N.C. Medical Examiners

SIDS rulings almost vanish in NC

In North Carolina, SIDS has nearly disappeared.

State officials have virtually stopped attributing deaths to sudden infant death syndrome, a rare condition that strikes otherwise healthy babies in their sleep without explanation.

The change follows a 2010 Observer investigation, which found that hundreds of infant deaths were wrongly attributed to SIDS. Experts say the decision to call so many cases SIDS masked the dangers of a widespread practice: Parents risk suffocating their babies when they sleep with them or put them to sleep on their stomachs. In some cases, it also allowed irresponsible parents to go unpunished after preventable deaths.

In recent years, cases linked to SIDS by state medical examiners have plunged. In 2012, just 5 percent of deaths of babies under the age of 1 were blamed on SIDS – down from 53 percent in 2008, state data show. At the same time, infant deaths attributed to “ill-defined” causes jumped from roughly 11 percent in 2008 to about 65 percent in 2012.

The shifts in North Carolina reflect a national trend that began more than a decade ago. Many medical examiners in other states acknowledge that, in the past, they often misdiagnosed the causes of infant deaths. They now ascribe the deaths to preventable causes.

In North Carolina, the change could help awaken parents to the dangers of sleeping with their babies. It also could make it easier for authorities to prosecute some infant death cases, officials say. The reason: SIDS cases are classified as natural deaths, but those that are ruled “undetermined” are not.

The implications of the change can be seen in coastal Brunswick County, where two babies died mysteriously in the same home in 2012 and 2013. Dr. Douglas Hiltz, the medical examiner who investigated the deaths, told the Observer they were the types of cases that once would have been attributed to SIDS.

The first baby, James Robert Phillips, was 4 months old when he died in June 2012. Medical examiners found that he had suffocated because of undetermined causes while sleeping with his mother, Katherine Anne Jennings.

The second baby, 8-month-old Luke Stephen Phillips, died on Dec. 13, 2013, under almost identical circumstances: He was sleeping with Jennings on the couch when he was found unresponsive. The medical examiner’s office ruled that he died from accidental suffocation.

Last month, authorities charged Jennings with involuntary manslaughter in the second death.

Suspicions about the change

North Carolina Chief Medical Examiner Dr. Deborah Radisch attributes the dramatic decline in SIDS cases to new research showing that unsafe sleeping arrangements kill babies much more often than was once believed.

“When I trained 30 years ago, we were taught that you couldn’t really roll over on a baby; that sleep surfaces were safe,” Radisch said. “ That’s changed.”

Radisch’s predecessor, former longtime Chief Medical Examiner Dr. John Butts, was slow to embrace the change. When leading states and counties began moving away from attributing infant deaths to SIDS, Butts did not. He said he believed it was unfair to blame caregivers when he could not definitely identify the cause of death.

But when Radisch took over as chief medical examiner in 2010, she had a new approach. In a 2011 memo to the state’s roughly 350 medical examiners, Radisch said cases should be labeled SIDS only “if all the investigative findings and risk factors are negative.”

Still, Radisch said it’s usually impossible for medical examiners to prove that someone rolled over on a baby, so they are forced to classify many deaths as “undetermined.”

But some contend that the shift from SIDS to “undetermined” rulings fails to address fundamental problems in the state’s system for investigating suspicious deaths.

Dr. Patrick Lantz, a forensic pathologist at Wake Forest Baptist Medical Center, noted that medical examiners in North Carolina continue to do little more than cursory investigations.

From 2001 to mid-2013, medical examiners visited death scenes in just 5 percent of infant cases, the Observer found. Nationally, states and counties with leading death investigation systems visit the scene in almost every case and give child deaths extra scrutiny.

“We are not doing any more investigating than we were in 2001,” Lantz said. “Undetermined is saying ‘I don’t know why.’ You could call it the ‘I-don’t-know-why-your-baby-died disease.’ ”

SIDS halted investigations

Most medical examiners around the country now realize the mistakes they made in classifying infant deaths had serious implications, said Dr. Gregory Schmunk, chairman of the board of directors for the National Association of Medical Examiners.

“If we call it SIDS, law enforcement doesn’t care, prosecutors don’t care, child advocates don’t care,” said Schmunk, who serves as chief medical examiner for Polk County, Iowa, which includes Des Moines. “If we call them undetermined, people take a second look. We’ve recognized that the majority of these cases are preventable.”

Some North Carolina prosecutors say the move away from SIDS rulings has made it easier to pursue criminal charges in the deaths of babies.

Lee Bollinger, the assistant district attorney who is prosecuting the mother in the Brunswick County case, said that pursuing criminal charges would have been much more difficult if the babies’ deaths had been blamed on SIDS.

That’s because prosecutors need a cause of death to press charges. And in SIDS cases, an autopsy does not show an explainable cause of death.

“That would be a tremendous hurdle to a prosecutor,” Bollinger said.

Jennings, the mother of the two children, now lives in Charlotte. Dustin Sullivan, the Brunswick County lawyer who represents her, said he would not allow her to talk to the press. He said it’s too soon to say how Jennings would plead and whether the state was justified in filing a criminal charge.

Gaston County District Attorney Locke Bell recalled a case about five years ago when an apparent suffocation death was ascribed to SIDS. His office wanted to prosecute the baby’s caregiver. But before filing charges, Bell said prosecutors had to present additional evidence to the state chief medical examiner’s office and persuade them to change the cause of death to “undetermined.”

Even when prosecutors went to such lengths, defense lawyers could use the original SIDS rulings to bolster their cases, Bell said.

“A defense attorney can say, ‘Doctor, you said it was SIDS until a prosecutor asked you to change it.’ That’s going to hurt you in front of a jury,” Bell said.

In one recent case, a lawyer used a SIDS ruling to defend the Charlotte day care center where 4-month-old Logan Bryant died in June 2013.

State documents say workers at Chesterbrook Academy in University City put Logan to bed on his stomach and covered his head with a washcloth – an arrangement considered too dangerous for infants.

An investigative consultant recommended that the state close the day care. But the state put the center on probation after Steven Meckler, the day care’s attorney, cited the SIDS ruling. Meckler noted that the medical examiner’s office didn’t “attribute the child’s death to any acts or omissions” by the day care’s staff.

Two of the center’s workers have been charged with misdemeanors. Chesterbrook recently agreed to a confidential settlement in a lawsuit filed by Logan’s parents.

‘A better place’

Major health organizations recommend that adults should not sleep with babies. To reduce the risk of suffocation, the American Academy of Pediatrics recommends putting babies to sleep on their backs alone in a crib with no objects.

But studies show a majority of parents sleep with their babies at least some of the time. Supporters say the practice helps babies rest better, leads to more emotional stability and is done safely in other cultures.

Some worry that the declining use of the SIDS label could turn well-meaning parents into criminal suspects.

“There is a risk with co-sleeping, but some people are just too poor to have a crib,” said Lantz, the Wake Forest Baptist pathologist. “To criminalize that is wrong.”

Medical examiners are supposed to call deaths SIDS only after a thorough scene investigation, autopsy and review of a baby’s medical history have ruled out all other causes.

But the Observer’s 2010 investigation found that although hundreds of infant deaths in North Carolina were blamed on SIDS, about two-thirds of the cases involved circumstances that suggested the babies suffocated. Some died facedown in pillows and soft couches, or in adult beds alongside one or more people.

In other cases highlighted in the Observer series, police suspected foul play but were unable to make arrests. In one 2007 case in Gaston County, a medical examiner ruled that a 1-month-old baby died from SIDS – even after the child had reportedly been choked by a man and had fallen to the ground from a caregiver’s arms.

When Radisch replaced Butts in 2010, she promised to review how the state classified infant sleep deaths.

Soon afterward, the percentage of infant death cases attributed to SIDS dropped sharply. In 2012, North Carolina medical examiners blamed just 5 percent of infant deaths on SIDS – down from 27 percent the previous year.

For years, North Carolina has had one of the nation’s highest infant mortality rates, due largely to poor health among low-income mothers.

Officials have used cause-of-death statistics to spot trends, allocate resources and address the problem.

Janice Freedman, executive director of the North Carolina Healthy Start Foundation, a Raleigh-based nonprofit dedicated to reducing infant death and illness, said SIDS was used too loosely in the past. The change, she said, should allow public health officials to focus more accurately on preventable deaths.

“We’re in a better place than we were 10 years ago,” she said. “We are moving in the right direction.”

Staff Writer Gavin Off contributed.

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