This entry was named an Honorable Mention.
Judges’ comments:
If the message of this powerful ensemble series could somehow capture the attention of public health officials not just in North Carolina, as it did, but around the nation, hundreds, perhaps thousands, of infant deaths might be prevented.
A well-researched, well-written and nuanced series of stories that will no doubt save lives.
1. Provide the title of your story or series and the names of the journalists involved.
Reporters: Fred Clasen-Kelly, Karen Garloch, Lisa Hammersly, Franco Ordonez.
Photographs and video: Phil Hoffman, John Simmons, Jeff Wilhelm.
Graphic artist Bill Pitzer.
Editors Doug Miller, Jim Walser.
Copy editor: Rogelio Aranda
2. List date(s) this work was published or aired.
Original six-day series was published Sunday June 6, 2010-Friday, June 11, 2010. Major follow-up articles were published Sept. 5, 2010; Oct. 10, 2010; Nov. 13, 2010 and Dec. 14, 2010.
3. Provide a brief synopsis of the story or stories, including any significant findings.
In North Carolina, about 100 babies per year die in their sleep of Sudden Infant Death Syndrome, which experts say is a diagnosis used only after a thorough investigation rules out all other possible causes. It’s a mysterious death that doctors still don’t understand, consider unpreventable and — in North Carolina — completely natural. But after Charlotte Observer reporters examined more than 550 SIDS cases over five years, they found that about two-thirds of SIDS babies were sleeping in risky situations that suggested the cause could have been suffocation. SIDS babies in North Carolina, the newspaper found, were often sleeping face down in a pillow, or in an adult bed piled with blankets, or with two or three other people who could have rolled over on the baby. Sometimes the infants were face down on sofas, or on their own parents’ chests in a recliner. At least one baby died face down in the arms of a parent who had lost another infant in a risky sleep situation. And though the SIDS diagnosis isn’t recommended unless doctors can exclude all other causes of death, reporters found 50 SIDS autopsies where the pathologists wrote notes saying they couldn’t exclude overlying by an adult or other potential cause of suffocation. The state’s chief medical examiner, Dr. John Butts, said he believed the SIDS label was a favor to parents. It helped spare them from feeling guilt that they may have contributed to their baby’s death, especially since medical authorities aren’t really sure what causes SIDS. But experts nationally said the SIDS label in those cases deprives parents and other members of the public from knowing the truth about the life-or-death consequences of putting infants in unsafe sleep situations. We spoke to several medical examiners who say that now, after they perform in-depth investigations to learn more about the death scene, they almost never diagnose an infant’s death as SIDS. The newspaper also found North Carolina doesn’t send trained investigators to most infant death scenes, even though that is considered the best practice. Local law enforcement officers are asked but not required to investigate each child’s death. One admitted getting a call about a dead baby and rolling over and going back to sleep. When officers went to the scene, many didn’t have training in child death scene investigations. And local medical examiners, paid $100 per case whether they go to death scene or not, were just as spotty in putting together a complete investigation.
4. Explain types of documents, data or Internet resources used. Were FOI or public records act requests required? How did this affect the work?
We used medical examiner’s reports and autopsies to build an Excel spreadsheet on the 550 infant deaths. The main cost was time. To have records pulled and copied cost us about $600. Sadly, NC autopsies
and medical examiner reports from 2003-2008, which were the most recent complete years, were not available in electronic form. We had to pay the state to hire a temp to copy the reports we needed and mail them to us. The cost was about $350 for that. More difficult to get were completed checklists that some law enforcement agents filled out, as requested, about the death scene for the medical examiner’s office. These are also paper reports. The medical examiners office considered them non-public. After consulting with our attorney, we submitted a public records request for the documents and suggesting the medical examiners office redact any medical history that would be considered non-public. The medical examiner’s office took the request to the state attorney general’s office, which ruled in our favor. Still it took weeks to get that information, and cost another $250 to hire a temp, make the copies, etc. And it took days to tabulate the information. In all, how North Carolina handles SIDS deaths was not a topic that most interested citizens could find out about easily. It took a large, committed news organization.
5. Explain types of human sources used.
National sources included SIDS experts with the federal Centers for Disease Control and Prevention and with national medical examiner groups that recommend standards. We interviewed more than a dozen medical examiners in other states to learn about their practices, and also interviewed forensic pathology professors. Of course, we conducted repeated interviews with North Carolina’s chief medical examiner and other medical examiners who perform autopsies on infants for the state. In addition, we talked to many national and local experts in safe sleep practices for infants, and with hospital workers who work with new parents to try to prevent future deaths. And we talked to a mother who lost her baby to SIDS more than a dozen years ago, but believes now that the baby suffocated under a pile of bed covers. We also looked closely at a handful of infant SIDS deaths where authorities suspected neglect or abuse may have played a role. But the SIDS diagnosis — a natural death in North Carolina — left them hamstrung to carry the case further. We contrasted that against at least one district attorney who believed more suspicious infant deaths could be prosecuted even if they were diagnosed as SIDS — and he had personally prosecuted several successfully.
6. Results (if any).
The state’s most powerful legislative task force for child safety says it will put in place this year a requirement that all law enforcement basic training will include a new segment on infant death scene investigation. That training to record the baby’s position, exactly the sleep surface, how many blankets were surrounding the baby, etc., should help medical examiners get closer to the truth. After the longtime chief medical examiner retired last summer, the new top medical examiner Dr. Deborah Radisch announced this fall that she will look at reworking the philosophy for diagnosing SIDS deaths in North Carolina. She is expected to move away from diagnosing virtually all unexplained deaths as SIDS, even when infants were co-sleeping with adults, in and under blankets, on sofas or face down in pillows. Radisch and the legislative task force also want to see the state regionalize the medical examiner’s office and hire trained death scene investigators who could go to homes where babies die. All these steps move North Carolina toward the best practices for diagnosing unexplained infant deaths. In addition, The Charlotte Observer printed a safe-sleep poster in the paper and made copies that were sought by hospitals throughout the area and posted in their maternity rooms. We offered videos online showing nurses correctly making a safe infant bed — and we showed examples that weren’t safe. Also, one N.C. sheriff re-opened a cold case of an infant death that had been ruled SIDS. The parent had a previous infant die in unsafe sleep conditions. The investigation continues.
7. Follow-up (if any). Have you run a correction or clarification on the report or has anyone come forward to challenge its accuracy? If so, please explain.
There have been no corrections or clarifications. This series and follow-ups involved exposing public officials — doctors — who were not in step with the best practices of diagnosing the deaths of sleeping infants. And it looked at the poor quality of investigations by police and other death scene investigators. We knew early in the process there would not be a clean, quick fix to the problems. The issue involved excellence versus sloppiness; best practices versus out-of-date ideas. No one would likely go to jail because of our reports. No one likely would even get fired or demoted (the longtime chief medical examiner was planning to retire anyway last summer). But the stakes were enormous. In North Carolina, SIDS hid the truth behind how 100 infants were dying each year. And in many cases it probably was not from an unpreventable killer called SIDS. It was because they were sleeping face down in a pillow and couldn’t turn their heads to get the oxygen they needed. We believed this was a series that would save lives — but we might never know how many and which lives were saved. And we believed changing diagnostic and investigative procedures at the state level would take a lot of money at a time when money is especially hard to come by. Even so, North Carolina is seeing the beginning of what may become dramatic improvements.
Has anyone come forward to challenge its accuracy? If so, please explain.
8. Advice to other journalists planning a similar story or project.
One difficulty was the spottiness of information in the public records. In two-thirds of cases, the medical examiners’ reports noted that the baby was sleeping in a risky situation and what it was. The rest of the reports were mostly silent on that question. It was extremely rare — just a handful of cases — where reports noted an infant was sleeping in the manner that is considered the safest: on its back, alone in an uncluttered crib or bassinet. We spotted the SIDS issue almost by accident. In North Carolina, SIDS was a completely silent killer that almost no one talked about. Getting records and analyzing the problems were time-consuming. Learning about the best medical practices was too. And even some sources that should have been most eager to help were quiet: some safe-sleep proponents didn’t want to anger breastfeeding advocates who believe they should sleep with their infants.