Winner of Pulitzer Prize in National Reporting
Reforming the investigation system
Gannett News Service Series
Marjorie Lundstrom and Rochelle Sharpe
Getting Away with Murder: Reforming the investigation system
When the hospital notified coroner Sue Townsend about the baby, she was alarmed. The child was 11 months old, dead – a simple case of Sudden Infant Death Syndrome, she was told. “I just didn’t like it,” said Townsend, coroner in Aiken, S.C., who is skeptical of any SIDS victim over six months. “It was one of those gut feelings that something here wasn’t right.”
Townsend picked up the body, then rushed with police to the child’s home. Her fears were confirmed. Inside, the baby’s identical twin was near death, so malnourished he was suffering from rickets.
Robert, who weighed less than 13 pounds, was quickly removed from the home and hospitalized. Today, nearly four years later, he is a thriving preschooler whose adoptive parents still marvel that it was a coroner who saved the baby’s life.
But coroners and medical examiners nationwide do not deal only with the dead. In the desperate struggle to identify and prevent child abuse, they’ve stepped out of the morgue and into homes, courtrooms and legislative halls.
Although the nation’s death investigation system is in disarray – enabling many child-abuse deaths to go undetected – there are promising signs of reform. A three-month investigation by Gannett News Service showed that while many states don’t bother to autopsy their most suspicious child deaths, some medical examiners and coroners are setting an example.
• The New England and Pacific Coast states had outstanding track records in aggressively investigating child deaths, according to a review of all the nation’s 1987 death certificates for children under nine. While some states give absolute discretion to the local coroner, Dr. William Sturner, Rhode Island state medical examiner insists that every child’s death be reviewed by both a pediatric and forensic pathologist.
• Some states are promoting laws that would mandate autopsies in all suspicious child deaths, and require their coroners to receive better training.
• Many coroners and medical examiners are joining newly formed death review committees that can save the lives of other children.
• A handful of medical examiners are willing to scrutinize the injuries of live children and pursue those difficult cases in court.
“In America, the coroner or medical examiner has a very bad reputation – that here’s this guy with a hunchback and abnormal personality who eat sandwiches between dead bodies,” said Dr. Boyd Stephens, the San Francisco medical examiner who also heads the county’s child death review team.
“It’s hard to translate that into someone who is concerned about life and the welfare of the community.”
Stephens had nearly a flawless performance record in the city and county of San Francisco. Gannett News Service found that San Francisco officials had ordered autopsies in 96 percent of their child suspicious child deaths in 1987. Like Rhode Island, the Northern California city is a believer in collaboration in all child deaths.
It was a highly publicized death of 14-month-old Nathan Moncrieff in the Bay Area that inflamed the city and helped spawn its successful child death review committee. Nathan had been beaten to death in 1986 by his foster parents – a transvestite and his male lover, posing as a married couple.
Today, every sudden and unexpected death of a child in San Francisco is carefully reviewed by a committee, which includes Stephens and representatives of social services, police, mental health and other child advocacy groups. The members share their information and hope to learn why every child died, which agency, if any, made mistakes – and whether any other children may still be in danger.
Out of these tragedies have come heartwarming victories.
When the San Francisco medical examiner’s office told Michael Hancock, a death review committee member and the Welfare Department investigator, about the autopsy of a dehydrated 6-month-old infant last year, he raced to the child’s home. There, the day after Christmas, he found a second child living in an impoverished household without food, heat or furniture. The child immediately was removed.
California now has 23 such committees, and the idea is spreading rapidly across the country, where feuds among agencies have hampered child-abuse investigations.
Turf battles are so vicious in some places that social services workers jealously guard their files on murdered children to avoid any public blame. Those workers who are anxious to expose details of disturbing cases can be paralyzed by state confidentiality laws, which restrict release of information about children.
In fact, some social workers are forbidden by state confidentiality laws to confirm that a child has even been killed, making it impossible for anyone to accurately count the number of child-abuse deaths nationwide.
“We can tell you how many cars are sold in the last hour, but some states don’t keep track of how many children are killed,” said Leslie Mitchel, an analyst with the Chicago-based National Committee for Prevention of Child Abuse, the only agency that attempts to quantify child-abuse deaths.
Asked Douglas Besharov, a child-abuse expert at the American Enterprise Institute: “Why do we have to have confidentiality after a child is dead? Who are we trying to protect?”
Missouri’s Department of Social Services, for one, has asked its lawmakers to relax confidentiality laws so that child-abuse information can be readily revealed to medical examiners, coroners, school administrators, juvenile court officers – and, in some cases, the general public.
The proposal grew out of a statewide furor this month over Dante Mosby, a 19-month-old child whose death in 1984 helped spawn numerous recommendations for reform. The Missouri Department of Social Services, which has been blocked from releasing many details of the Mosby case, has gone to court seeking the right to exhume and autopsy the child’s body. A decision is expected early next year.
It was the brutal death of 11-week-old Jeremiah Nissly in Pennsylvania in 1986 that also precipitated action. Two years after the child’s death, assistant attorney general Marylou Barton, haunted by the Nissly case, formed a statewide child death advisory board.
When she was prosecutor in Lancaster County, Barton received a call that Jeremiah may have died of child abuse. Furious that a hospital pathologist took only 30 minutes to conclude the baby was a SIDS victim, Barton ordered a second autopsy – standing guard over the eight-hour procedure.
Indeed, the second pathologist found more than 35 fractures; the child had been shaken to death. The father was convicted of third-degree murder and sentenced to five years probation.
“It made me mad,” she said. “I was determined that this was not going to happen again.”
Today, at Barton’s urging, Pennsylvania’s board is going beyond its bimonthly review of disturbing child deaths. In September, panel members considered the plight of a living child – a 2-month-old baby who appeared to be severely beaten, yet doctors were reluctant to declare it a child-abuse injury.
Angry and frustrated, the Pennsylvania state trooper had traveled to the board’s meeting in Harrisburg to plead with members to take action in the case; they agreed to examine the child’s X-rays and apply some pressure locally.
Examining live victims of child abuse also is becoming a new focus for some medical examiners, not content to confine themselves to the morgue. Prosecutors and social workers increasingly consult forensic pathologists about live children, whose injuries may be difficult to discern.
“It makes perfect sense to go and look at a living child,” said Dr. Kris Sperry, an associate medical examiner in Atlanta. “We’re trained as doctors first, anyway. And we’re experts at injury interpretation.”
As a medical examiner in New Mexico between 1985 and 1989, Sperry estimates he saw 175 living children, of whom 75 percent were abuse victims. For all his efforts, Sperry said he has been criticized by other pathologists and defense attorneys who believe he is overstepping his bounds.
“I had a defense attorney in New Mexico tell me I could see child-abuse in a peanut butter sandwich,” he said. “What that told me is, ‘I’m doing my job.’ ”
Sperry dismisses criticism from some colleagues as the product of their own laziness and discomfort at getting involved with social workers, police and prosecutors.
“I believe I’m in the position where I’m the only one who can speak for a dead child who can’t talk – and maybe never could,” he said.
Speaking for abuse victims lands many medical examiners like Sperry in court, where they frequently testify as key witnesses for the prosecution. Often, they are the only witnesses because spouses stick together, and surviving siblings are too young or too frightened to talk.
Medical examiners’ testimony has become even more important in recent years as prosecutors lose interest in pursuing these difficult cases, said Robert Parish, assistant attorney general in Utah.
“It’s got to be almost a perfect case before they prosecute,” he said.
Testimony of medical examiners also can be key to defense attorneys, whose clients may be falsely accused of murder. “It works both ways,” said San Francisco medical examiner Stephens, who proved that one child died of SIDS despite accusations by family members that the mother had been abusive.
Without an autopsy, neither side is likely to have a solid case, experts said. Yet autopsies on children are conducted haphazardly in America, and children frequently are buried without any investigation whatsoever, Gannett News Service found.
With the autopsy key in detecting child abuse, some states, including Pennsylvania and Missouri, are considering laws that would require more autopsies of children who die unexpectedly. Several more states, like California and Minnesota, have joined Illinois’ lead in drafting protocols for the death investigators – guidelines that spell out precisely how children’s deaths should be handled.
Many coroners and medical examiners are skeptical of these moves, saying they should have complete discretion in ordering an autopsy. They believe the emphasis should be on education and increased training – particularly for coroners, who often don’t have medical degrees.
“You cannot mandate quality. You can only train quality,” said Dr. Harry Bonnell, chief deputy coroner in Hamilton County, Ohio.
Townsend, who has fought for more coroner training in South Carolina, honed her investigative skills working for the state police and sheriff’s department. A coroner since 1982, Townsend continues to attend child-abuse seminars, a practice she says may help her save more lives. In her office in Aiken, S.C., she gazes often at a memento of her greatest triumph: a picture of Robert, the child she saved four years ago. The child’s natural parents were convicted of negligence of a child and each received a 10-year prison sentence, which was suspended to one year, plus probation.
“He’s what keeps me going,” she said. “When you get up at 2 in the morning, get out of your warm bed and go out in the freezing rain – and you’re wondering what in the hell you’re doing – you see this picture of Robert and say, “That’s why I’m here.”