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Bundock EA, Corey TS, Andrew TA, et al., editors. Unexplained Pediatric Deaths: Investigation, Certification, and Family Needs [Internet]. San Diego (CA): Academic Forensic Pathology International; 2019.
KEEGAN
“Keegan was 8 months old with a loving 3-year-old sister at the time of his passing. Once they stopped working on Keegan, my husband held him, while I threw up, screamed, and cried in a fetal position. At my husband’s encouragement I held Keegan and then laid down with him in our bed. The police officers told me I needed to get out of the bed and leave Keegan so they could start an investigation. I needed more time. A woman from CPS told me I had to leave, or the police would have to question me and that I wouldn’t want that. I reluctantly left out of fear.”
– Keegan’s Mom
OUTLINE.
Due to its complexity and the important role it often plays in cause-of-death determination, infant death scene investigation has received a large amount of attention and has been the subject of several attempts at standardization in the past three decades. This issue has received significant scrutiny from the Centers for Disease Control and Prevention (CDC), leading to the development of guidelines for the investigation of sudden unexplained infant death (1), and the creation and publication of the Sudden Unexplained Infant Death Investigation Reporting Form (2). Investigations of deaths in older children, aged one year through prepubescence, is much less uniform and less procedural guidance is available. Death scene investigation requirements will vary based on the age and development of the child as well as the circumstances surrounding the death. Deaths of children in specific situations, including reported or concealed drowning (3) and deaths during athletic activities (4, 5), have been discussed in other forums. Support and resources for child death investigations are becoming more available and accessible, including through the Sudden Unexplained Death in Childhood Foundation and the Sudden Death in the Young Case Registry (6, 7).
The scope of deficiencies in non-infant child death scene investigation is largely unknown, as there is no standardized or required protocol to ensure accurate and thorough death scene investigations in this age group. Even in infant deaths, where more published literature and training is available, there is wide variation in the quality of investigations and adherence to best practices (8, 9). This is in part due to the piecemeal nature of death investigation systems, with variable coroner and medical examiner systems functioning at a range of county, regional, and state levels. Even within a single system, inconsistencies have been documented in the performance of child death investigations (10). Mandates and policies regarding scene investigations, regardless of decedent age, depend on local regulations and statutes and, thus, vary widely from state to state. Similarly, the qualifications and training of death investigators varies across the US. The general processes of an infant or child medicolegal death investigation are summarized in Appendix 3.
Ideally, a complete scene investigation is a mandatory component of a thorough child death investigation, and as such, any death falling under the jurisdiction of a medical examiner/coroner system should be investigated by a certified medicolegal death investigator who is independent from law enforcement. If a certified medicolegal death investigator is not available, the next best practice is to ensure the death is investigated by an individual with knowledge of and training in pediatric death investigation. Because each death scene is unique, investigation requirements will vary according to the circumstances and the age and development of the child. Scene investigation is closely tied to the family interview and other data gathering which is discussed elsewhere in this publication. The use of a standard infant/ child death reporting form ensures that required information is gathered uniformly. This is particularly helpful for jurisdictions with infrequent child deaths, where investigators may have less experience with the intricacies of these cases. In addition to collecting information about the immediate circumstances and medical/developmental history, numerous environmental factors including housing and living environment, sleeping arrangements, and day care/school exposure must be considered to document risk factors and/or potential exposures. Because the scene holds critical information, a proper and timely scene investigation must be performed to correctly classify the cause and manner of death, even for children that are transported to the hospital. It is recommended that the scene investigation be performed within 24 hours, whenever possible. This ensures that any potential hazard or toxin can be properly identified and remedied before exposure or harm of other persons. The geography of some jurisdictions may prohibit scene response within 24 hours. In these instances, the scene should be investigated as soon as possible for that jurisdiction.
As with any appropriate death investigation, the scene response should include documentation of the child’s general and immediate living environment. Care should be taken to evaluate the scene for any potential hazards or causes of death, including sources of suffocation or asphyxia, blunt trauma, poisoning, allergens, or other exposures. For deaths occurring during a sleep period, evaluation and documentation of the bedding materials (such as the presence of a pillow top and/or excessive bedding materials) is essential. The number and types of blankets, pillows, sheets, and toys should be detailed, and the softness, thickness, and location of such items should be assessed and noted.
Use of a doll to reenact the circumstances under which the child was found is recommended for all children up to 24 months of age, children with developmental delay, and children with a history of seizures. This visual documentation may provide valuable information regarding the mechanism of death (11, 12). For the doll reenactment to be successful, the process and purpose should be explained to the parent/caregiver. Different types of dolls are available for this objective. Featureless, cloth, weighted dolls have the benefit of being posable and of similar weight to small infants (Image 4.1A). However, they lack facial features which makes it more difficult to document obstruction of the nose or mouth, and they are difficult to position. If utilizing one of these dolls, it is recommended that a face be drawn on the doll to approximate the nose and mouth, as well as to indicate the front of the doll. A life-like, articulated baby doll may also be used (Image 4.1B). These dolls have the typical facial features of an infant/child. However, most will require some modification to make their heads turnable, and the available sizes are limited. Regardless of which type of doll is used, it should be handled with care during the reenactment and placed and photographed in the environment to depict how the child was initially placed and how the child was subsequently found (Image 4.1 C and D). To reduce the caregiver’s emotional stress and minimize future negative associations, the use of an item belonging to the child, such as a stuffed animal, is not recommended.
Featureless, cloth, weighted dolls (A) or life-like, articulated dolls (B) should be used for reenactment of the placed (C) and found (D) positions during investigation of an unexpected infant death.
The basic approach to infant death scene investigations has been described in detail by the CDC and endorsed by the National Association of Medical Examiners (NAME) and the American Board of Medicolegal Death Investigators (1). These guidelines are easily translatable to deaths in children over 12 months of age, and include performing a scene walk-through and briefing, photographic documentation, doll reenactment as applicable, and written descriptive records. Documentation should include recording of the condition of the residence, lighting, power and heat sources, and ambient temperature. The medicolegal death investigator should be aware of physical evidence and collect any fragile or trace evidence as appropriate and in accordance with local laws. An initial body exam should also be performed in conjunction with the scene investigation, to include documentation of clothing, rigor mortis and lividity, evidence of resuscitative attempts or therapy, and observed injuries.
Photography is one of the most important scene investigation tools. Adherence to a standard photography protocol ensures that the investigator will document the scene findings in a permanent visual medium that can be preserved for later review as necessary. Photographs should parallel the scene investigation, beginning with documenting the broad environment and moving inward to focus on more immediate subjects including sleep environment, potential exposures, and other hazards. Photographs of the decedent should be taken at the time of the investigator’s arrival, prior to manipulation of the body. When the doll reenactment is performed, photographs and/or video should be taken to show the positions in which the child was placed and found, including head/face, neck, and body positioning. Which photographs represent the placed and found positions must be documented, ideally within the photo itself by use of labels (Image 4.1 C and D). In addition to the overall and immediate scene surroundings, photographs should be taken of the body, the location where the body was found, potential sleeping surfaces, blood or body fluid patterns, any items of environmental concern, and any other viewable evidence. It is recommended that photographs be taken with and without rulers for scale documentation. Photographic documentation of the scene may be available from other sources and should be sought in conjunction with the medicolegal investigator’s routine photography. Inquiries should be made as to the availability of home surveillance or crib monitor videos, as well as first responder (law enforcement, fire department, or paramedic) photographs or body camera footage. Cell phone and social media videos and pictures may also be obtained from the parents for review of the child prior to death.
Removal of the child from the residence should be performed with care and compassion. The decision to allow the parent(s) to view and/or hold the child falls with the investigating agency; however, in most cases it can be accommodated without compromising the investigation. When possible, it is recommended to allow the parent(s) to view and hold the child under supervision. When removing the child from the residence, the child should be wrapped in a sheet or blanket and carried to the transport vehicle to be placed inside a body bag and/or transport box.
Frequently, children are transported to a health care center prior to the pronouncement of death, which creates two sites for scene investigation. The primary information will come from the location where the event occurred, and thus scene investigation at that location (residence or other site) must occur regardless of where the child was pronounced dead. Response to the hospital is also necessary, as this provides the first opportunity for viewing the child and noting any externally apparent findings. In addition, first contact with the family frequently occurs at the hospital due to the timing of the medicolegal death investigator’s response. Interaction with emergency medical response team members and hospital personnel is valuable and should be sought. Preliminary medical information may be available and other protocols can be instituted and communicated as necessary. These protocols may include guidelines regarding handling of the body, postmortem imaging availability through the medical facility, preservation of items of medical therapy, supervised family viewing or holding the deceased infant or child, and obtaining keepsakes such as handprints, footprints, or locks of hair (13).
Guidance for investigation is summarized in Table 4.1, with the understanding that jurisdictions that cannot currently meet these ideals may use them to set goals for obtaining proper resources, certifications, and training.
Procedural Guidance and Key Considerations for Scene Investigation.
Interviews with witnesses or persons involved in the care of an infant or child who died suddenly and unexpectedly are critical to helping the medical examiner/coroner explain why and how the death occurred. In 1996, the CDC developed the Sudden Unexplained Infant Death Investigation Reporting Form (SUIDIRF). The reporting form was intended for use by local jurisdictions to improve uniformity and thoroughness of information (2). Before the advent of this form, such investigational tools were not widely available. After evaluations of the 1996 form revealed that users found the SUIDIRF cumbersome and difficult to use, the CDC convened a national working group representing medical examiners, coroners, death scene investigators, researchers, and Sudden Infant Death Syndrome (SIDS) organizations to revise the SUIDIRF (14). Training materials were also developed and disseminated through multiday regional trainings across the country from 2006 to 2008 (15). The revised SUIDIRF and accompanying training materials were endorsed by the National Association of Medical Examiners, the International Association of Coroners and Medical Examiners, the American Board of Medicolegal Death Investigators, and the National Sheriffs’ Association. About two-thirds of US medical examiners/ coroners who certify infant deaths reported using the SUIDIRF or a jurisdictional equivalent, with more frequent use in jurisdictions serving populations ≥ 250 000 persons and less frequent use in smaller jurisdictions (16). Completion of the SUIDIRF in infant death investigations remains voluntary.
While recommendations for interviewing family members, caregivers, and other witnesses have been developed for infant deaths, these are easily modified for child deaths. A SUIDIRF update being developed at the time of this publication will soon be available on the CDC website (17). Infant and child death reporting forms provided in this publication (see Appendices 3 and 4) are modifications of the SUIDIRF (17). An infant and child death scene investigation form provided by the Michigan Child Death Review program is available in a modifiable electronic version (18). Such forms are important investigational tools that guide data collection and provide the forensic pathologist with crucial information about the circumstances of the death and risk factors present. The forms guide the investigator in conducting witness interviews and gathering scene information, with special focus on aspects unique to this age group such as: location of and position in which the infant was placed to sleep, location, and position in which the infant was discovered unresponsive, medical history (e.g., previous illness or health concerns, feeding and growth patterns, medication use, and immunization history), family medical history (e.g., previous sibling death and/or health issues, and caregiver mental health issues), usual infant sleep practices, social service agency involvement, household composition, maternal pregnancy and birth history, and attempted resuscitation and emergency services responses. Diagram templates for documenting the scene and body and a free-text narrative section are also part of the form.
In addition to providing the SUIDIRF, the 2006 training initiative provided a booklet of guidelines for conducting an infant death investigation and a training curriculum to teach medicolegal death investigators how to conduct infant death scene investigation/ witness interviews and write narrative reports for the forensic pathologist, all of which are available online (1).
Interview content and skills are a special emphasis of death investigator training materials (19). Family members, caregivers, and healthcare providers can provide vital background information about the infant. It is important that the investigator identify and speak with the person who last placed the infant (usually for sleep), last knew the infant was alive, and the person who discovered the infant dead or unresponsive. The investigator also needs to find out about the infant’s earlier activities, and must document medical, dietary, and maternal pregnancy history. It is important that the medicolegal interviews with grieving family and caregivers be performed in a professional and sensitive manner, as an interview rather than as an interrogation. Cultural differences must be appreciated and both verbal and nonverbal behavior assessed (20).
It is also important to interview first responders (emergency medical service, law enforcement, fire department), social services, and child protective service investigators as these professionals who arrive at the scene before the death investigator and often have important information regarding the infant’s position and scene environment (21). When the scene of death and the infant’s primary residence differ, some information about both locations will be needed (e.g., smoke exposure) (21). All activities of the medicolegal death investigator must, of course, be consistent with local laws, statutes, and customs (20).
Realizing that medicolegal death investigators may lack formal training in communicating with people in crisis and/or grieving, the Scientific Working Group for Medicolegal Death Investigation developed Principles for Communicating with Next of Kin during Medicolegal Death Investigations, published in 2012 (22), which contains 13 principles for communicating with family members including a reminder to answer the family’s questions about death investigation and autopsy process and a list of “what to say and what not to say” (22). Similar topics are covered in Chapter 12 (Family Needs and Follow-up Care) of this publication as well.
Many investigation guidelines developed for use in cases of infant death can be easily modified for use after deaths of children over one year old. However, the list of topics that must be addressed will be more expansive and will vary depending on the child’s environment and medical history. Toddlers are more mobile than infants and, thus, both 1) less susceptible to unsafe sleep environments and 2) more susceptible to other hazards (i.e., chemicals, injuries, airway obstructions, falls). Also, some disorders become symptomatic as a child develops, such as epilepsy, cardiac arrhythmias, asthma/allergies and some metabolic and genetic conditions. Exposure to infection also increases as children enter school or day care. All of these should be kept in mind when interviewing the parents, caregivers, teachers, and coaches, etc. The Sudden Death in the Young (SDY) Case Registry developed a set of investigative tools for investigation, family interview, and autopsy. The SDY Case Registry also provides tools for classification of child deaths (up to age 20 years) that facilitate surveillance and research (7). A child death report form is included in Appendix 5 of this publication.
A great variety of records may be helpful in determining cause and manner of death. In instances of sudden unexpected pediatric deaths, the following records should be sought, as appropriate to age: 1) birth records, 2) pediatric care records (to include newborn screening, immunization and growth charts), 3) first responder records, 4) emergency department records (if the child was transported to the hospital), 5) current or prior hospitalization records, 6) child protective services records, 7) school health and counseling records, and 8) physical training records.
Use of electronic devices and social media is beginning at younger and younger ages. Currently, the average child getting his/her first smartphone is around 10 years old (23). Children as young as 11 years old frequently have social media accounts (23). Social media sites and other publicly available data sources may provide indications of cause and manner of death. Law enforcement may be particularly helpful in obtaining access to this critical information. Investigators should become knowledgeable about current social media platforms, and when necessary, work with the other agencies and computer forensic analysts to obtain information from electronic devices. On-site and web-based trainings are available and free training is often offered at local library and community centers. As social media platforms frequently change, it is important to stay up to date and retrain as necessary.
Medicolegal death investigation agencies should work with local hospitals, emergency medical providers, and other pooled interoperable systems to obtain access to decedent records. Most medical offices and hospitals have converted to electronic medical records which may facilitate sharing of records – particularly with the conversion of most medical examiner/coroner offices to electronic or web-based case management systems. To receive and maintain sensitive medical records electronically, the medical examiner/coroner case management system must be secure and access-controlled.
Obstacles to a complete records review may include difficulty in obtaining sensitive records from schools and other agencies. In addition, death investigation case management systems may not support the electronic transfer and storage of medical records, and medical examiner/coroner offices may be staffed with personnel who lack information technology skills.
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