Reprinted with the permission of the Atlanta Journal and the Atlanta Constitution.

THE FORGOTTEN CHILDREN: Justice undone: Bungled investigations let killers off
Jane O. Hansen - Staff
Sunday, April 23, 2000

ON THE WEB: For more information about this topic:

Identifying and classifying children's deaths: www.sunlink.net/~browning/nmcfr.htm National Clearinghouse on Child Abuse And Neglect Information: www.calib.com/nccanch/ Guide to Investigating Physical Abuse and Homicide: ncjrs.org/txtfiles/batchild.txt National Center on Child Fatality Review: child.cornell.edu/ncfr/home.html#ncfr The Best of Intentions: An Evaluation of the Child Fatality Review Process in Georgia: www.sph.emory.edu/CIC/gafatality.html (NOTE:This link was omitted from the AJC article)

Terrell Peterson, 5, was murdered. But his killer might get away with it.

Dreahon Mainor, 22 months, overdosed on sleeping pills and was strangled, medical examiners say. But a prosecutor said the toddler's death "was nothing more than an awful accident," and the case was closed.

Christina Bass, 7 weeks, died from natural causes. Or did she? A forensic pediatrician says the real question is whether the infant's death should have been labeled "undetermined" or a homicide.

These three Georgia children, and many others, have something in common: a flawed investigation into their deaths.

It is easier to kill a child than an adult. And in Georgia, it is easier to get away with it. That was supposed to change more than a decade ago when a governor's task force called for sweeping reforms, including more complete investigations of children's deaths: Autopsies would be conducted by forensic pathologists. An immediate investigation of the crime scene would provide critical information.

Eleven years later, most investigations into children's deaths in Georgia remain inadequate. As a result, some children's deaths are inaccurately written off as natural or accidental, and justice for many child victims is never served.

"The bottom line is people who kill children are not brought to justice," says J. Tom Morgan, DeKalb County's district attorney.

At the root of the problem are police, medical examiners and prosecutors untrained in the nuances of children's deaths and unwilling or too busy to work together, experts say. Add the failure of the Department of Family and Children Services to share child abuse histories with law enforcement, and children's deaths are too easily mishandled and misclassified.

A preliminary report released Thursday by yet another task force on child protection barely mentions the need for better investigations into children's deaths. But Morgan, a national expert on child abuse who also chairs the state's child fatality review team, says proper investigations are critical to protecting surviving siblings and bringing child killers to justice. He's spearheading a move to create specially trained teams that would include law enforcement and child welfare workers and investigate every suspicious death of a child.

Despite suspicions of foul play, Georgia authorities have closed or dropped investigations of many children's deaths without solving them, according to a Journal-Constitution review of records obtained under court order. Often the cases were closed because law enforcement or medical examiners did not know what social services workers knew. In some cases, police failed to secure the crime scene before evidence could be destroyed or to interview family members before they had extra time to fabricate stories.

In other cases, authorities determined a child was murdered, but never charged anyone with a crime. Child victims are most likely to be killed by their parents. With no one seeking justice in their behalf, their cases more easily slip through the cracks.

Dreahon Mainor, a Camden County child, died in 1996 from an overdose of sleeping pills --- possibly accidental. But the toddler also was strangled, according to medical examiners. Investigators with the Camden County sheriff's office did not interview key family members until days after the death. Based on the interviews and autopsy findings, investigators reported they asked two family members to take a lie detector test but they refused.

Although medical examiners found the child covered with scars and ruled the death a homicide, the prosecutor said he found no evidence of foul play and believed Dreahon's death was an accident.

In Terrell Peterson's case, police seized evidence from the child's home without a search warrant. The 5-year-old was killed in 1998, and his grandmother, aunt and aunt's boyfriend have been charged with murder. But a judge threw out key evidence obtained in the search, seriously undermining the state's case.

Children's deaths present unique challenges to law enforcement and others. Children die differently than adults, and their homicides are often trickier to detect. When an adult is shot or stabbed to death, it is evident a crime was committed, and the question is, who did it. With a child, and particularly an infant, there may be no weapon, no outward signs of injury, and the challenge is to determine how the child died and whether it was natural, accidental or intentional.

For instance, an autopsy may provide the only clues of shaken baby syndrome --- a violent shaking that can cause brain damage.

When an autopsy is delayed, as it sometimes is in rural areas when a forensic pathologist is not available, critical time is lost. Morgan recalls one child who was not autopsied until two days after his death. "No one suspected a homicide until the autopsy," he said. "In 48 hours, you can do a lot of covering up of evidence."

At the same time, an autopsy alone may not be enough to determine how a child died. Pathologists say it is difficult to distinguish between SIDS and intentional suffocation. An investigation of the circumstances and the scene of the death becomes crucial in making the right call.

SIDS presents its own challenges. The wide majority of SIDS deaths are tragic natural deaths. But some are misdiagnosed, according to the Centers for Disease Control and Prevention, which estimates that 1 in 6 SIDS deaths --- or close to 1,000 each year --- are due to other causes, including child abuse.

"It is feared that murder or accident can masquerade as a SIDS death," the first state task force wrote 11 years ago.

SIDS is a diagnosis of exclusion, when no other explanation can be found. Today the accepted definition is the sudden death of a child under 1 that remains unexplained after an autopsy, death scene investigation and review of the victim's medical and family case history. Without all three elements, the death should not be considered SIDS.

Yet records of Georgia's dead children show many cases where SIDS may have been diagnosed inappropriately. One SIDS baby died after her mother, an alleged drug addict, had disconnected the medically fragile 3-month-old from a heart monitor, then left the baby at an Atlanta motel with a male acquaintance.

Another SIDS baby, a 6-week-old, died shortly after her grandmother took out a life insurance policy on the infant. Police and child welfare workers were suspicious when they learned the woman had also taken out a policy on the baby's 18-month-old sibling just before that child was hospitalized for severe neglect.

Another unrealized reform

When Christina Bass died in 1996, Dr. Kris Sperry, now chief medical examiner for the state, marked the infant's death SIDS.

At the time, Sperry did not know the baby and her family were well-known by DFACS, nor did he know what was in the agency's files: reports that the infant had been born with cocaine in her blood and abandoned at birth by her mother.

He could have had that information if DFACS had developed a computerized database that could be shared with certain agencies --- another unrealized reform the task force and Georgia Legislature called for a decade ago.

In his autopsy report, Sperry noted evidence of blunt force trauma to the baby's head, but he says it was by no means serious enough to cause her death.

Several experts now say the death should never have been called SIDS. "If there's any head injury, it's not SIDS," says Dr. Randell Alexander, director of the Center for Child Abuse at Morehouse School of Medicine. "Without checking police records and without checking DFACS records, you can't call it SIDS."

Had Sperry known of the baby's social history, he says he might have marked her death undetermined rather than natural, leaving open the possibility of accident or homicide. Even then, Sperry said, detectives would have lacked interest in the case.

"It becomes a Catch-22," he said. "The detective doesn't want to investigate if we don't call it a homicide, and we can't call it a homicide without further investigation."

Sperry said that many detectives expect an autopsy to yield black and white results. "It's because they don't understand," he said. "They have unrealistic expectations of what the autopsy will show."

That's why a team representing law enforcement, the district attorney, DFACS and the coroner or medical examiner needs to respond immediately to a child's death, Morgan says. "If you don't work together as a team, the detectives are waiting on the doctor to do the autopsy, but the doctor cannot do the autopsy in a vacuum. He needs the history of the child."

Without a quick and thorough autopsy and investigation, too many children's deaths are ruled "unexplained" or "undetermined."

When a 5-month-old died unexpectedly in 1996, the medical examiner refused to rule on a cause of death because the child was the second baby in the family to die under similar circumstances within four years. The autopsy report notes the extreme rarity of two SIDS deaths in the same family and the "inherent suspicion that other subtle, yet traumatic, causes" may have resulted in the death.

Police and medical examiners' files contain no sign that they knew the child's mother had gone to the DFACS office just before the child's death, saying she was depressed because her husband was ignoring her. Nor did they know she had taken another of her children to the hospital years earlier with an unexplained skull fracture, according to records. Had they known, the case may have taken a different turn.

Law enforcement officers in particular need special training in dealing with child deaths, which can be a highly emotional experience, even for seasoned officers, Morgan says. With no immediate evidence of a crime, officers untrained in child deaths are less likely to secure what could be a crime scene in the face of a grieving family.

Inexperienced detectives in the JonBenet Ramsey case failed to "immediately separate and interrogate the parents, which is the first thing you do in child homicides," Morgan says. "You want to make sure parent A's story is the same as parent B's."

Unlike adult victims, young children are most likely killed by those entrusted with their care. More than half of such victims are killed by their mothers or fathers; another 29 percent are killed by other relatives or male acquaintances, often their mother's boyfriend.

Police also need the right skills in interviewing possible suspects. Rather than come down harshly, they should be empathetic, Morgan says. "In most child deaths the intent was not to kill the child. The child was crying or had a messy diaper and the parent lost it. Therefore police need to take that into account when interrogating them."

The goal is to win a confession, Morgan says.

As a former member of the U.S. Advisory Board on Child Abuse and Neglect, Morgan has been inspired by the successes that have been realized across the country by those who have adopted the team approach.

In Los Angeles, once a unified team began investigating children's deaths, law enforcement began to present more cases to the district attorney for prosecution, cases were more successfully prosecuted, and sentences stiffened dramatically, says a former L.A. prosecutor.

"In jurisdictions that have implemented these teams, we've seen charging and conviction rates go up astronomically," Morgan says.

Morgan is trying to get similar teams in place around Georgia. Working closely with DFACS officials, Morgan wants to try out the teams in five judicial circuits where district attorneys have expressed interest.

"We want to get all the people who have an obligation to protect kids at the hospital and at the scene at the time of the incident, which is critical," says David Hellwig, head of child protective services for the state. "You've got to see whether the circumstances at the scene are consistent with the child's death and consistent with the explanation."

While DFACS officials have embraced the idea, law enforcement is the chief stumbling block in Georgia, say Morgan, Hellwig and others. "It's a turf battle," Morgan says. "It's the old 'We're in charge of homicide investigations and we don't want anyone else doing it.' "

Only the Lookout Mountain circuit, which covers four northwest Georgia counties, has put a team in place. Almost as soon as it formed, it got its first case.

The night District Attorney Herbert Franklin got the call last November that a 10-month-old baby had died under suspicious circumstances, he immediately activated the team. Among those who met him at the hospital were a GBI agent, a sheriff's investigator, the coroner and a DFACS representative. Within hours, they had pulled medical records, looked for any history of child abuse, interviewed the father and mother separately and gotten the father's consent to search the house. The father said the baby had fallen off the changing table.

But their investigation and the autopsy suggested otherwise. When they told the father, Christopher Crosson, their findings did not square with his explanation, he confessed to losing his temper and injuring the baby because she had soiled another diaper. He said he'd made up the story about the baby falling from the changing table on his way to the emergency room.

Crosson is awaiting trial on murder charges.

"It worked pretty much as it was intended to," Franklin says. "Everyone utilized their own strengths."