By THOMAS HARGROVE and JOHN HALL
Scripps Howard News Service

Hundreds of Americans kill their babies every year. Depending on where they live, they may well get away with it.

States that aggressively review infant death investigations are finding twice as many homicides as states with little or no such oversight, a Scripps Howard News Service study of 40,000 infant deaths has found.

The Scripps findings are the first statistical evidence that geography largely determines if a parent or caregiver will get caught after suffocating or smothering a baby -- deaths that can appear so similar to Sudden Infant Death Syndrome (SIDS) that only a thorough investigation and review can determine the difference.

Child safety experts unanimously agree that correctly diagnosing the cause of death is essential to saving babies in the future. Yet there are no national standards, or even incentives, for state and county governments to conduct careful reviews of sudden and unexpected infant deaths.

One tragic result is that some people are getting away with the murder of infants in their care.

Linda Norton: Linda Norton, a forensic pathologist from Dallas, said it is easy for infant homicides to be mistaken for Sudden Infant Death Syndrome. "I often tell people that if you want to commit murder and get away with it, come see me," said Dallas-based forensic pathologist Linda Norton, a nationally prominent consultant in child murder cases. "I know the best places to go."

Norton became famous when she convinced New York authorities to seek a serial killer after reading a 1972 medical journal that concluded the deaths of three children in the same family showed SIDS has a genetic link. Police eventually confronted Oswego, N.Y., housewife Waneta Hoyt, who confessed in 1995 that she had smothered all three to silence their crying. She also admitted she'd killed an additional daughter and son after the journal article had been written.

One place where killing a baby is most likely to be discovered is Arizona, the Scripps study found.

Infant deaths in Arizona are investigated by professional medical examiners who are also medical doctors, a stark contrast to the more than two dozen states that allow election of coroners who often don't have college educations or formal medical training.

Arizona also has a network of local child death review teams overseen by a statewide Child Fatality Review Program with authority to order further investigations if foul play is suspected, a standard most states don't have.

As a result, Arizona leads the nation in the detection of infant homicide. One out of every six sudden infant deaths in that state was ruled a homicide during the five-year period from 2000 to 2004, the Scripps study found.

"That's depressing. But, in a way, it's also very good that we are picking up on these cases," said Mary Ellen Rimsza, chairwoman of the Arizona Child Fatality Review Program. "My experience, definitely, is that sometimes child abuse deaths are misdiagnosed as accidents."

At the other end of the spectrum is the state of Idaho, which is the only major jurisdiction in the United States that has no formal review process for the deaths of children.

Map: States with Child Death Review boards: A map of the 48 contiguous United States shows which states have local or state Death Review Boards.Only one of every 14 cases of sudden and unexpected infant death in Idaho was declared by the state's all-elected coroners to be a homicide. (Coroners with medical degrees are in the minority there.) Idaho is reporting infant homicides at a rate at least 14 percent below the national average.

Idaho authorities said they are not proud of their status as the only place not reviewing juvenile deaths and they do not dispute Scripps' findings that the state lags the national average in reporting cases of infanticide.

"You don't have to convince me that not having a child death review team is a bad thing," said Boise attorney Kirtlan Naylor, chairman of the Idaho Children at Risk Task Force. "This study will be very beneficial when we contact our legislature. We don't want to be the only state in the U.S. not to have a child death review team."

Theresa Covington, director of the Child Death Review Policy Center at the University of Michigan, said the Scripps study is the first published proof that oversight of death investigations will increase the detection of murder.

"Absolutely, the process of review improves the quality of death investigations. That's clearly what these data show," she said.

Rep. Frank Palone: Rep. Frank Pallone, D-N.J., who chairs the House Energy and Commerce Subcommittee on Health, said a study by Scripps Howard News Service has convinced him to begin congressional discussions with the national Centers for Disease Control and Prevention.Rep. Frank Pallone, D-N.J., who chairs the House Energy and Commerce Subcommittee on Health, said the Scripps data has convinced him to contact the national Centers for Disease Control and Prevention "to see how we can improve the accuracy of the data and, therefore, our response to the tragic problem of infant deaths."

"This study clearly shows that a more accurate and aggressive approach to children's death reviews is needed," Pallone said.

Covington early next year will publish similar findings in the American Journal of Public Health. She found that death review teams are reporting significantly more "child maltreatment fatalities" than coroners and medical examiners are recording on death certificates.

Covington and other experts warn that infant homicide "is a very rare event" and should not tarnish the overwhelming majority of grieving families who have lost children because their babies spontaneously and mysteriously stopped breathing.

Almost all of the parents touched by sudden infant death are innocent of any crime, they say. But it is also true that significant numbers of infanticides are overlooked every year because of failures of the medical investigation into their deaths.

The Scripps investigation found that, as a group, states with both local and statewide child death oversight boards detect 27 percent more infant homicides than do states with little or no review. Some individual states with aggressive review policies detect infanticide at even greater rates.

Investigators have long suspected that most infant homicides go undetected or, at least, unproven. Instead, these deaths frequently are misdiagnosed as the result of SIDS or, increasingly, by the medically useless designation of death by unknown causes.

The U.S. Advisory Board on Child Abuse and Neglect warned in 1995 that its analysts believe the actual number of homicides among very young children is double the official reports. If so, then only a fraction of infant homicides result in successful prosecutions of the killers, although the exact number of convictions for infanticide is not known.

"The problem is there is no hard and fast sign that a child has suffocated," said Norton, the forensic pathologist.
A memorial to "Dawn": Sometimes infant homicides are obvious, even though they frequently go unsolved. The body of a newborn infant girl was found April 5, 2006, inside a plastic garbage bag in Kitsap County, Wash. Authorities, who are still searching for the mother, named the child Dawn. "She saw the dawn of her life and little more," said Kitsap County Coroner Greg Sandstrom. Veteran homicide investigators agreed that infant killings are often overlooked.

"It certainly doesn't surprise me. Around here, someone's uncle is the sheriff and so the nephew is the coroner," said Danny R. Smith, a private investigator in Boise, Idaho, who investigated many infant deaths during his 21 years at the Los Angeles Sheriff's Department.

"Cases that are misclassified as SIDS are the least likely to be resolved, in my experience. I had one case of a woman who suffocated her child while sleeping. It was ruled accidental. But she's also had another so-called SIDS case earlier with another of her children. We just couldn't prove anything," Smith said.

If the entire nation detected infant homicides at the rate in Arizona, nearly 700 baby killings would be reported each year. But if the nation detected infant murders as infrequently as Idaho, the annual homicide figure would drop below 300.

In 2004, the most recent year for which complete information is available, medical authorities reported only 379 infant homicides. The figure has been closer to 300 in other recent years. Many of these were not prosecuted for lack of evidence that would convince a jury.

Medical authorities consistently report much larger numbers of infant homicides to the CDC than local police departments are reporting to the FBI, since coroners do not have to identify a suspect or determine criminal intent. Police documented only 201 infanticides in 2004, for example, according to the FBI's Supplemental Homicide Report issued last year.

The Scripps study found that the detection rates for infant homicides rise steadily and predictably according to the amount of review each state conducts. At the bottom is Idaho with no death review and a homicide rate of 7.1 percent for cases of sudden, unexpected infant death.

Fifteen states rely solely on a single statewide board to try to provide oversight for all child deaths. They are Alaska, Arkansas, Connecticut, Iowa, Kansas, Maine, Mississippi, North Dakota, Nebraska, New Hampshire, New Mexico, Rhode Island, Utah, Vermont and West Virginia.

Often these statewide boards are staffed entirely by volunteers who have other duties. Such boards usually meet four times a year, but meetings are frequently poorly attended and often lack a quorum. The homicide rate in this group was 7.5 percent.

Twenty-two states rely on a network of local review teams, often a gathering of veteran homicide investigators, assistant coroners and independent forensic experts. Child safety experts said if states couldn't have both local and statewide review, then local-only review is preferable to state-only review.

The states with local-only boards are: Alabama, California, Georgia, Hawaii, Illinois, Louisiana, Massachusetts, Maryland, Michigan, Missouri, Montana, Nevada, New York, Ohio, Oregon, Pennsylvania, South Dakota, Tennessee, Texas, Washington, Wisconsin and Wyoming.

The homicide rate in states with local-only review was 8.0 percent.

But 12 states had both statewide and local child death review teams during the period of the Scripps study. They are: Arizona, Colorado, Delaware, Florida, Indiana, Kentucky, Minnesota, North Carolina, New Jersey, Oklahoma, South Carolina and Virginia.

In these states, every child's death is reviewed at least two times after the coroner or medical examiner issues a diagnosis for the cause of death. The homicide rate was 9.0 percent of all sudden infant deaths in these states.

Theresa Covington: As director of the National Center for Child Death Review Policy and Practice at the University of Michigan for the past decade, Theresa Covington is a strong advocate for more thorough and professional investigations of infant deaths."That's good to hear," said Covington at the National Center for Child Death Review. "We have known anecdotally for years that communities that have review teams have a much better system of investigation. They are doing a much better job looking at sudden and unexplained infant deaths."

Norton agreed. "When presenting a case to a death review board, by definition, you are going to get a whole lot more information about the case," she said. "That's much better than, say, an elected coroner who doesn't even bother to get an autopsy."

Experts also agree the more review each infant death receives, the greater the chance human error or foul play will be detected.

"We review all of these cases at the local level and, yet again, at a state level," said Stephen Nelson, chairman of the Florida Medical Examiners Commission. "It gives us a bunch of different eyes reviewing these deaths."

Florida's medical examiners reported 115 infant homicides during the five-year period of the study, a rate well above the national average. In fact, Nelson said the state's review board had detected a suspicious infant death the morning he was interviewed for this story.

"We just had a meeting in my office with the state attorney to talk about a child's death with which we were not comfortable. The child had some old injuries, so we clearly decided not just to call it SIDS," Nelson said. "We are going to call it 'undetermined' until local law enforcement provides us with some more information."

The experts warn that it's probably a mistake for states to rely on a single state board to review all infant deaths.
"When we have local review, we have a much better outcome," said Covington. "But a review only at the state level has quite a few layers working downward before they can make changes at the local level."

Mississippi, with a lower-than-average infant homicide rate, has a fledgling child death review team that is struggling to find its way.

"We are hoping to establish meaningful child death review, not just a bunch of paperwork, but it takes a lot of work," said Mississippi board chairwoman Elizabeth Christ. "Last year we had three full meetings. This year we are trying to meet on a quarterly basis. It's hard to keep up the energy when so much of this is voluntary."

In addition to Arizona, there were five states and the District of Columbia that reported a double-digit percentage of their sudden infant deaths were discovered to be homicides. The other states were Alaska, Nevada and Utah at 12 percent each and Indiana and New Jersey, both at 11 percent. The District of Columbia had 18 percent.

Authorities in states that have been successful in detecting homicides say it is critical to urge coroners to avoid routinely resorting to a diagnosis of SIDS.

"We've made an effort over the last several years to educate and to try to emphasize that SIDS is not a diagnosis that you can make without a full autopsy, a scene investigation and reviewing a complete medical history," said Roland Khor, a member of the Indiana State Child Fatality Review Team.

Khor exactly summarized the requirements for a SIDS diagnosis as set by the World Health Organization and the Centers for Disease Control and Prevention.

As a result, Indiana has a homicide detection rate nearly a third higher than the national average and a rate of reported accidental suffocation more than double the national average. In Vigo County, where Khor is coroner, only about a third of recent infant deaths were blamed on SIDS. More that a quarter of his cases were homicides, and a similar number were ruled accidental suffocations.

"We're really coming down hard on coroners who try to make that diagnosis without doing those three steps to verify it," Khor said. "SIDS is a very narrow diagnosis. I think the coroners of Indiana are responding very well to that education."

Sometimes highly motivated local death review teams also can have a profound impact on how infant mortality is investigated. More than half of the 93 infant deaths in Marion County, Indiana, were ruled to be accidental suffocations, making Indianapolis one of the least likely major metro areas to diagnose SIDS.

"You see time after time that these babies have died because they are sleeping in an unsafe place," said Barbara Johnson, coordinator of the Marion County Child Fatality Review Team.

Johnson was so troubled by the real cause of infant death in her county that she founded the Indiana Safe Sleep Network to convince parents to avoid improper bedding, dangerous clothing and adult co-sleeping with infants.

"Prevention is the best result of what comes out of child fatality review," she said.