Underascertainment of child abuse fatalities in France: retrospective analysis of judicial data to assess underreporting of infant homicides in mortality statistics.

OBJECTIVES

Test the hypothesis of an underestimation of infant homicides in mortality statistics in France; identify its causes; examine data from the judicial system and their contribution in correcting this underestimation.

METHODS

A retrospective, cross-sectional study was carried out in 26 courts in three regions of France of cases of infant deaths submitted to the courts, 1996-2000, with follow-up of their files until case closing (1996-2008). For each case, cause of death established by the courts was compared with ICD cause of death as coded in official mortality statistics.

RESULTS

We examined 247 cases. Shortcomings in investigations were noted (autopsies: 75% of cases; fundus examination: 11%; diagnosis of sudden infant death syndrome [SIDS] without autopsy: 41%). Eighty deaths were considered homicides by the courts. Homicide rates in the court study are 2-3.6 times higher than those in mortality statistics. Nearly 1/3 of "accidental" deaths and 1/4 of deaths from unknown cause in mortality statistics are homicides. Mechanisms of underascertainment are: physicians' inappropriate death certification and underreporting of suspicious cases; inadequate investigation of cases; incomplete communication of final medical and forensic results to the mortality statistics department.

CONCLUSIONS

In a country where neither transportation of the body to a hospital nor autopsy is obligatory, judicial data can make an important contribution to correcting mortality statistics.

PRACTICE IMPLICATIONS

This study led to the first French protocol for investigating sudden unexpected deaths in infancy (SUDI). The protocol includes a physician "training" section focused on understanding the symptomatology and risk factors of violence, as well as the quality of death certification.