions: A bruise caused when skin tissue is crushed Hematoma: A lump that develops when a pool of blood collects Petechiae: Very small bruises caused by broken blood capillaries Purpura: Small bruises occurring in groups Ecchymosis: A large bruise Bruising Bruises my be difficult to see if they were made immediately before death Bruises take a while to develop even in a living person Many internal injuries do not show at all on the skin, especially before death These are not discovered until an autopsy is performed Suffocation Difficult diagnosis Requires investigation and corroboration by witness/perpetrator statements Minimal or no external or internal trauma Petechiae Tiny broken capillary broken blood vessels Everyone has them A hard bout of coughing or vomiting can cause facial petechiae, especially around the eyes Petechiae may or may not be present If petechiae are present, they are suggestive but not diagnostic of suffocation or smothering Head Injuries Concussion The Jostling of the brain’s soft matter. Often leaves a patient dazed or unconscious. Recovery will be complete, leaving only a cut or bruise on the scalp or head Contusion A more serious bruising of the brain. Often involves unconsciousness for days or weeks Laceration Involves a tear in the brain substance, bruising, and torn blood vessels. Often leads to subdural hematoma Fatal Falls In most cases, a trivial injury occurs when a child has a routine fall When a child is reported to have had a routine fall and presents with a skull fracture, cerebral edema, retinal hemorrhages, subdural hematomas, abuse should be indicated Suspect child abuse whenever the child presents with serious head injury, with or without skull fracture, as a result of a reported fall from a bed, sofa, or crib Shaken Baby Syndrome SBS results from violent shaking of an infant or toddler Every shaken baby investigation should focus on two major issues: What was the nature of the injuries to the child and, to a reasonable medical certainty, what can be said about when the injuries were afflicted? Who committed the acts which resulted in those injuries? Inconsolable crying is the most frequently reported reason by caretakers for losing control with a child Other reasons include frustrations related to toilet training, fussy eating, and adults having unreal expectations for a child's behavior A one-time violent shaking episode, of even two to three seconds, can cause partial or complete loss of vision, hearing impairment, a fractured skull, broken bones, seizure disorders and learning disabilities. One of the cornerstones of a successful investigation is recording the scene and the lawful seizure of evidence. A disciplined investigator should ask him/herself: Shaking - Immediate Consequences Breathing may stop or be compromised Extreme irritability Seizures Limp arms and legs or rigidity/posturing Decreased level of consciousness Vomiting; poor feeding Inability to suck or swallow Heart may stop Death Shaking - Long-Term Consequences Learning disabilities Physical disabilities Visual disabilities or blindness Hearing impairment Speech disabilities Cerebral Palsy Seizures Behavior disorders Cognitive impairment Death Why? Babies' heads are relatively large and heavy, making up about 25% of their total body weight. Their neck muscles are too weak to support such a disproportionately large head. Babies' brains are immature and more easily injured by shaking. Babies' blood vessels around the brain are more susceptible to tearing than older children or adults. Common Symptoms Lethargy / decreased muscle tone Extreme irritability Decreased appetite, poor feeding or vomiting for no apparent reason Grab-type bruises on arms or chest are rare No smiling or vocalization Poor sucking or swallowing Rigidity or posturing Difficulty breathing Seizures Head or forehead appears larger than usual or soft-spot on head appears to be bulging Inability to lift head Inability of eyes to focus or track movement or unequal size of pupils In a study of 151 cases of head trauma related to SBS The age range of victims was three weeks to 24 months, with a median range of five months 60% of victims were male. 23% of the victims died. Biological mothers were responsible for 12% of injuries. Female babysitters, a previously unrecognized group of offenders, caused 17% of the injuries. Male babysitters accounted for 3% of the injuries. Male perpetrators (usually the biological father or the mother's boyfriend) outnumbered females 22:1. Children’s Hospital, Denver, Colorado, from 1990 through 1995 173 cases of abusive head trauma in children less than 3 years old Since the mechanism of injury cannot always be accurately determined in child abuse cases, children who had experienced shaking, impact to the head, or both The mean age of the 173 children was eight months All of the children suffered serious head injuries. Thirty-one percent of the children had previously been seen by a physician who did not recognize the diagnosis of abusive head trauma. Many of the 54 children whose head injuries were missed were seen by doctors on multiple occasions after their injuries. For children whose head trauma was missed, the average length of time to diagnosis head trauma from the day of the first doctor visit was 7 days. When missed cases were compared to recognized cases, several factors were found to be significantly different. The severely injured children were more likely to be recognized as having head trauma at their first visit to the physician. At the first visit, children who were comatose, whose breathing was compromised, who were seizing or who had facial bruising were more likely to be accurately diagnosed. Abusive head trauma was missed significantly more often in children who were Caucasian than in children of minority races, and was more likely missed in families where both parents lived with the child. How much force is necessary to cause injuries in shaken baby syndrome? How many times do you have to shake an infant or young child to cause damage? No firm answer exists Shaking probably lasts a maximum of 20 seconds or less. In most cases the period of shaking is 5 to 10 seconds. To cause brain damage sufficient to allow clinical detection of the syndrome, severe forces must be used. On mechanical/physiologic grounds and by experience with perpetrators who have been convicted or confessed to the shaking, it is clear that to lift an infant and shake requires an adult or an adult-sized person. A common misconception regarding non-accidental head injuries is that severe brain injury only develops if the victim is shaken "50 to 100 times". However, a single forceful impact is sufficient to produce very high deceleration forces in the infant's brain. It is these forces which result in bleeding to the eyes and brain. The injury is often the result of a single loss of control where the baby may be shaken but is also thrown down because the caretaker is still angry Crime Scene Evidence Every crime scene is three dimensional. Always look in every direction including up. Take detailed notes. Never assume cause of death Collect everything in the immediate vicinity of the reported trauma, such as, crib, bedding, sheets, toys Items impractical to seize should be measured along with the manufacture name and model being recorded (living room sofa, kitchen table, wall to wall carpet etc) Looking for evidence such as: o Last meal o Baby bottle o Diaper for last movement o Trash cans o Dumpster o Wash machine for soiled clothes o Refrigerator/cabinet for foods o Medicines Examination should include trash containers, laundry chutes and bins and areas outside widow wells (places where a suspect could hastily discard items in a location that he or she hopes will be overlooked Look for any possible stressors such as a job layoff notice, bank statement listing NSF checks, all of which coupled with a crying infant may culminate in a shaking episode Knowledge of the possible stressors in the care giver's life provides themes during subsequent interviews Bite marks/other bruises Color of injury may indicate time table of events Animal vs child/adult bites Foot, shoe, tire impressions An emphasis should be made on seizing trace evidence (hair, blood, fibers, body fluids, paint chips, fragments, etc.), as these items may directly affirm or negate the presenting history. If the investigator suspects a staged scene, latent fingerprint examinations may be helpful. The investigator at the scene should collect everything in the immediate vicinity of the reported trauma, e.g. crib, bedding, sheets, toys, etc. Look for any possible stressors such as a job layoff notice, bank statement listing NSF checks, all of which coupled with a crying infant may culminate in a shaking episode Knowledge of the possible stressors in the care giver's life provides themes during subsequent interviews Search Warrants Always LAWFULLY conduct the search of the crime scene This includes consent searches, search warrants, and exigent circumstances searches The investigator should not cue the care giver by inserting words and phrases that clearly specify possible child abuse/homicide The investigator should list generic terms such as: searching for “items” regarding the “incident”, “occurrence”, “accident”, etc If you do not have sufficient probable cause to support a search warrant, ask the suspect to sign a “consent to search” form Repeated Abuse Children are rarely severely abused or killed in a single incident where there is no evidence of a pattern of prior conduct, often evidenced by preexisting injuries, such as rib fractures, skull fractures, older bleeding within the skull, bruises, or simply changes in the baby's behavior with no apparent cause. 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