Deaths Due to Child Abuse: A 6‐Year Review of Cases in The Cook County Medical Examiner's Office

Case files from the Cook County Medical Examiner's Office from 2007 to 2012 were reviewed to analyze homicides due to physical child abuse in children <3 years old. Fatal cases mostly involved younger subjects. Intracranial injuries were the leading cause of death, while death due to extracranial injuries was uncommon. Eyes were involved in most of the cases. Spinal cord was involved in about 1/3 of the cases, mostly in the thoracic area. In some cases, previous injuries were present. There were significant differences in the pattern of injuries between age groups. Subjects showing signs of impact to the head and subjects with no evidence of an impact showed no significant difference in internal injuries. The association of multiple injuries is highly suggestive of child abuse. In suspected child abuse, a postmortem examination including neuropathological, ophthalmological, and radiological information should be always evaluated, together with investigative reports and the medical history.     

Fatal child abuse-maltreatment syndrome. A retrospective study in Ontario,Canada, 1990-1995

Child death due to repeated episodes of physical assault or neglect has been termed the child abuse-maltreatment syndrome (CAMS). We characterized the injuries in a series of fatally abused or maltreated child to delineate objective diagnostic criteria for the CAMS for use by clinicians and pathologists. All deaths (age <17 years) investigated by the Office of the Chief Coroner for Ontario, Canada during the time period 1990-1995 were reviewed. Cases of CAMS were defined as death due to lethal recent injury or malnutrition in the presence of significant old (healing or healed) injuries indicative of repeated episode of inflicted trauma. The nature and frequency of the various injuries was determined. The frequency of the shaken baby syndrome, and the types and frequency of ano-genital injuries were also studied. Twenty-one cases of fatal CAMS were found in the study period. Most cases had significant recent head injury with intra-cranial hemorrhage (71%). Other significant recent injuries commonly observed included blunt injuries of the skin and soft tissues (67%), blunt abdominal trauma with visceral injuries (14%), and fractures (18%). Eight cases (38%) fulfilled accepted criteria for the shaken baby syndrome. Many children with fatal head injuries had evidence of older head trauma (38% of all cases). A significant minority of cases had evidence of malnutrition due to neglect (10%) or ongoing ano-genital injuries (10%). Most cases of child homicides due to repeated episodes of abuse or maltreatment involve head trauma including shaken baby syndrome. Fractures of long bone and ribs, the classical markers of child abuse, were relatively infrequent compared with head injury. A proportion of cases had ano-genital injuries due to repeated sexual abuse or punitive maltreatment. All clinicians and pathologists must recognize the wide spectrum of injuries in child abuse to ultimate protect the victim or other children in an at-risk situation.     

Distinct age-related differences among victims in cases of suspected child abuse

Evidence describing age-related differences among children with suspected physical and sexual child abuse is lacking. We describe findings in severe cases of suspected abuse. Cases with 756 children <15 years old were included during 2001–2013 at the Department of Forensic Medicine, Aarhus University, using forensic evaluation documents, medical records, and court proceedings. Eight percent of children <4 years old died from child abuse, 36% through violence resulting in death, and 64% by manslaughter, whereas 1% > 4 years old died, solely by manslaughter. External injuries were mainly located to head and torso in children <4 years old, changing to the upper and lower extremities in older children. Child sexual abuse was suspected in 52% of cases with living children <4 years old, 83% of children 4–7 years of age, 88% of children 8–11 years of age, and 93% of children >12 years old. Anogenital findings were mainly caused by other medical conditions in children <4 years old, hymenal clefts in the superior half of the hymenal rim were almost exclusively found in children between 8 and 11 years of age, whereas both superficial and complete hymenal clefts in the inferior half of the hymenal rim were found in children >12 years old. The present study describes age-related differences in victims of suspected child abuse. Fatal versus nonfatal child physical abuse and the significance of hymenal findings in child sexual abuse could be studied further.     

A decade of pediatric homicide: a retrospective study at the Medical University of South Carolina.

More than 3 million children are abused and/or neglected each year in the United States. Unfortunately, a significant percentage of these cases result in homicide by child abuse or child neglect. Causes of death range from blunt force trauma and shaking to asphyxia to immolation. We retrospectively reviewed all pediatric forensic cases referred to the Medical University of South Carolina Forensic Pathology Section over the past 10 years, from January 1986 to December 1995. Of these, we looked only at children < or =5 years of age. The majority (342 cases, 69%) of these deaths were classified as natural, 96 (19%) as accident, and 60 (12%) as homicide. Of the homicides, we examined the cause of death; age, gender, and race of the victim; relationship to the perpetrator; time interval between injury and death; and the initial history given as to the cause of the injury. The cause of death fell into nine categories, the number one category being head trauma. Forty-five percent of the homicides were by head trauma, 12% by abdominal or body trauma, 25% by asphyxia (with half of these due to drowning), 10% by carbon monoxide poisoning or thermal injury, and the remaining 8% involving cases of neglect, stabbing, and poisoning. The majority of the homicide victims were male (67%) and black (67%). Forty-six percent were < or =1 year of age. Approximately 25% of the homicide cases were designated as shaken baby syndrome (SBS). In 97% of the cases, the assailant was known to the victim and was a family relative in 77%. Sixty-three percent of the assailants were female and 45% of the assailants were male; in 12%, the assailants were both parents, and in 1 case, the assailant remains unknown. Of the asphyxia deaths, 87% of the assailants were female. The time interval between injury and death ranged from minutes to hours in most cases to months in cases of repeated abuse and chronic injury and sequelae. The time interval between injury and the onset of symptoms remains unknown in most cases due to inconsistencies in the history and lack of credibility of the caretaker. The most common initial history given was "a fall" (20%). We report our findings of a decade of pediatric homicides to increase awareness of the common scenarios and case histories, demographics of the victims, causes of death, and perpetrators of pediatric homicide.     

Detection of medical examiner cases from review of cremation requests

Title 9, Chapter 19, Article 3 of the Arizona Administrative Code requires all bodies that are to be cremated must have the death certificate reviewed by a county medical examiner. In Tucson, AZ, and surrounding Pima County, all cremation requests are submitted to the Forensic Science Center, where the death certificates are reviewed by one of 5 board-certified forensic pathologists. In 2002, there were 5557 cremation requests, and in 2003 there were 5662 cremation requests. Of these requests, 670 (12.1%) and 447 (7.9%) death certificates were flagged for further investigation in 2002 and 2003, respectively. Eventually, 47 cases (0.8% of total, 7.0% of flagged cases) were accepted as medical examiner cases in 2002, and 43 cases (0.8% of total, 9.6% of flagged cases) were accepted as medical examiner cases in 2003. In 2002, the majority of cases were handled as a records review; however, 4 cases were brought in for autopsy and 1 was certified after an external examination only. In 2003, all cases were certified via a records review. The manner of death in all but 3 of these deaths was certified as accident, with complications of remote trauma being the most common proximate cause of death. The 3 most common injuries were complications of fractured pelvis or femur (15 in 2002, 22 in 2003), head injury due to fall (18 in 2002, 8 in 2003), and complications of remote motor vehicle accident (3 in 2002, 6 in 2003). The other 3 deaths included 2 homicides, 1 in each year, and 1 suicide in 2003.     

A 25-year retrospective review of deaths due to pediatric neglect

Neglect, defined as the failure of a caregiver to adequately provide safety, food, clothing, shelter, education, protection, medical/dental care, and supervision for a child in his/her care, is a relatively uncommon but important cause of child mortality. A retrospective review of pediatric deaths (age 18 years or less) referred to the Medical University of South Carolina Forensic Pathology Office for autopsy over the past 25 years revealed 16 deaths due to some type of pediatric neglect. Cases were analyzed as to age, sex, race, cause and manner of death, autopsy findings, ancillary studies, past medical history, social/family history, and caregiver. Six cases of malnutrition/starvation and/or dehydration were identified, composing the most common cause of death in the neglect cases identified and the majority of the homicides due to neglect. Other deaths in which neglect contributed significantly included toxic ingestions (2 cases), hyper-/hypothermia (2 cases), unusual drowning/aspiration (4 cases), electrocution (1 case), and delayed/absent medical therapy (2 cases, including one of the previously mentioned ingestions). Of these additional cases, 7 were certified as accidental manner, 2 as natural, and 1 as a homicide. Cases which fell into a "gray zone" in which the appropriateness of invoking neglect was a matter of opinion or societal convention were excluded from the review; examples included conventional accidental drowning, choking on food or aspiration of foreign body, overlying/wedging during sleep, accidental hanging, and motor-vehicle traffic accidents (pedestrians, unrestrained passengers). The findings of this review reinforce the fact that malnutrition/starvation and dehydration compose the most common form of lethal pediatric neglect while highlighting less common forms of neglect and the difficulty of determining manner of death in cases in which neglect plays a more questionable role than in seemingly clear-cut malnutrition/starvation and dehydration cases. We demonstrate the typical victim and scenario that investigators will encounter in cases of fatal pediatric neglect, often a child under the age of 1 year who has been deprived of food and/or drink for some time, or an older, more independently mobile child who has not been adequately supervised. These children may or may not have a demonstrable prior history of maltreatment or (nonfatal) neglect, and review of medical records is an important part of the investigation. We additionally discuss key gross autopsy findings, appropriate specimen collection, helpful ancillary studies, microscopic findings of significance, potential mimickers of neglect, and other special considerations in cases of pediatric neglect.     

Mountaineering fatalities on Mount Rainier, Washington, 1977-1997: autopsy and investigative findings.

Mountain climbing is a popular recreational activity with a growing number of participants and associated fatalities. To define the characteristics of these fatal incidents and the typical autopsy findings in the victims, we reviewed the autopsy and investigative findings of all fatalities that occurred on Mount Rainier from 1977 through 1997. A total of 50 deaths occurred in 29 separate incidents. Fifty-eight percent of accident victims died as the result of a fall; another 34% died as a result of an avalanche. The incidents leading to death occurred at an average altitude of 3652 m (11,977 feet); range, 2073 to 4389 m (6800-14,400 feet). The average age of the victims was 31.2 years (range, 17-55 years), and 47 of the 50 were men (94%). Bodies were not recovered in 13 cases (26%). Autopsies were performed in 30 of the remaining 37 cases. At autopsy, the cause of death was ascribed to multiple injuries in 12 cases (40%), isolated head and neck injuries in 7 cases (23%), and chest injuries in 1 case (3%). Asphyxia and hypothermia were the cause of death in 8 cases (27%) and 2 cases (7%), respectively. The frequency of specific injuries is presented by anatomic region. The unique autopsy and investigative features of mountaineering deaths are discussed.     

Intra-familial child homicide in Finland 1970-1994: incidence, causes of death and demographic characteristics

The purpose of this study was to investigate all child homicides for the 25-year period, 1970-1994 in Finland and to analyse the specific characteristics of the filicide cases. A total of 292 child homicides occurred during this period. In 201 (69%) cases the offender was a parent or a stepparent of the child. Altogether, 173 (59%) of the victims were boys and 119 (41%) were girls. For the closer examination of the filicide cases we excluded the neonaticide and homicide-suicide cases. Consequently, we report on 70 filicide victims. Of these victims, 42 (60%) were boys and 28 (40%) were girls. Twenty six (37%) of the children were killed before the age of 1 year and 53 (79%) before the age of 5 years. The offender was the mother in 43 (61%) cases and the father or the stepfather in 26 (37%) cases. The victims of the mothers were younger than those of the fathers. The most frequent causes of death were head injuries, drowning and suffocation. The most common means of assault were battering, drowning and strangulation. One in two of the fatally battered children had a documented history of previous abuse.     

John and Jane Doe: the epidemiology of unidentified decedents

Abstract:  The number of people who cannot be identified at the time of death, sometimes referred to as John or Jane Does, is unknown, and little is known about them as a group. The study's objectives were to estimate the number of annual unidentified deaths, to identify demographic characteristics associated with dying unidentified, to determine whether the rates of such deaths vary geographically or over time, and to better characterize the causes of death. This was a population-based surveillance study of data collected from death certificates from 1979 to 2004 in the U.S. Subjects were selected by the absence of name, date of birth, and Social Security Number on their certificates. Main outcome measures were distributions by age, sex, and underlying cause of death and rates by sex, race, year, and state of death. An average of 413 unidentified persons died each year. The peak year was 1987 with 691 deaths, a rate of 28.5 per 10 million people. The rate declined to 9.7 per 10 million in 2004. Most unidentified decedents were male (80.6%). Unidentified death rates were highest among black people and in the Southwest. Among deaths for which the cause was known, 82.7% were due to injuries. Among injury deaths, 31.8% were homicides. Improvement in identification technology may have reduced rates of unidentified death since the 1980s. In addition, variations in rates of unidentified decedents may reflect changes in risk factors such as homelessness and substance abuse.     

Child and adolescent victims in forensic autopsy: a 5-year retrospective study

Children of more than 3 years of age and adolescents have been largely overlooked in the forensic literature, especially the 4-9 age group. Thus, the present study was undertaken to address this particular issue of child and adolescent victims in forensic autopsies. On a 5-year period (2000-2004) in Quebec province (Canada), all forensic autopsy cases of children and adolescents from 4 to 19 years of age were retrospectively studied. A total of 223 cases of child and adolescent deaths (148 males, 75 females; 6.6% of all forensic autopsies) were reviewed. Age, gender, manner of death and cause of death were analyzed for all victims organized into three groups of age: 4-9, 10-14, and 15-19. Moreover, homicide cases (n = 54) are further analyzed in terms of method(s) used (firearm, sharp force, asphyxia, blunt force, intoxication). This 5-year retrospective study may contribute to a better understanding of typical deaths in the 4-19 group of age and therefore, bring a working basis for the forensic pathologist or medical examiner/coroner.     

Sudden epilepsy deaths and the forensic pathologist

Sudden unexpected deaths in epileptic persons are not rare events, most commonly encountered by the forensic pathologist rather than the clinician. Such deaths may represent 1-1.5% of all "natural" deaths certified by the medical examiner or coroner. The typical victim is a black male about 30 years of age who tends to abuse alcohol, with a history of generalized epilepsy for more than 1 year and likely for more than 10 years. There are a lack of obvious anatomic causes for the death at autopsy, but 60-70% of cases will have a lesion in the brain (most commonly old trauma) to explain the epilepsy. Most victims have no blood levels of anticonvulsant medications at the time of death. We have evolved a form for use by medical examiner/coroner's investigators at the scene to collect relevant information which will be of assistance to the pathologist in interpreting the case. Estimated prevalence of sudden epilepsy death, mechanisms, and other features of such cases are reviewed briefly.     

Clinical forensic examination findings and legal outcome in cases of suspected physical child abuse

Clinical forensic examinations performed at the Institute of Legal Medicine of the Hanover Medical School between 1999 and 2008 in cases of suspected physical abuse of children were analyzed retrospectively with special emphasis on the legal consequences. Altogether, 192 children (85 girls, 107 boys) with a median age of 4.4 years were examined. In 47 cases (24.5 %), the clinical forensic examination findings were interpreted as accidental injuries, birth traumas or unspecific findings. 29 victims (20.0 %) had suffered a shaken baby syndrome. Only part of the presented cases ended with conviction, which was more likely if the victims were aged between 7 and 11 years. Prison terms of 2 years and more were imposed only if the child suffered potentially or acute life-threatening injuries or if additional anogenital lesions were diagnosed indicating sexual child abuse.     

Pathologic features of childhood pedestrian fatalities

A retrospective analysis of 68 cases of fatal childhood pedestrian accidents in South Australia that occurred over a 20-year period from January 1977 to December 1996 was undertaken. The age range was 12 months to 16 years (average, 7.6 years), with a male to female ratio of 41:27. The most common site of significant injury was the head (91.2%), followed by the abdomen (50%), chest (47.1%), and neck (38.2%). The most frequently encountered significant injury combinations involved the head, chest, and abdomen (14.7%); the head and chest (11.8%); and the head, neck, and abdomen (11.8%). Injuries were severe, consisting of extensive compound and comminuted skull fractures, neck fractures, and massive intraparenchymal brain and internal organ damage with avulsions and fragmentation. Non-life-threatening limb injuries occurred in 88% of cases. A distinct subgroup involved infants and younger children playing in driveways at home who were hit by reversing vehicles. The injuries were often of such a severe nature that death was instantaneous and with no possibility of successful medical intervention. More deaths occurred during the winter than summer months.     

Medical examination of sexually abused children: medico-legal value

The Department of Forensic Medicine (forensic pathology and clinical forensic medicine), Aarhus, Jutland, Denmark, performs examinations of children suspected to have been sexually abused when reported to and requested by the police in Jutland, Denmark. Jutland covers an area of 210,000 km2 with about 300,000 inhabitants in Aarhus. A colposcope initially equipped with an Olympus camera, but now with a video camera attached has been used since 1994. Since 1994 the department has performed more than 100 examinations of children suspected of having been sexually abused. A preliminary study was taken to evaluate all cases from 1995 including the legal outcome. RESULTS: The material included 34 cases with three boys, mean age 11 years, and 31 girls, mean age 8 years, at the time of the examination. The sexual abuse events were fondling including penetration of the vagina, vaginal (14), anal (7), and oral (5) intercourse as well as cunnilingus and nontouching abuses. The medical examination was most often performed more than a week after the abuse. The examination revealed normal findings in 23 cases, nonspecific findings including erytherma in 13 cases, and in only one child was a traumatic lesion with rupture of the hymen seen. The perpetrators were above 25 years of ane and were family members or someone known to the child. Nine perpetrators were convicted at court, of whom three admitted having abused the child. CONCLUSION: A medical examination in cases of sexual child abuse seldom provides a legal proof of sexual abuse. The most important is the story told by the child. Therefore, the examination is a supplement which may support or remain neutral to the story told by the child.     

Investigation of sudden infant deaths in the State of Maryland (1990-2000)

The Office of the Chief Medical Examiner (OCME) has recorded a significant decline in the deaths of sudden infant death syndrome (SIDS) in the state of Maryland since 1994. However, infants who died of accidental or non-accidental injuries remained consistent during the same time period. This report focuses on the epidemiological characteristics and scene investigation findings of infant victims who died suddenly and unexpectedly in Maryland between 1990 and 2000. A retrospective study of OCME cases between 1990 and 2000 yielded a total of 1619 infant fatalities. 802 infant deaths were determined to be SIDS, which represented 50% of the total infant deaths in our study population. Five hundred and twenty-three (31.8%) deaths were due to natural diseases, 128 (7.9%) deaths were accidents, and 74 (4.6%) were homicides. The manner of death could not be determined after a thorough scene investigation, review of history and a complete postmortem examination in 92 (5.7%) infants. SIDS deaths most often involved infants who were male and black. The peak incidence of SIDS was between 2 and 4 months of age. The majority of SIDS infants (60%) were found unresponsive on their stomach. Among SIDS infants, 269 (33.4%) were found in bed with another person or persons (bed sharing). Of the bed-sharing SIDS cases, 182 (68%) were African-American. In the past 11 years, 52 infants died of asphyxia due to unsafe sleeping environment, such as defective cribs, ill-fitting mattresses, inappropriate bedding materials. Of the 74 homicide victims, 53 (70%) involved infants less than 6 months of age. Twenty (27%) exhibited the classical abuse syndrome characterized by repeated acts of trauma to the infants.     

Inadvertent clavicular fractures caused by "chiropractic" manipulations in an infant: an unusual form of pseudoabuse

A nine-month-old child was found unresponsive in his crib, five hours after his last feeding. At autopsy, there were no external or internal signs of abuse or neglect, and a few visceral pleural and epicardial petechiae were consistent with the sudden infant death syndrome (SIDS). However, postmortem total body radiographs revealed healing, symmetrical clavicular fractures and a healing left medial humeral epicondyle fracture. The parents had no explanation for these injuries and denied causing any harm to the child. The location and nature of the fractures strongly suggested abusive origin, and the case was reported to the police and the district attorney's office as child abuse. During the investigation, information from the parents indicated that the child had undergone "chiropractic" manipulations by an unlicensed therapist, between three and four weeks prior to death, to correct supposed "shoulder dislocations." This time interval correlated with the histologic age of the injuries, and the history explained their unusual bilateral location and appearance. The parents were exonerated of abuse charges, and the death was ascribed to SIDS.     

Cocaine and homicide in Memphis and Shelby county: an epidemic of violence

In Memphis and the surrounding county, there were a record number of homicides (179) in 1986. During the same year, there was a marked increase in medical examiner cases where tests were positive for cocaine or its metabolites. Review of medical examiner and toxicology records from 1980 to 1986 found 87 cocaine related deaths; 46 of these were homicides. In 1986 alone, there were 53 cocaine related deaths, all manners, and 31 cocaine related homicides. In this year, 17.3% of the homicides were positive for cocaine or metabolite. The cocaine related homicides were similar to other homicides in terms of age, race, sex, blood ethanol concentration, and cause of death being due most often to firearms. In homicide cases in which an abuse drug was detected, cocaine accounted for the entire increase in 1986. Police records indicated that cocaine directly contributed to the homicide in 39% of the cases in which the drug was found. In other cases, we speculate that cocaine altered behavior may have contributed to the victim's being murdered either during the drug "high" or during the posteuphoric depression or withdrawal phase.     

Influence of alcohol intoxication of pedestrians on injuries in fatal road accidents

Pedestrians belong to the group of road users with the highest mortality rate. The frequency of road accidents involving pedestrians is 2% but pedestrians represent as many as 13% of all road accident deaths. Because of the mechanism and dynamics of injury and the effects of alcohol on physical and mental performance, pedestrians under the influence of alcohol are classed among the road users most at risk.Our retrospective study included 125 pedestrian fatalities treated at the Institute of Forensic Medicine, Faculty of Medicine, University of Ljubljana between 1999 and 2006. We classified the victims into two groups by blood alcohol level Group I (alcohol positive) and Group II (alcohol negative), defined differences in gender, age, incidence of injuries and established causes of death and period of survival following the road accident. In Group I (n = 53) 96% were male and 4% female; the average age was 45.6 years. In Group II (n = 72) 40% were male and 60% female; the average age was 63.1 years. The percentage of injuries to individual parts of the body was higher in Group I than among the deceased pedestrians in Group II. The most common cause of death in both groups was craniocerebral trauma. Death occurred in the first 6 h following the accident in 92% of cases in Group I and in 69% of cases in Group II.Alcohol-positive pedestrians are predominantly younger men, who have a higher level of risk of a road accident, greater incidence of injuries and a shorter period of survival following a road accident.