When Children Die, We Need to Know Why

1. When Children Die, We Need to Know Why Sudden Unexplained Infant Death Investigation

2. SUIDI National Training Academies

3. North Dakota�s Team Medical Examiner/Coroner Dr. William Massello III State Forensic Medical Examiner Post-Secondary Teaching Professional Dr. Arne Graff, M.D. Meritcare Children�s Hospital, UND School of Medicine Law Enforcement Officer Special Agent Mark Sayler ND Bureau of Criminal Investigation Medicolegal Death Investigator Ed Bina Grand Forks County Coroner�s Office Child Protection Expert Marlys Baker NDDHS, ND Child Fatality Review Panel

5. Sudden Unexplained Infant Deaths (SUIDI) The sudden and unexpected death of an infant due to natural or unnatural causes

6. The Problem Inaccurate reporting and non-standard practices of classifying infant deaths.

7. "There's no rhyme or reason to what medical examiners are diagnosing as SIDS, suffocation, strangulation or undetermined. The variability is across the country and within the states.� Theresa Covington, director of the National Center for Child Death Review

8. Several Causes of SUID

9. Sudden Infant Death Syndrome(SIDS) Diagnosis of exclusion Given only after all other possible causes of sudden, unexplained death have been ruled out by careful case investigation

10. ND Statutory Definition Cause of death - Determination. �The term "sudden infant death syndrome" may be entered on the death certificate as the principal cause of death only if the child is under the age of one year and the death remains unexplained after a case investigation that includes a complete autopsy of the infant at the state's expense, examination of the death scene, and a review of the clinical history of the infant (NDCC 11-19.1-13)

11. SUID Explained Accidental suffocation Poisoning Head injury Metabolic disorder Neglect or homicide Hypo or hyperthermia Unexplained SIDS Cause unknown or unspecified SIDS, but cannot rule out suffocation from unsafe sleep environment

12. "The whole reason for keeping count is to figure out how to avoid the next infant death." Dr. James Kemp, SIDS researcher, St. Louis University

13. A Death Scene Investigation needs to be performed on All Infant Deaths Even if baby was transported to hospital

14. Top 3 Causes of Child Deaths In North Dakota

15. North Dakota SIDS & SUIDI Deaths

16. ND Child Fatality Review Panel Annually, since 1996, the CFRP has expressed concern about the quality of death scene investigations in deaths classified as SIDS Missing/poor quality of information Lack of/inadequate interviews Lack of scene investigation/visit Lack of Coroner involvement Poor quality documentation

17. The Result Difficult or impossible to: Monitor trends in SUID, Conduct research to identify risk factors, Design interventions to prevent these deaths, Evaluate programs aimed at prevention.

18. Death Scene Investigation Information obtained at the scene is crucial for distinguishing between a natural death, an accidental death, or a homicide.

19. Examples No SUIDI Reporting Form or no written report SUIDI Reporting Form completed by someone who was not at the scene Interviews completed more than a week after the death No scene visit (death pronounced at a hospital) Coroner not contacted

20. SUIDI Top 25 CDC recommends 25 elements of investigative information critical to determining the cause and manner of death in the investigation of sudden, unexplained infant death. The �Top 25� should be collected and provided to the forensic pathologist BEFORE the forensic autopsy is performed.

21. SUIDI Top 25 In addition to general scene/case information, these 5 groups are critical: Sleeping environment Infant development/history Family information Exam Investigator insight

22. The Sleeping Environment Asphyxia Evidence of overlying, wedging, choking, nose/mouth obstruction, re-breathing, neck compression, immersion in water, etc Sharing sleep surfaces Changing sleep condition Hypo/hyperthermia Environmental hazards Unsafe sleeping conditions

23. Infant Development/History Identify normal versus abnormal infant growth �Failure to Thrive� Understand growth charts Identify developmental milestones Gross/fine motor skills Social, Language, and Cognitive Skills

24. Infant Development/History Diet Recent hospitalization Previous medical diagnoses History of acute life-threatening events History of medical care without diagnosis Recent fall or other injury

25. Family Information History of religious, cultural or ethnic remedies Cause of death due to natural causes other than SIDS Prior sibling deaths Previous encounters with police and/or social service agencies Request for tissue or organ donation Objection to autopsy

26. Exam Pre-terminal resuscitative treatment Death due to trauma, poisoning or intoxication

27. Investigator Insight Overview of Investigation Suspicious Circumstances Other Alerts to Pathologist Physical evidence and gathered information

28. What is Needed? Interviewing Scene Investigation and Doll Reenactment Information Dissemination

29. Interviewing Data collection Scene security Identifying witnesses Coordination with other investigating agencies Infant information Past medical history Details of incident (LKA, placer, finder) SUIDI reporting form

30. Interviewing Witness interviews EMS & hospital involvement Law enforcement Prior law enforcement investigations? Disposition of infant & evidence Caregivers, family, etc.

31. Scene Investigation The �Macro� Scene The �Micro� Scene

32. The �Macro Scene� Building ownership & use Language and culture Photography Identify individuals at the scene Scene safety and evidence preservation Recognize need for additional resources (interpreters, etc.)

33. The �Micro Scene� Temperature Condition Smells, Peeling paint, Evidence of illegal activity Basic utilities Cleanliness Pets, Sick individuals, Vermin

34. The �Micro Scene� 2 Feeding habits Introduction of new foods, Food Allergies, Food inappropriate for age Room

35. The �Micro Scene� 3 Bed/Sleep surface Texture Blankets/pillows Other items (toys)

36. The �Micro Scene� 4 Document decedent Establish location Identify rigor mortis, livor mortis, temperature Identify potential injuries

37. Doll Reenactment Placing the doll Placer Last Known Alive Finder Documentation

38. Next Steps Collaborative local team meetings to better communicate about roles Medical Examiner & Coroners Law enforcement Medical Professionals Child Protection Death Investigators EMS

39. Next Steps Education/training Doll Re-enactment Interviewing Techniques Documentation & Reporting