Getting Away With Murder – Part 2

Winner of Pulitzer Prize in National Reporting
Sloppy investigations miss murderers
Gannett News Service Series
Marjorie Lundstrom and Rochelle Sharpe

Getting Away with Murder:Sloppy investigations miss murderers

Deep in the boot heel of rural Missouri, no one knows why Dante Mosby died.”¨ The last months of the boy’s short life were spent in hospitals, where doctors suspected child abuse and called authorities.

But when the 19-month-old toddler died, the acting coroner saw no need to autopsy or investigate further. “Natural causes, exact cause unknown,” he wrote on the death certificate.

Then the case was closed.

Today – more than six years after the boy’s death – Dr. Mary Case, the St. Louis medical examiner, is continuing her crusade to dig up the child’s body to search for clues of a crime.

“The truth was buried with that boy,” said Gary Stangler, director of Missouri’s Department of Social Services, which went to court this year seeking authority to exhume the body.

The Dante Mosby case is not unique. Often, the death of a child can go overlooked and almost forgotten.

Nationwide, many coroners and medical examiners do not autopsy children who die under suspicious circumstances, according to a three-month investigation by Gannett News Service. Some don’t even bother to visit the death scene, a crucial element in determining why a child died. Those willing to do thorough investigations often don’t get the chance because private physicians failed to refer cases to them.

“One of the best ways to detect murders would be to mandate the children be autopsied,” said Dr. Linda Norton, a former Dallas medical examiner. “They get buried, and we never know.”

No one can know how many children’s murders go undiscovered. But Gannett News Service found overwhelming evidence that many states’ death-investigation systems are so flawed that hundreds of child homicides could easily be missed.

A computer study of all 1987 death certificates nationwide for children under nine revealed that officials in Southern states often fail to investigate suspicious child deaths. Of the 10 states with the lowest autopsy rates, eight are in the South.

Some counties in Southern states saw no need to autopsy any children at all. In Arkansas, which has one of the nation’s lowest rates, officials in 30 of 75 counties autopsied no children in 1987 – yet 72 children died in those counties.

The death certificates for 1987, the latest year available from the federal government, also showed that rural areas are more lax than urban areas in handling child deaths.

In cases where experts say the cause of death must be determined by autopsy – such as asphyxiation and Sudden Infant Death Syndrome, or “crib death” – rural counties nationwide autopsied 77 percent of their children. Urban areas tackled 95 percent of their cases.

Rural areas were so lax that they often ruled a child died of “undetermined causes” without performing an autopsy. In rural counties, only 64 percent of the “undetermined” cases were autopsied, compared with 85 percent in urban areas.

“That’s just a total paradox. How do you say a case is undetermined without an autopsy?” said Dr. Paul Kleinman, director of pediatric radiology at the University of Massachusetts Medical Center.

The computer findings underscored the haphazard nature of death investigation in America, with its patchwork of state laws and individual expertise.

In many states, bus drivers, janitors, gas station attendants and funeral directors are elected as coroners, often with little more than high school educations. Yet they are charged with determining whether to call for an autopsy.

“I just worry about some of the coroners in the less populated counties, far away from pathologists,” said Frank Barron, county coroner in Columbia, S.C. “I don’t think they’re competent to be coroners, but the reason they’re elected is because nobody else wants the job.”

Said Dr. Kris Sperry, an associate medical examiner in Atlanta: “There are coroners in Georgia who are functionally illiterate. They can’t even spell the things they have to put on the death certificates.”

Only 23 states rely solely on medical examiner systems, where full-time physicians or forensic pathologists investigate deaths. Highly trained in the scientific and legal investigation of death, forensic pathologists are a scarce commodity. With only about 300 in the country, states often compete for their autopsy skills.

The autopsy of the child, which generally takes two to four hours involves a thorough external examination and the opening of the torso and skull to view internal organs. Incisions often are made in the child’s back, arms, legs and buttocks to find bruises. In suspected child-abuse cases, many pathologists also will scrutinize X-rays for bone fractures, and take specimens to search for drugs and poisons.

Parents do not normally object to autopsies on their children, said coroners and medical examiners. But some states, including New York, New Jersey and Ohio, allow families to refuse an autopsy on religious grounds.

“An autopsy may be repulsive to a lot of people – it’s even repulsive to me,” said Dr. Ronald Reeves, a former medical examiner in Florida. “But at the same time, if the child dies there ought to be a reason for it. We ought not to just write it off.”

In child deaths, autopsies have yielded key evidence. Reeves, who now specializes in child-abuse autopsies, said he proved that one suspected SIDS victim actually had died of head injuries, which a hospital pathologist had overlooked. In New York City this summer, a teenage couple told police their 6-day-old son had been eaten alive by their German shepherd. But the medical examiner’s office said an autopsy on both the dog and on the child’s remains indicated that the infant had been killed and dismembered before the dog ate him. The 19-year-old father has been charged with second-degree murder.

Unlike medical examiners, who do most of their own autopsies, coroners must send bodies to the nearest pathologist – sometimes hundreds of miles away. Jimmy Owens, a spokesman for the coroner’s office in Florence, S.C., said his county often must send bodies to the Medical University of South Carolina in Charleston. “It takes forever and ever to get results,” he said, adding that reports can take four to six months.

Some pathologists are better than others. One pathologist who studied a full-body X-ray of a child could not determine the cause of death, said Michael Norris, coroner in Cumberland County, Pa. Later, the pediatric radiologist scanning the same X-rays spotted dozens of fractures, he said.

In one rural Southern county, the coroner is forced to transport most child cases to nearby cities because the local pathologist “breaks out in hives if you mention ‘court.’ ”

Fear of the courtroom is not the only obstacle to thorough death investigations. Officials in several states agreed that coroners often are hamstrung by budgets. When the money’s gone for autopsies – which average $950 each – the squeeze is on to stop requesting them.

“When you have a dead body, you can’t wait two weeks to get a decision from county council about whether you can afford to do an autopsy,” said South Carolina coroner Baron. “I’m afraid a lot of these coroners just don’t do them.”

Coroners are susceptible to other kinds of small-town politics, too. Missouri, for instance, pays its rural coroners an average of $1,200 a year to be on call 24 hours, seven days a week.

At those wages, it is often only the local funeral director who is eager to moonlight as coroner – an arrangement that’s good for business, but potentially bad for autopsies.

“If the family says, ‘No, I don’t want my baby autopsied,’ they’re not going to do it – especially if the family is their customer,” said Jay Dix, medical examiner in Boone County, Mo.

In settings that thrive on neighborliness and familiarity, experts fear, it is tempting for many death investigators to bypass autopsies on children because they sympathize with a grieving family, or can’t believe them capable of murder.

In one Pennsylvania county this year, a coroner ruled a suspicious death SIDS and allowed the body to be cremated without an autopsy. An outraged social worker speculated that the coroner had been influenced by the middle-class parents’ demeanor. The coroner, who denied any wrongdoing, was chastised by the state’s child death advisory board.

It was an inexperienced coroner in Missouri who failed to order an autopsy for Dante Mosby, who died Aug. 1, 1984, in rural Portageville. On the day Dante died, Sheriff Walter Ivy was acting as coroner because the elected coroner was campaigning for Ivy’s job. He pronounced the boy dead, unaware that several specialists had diagnosed the boy’s previous injuries as abuse-related.

Dr. Mary Case, chief medical examiner in St. Louis and St. Charles counties, heard about the boy’s death from his doctors. She was horrified by the rural authorities’ apparent lack of interest; they were outraged by her interference.

“You could talk with these people until your tongue drops out, but it makes no difference,” she said. “These are backward people. They don’t really care.”

Before the state intervened this year, Case had waged her own long-distance fight with officials in southeastern Missouri, where they continue to oppose Dante’s exhumation.

Ivy, who said he can “just barely recall the incident,” acknowledged that it was “ridiculous” that he should be filling in for the coroner. “I wasn’t a medical examiner,” he said. Prosecuting attorney Hal Hunter Jr. contends he has no suspects, and that an expensive exhumation likely would prove nothing.

But the state Department of Social Services has vigorously filed court actions seeking authority to exhume and autopsy the boy’s body, a move also opposed by the child’s family, who say they have endured enough anguish. The state filed an appeal last month after a lower court rejected its request.

Alarmed by this and other disturbing cases, a Missouri task force last month proposed sweeping changes in the way the state investigates children’s deaths. Among many recommendations is a requirement that counties aggressively review all suspicious deaths of children under 15, which is guaranteed to require more autopsies, especially in rural areas.

Georgia, too, recently overhauled its system for reviewing child deaths. The state passed a law early this year requiring autopsies for all children under age 7 whose deaths are unexplained. The law also doubled training requirements for coroners, and established a regional system of forensic pathologists to aid rural coroners.

Although Georgia’s regional system is yet to be funded, similar approaches have been successful in states like Oregon, with vast rural areas.

But requiring more autopsies may not be enough. Experts say death-scene investigations are as important as autopsies in detecting child murders Many coroners and medical examiners skip this crucial step.

“You cannot do a proper job in the morgue if you don’t know what the scene looked like,” said Dr. George M. McCormick, coroner in Shreveport, La., and a private forensic pathologist.

McCormick said he investigated one case where a toddler had been scalded to death in the bathtub. The mother claimed the child had accidentally burned himself while she dashed out for cigarettes.

To McCormick, the story and the scene didn’t match. The tub spigots were too high for the baby to reach and the child wasn’t strong enough to turn them anyway. And, the burns were far too severe to corroborate a quick errand.

“The scene proved the homicide,” he said.

But coroners and medical examiners can’t do anything about a child’s suspicious death unless it is reported to them. For that, they must rely on pediatricians, family doctors and emergency room physicians.

“We have no control over which cases we autopsy. If I didn’t get a body, I don’t know anything about it,” said Dr. Fahmy Abdel Malak, Arkansas state medical examiner. He surmised this might be one reason why his state had one of the nation’s lowest autopsy rates.

Dr. George Nichols, chief medical examiner in Kentucky, said hospital doctors sometimes forget to refer suspected child abuse victims to the morgue, especially when the child lingered for weeks.

Worse yet, some doctors actually help parents conceal their crimes by looking the other way. Dr. Lloyd White, chief medical examiner in Mississippi, said some physicians are ignoring telltale signs of abuse.

“They don’t want to get involved; they don’t want to testify,” he said. “What happens is, people get away with it.”