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 MassKids is urging the Governor to create oversight and accountability at the Medical Examiner’s Office so that decisions about the causes of suspicious Infant deaths, currently being made unilaterally by individual M.E.s, can be appropriately reviewed, and any changes in the official cause of death can be properly evaluated. This call is in response to three cases involving infants whose deaths were initially ruled homicides and caused by Abusive Head Trauma and were later independently changed to cause of death “undetermined.” See MassKids Press Release and the Boston Globe’s reporting on these cases.



Governor Baker Urged to Improve Oversight at the Medical Examiner’s Office to Better Address Child Deaths

August 26, 2016, BOSTON, MA – Child advocates today are publicly urging Governor Baker to appoint an independent panel of forensic experts to review current practices at the State’s Medical Examiner’s Office, and recommend how oversight and accountability can be improved as it relates to determining the official causes of suspicious child deaths. The call by MassKids, a statewide child advocacy organization, is in response to three cases of infants whose deaths were investigated by the Boston Globe and reported on earlier this week. Abusive Head Trauma or Shaken Baby Syndrome was ruled by the Medical Examiner’s Office to be the cause of injuries that led to the deaths. During an 18- month period, however, those initial determinations of homicide, were later revised to “undetermined.” These judgements have now been called into question because the three Medical Examiners who made those decisions in each of their respective cases, appear to have been heavily influenced by defense lawyers committed to debunking Abusive Head Trauma as a credible syndrome in order to defend their clients charged with the homicides. The impartiality of at least two of the M.E.s has also been raised because each of them has or is now benefitting financially by testifying in court in favor of the defense in such cases.

Jetta Bernier who directs MassKids, describes why the lack of oversight and accountability for these decisions is unacceptable. “When agencies that are a part of our state’s child protection system including DCF, medical providers, police, and district attorneys, are involved in child death cases, multiple players in each of those systems participate in the investigation and decision making about circumstances surrounding those deaths. In Boston hospitals, for example, when a seriously injured child is seen, a multidisciplinary group of experts including pediatricians, radiologists, ophthalmologists, and other specialist share their combined knowledge to make a differential diagnosis about the cause of those injuries. While no system is fail safe, this team approach provides the best possible chance that the diagnosis will be accurate. How is it then that in the Medical Examiner’s Office, also a critical member of the child protection system, a single M.E, without consultation with and formal review by the Chief Medical Examiner or other forensic experts, can make a unilateral decision on the cause of death of a child, and even change their mind later, without ever having to account to anyone? This is untenable.”

The Secretary of Public Safety, Daniel Bennett, indicated earlier this week that he has no concerns about individual Medical Examiners having total authority and autonomy to determine or revise causes of death without ever having to consult with or defend their decisions with the Chief Medical Examiner.

“It has been well known that for decades the Medical Examiners’ Office has been underfunded and understaffed,” noted Bernier. “As a result, its policies and practices have only garnered it a “partial accreditation” with the National Association of Medical Examiners. Other states have policies that require the Chief Medical Examiner or a second M.E. to review and sign off on decisions involving any homicide, the death of a child under age 2, and any case in which the cause of death is ruled “undetermined. Massachusetts is clearly out-of-step with these best practices.”

MassKids believes an independent panel of forensic pathologists could recommend to the Governor how to build checks and balances into the system and finally bring the M.E.’s Office into full accreditation. According to Bernier, “We applaud the Governor for his commitment to improving our state’s child protection system and for the strides that are being made at DCF. But the M.E.’s Office is also a critical part of child protection and his commitment should extend to that agency, as well. If decisions about the causes of child deaths are made unilaterally and without any oversight and review, errors will be made. As a result, justice for those children will be lost, those who commit crimes against them will not be held accountable, and our ability to prevent other children from similar deaths will be undermined.”