Winner of Pulitzer Prize in National Reporting
Sloppy investigations miss murderers
Gannett News Service Series
Marjorie Lundstrom and Rochelle Sharpe
Getting Away with Murder: Sloppy investigations miss murderers
It is easy to kill a child and bury the secret.
Throughout America, poorly trained coroners and shoddy death investigations are helping mothers and fathers get away with murder. Children are frequently buried without anyone knowing why they died, according to a three-month investigation by Gannett News Service.
“I believe all kinds of homicides are being missed,” said Mary Case, medical examiner in St. Louis, Mo. “Children are being killed and just buried.”
Dr. Ronald Reeves of Tallahassee, Fla., said he believes child-abuse deaths are “grossly underestimated.”
“Children are expendable items that can be killed and disposed of,” said Reeves, a former medical examiner now specializing in children’s deaths.
Three children are known to die of child abuse every day, but at least three more child-abuse deaths each day are believed to go undetected, according to pathologists, prosecutors and child welfare advocates interviewed in 32 states.
These are the children whose deaths are incorrectly labeled accidental, undetermined or due to natural causes – sometimes as Sudden Infant Death Syndrome. These are the children no one bothered to autopsy.
However disturbing an autopsy may be – especially to grieving families – experts agree the procedure is a key to detecting child abuse.
But in a computer study of all death certificates nationwide in 1987 – the latest year available from the federal government – Gannett News Service found that autopsies on children are conducted almost by whim. Whether dead children are autopsied appears to depend more on where they lived than on the circumstances of their death.
Nobody suggests that every child be autopsied, since many die of birth defects or well-documented illnesses. But since children are the least likely to die unexpectedly, their deaths should be the most thoroughly examined, experts say.
Yet, this is not the case. The 49,569 death certificates for children under 9 revealed:
– Overall, autopsy rates for these children vary widely from state to state, ranging from 29 percent in Mississippi to 67 percent in Rhode Island. The autopsy rate dipped to 23 percent in Tennessee, but the poor performance may reflect lax bookkeeping: Officials there did not completely fill out nearly half the death certificates.
– The South consistently had the nation’s lowest autopsy rates. An examination of rates reported by the 305 largest cities showed that the bottom 10 were all in the South. Florence, S.C., for instance, autopsied 13 percent of their children under 9 compared with 82 percent in Great Falls, Mont. Overall, the East South Central states (Alabama, Kentucky, Mississippi, Tennessee) autopsied an average 31 percent of their children, compared with a 54 percent average in the Pacific states (Alaska, Hawaii, California, Oregon, Washington.)
– Of 7,422 child deaths in the United States in 1987 that most experts would call suspicious, 531 were not autopsied. These were children whose deaths were labeled, among other things, Sudden Infant Death Syndrome, undetermined or asphyxiation – yet no autopsy supported those findings. Experts fear undetected murders are most likely slipping into these kinds of categories.
– Across the country, almost one out of every in 12 deaths diagnosed as SIDS was not autopsied – a flagrant violation of accepted medical procedure. A finding of SIDS, also known as “crib death,” means that every other cause of death should have been ruled out through autopsy, according to the National Institutes of Health, the nation’s leading biomedical research center.
“I would expect there would be some regional differences in . . . autopsies, but this is an amazing difference,” said Dr. Gib Parrish, epidemiologist at the Centers for Disease Control.
These discrepancies and shortcomings are due in part to wide variations in state autopsy laws.
Tennessee, which had the lowest autopsy rate in the country, restricts medical examiners to ordering an autopsy only in cases of suspected homicide, said Dr. Charles Harlan, the state’s chief medical examiner. “Tennessee has one of the most regressive medical examiner acts in the country,” Harlan said.
To plug such loopholes, states like Pennsylvania and Georgia are advocating mandatory autopsies in all sudden and unexplained deaths of children.
Other states, including California, Colorado, Illinois, Missouri, and Oregon have formed review committees to scrutinize the way every child’s death was handled. By rounding up every potential player in a death investigation – including the medical examiner, the social worker, the police, the prosecutor – officials hope to identify flaws in the system and protect other children.
Colorado and Missouri, for instance, found that more than a third of all their child deaths had been inadequately investigated – or not investigated at all.
“We all sit a little straighter when someone is watching us,” said Dr. Michael Durfee, a California psychiatrist who has promoted child death review commissions nationwide.
Without thorough investigation of children’s deaths, others may be in danger. Many times, children had siblings – brothers and sisters who remain in the custody of a killer.
“Parents don’t just abuse one,” said Dr. Richard Krugman, chairman of the U.S. Advisory Board on Child Abuse and Neglect. “There are substantial risks to other children if we don’t accurately make this diagnosis.”
Added Dr. Linda Norton, a former medical examiner in Dallas: “It’s like leaving a child with a pit bull.”
In recent years, experts have seen an alarming increase in reported child-abuse fatalities. In 1989, a record 1,237 children died from abuse – up 39 percent from 1985, according to the National Committee for Prevention of Child Abuse, the only agency that tracks such deaths. These figures say nothing of the hundreds of children who suspicious deaths go unexplained.
Authorities are convinced some of them were murders.
In Missouri, for example, a pathologist found that 3-year-old Justin Minogue had died last March of peritonitis, an inflammation of the abdominal lining. While the coroner planned to attribute the boy’s death to natural causes, a funeral director was shocked by the child’s bruised and battered body and called police. A second autopsy proved that a severe beating had caused the peritonitis, and his 26-year-old stepfather, Leon Williams II, has been charged with second-degree murder.
In Utah, a coroner declared 3-year-old Michael Benjamin Barrie had died of an aneurysm in December 1986. Months later, after the body was exhumed, an autopsy proved that the boy had been suffocated – and that 11 ribs had been broken. Stephen Ray Allen, the mother’s boyfriend, was convicted this year of second-degree murder.
It was not until this year that authorities in Kansas and Texas began unraveling one of the most grotesque child death cases in history. Diane Lumbrera, 32, is suspected of murdering six of her children and another child relative over a 14-year period.
Although six of the children died in the Texas Panhandle, the horrible pattern was overlooked as investigators attributed each death to natural causes. But the death of a seven child in May aroused suspicions in Garden City, Kan., where Lumbrera had moved, and the former meatpacker was sentenced to life in prison in November for the 4-year-old’s death. She since has been extradited to Texas, where she has been indicted for killing the other six. Lumbrera faces a possible death penalty in Texas.
In each of the cases, death investigators may have unwittingly done more to conceal the crimes than they did to solve them.
Where once social workers absorbed the blame for botched child-abuse cases, today coroners and medical examiners are coming under increasing scrutiny. In every county, it is the coroner or medical examiner who decides whether a death is suicide, accidental, homicide or due to natural or undetermined causes. Most urban areas depend on highly trained medical examiners and forensic pathologists, skilled detectives in the mysteries of death.
But rural areas rely on elected coroners – often the local funeral director or a janitor, bus driver or coal miner – and the quality of death investigation is more uneven. While some coroners have impeccable records, others are not trained to recognize child-abuse and lack the budgetary or political incentive to order an autopsy.
Michael L. Norris, coroner in Cumberland County, Pa., used to talk to one of his fellow coroners about the financial constraints of their profession:
“I told him if I were going to commit a homicide, I’d do it in his county in the last three months of the year, because he’s always out of money and he wouldn’t do an autopsy.”
Money could well be the underlying reason autopsies are not done nationwide. Several medical examiners and coroners believe that the South may have some of the lowest rates because some of its counties are among the nation’s poorest.
“The South does not have a forward tradition in forensic pathology, even though there are some very very good centers,” said one prominent medical examiner, who asked not to be named. “They have a tradition and lifestyle that’s still very laid back – innocent in some ways, oppressive in others.”
In Florence, S.C., which has the lowest autopsy rate of the 305 largest cities, county coroner James C. Gregg Jr. said he investigates every death as thoroughly as he can. But often, he said, he does not even know about some cases, because local physicians sign the death certificates without autopsies.
Even when they get the cases, the best investigators can still miss murders.
“It’s very easy to kill a child and not leave a whole lot of evidence,” said Reeves, the Florida forensic pathologist. “A child is so small he can’t fight back, so there can’t be any evidence of trauma.”
In one case in Texas, a mother wrapped her child in blankets until his temperature reached 107. The circumstances of the child’s death, which confounded medical professionals, came to light only after the woman confessed to her psychiatrist.
“There’s no way I would have thought of that. Without her confession, there was no way to prove it,” said Dr. Jeffrey Barnard, senior medical examiner in Dallas, who handled the case.
But more often, a child’s body holds the clues of abuse – evidence that only an autopsy can reveal.
In Hamilton, Ohio just north of Cincinnati, it was a coroner who discovered what 50 other physicians had missed: the reason 3-year-old Matthew Peters could never stop vomiting.
Only after an autopsy did Dr. Harry Bonnell, chief deputy coroner in Hamilton County, find that Matthew’s mother had fed him Ipecac, a syrup that induces vomiting. While Judi Peters appeared the model parent, hovering over her suffering son, she slipped more Ipecac into his hospital feeding tube. The boy vomited to death. Peters confessed to the crime and was sentenced to five to 12 years in prison for involuntary manslaughter and child endangerment.
“When my office received the results from the coroner’s office, I can only describe it as mass shock,” said Dr. Robert Lerer, the boy’s pediatrician. “She seemed to be almost an inspiration to other parents.”