Investigating the unthinkable

Thursday, Sept. 7, 2006 | 7:13 a.m.

Clark County coroner investigator Bill Gazza stands in a dark room with a remote in his hand.

Click. A photo appears of an infant whose circular burns follow the winding wire of an electric stove top.

Click. It's a tight shot of raccoon-eye bruises that come with blunt head trauma.

Click. It's a photo of adult bite marks in the flesh of a child.

"Have you ever seen anybody do that?" Gazza asks his audience, all crime scene investigators, police officers or forensic science students who have gathered for this seminar on child death investigation.

Click. Gazza pauses. You can see teeth marks through the bruise. "It's not a loooove thing," he says.

So what is it? That depends on whom you ask.

Fact is, there has never been a national standard for investigating suspicious child deaths. Across the country, different coroners, different police organizations and different child welfare agencies conduct child-death investigations on their own terms, with their own protocols.

The end result, according to the Centers for Disease Control and Prevention, is that child-death statistics could be skewed. One agency's crib death, for example, is another's idea of deadly neglect.

And the discrepancy in reporting both possibilities could prevent medical experts from understanding either, which is why Gazza is flipping through bleak slides in a dark room.

In March, the CDC released a standardized manual for national use in investigating sudden and unexplained infant deaths. The Clark County coroner's office is starting to use the manual, and there's an effort under way to get other local agencies using it as well.

So when Gazza hands out a rough, 20-page partial copy to the audience, there's a chance he's giving them some glimpse of the future.

The new investigation protocol was created as part of a 2004 CDC initiative addressing Sudden Infant Death Syndrome (SIDS), the leading cause of death among infants under age 1. While SIDS diagnoses are supposed to be made only after every other possibility has been exhausted, instances where deaths have been wrongly attributed to SIDS have impeded researchers from accurately monitoring trends and determining risk factors. The CDC hopes that national standards for investigating unexplained child deaths, paired with training to instruct investigators on using the new manual, will encourage more accurate reporting.

Without accurate reporting, Gazza tells the class, researchers may never understand the totality of SIDS, what causes it and how to prevent it.

"We have to set protocols," he says. "We have to have some sort of standards."

The sentiment echoes those made by national child-welfare expert Theresa Covington to members of the state's Blue Ribbon Panel for Child Death Review in January. Nevada hired Covington to investigate 79 suspicious child deaths that occurred in Clark County between 2001 and 2004, after concerns emerged that child fatalities were being underreported during that period.

In almost half the cases reviewed, she concluded that charges of abuse and neglect should have been substantiated. She deemed almost a quarter of the cases incomplete. One day after giving the report, Covington told the Sun that poor communication and coordination among Clark County agencies with a stake in child-death investigations - the coroner's office, law enforcement, family services and the district attorney - hindered child-death investigations.

The new CDC investigation manual is supposed to change all that. It walks any investigator - law enforcement or not - through a child death-scene investigation, reminding the reporting authority to take notes on how the child felt upon discovery (sweaty? rigid? limp?); whether there were signs of mold or peeling paint or strange odors at the scene; whether the primary caregiver was present; and what that person was doing at the time the ambulance or police arrived.

Those and other small-scale observations can be crucial when determining the cause of death.

Clark County Coroner Michael Murphy believes that agencies from across the state will adopt the new investigation manual, and he's thrilled about it.

"Someone that looks at this initially might think, 'Oh, this is a lot of work,' " Murphy says, flipping through the manual Tuesday. "Once you recognize it for what it is and realize that if you go through it - it leaves no stone unturned - then it becomes this very simple guideline that will walk you through the process to ensure that you have covered all bases."

In 2008, the CDC will select and pay for a handful of Nevada officials to attend a summer training seminar in Seattle, where the state representatives will be instructed in using the new child-death investigation manual. Upon return, they will host smaller-scale regional training seminars to spread the new protocol through the rank-and-file at government agencies concerned with child death.

"By having that communication, establishing those types of standards, making sure that we are working and living by those standards, that helps lower the anxiety maybe between the different organizations, and that helps communication so that ultimately we are all on the same page," Murphy says.

Murphy was among several national consultants the CDC tapped to create the manual, and therefore got an early jump on adopting the new practices at the coroner's office. He has been trained in using the manual and is seeing to it that members of his staff are made familiar with the new procedures as well, even if the changes aren't all that radical.

Crime-scene investigators from the coroner's office have long used a guided format for investigating child deaths and shared that investigation protocol with Metro police and other officials. The difference this time, Murphy says, is that the CDC form ensures everyone involved asks the right questions and, moreover, asks the same questions.

"When you have appropriate open communication, you have greater understanding," he says. "It's a matter of making sure that when we say apple, we know what our apple is. When we say orange, we know what our orange is. It's been done - it maybe has not been done in this formal of a process."

At the recent seminar, Gazza flips on the lights after his slide show and lecture, and tells his audience to turn their heads to the left. Half the room - many professional investigators or law enforcement specialists - turns the wrong direction.

It draws laughter, but Gazza is trying to illustrate how easy it is to skew facts if investigators are too quick, casual or comfortable in their summation of child-death scenes.

Evidence collected at the scene can be critical for a coroner trying to determine the cause of death, and the new CDC manual can help ensure that investigations are conducted carefully and cleanly.

Still, Gazza suggests, there's a certain science to a good investigator's gut instinct that can't be mandated by a manual.

"Go to the scene," he says. "It's there. The scene talks to you - you know how to read it."