COMMENTARY ON HEALTH, SAFETY : Studying Yesterday’s Deaths Could Save Tomorrow’s Children : Studying these horrifying cases are bearable only by knowing that it could prevent future tragedies.

The large brown envelope arrived two days ago. It remains unopened on my desk. I know what’s inside. In it are the stories of 75 children--dead children. The wonderful promise of early spring unfulfilled. Their deaths are classified as natural, accident or homicide. But those words sanitize the stories. Sorrow, tragedy or horror are better words, I think.

Amy: 5 months; sudden infant death syndrome. A healthy baby, the first and much-longed-for child of an older couple.

Lu Thi: age 6; leukemia. Two years of aggressive treatments, weight 28 pounds, bald, bruises.

Brett: age 3 months; multiple congenital anomalies. Older brother has an inoperable brain tumor, older sister has cerebral palsy.

Laura: age 11; cystic fibrosis. Ten-year history of illness.

Sorrow. I feel pain. I feel anguish for the suffering of the children: hospitalizations, needles, tubes, machines, pain, long lonely nights. I feel sorrow for the parents, knowing they watched death’s slow onslaught. We have no answers to the question of why, why do little children suffer?

Brian: age 4; gunshot wound to the head. Shot by 5-year-old neighbor child with neighbor father’s gun. Playing in neighbor parents’ bedroom.

Allison: age 2; chest compression. Car backed over child in home driveway. Father driving family car.

William: age 17 months; head trauma. Fall from balcony through railing with widely spaced rails.

Christopher: age 8 months; hanging. Child hanged himself on the seat strap of a highchair while trying to get down. Mother was preparing dinner in the same room.

Jennifer: age 2; drowning. Grandparents’ spa during a Fourth of July family party.

Kay: age 9 months; electrocution. Electric cord to lamp in baby’s room had all insulation stripped off the wires. Baby climbed out of crib and grabbed the wires.

Tragedy. I feel agony, I feel frustration. The phrase “if only I” echoes through each of these stories. The tragic deaths are usually from injuries. Accident implies that the incident was somehow unavoidable. But injuries are preventable. These deaths chronicle personal failure on the part of the responsible adult. Most of the tragic deaths involve a momentary lack of supervision, or failure to provide a safe environment for a child--or both.

“If only we could turn the clock back just a few minutes or seconds.” “If only I had not answered the phone or door.” If only, if only. . . . But there are no second chances for these children. One minute everything is fine; the next minute a child is dead. Gone forever.

Tragic deaths are always compounded by the grief of guilt. From these deaths we try to learn and develop strategies to prevent similar child deaths.

Rebecca: age 20 months; pneumonia and 21 fractured bones, retinal tears and vaginal scarring. Some fractures are new, some old. Battered child, sexual abuse.

Baby Doe: a few hours old; strangulation. Found in a dumpster behind a supermarket, a paper towel stuffed in the mouth.

Jesus and Jose: Ages 4 and 5: gunshot wounds to the heads and torsos. Mother shot sons and then committed suicide.

Monica: age 1 month. blunt trauma with skull fracture, optic nerve hemorrhage. Battered by fists and shaken by assailant.

Horror. I feel outrage. And disgust. These deaths make me sick. They are all homicides. Murders! These are deaths that result from large people doing unimaginably horrible things to very little people. Sometimes these deaths occur after months or years of brutality. For these children death may be a welcome escape from a world too cruel to endure. These deaths challenge the system. How did the protective agencies fail the child? How can we identify these children or parents and intervene before a fatal incident? We try to learn signals from these deaths and then develop systems that will prevent others.

Every six weeks the large brown envelopes are sent to all members of the Orange County Child Death Review Team. I wonder if the other envelopes lie unopened on other desks too.

We are all challenged with the same task. We review the death of each child and add any information we have or find that relates to the child’s death. The team then meets at the coroner’s office where the coroner’s chief forensic investigator chairs the meeting and presents the coroner’s findings as to the cause of death.

A pediatrician and a public health nurse from the Health Care Agency add medical information and family social history. The Social Services Agency adds information about past reported abuse of the child or its siblings and whether the child was ever in the court system. A deputy from the district attorney’s office adds information. Cities attend and add information from police reports on the scene of the incident, the circumstances surrounding the fatal event and the family responses. I add information about past medical problems that may or may not be related to the child’s death.

Mostly I ask questions. Why were methamphetamines found in the blood of a 2-year-old who drowned? Why was a lamp cord with the insulation stripped off the wires left in a baby’s room? Why did a fall from a couch cause fatal head injuries? Why were the rails in the balcony so widely spaced a child could easily walk between them?

Sometimes I go looking for answers. We can do things that will prevent similar child deaths in the future. That’s the reason we do this. Recently I began gathering information about protective balcony railings and plan to develop a strategy to upgrade balcony railings so that we will not have another child fall to its death through widely spaced railings.

The Child Death Review Team does make a difference. Immediately, suggestions for removing siblings from the home may protect their lives. Looking long-term, programs are being initiated that we hope will reduce child deaths. The Orange County Health Care Agency is currently developing a Drowning Prevention Program with a grant awarded by the state Department of Health Services.

It is not easy to study the deaths of children on a regular basis. But knowing that the team’s work can prevent a child’s death makes the assignment bearable, and gives me the courage to open that envelope every six weeks.