Sudden, Unexplained Infant Death Investigation
Sudden, UnexplainedInfantDeathInvestigationSUIDI SUIDI SUIDI SUIDI SUIDI SUIDISUIDI SUIDI SUIDI SUIDI SUIDI SUIDISUIDI SUIDI SUIDI SUIDI SUIDI SUIDI SUIDISUIDI SUIDI SUIDI SUIDI SUIDI SUIDI SUIDIInfant Death Investigation:Guidelines for the Scene InvestigatorDEPARTMENT OF HEALTH AND HUMAN SERVICESMaternal and Infant Health BranchDivision of Reproductive HealthCenters for Disease Control and PreventionAtlanta, Georgia 30333
Project Funding Provided by theCenters for Disease Control and PreventionAtlanta, GeorgiaContract #200-2005-13514Randy L. Hanzlick, MDChief Medical ExaminerFulton County Medical Examiners OfficeAtlanta, GeorgiaJeffrey M. Jentzen, MDChief Medical ExaminerMilwaukee County Medical Examiners OfficeMilwaukee, WisconsinSteven C. Clark, PhDDirector of Research and DevelopmentNational Association of Medical ExaminersEducational ConsultantAmerican Board of Medicolegal Death InvestigatorsThis information handbook is intended as a guide to recommended practices the investigating infant deaths and reporting scene data to the pathologist. It is not intended to take theplace of existing laws or regulations.
Sudden, UnexplainedInfantDeathInvestigationGuidelines for the Scene InvestigatorApproved by the National Steering CommitteeonSudden, Unexplained Infant DeathEndorsed by theAmerican Board of Medicolegal Death InvestigatorsNational Association of Medical ExaminersNational Sheriffs’ AssociationProject ManagerTerry W. Davis, EdDCenters for Disease Control and PreventionJanuary 2007
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Table of ContentsSection AInvestigative Tools and Equipment. 1Section B Arriving at the Scene. 31. Introduce and Identify Self and Role . 32. Exercise Scene Safety. 43. Confirm or Pronounce Death. 54. Participate in Scene Briefing. 65. Conduct Scene “Walk Through” . 76. Establish Chain of Custody . 87. Follow Evidence-Collection Laws . 9Section C Documenting and Evaluating the Scene. 118. Photograph Scene . 119. Develop Descriptive Documentation of Scene . 1210. Establish Probable Location of Injury or Illness. 1311. Collect, Inventory, and Safeguard Property and Evidence . 1512. Interview Witness(es) at Scene . 16Section D Documenting and Evaluating the Body. 1713. Photograph Body and Doll Reenactment. 1714. Conduct External Body Examination (Superficial). 1815. Preserve Evidence (On Body) . 1916. Establish Infant Identification . 2017. Document Postmortem Changes. 2118. Participate in Scene Debriefing. 2219. Determine Notification Procedures (Next of Kin) . 2320. Ensure Security of Remains. 24Section E Establishing Infant Profile Information . 2521. Document Discovery History . 2522. Document Terminal Episode History. 2623. Document Infant Medical History . 2724. Document Caregiver Mental Health History . 2825. Document Caregiver Social History . 29Section F Completing the Scene Investigation . 3126. Maintain Jurisdiction Over Body. 3127. Release Jurisdiction of Body. 3228. Perform Exit Procedures. 3329. Assist Family . 34SUIDI Top 25 . 39iii
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InfantDeathInvestigationGuidelinesSection AInvestigative Toolsand EquipmentSection BArriving at the SceneSection CDocumenting andEvaluating the SceneDocumenting andSection D Evaluating the BodySection EEstablishing InfantProfile InformationSection FCompleting theScene Investigationv
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7.28.29.30.Body bags or transport case (with ID tags).Business cards/office cards with contact information.Camera (digital).Clean white linen sheet (stored in plastic bag).Communication equipment (cell phone, pager, radio).Disinfectant.Evidence containers (paper bags, envelopes, containers,boxes, etc.).Evidence tape and seal.First aid kit.Flashlight.Gloves (universal precautions).Hand lens (magnifying glass).Investigative notebook.Local maps.Measurement instruments (tape measure, ruler, etc.).Medical equipment kit (scissors, forceps, tweezers, swabs, etc.).Official identification (for yourself).Paper bags and envelopes.Phone numbers (social services, child protection agencies, etc.).Plastic trash bags.Portable computer (laptop, pocket PC).Portable lighting.Reenactment doll.Scene reporting forms (SUIDI Reporting Form or locallyapproved equivalent).Specimen containers (for evidence items and toxicologyspecimens).Tape and/or rubber bands.Thermometer.Voice recorder.Watch.Writing implements.1A
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Arriving at the Scene1.Introduce and Identify Self and RolePrinciple: Introductions at the scene allow the investigator to establish formal contact with all official agency representatives. Unlikemost other death scenes, many infant deaths create multiple scenes,each requiring the investigator to communicate with people whohave different roles and responsibilities. Emergency medical services (EMS), law enforcement, hospital, and daycare employees areall valuable investigative resources. The investigator must identifythe first responder or agency contact to ascertain if any artifacts orcontamination may have been introduced to, or removed from, thedeath scene. Investigators must work with other official personnelto ensure all scenes and key witnesses are identified before startingthe investigation.Procedure: Upon arrival at the scene, the investigator should1. Identify the lead investigator at the scene and present identification.2. Identify other essential officials at the scene (e.g., EMS, emergency department personnel, childcare providers, social/childprotective services).3. Explain the investigator’s role in the investigation.4. Identify and document the first essential official(s) to the scene(first “professional” arrival) for investigative follow-up.5. Determine if the scene is safe to enter and conduct the investigation.Summary: Infant death scenes can become crowded with emotional family members and witnesses. Introductions at the scene helpestablish a collaborative investigative effort with all professionalparticipants. It is essential to carry official identification.3B
2.Exercise Scene SafetyPrinciple: Determining scene safety for all investigative personnelis essential to the investigative process. The risk of environmental andphysical injury must be removed before starting a scene investigation. Environmental and chemical threats, hostile family members,and other witnesses may pose potential risks to investigators andmust be controlled or removed from the scene before starting theinvestigation.Procedure: Upon arrival at the scene, the investigator should1.2.3.4.5.6.Secure the vehicle and park as safely as possible.Assess or establish physical scene boundaries.Identify incident command.Use personal protective safety devices (as required).Arrange for removal of animals or secure as necessary.Obtain authorization to enter the scene from the person responsible for scene safety (e.g., law enforcement, fire marshal).7. Observe and protect the integrity of the scene and evidence to theextent possible from contamination or loss by people, animals,and elements.Note: Because of potential scene hazards (e.g., crowds, poisonousgases, traffic), the body may have to be removed before the sceneinvestigation can continue.Summary: Environmental and physical threats to the investigatormust be removed in order to conduct a scene investigation safely.The investigator must endeavor to protect the evidence againstcontamination and loss.4
3.Confirm or Pronounce DeathPrinciple: Appropriate personnel must make a determination ofdeath before the death investigation is initiated. The confirmation orpronouncement of death determines jurisdictional responsibilities.Procedure: Upon arrival at the scene, the investigator should1. Locate and view the body.2. Check for pulse, respiration, and reflexes, as appropriate.3. Identify and document the person who made the official determination of death.4. Document the time death was pronounced.5. Ensure the death is pronounced, if required.Summary: Once death has been determined, rescue/resuscitativeefforts cease and medicolegal jurisdiction can be established. It isvital that this occur before the medical examiner/coroner assumesany responsibilities. If the infant was transported from the incidentscene to the hospital, communicate with both EMS and emergencydepartment personnel to determine where and when the death was“first” pronounced (i.e., infant dead at incident scene or transportedto hospital, then pronounced).5
4.Participate in Scene BriefingPrinciple: The infant death investigation may involve multiplemedical, legal, social, as well as public and private family healthagency representatives. Scene investigators must recognize thevarying jurisdictional and statutory responsibilities that apply toindividual agency representatives and the role of each of the childfocused organizations involved with infant deaths. Determining eachagency’s role in the investigation and eventual follow-up is essentialin planning the scope and depth of each scene investigation and therelease of information to the public.Procedure: Upon arrival at the scene, the investigator should1. Locate the first responder and/or lead investigator.2. Document the scene location consistent with other agencies.3. Determine the nature and the scope of investigation by obtaining prelimi-nary investigative details (e.g., suspicious versusnonsuspicious death).4. Identify and document witnesses and their relationship to thedecedent.5. Determine and document the individual(s) who last placed theinfant down, last knew the infant was alive, and discovered theinfant dead.6. Ensure that initial accounts of the incident are obtained from theprofessional and nonprofessional responders.Summary: EMS personnel are key resources at the scene briefing.Document their initial observations of witness reactions during thefirst minutes after their arrival. First responders’ observations ofunusual behavior, the removal of items from the scene, or peopleleaving the scene may prove valuable. The scene briefing allowsfor initial and factual information exchange between participatingagency representatives. This includes scene location, time factors,initial witness information and behavior, agency responsibilities,investigative strategy, and follow-up activities.6
5.Conduct Scene “Walk Through”Principle: Conducting a scene “walk through” provides the investigator with an overview of the entire scene. The “walk through”allows the first opportunity to locate and view the environmentwhere the infant was placed, last known alive, and found dead orunresponsive. In addition, items of evidentiary value may be identified, and initial investigative procedures can be established to ensurea systematic examination of the scene and body.Procedure: To establish scene parameters and become familiarwith the environment, the investigator should1. Locate the first responder and/or lead investigator.2. Determine the location where the infant was discovered deador unresponsive.3. Determine the location where the infant was last known alive.4. Determine the location where the infant was placed.5. Identify visible physical and fragile evidence.6. Document and photograph fragile evidence immediately andcollect, if appropriate.7. Observe the physical living environment.8. Locate and view the decedent, if possible.Summary: Unlike most death investigations, the decedent in an infant death has almost always been moved since discovery. Therefore,it is essential that the investigator use this first opportunity to locateand evaluate the location(s) within the scene where the infant waspurported to have been moved between placement and discovery,while also noting existing environmental conditions that may haveaffected the infant. The initial scene “walk through” is essential tominimize scene disturbance and prevent the loss or contaminationof physical and fragile evidence.7
6.Establish Chain of CustodyPrinciple: Ensuring the integrity of the evidence by establishingand maintaining a chain of custody is vital to an investigation. Documenting the collection and handling of all evidence and propertywill safeguard against subsequent allegations of tampering, theft,planting, and contamination of evidence.Procedure: Throughout the investigation, those responsible forpreserving the chain of custody should1. Document the scene location and the investigator’s time of arrival.2. Determine the custodian(s) of evidence, the agency(ies) responsible for collecting specific types of evidence, and the evidencecollection priority for fragile/fleeting evidence.3. Identify, secure, and preserve evidence with proper containers,labels, and preservatives.4. Document the collection of evidence by recording its location atthe scene, time of collection, and time and location of disposition.5. Develop personnel lists, witness lists, and documentation of arrival and departure times for personnel.Summary: It is essential to maintain a proper chain of custody forevidence. Through proper documentation, collection, and preservation, the integrity of the evidence can be assured. All items removedfrom the scene must be accounted for. Establishing and maintainingboth evidence and property logs will reduce the likelihood of a challenge to the integrity of the evidence.8
7.Follow Evidence-Collection LawsPrinciple: The investigator must follow local, state, and federallaws for the collection of evidence to ensure its admissibility. Theinvestigator must work collaboratively with all agency representatives to determine which agency has the legal authority to performspecific tasks related to collecting evidence.Procedure: The investigator, before or upon arrival at the deathscene, should work with other agencies to1.2.3.4.5.Determine the need for a search warrant.Determine each agency’s legal investigative parameters.Assign evidence-collection tasks based on legal parameters.Document the collection of all evidence.Document the collection of all items removed from the scene.Summary: Following laws related to collecting evidence will ensure a complete and proper investigation in compliance with local,state, and federal laws, admissibility in court, and adherence to office policies and protocols. Witness statements obtained at the sceneoften prove to be the most significant pieces of evidence collectedduring the infant death investigation. These statements should beascertained and documented by the professionals responsible andmost qualified to do so.9
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DocumentingandEvaluatingtheScene8.Photograph ScenePrinciple: The photographic documentation of the scene createsa permanent historical record. If a forensic autopsy is performed,scene photographs are required to begin that procedure. Photographs taken at the scene provide forensic scientists with the detailsrequired to correlate scene findings with physical findings, and provide corroborating evidence that constructs a system of redundancy,should questions arise concerning the report, witness statements, orevidence.Procedure: Before moving the body or evidence, or during the dollreenactment, the investigator should1. Remove all nonessential personnel from the scene.2. Obtain an overall (wide-angle) view of the scene to place thespecific scene in its spatial context.3. Photograph the immediate scene, showing environment.4. Photograph a doll reenactment depicting placed and found positions, and locations within the scene environment.5. Photograph all known and suspected sleeping surfaces.6. Photograph items of environmental concern in relation to placed,last known alive, and found locations.7. Obtain some photographs with scales.8. Obtain photographs even if the body or other evidence has beenremoved or moved.Note: Doll reenactment photographs assume movement of evidenceand property. If the infant’s body is present, document any movement.Summary: Photography allows for the best permanent documentation of the death scene. It is essential that accurate scene photographsare available for the forensic pathologist, other investigators, agencies, and authorities to recreate the scene. It is essential that the investigator obtain accurate photographs before releasing the scene.11C
9.DevelopDescriptiveDocumentationofScenePrinciple: Written documentation of the scene(s) provides apermanent record that may be used to correlate with and enhancephotographic documentation, refresh recollections, and record observations.Procedure: After photographic documentation of the scene andbefore evidence is removed, the investigator should1. Document the residential environment, including the number ofpeople living at the residence and its condition.2. Diagram/describe in writing items of evidence and their relationship to the body in placed, last known alive, and found locations,with necessary measurements.3. Describe and document, with measurements, blood and bodyfluid evidence, including volume, patterns, spatters, and othercharacteristics.4. Describe the scene environment, including odors, lights, temperatures, and other fragile evidence.5. Describe powered appliances or devices present.6. Write a descriptive caption for each photograph depicting aSudden Unexplained Infant Death Investigation (SUIDI) Top 25issue (see page 39) and provide to the pathologist before autopsy(if required).Summary: Written documentation is essential to correlate withphotographic evidence specific to the SUIDI Top 25 issues that typically affect infants and to provide that information to the pathologistbefore autopsy. Written documentation also assists police, otherforensic scientists, and judicial and civil agencies with a legitimateinterest in recreating the scene.12
10. e: The location where the infant is first viewed by theinvestigator may not be the actual location where the injury/illness that contributed to the death occurred. It is imperative thatthe investigator attem
mination of death. 4. Document the time death was pronounced. 5. Ensure the death is pronounced, if required. Summary: Once death has been determined, rescue/resuscitative efforts cease and medicolegal jurisdiction can be established. It is vital that this occur before the medical examiner/coroner assumes any responsibilities.
found, and this is the group of babies called sudden infant death syndrome (SIDS), which is defined as: The sudden unexpected death of an infant, under one-year of age, with onset of the fatal episode apparently occurring during sleep, that remains unexplained after a thorough investigation, including performance of a complete autopsy, and
Sudden Infant Death Introduction: The terminology used in the area of sudden infant death is complex. Firstly, the distinction between Sudden Infant Death Syndrome (SIDS) and other Sudden Unexplained Deaths in Infancy (SUDI) is difficult particularly in the context of co-sleeping (Shapiro-Mendoza et al., 20061). For consistency within this .
According to the National Institute of Health, Sudden Infant Death Syndrome (SIDS) is the sudden, unexplained death of a baby younger than 1 year of age that doesn't have a known cause even after a complete investigation. This investigation includes performing a complete autopsy, examining the death scene, and reviewing the clinical history.
of Justice, National Institute of Justice; 1999. 3. Clark SC, Ernst MF, Haglund WD, Jentzen JM. The Medicolegal Death Investigator: A Systematic Training Program for the Professional Death Investigator. Big Rapids, Mich: Occupational Research and Assessment; 1996. 4. Sudden, Unexplained Infant
3 ‘‘(5) SUDDEN UNEXPECTED INFANT DEATH; 4 SUID.—The terms ‘sudden unexpected infant death’ 5 and ‘SUID’ mean the sudden death of an infant 6 under 1 year of age that when first discovered did 7 not have an obvious cause. Such terms include those 8 deaths that are later determined to be from ex-9 plained as well as unexplained causes.
Healthy People 2010 Objective 16-1e: Postneonatal deaths (between 28 days and 1 year) . Half of these sudden, unexplained infant deaths are due to sudden infant death syndrome . infants born 02-03 versus an infant classified as dying from SUID based on the following variables: infant race, number of prenatal care visits received by birth .
your Infant Car Seat, as described in the instruction manual provided by the Infant Car Seat manufacturer. † WHEN USING ONLY ONE INFANT CAR SEAT ADAPTER OR TWO FOR TWINS, THE FOLLOWING INFANT CAR SEATS CAN BE USED: † If your Infant Car Seat is not one of the models listed above, DO NOT use your infant car seat with this car seat adapter.
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