Cover Story : THE TOUGHEST HOMICIDES OF ALL : Last Year in L.A. County, About 40 Children Were Killed by Their Parents or Caretakers. If Not for the Child Death Review Team, Many of the Killers Would Have Gotten Away Wit It.

All eyes in the coroner’s conference room turn to Deputy Medical Examiner Eva Heuser, a sweet-faced grandmother with an uncanny knack for getting bodies to reveal their secrets. The Child Death Review Team is having its monthly meeting, and it has finally reached the question of how toddler John-John Plummer died. (The details of this case, including the names of the victim, have been changed to ensure the confidentiality of the team’s deliberations.)

From the start, uncertainty had shrouded the death of the boy, who was killed by a subdural hematoma, an injury in which the brain is sheared from the cranium and crashes back and forth like a doomed ship against the rocks. Only two things cause subdural hematomas in children: a high-velocity impact like a car crash, or a violent, head-snapping assault by an enraged adult.

John-John was nowhere near a car the day he died. According to the police report, his father’s girlfriend had watched in panic as John-John, eating a peach, slumped and turned pale while sitting on his training potty. Minutes before, the father had abruptly left the modest house they shared in Hawthorne.

After more than a decade reviewing hundreds of such cases, the 15 professionals in the room--a detective, a prosecutor, two sheriff’s deputies, a psychiatrist, a social worker, a pediatrician, a violence prevention expert and seven others from various agencies--knew that without hard evidence against the father, one might as well blame the wind.

At one end of the sparse room sits psychiatrist Dr. Michael Durfee, who in 1978 founded the committee. The first such team in the United States, the Child Death Review Team ferrets out the mysteries behind the toughest homicides of all--the killing of children by their parents or caretakers. Durfee, co-chairman of the team and director of the Los Angeles County Department of Health Services’ Child Abuse Prevention Program, turns to Heuser and asks, “What have you got, Eva?”

Heuser would have dreaded speaking up during the 1980s, the dark ages of investigating fatal child abuse, when she would have been alone in stating a case that could send a parent to prison. Police used to cajole her: “C’mon, doc, it’s just Sudden Infant Death Syndrome. Sign me off on this, huh?” But today, Heuser’s is a respected voice in an increasingly talked-about field. Flipping through her notes, she speaks almost with relish: “No child can be attacked like this dead child was, receive a massive subdural hematoma and ever sit up again on a potty or any other chair.”

Deanne Tilton Durfee, executive director of the county’s Inter-Agency Council on Child Abuse and Neglect (ICAN), under whose auspices the team operates, leans forward with interest. Soft-spoken and elegant in a crisp Anne Klein suit, Tilton Durfee knows that Heuser has been trying to link autopsy clues to a detective’s chronology of John-John’s final hours.

“You mean thisbaby was not sitting eating a peach when he collapsed?” Tilton Durfee asks.

“No,” says Heuser. “There is no way on God’s earth that a child with those mortal injuries ever held or ate a peach, even for a moment after he was attacked. It never happened.”

The room is silent as everybody weighs the implications of Heuser’s statement. The team’s co-chairman, Detective Bobby Smith, bureau consultant to the LAPD’s Juvenile Division, speaks first, “So, the girlfriend lied.”

Heuser nods vigorously. “This child was attacked and immediately collapsed after the father left the house,” she says. “The killer is whomever the child was with in that home, in that kitchen.”

Smith glances over at the LAPD detective who had sought the team’s help because he didn’t know how to link the father to the killing. The detective looks stunned. “Thanks,” he finally manages. “I’ll get on it.”

Thus the Child Death Review Team solved the Case of the Peach on the Potty. “It was,” Tilton Durfee says recently, “just as if Eva had said, ‘It was the Colonel, in the dining room, with the candlestick.’ ” The LAPD switched gears, and the girlfriend was quickly arrested and charged with murder.

Chalk up another dark victory for the people with the worst job in America. This year in Los Angeles County, 40 to 60 children--mostly babies, toddlers and preschoolers--will be beaten, shaken, suffocated, stomped, drowned, scalded or abandoned to fatal perils such as medical neglect, severe dehydration and gradual starvation by their parents or caretakers. Nationwide, at least 2,000 children will be killed this year, according to a report to Congress by the bipartisan U.S. Advisory Board on Child Abuse and Neglect, of which Tilton Durfee is chairwoman.

The federal report confirmed what the L.A. team has long known: fatal child abuse most often occurs because a father, mother’s boyfriend, stepfather, or, less often, a mother or other woman, can’t stand such irritants as a child’s crying, as well as bed-wetting, feeding difficulties or other perceived “disobedience.” Once considered a rare anomaly, fatal abuse and neglect is now recognized as a leading cause of death for children younger than 4.

Each month, as the team reviews cases like John-John’s, its members try to understand the weeks and hours leading to the killings. Using its own internal jargon perhaps as much to jog the memory as to distance themselves, the team has delved into more than 250 cases that range from murder to neglect during its 17 years. The Me No Breathe Case refers to the Lakewood grandmother who kept a beaten toddler squeezed beneath a small table and sofa and wedged under a pillow, finally suffocating him as he whispered, “Me no breathe.” The Tomato Sauce Case summarizes a tragedy in which an East Los Angeles mother killed her dehydrated baby with sodium-laden tomato sauce in a misguided effort to give the infant liquids.

The team considers more than 250 child deaths a year but reviews only 30 to 40 of them, selecting only possible homicides with the most nagging questions. Even if the perpetrator is known, many answers are not. Could someone have saved this child? Why did the system fail? Its most far-reaching work is to provide answers to why and how endangered children fall through society’s protective net and to motivate police, child protective service workers, doctors, coroners and the courts to create change.

Parents and professionals can no longer blame Sudden Infant Death Syndrome--medically defined as a lack of any known cause of death for children under 1--when a child dies from internal injuries. Years ago, the team discovered that careful autopsies could thwart such cover-ups. And the team spread the word statewide. In addition, police and prosecutors can now debunk tales in which parents blame their child’s severe injury or death on “falling off the sofa” or being “unusually clumsy”; thanks to the team, officials are trained to know why such injuries are impossible. And, at the county’s huge Department of Children and Family Services, the bulk of reforms in the past three years--and there have been many--are attributed by Director Peter Digre to the findings of the team.

As a child protective services official in Florida four years ago, Digre says, “I’d read everything the L.A. committee had reported” and he used that information to push for child-protection reforms in Florida.

Nobody knows how many parents are getting away with murder nationwide, but experts agree that California is the world leader, along with a handful of states, including Missouri and Colorado, in uncovering fatal child abuse and attempting to address its cause and prevention. But until Durfee began insisting in the mid-1970s that too many L.A. children were dying under suspicious circumstances, the systems designed to protect children were virtually blind to the problem. Ten or so years ago, a clear-cut homicide like the Broken Heart Case would have remained an unsettling mystery for local doctors and police. The parents would have been treated as victims, the secret buried with the child. But no more.

When 11/2-year-old Valentine Martin (the details have also been changed in this case) arrived at a county emergency room one night, losing blood pressure as fast as that of a severe car-crash victim, a physician telephoned Dr. Astrid Heger, director of the Center for the Vulnerable Child at County-USC Medical Center, to ask whether the mother’s story of a “bad fall” sounded right. Heger is an international authority on child abuse injuries and, for the past eight years, a self-described “squeaky wheel” on the Child Death Review Team. Even as she warned the doctor that Valentine was probably “bleeding out”--losing huge amounts of blood into her body cavities from a grave internal trauma--the girl died.

The next day, the coroner confirmed that a severe rupture had spurted blood from an area near Valentine’s heart that looked as if it had been squeezed beneath an asphalt roller. Such a wound cannot be caused by a fall. So what had killed the girl? When the team met the next month, it worked from a detailed report, gathered by ICAN program analyst Mitch Mason, who compiles the data from records of each dead child for the team: family contacts with hospitals, police, child protective service workers, therapists, pediatricians, whomever. Heger knew at a glance that Valentine’s list of hospital visits was too lengthy for such a short life.

“At 10 months of age, this child was evaluated by the same hospital where she died, but for an intercranial bleed,” Heger told the team. “She was sent home with ‘undetermined cause’ marked on her chart. Another hospital saw her at five months for ‘falling off a table.’ None of the doctors even entertained the diagnosis of inflicted injury.”

“Not again,” blurted out Bobby Smith, who has been known to chew out police who don’t want to believe that parents kill their children, and has little patience for those physicians who could easily intercede to save abused children but are still denying the problem. “Another battered child that the hospitals all missed?” Smith boomed.

“So, Bobby,” Durfee asked, “what have the police got?”

The police had plenty. Detectives and county social workers had fanned through the South Gate neighborhood where the Martins lived. They learned from neighbors, Smith reported, that “the stepfather used the little one as his personal football.” The aggravation in the room was palpable. They knew that more than 75% of the parents and caretakers who kill children in Los Angeles County are never reported beforehand, even though relatives, neighbors, doctors, teachers and others know the parents to be child abusers.

Compounding the situation, Valentine’s mother had lied to the doctors, who spent the last minutes of the girl’s life seeking a “fall” injury. “The mother was so quiet and neat that the doctors always believed her,” Heger said. “And when a child’s medical history is a lie, who can save them?”

Valentine’s stepfather pleaded no contest to manslaughter and went to prison. But, far more important to the team, as a direct result of this case, its members succeeded three years ago in promoting new guidelines that are finally being instituted in hospitals: children taken to emergency rooms for unwitnessed injuries are evaluated by a trained Suspected Child Abuse and Neglect medical team.

It was a key victory, tempered by a feeling most team members never shake. “Why didn’t these parents let me have this kid?” Heger asked. “I would have been happy to raise and love this child, and so would so many others.”

MICHAEL AND DEANNE TILTON DURFEE HARDLY SEEM LIKE THE SORT who’d cast a pall over a barbecue simply by saying what they do for a living. Their La Ca 7/8ada-Flintridge home has two goofy dogs, Misty and Trooper, and the kitchen is dotted with pictures of laughing kids: his children and grandchild, her nephews and niece and the neglected boys and girls whom the couple, who have no children together, have “adopted” over the years.

Tilton Durfee boasts a “really terrific homemade salad dressing” and Durfee practices the fine art of “tucking the dogs in” when his wife works late. But as soon as the phone rings, they are thrust into their other world. One day, it’s Time and Newsweek calling for comments on Susan Smith’s confession that she drowned her two sons, and on the conviction of Pauline Zile, who watched her husband bludgeon to death and bury her 7-year-old daughter in Florida. KCAL Channel 9 wants Tilton Durfee’s thoughts on the double fatality of two babies left in a sweltering car while their mother attended a 10-hour “party.” Then Durfee is needed again, by officials from Massachusetts and Washington, calling for advice on how to reform child protection efforts in their areas.

The couple don’t know how they got so hooked. Durfee, bespectacled and with salt-and-pepper hair, says he has always been attracted to the toughest jobs. After completing his medical degree at USC, he asked to be assigned to the children’s burn ward at County-USC, then worked as a chief physician and counselor for abused kids at MacLaren Children’s Center in El Monte and was chief resident of child psychiatry at the USC School of Medicine. “I was raised in a household where it was acceptable to experience anger at the wrongs of the world,” he says. ‘ “So the great thing is, I can take on worse and worse jobs and work out the anger as I go.”

Durfee, 53, still recalls the first time he attended the autopsy of an abused child. He had been talked into it by a legendary LAPD child-abuse detective, the now-retired Rich Parker. Durfee entered the autopsy room and saw the baby on a huge steel table. As the coroners started their work, Durfee found he couldn’t shake the oddest thought: “Hey, kid, you better sit up and say something right now, because if you don’t, these people are going to cut a hole in you.”

Later, back at home, he angrily accused his wife of not working hard enough to save children. “I’m telling a person who puts in 12-hour days to do more,” he says, “and I’m just about to say something truly awful to her, when suddenly I start to cry. I told Deanne: ‘The baby died.’ ”

Tilton Durfee, 52, understood. Like so many people in her field, she has a “ghost”--the memory of a baby who died on her watch. About 25 years ago, as a child-protective services worker, she was assigned the case of a mother known to be battering her preschoolers. The courts had ordered the children returned to the mother, so one morning she made a surprise visit.

“Inside the house,” Tilton Durfee remembers, “I found a beautiful new baby lying naked on a soiled diaper in an icy living room. I called out, but no one answered.”

She called the house from a nearby pay phone, an action she has often rethought. The mother answered, insisted that the baby was fine and agreed to an appointment a few days later. But the baby died before Tilton Durfee could get back inside. “I could have taken her away,” she says. “I know it wasn’t SIDS, but that’s what the coroner decided. No investigation.”

Unwelcome anger has a way of popping up. Recently, Tilton Durfee was unpacking after a trip while her nephew played. Suddenly, he crawled in her suitcase and curled up. She blew up, fighting back tears. “I just fell apart,” she says. “I told him, ‘Never ever do that again!’ ”

An image of the Burbank Suitcase Case from 14 years ago had flashed into her mind. A Burbank father had appeared on TV, sorrowfully explaining how abductors had taken his boy from a store. Tilton Durfee had never bought the story. But it took police three days to find the boy, savagely beaten to death by his dad and stuffed in a suitcase at home.

“You forget, sometimes, that you are living with these dead children,” she says of the team. “I think you become the parent that these children deserved to have.”

With her soothing voice and her Town & Country looks, Tilton Durfee is mobbed by kids at MacLaren Children’s Center when she visits their wing, right below her ICAN office. She began working with abused children shortly after earning her sociology degree from UC Santa Barbara. Later, as a member of the state attorney general’s Commission on the Enforcement of Child Abuse Laws, she began meeting with governors, legislators and Washington bureaucrats.

California Superior Court Judge Lois Haight, the highest-ranking woman in the Justice Department during the Ronald Reagan Administration, recalls that when she organized the department’s first conference on child molestation in 1984, it was still a taboo subject.

“Somebody introduced me to Deanne Tilton. I found this incredibly intelligent person who could talk in a very non-threatening way about terrible things, and she could just sweep along a room of people,” she says. “I am still very involved in child abuse, in part because Deanne has the quality of Theodosius: History says when Caesar talked, the crowd cheered, but when Theodosius talked, they marched. Well, Deanne gets us all to march.”

Friends and colleagues say the couple’s 10-year marriage has created a juggernaut of influence and resolve far greater than either could have mustered alone. Indeed, their vision of a network of child death review teams has finally swept a once-resistant nation. Today, there are more than 300 such teams in 48 states, largely due to Durfee’s incessant lobbying and the jarring annual reports on child death issued by the 27-agency ICAN.

Perhaps because of his decades in child psychiatry, Durfee operates in a non-linear world of ideas expressed in roaming sentences and esoteric allusions. Even his admirers cite the Doonesbury line, “A verb please, Senator.” A typically circuitous Durfee thought goes something like this: “Even though there are acts of faith Deanne may not care that much about, a data report, as much as everyone just did not understand where some of this child death review was going, what she knows, she knows good stuff.”

Tilton Durfee, a polished speaker, acts as translator. “I’m more often the negotiator in the political arena, while he’s more often the person with these incredibly persistent, radical ideas that keep turning out to be right.”

The pair joined forces shortly after Durfee founded the team. As a child psychiatrist, he was hearing horror stories from sexually and physically abused preschoolers about what was happening to them in their homes. “I thought if parents were doing these awful things to kids, they’ve got to be killing them, too.” By comparing the coroner’s records with medical records, he discovered that children were being battered to death, and nobody was noticing. He established the team to learn everything possible about child killings. Then when a deputy county counsel advised the multidisciplinary team that, under ICAN’s auspices, i had the right to review confidential child-abuse records, the team began demanding records from reluctant agencies.

But county officials, doctors, police, therapists and social workers swamped the team with criticism, demanding to know why it had opened a can of worms like fatal child abuse. Though a handful of leaders backed them in the early years--including Sheriff Sherman Block--social service and mental-health officials resisted sharing their files. “I wonder how incredibly ignorant we’d still be if Deanne hadn’t pushed everybody who had a title into a room at ICAN and said, ‘We really have to talk about this Durfee guy and his dead children,’ ” says former Deputy Dist. Atty. Ryan Rainey, now senior attorney of the Virginia-based National Center for Prosecution of Child Abuse.

“I know a lot of very driven people,” says Block, who’s also chairman of ICAN, “but I have never met anyone as driven as Michael Durfee, who had an unusual idea a long time ago and made this all happen.” In 1983, a former co-chair of the team, then-Deputy Dist. Atty. Jean Matusinka, launched a coroner’s inquest into the deaths of seven children who the team suspected had been murdered. Their death certificates listed manner of death as “SIDS,” “accidental” and various diseases. But their bodies told a different story. “They were,” recalls Heuser, “terrible cases of obvious homicide. It was misdiagnosis and kids falling through cracks.”

Even after the coroner’s inquest, which publicly validated the team’s suspicions, many police continued to deny that they were missing clues to abuse, and physicians and therapists, convinced that they were the best-informed, rejected the team’s notion that parents lied to them.

But a lot of people suddenly got smart after the Fifty-Two Agency Contact Case: A baby had been killed by starvation and multiple beatings. Ten agencies had been in contact with the family a staggering 52 times, investigating claims of domestic violence and drug abuse, child-abuse reports, suspicious infant injuries and drunken brawls with neighbors. Because no agency knew the other was involved, none felt the need to take the boy away.

“At the meeting,” remember Tilton Durfee, “a sheriff’s deputy got out butcher paper and mapped every single contact with this child. People just snapped to attention.”

“It was beautiful,” Durfee says, “to see how dumb we really were.”

At last, the team was taken seriously. Slowly, agencies began to share records and dig deeper. The team unraveled an otherworld in which judges were returning abused kids to homes where other siblings had been murdered, and families in which multiple killings of children had gone undetected. Realizing that Los Angeles could hardly be unique, Durfee began pressing for child death review teams elsewhere.

San Diego launched the second team, followed by other California counties and some states. Some copied Los Angeles partly to escape the haranguing Durfee, who wore them down with persistent phone calls and his quirky charm.

“You’ve got this strange, brilliant guy from L.A. calling officials all over the country every few months and asking, ‘How come you haven’t got a death review team yet?’ ” says Dr. Bernard Ewigman, associate professor of family medicine at the University of Missouri, Columbia. Ewigman and other health officials launched an exhaustive study in 1989 and discovered that 85% of all child abuse and neglect deaths in Missouri had been systematically misidentified as of natural, accidental or undetermined causes.

THE MORNING OF APRIL 7 WAS FAIRLY ROUTINE FOR THE CORONER, AS WORKERS weighed a small blond boy who died of “suspected child abuse” and wheeled him into the morgue. Eva Heuser mentioned the 21/2-year-old almost in passing, another case in the never-ending supply of tiny bodies. She walked down a stench-filled hallway (“Breathe through your mouth so you can stand it,” she advises visitors, “because you never get used to the smell.”) and into the photo room.

There he lay, a boy with long, dark eyelashes. IV punctures near his pelvis indicated that doctors had fought to revive him. On his foot was a toe tag, and upon it was a name that would soon prompt investigations of the county’s dependency court and the attorney panel that was supposed to protect him: Lance Helms.

Heuser brushed her silver hair away from her face and closed her eyes, as if to spirit this latest outrage to a child far away. “He looks like an angel. My own grandson is 2.” She pointed out the top of Lance’s feet, covered with strange, purplish bruises, bruises on his arm and torso. A forensic technician slowly turned Lance’s head, revealing a badly split lip, a bloody ear.

Heuser has autopsied nearly 300 children. “I’m ready to retire, I really am,” she says. “Umm, looks like a bite mark. Have to call the dentist in. We already know this little boy died of traumatic injuries. But the outside is just the tip of the iceberg. That’s why clinicians at hospitals have such difficult jobs figuring out abuse on living children. We pathologists can get to know every single bruise, the depth, the color inside, whether it was one attack or went on for months.”

The next day, the autopsy revealed many old assaults and showed that swift, severe punches delivered by an adult to Lance’s stomach caused his death. The punching-bag attack ruptured his internal organs and tore his peritoneum, spewing blood into his abdomen. Eve Wingfield, the girlfriend of David Helms, Lance’s father, was ordered to stand trial for second-degree murder and child abuse.

In a rare departure from the silence that enshrouds such killings, the public learned about Lance when his grandmother and aunt, Gail and Ayn Helms, who raised him from birth and fought to keep him away from his father, held a press conference. They denounced the Edmund D. Edelman Children’s Court for refusing to remove Lance from his father’s abusive North Hollywood home. Numerous entities, including the Child Death Review Team, are investigating why the legal system stubbornly relied upon a “biological family preservation” philosophy that ignored the danger, and are trying to find out exactly what Lance endured.

“We realize that the committee’s work is confidential,” says Gail Helms, “but Ayn and I hope the coroner or the D.A. will tell us everything about the day Lance died. If you haven’t lost a child to violence, you can’t know the unbearable pain of trying to fill their last hours with your own terrible imagination.”

The Helms case has been one of the few such deaths in Los Angeles to receive media attention. While largely unknown to the public, there are many other shattered families like Ayn and Gail’s. Their names can be found on the district attorney’s list of active and recent “baby murder” cases. It’s just two pages long, citing 36 defendants, manner of death and the defendant’s relationship to the dead child. But somehow the list seems endless: Anthony Bullock (trauma/father); Tivia Strothers and Lisa Smith (trauma/mother and mother’s girlfriend); Lorenzo “Larry” Casteneda (trauma/boyfriend of mother); Donald Ray Johnson (trauma/boyfriend of mother); Gerald Philip Slattery (trauma/father); Mark Ambrose Gibson (trauma/boyfriend of mother); Miriam Rivera and Arturo Isalias Perez (trauma/parents); Veronica Araujo (trauma/mother).

Because the children in these cases have usually been killed without independent witnesses or telltale weapons, the burden falls heavily on investigators. In Heuser, California has one of only a few dozen medical examiners nationwide who specialize in child abuse and neglect. Heuser, who gained her broad knowledge of childhood disease and trauma during 20 years at Children’s Hospital, says that children are still treated as property or lesser beings. “Even my fellow physicians are indoctrinated to think that death and disease are only important if they happen to adults.” With such double standards, she says, “I just love the team because they don’t look at me and see a middle-aged woman spouting off. When I know what I’ve got, they really listen to me.”

Long before such facts appeared in medical books, Heuser began warning the L.A. team that parents could mask fatal attacks because a child’s tissue is extremely elastic. She says physicians had always assumed that children bruise the same way as adults. But she saw many dead children with few or no marks on the outer skin and discovered that the blow’s force had traveled through flexible outer tissues, hitting, crushing or rupturing organs and veins deep within.

When the manner of death can’t be determined, Heuser now knows, suffocation is a strong possibility. It’s “a virtually perfect mode of murder since the babies don’t struggle,” says Jack Miller, a sheriff’s representative on the team. “You leave no outside marks and no inside damage.”

The team’s multidisciplinary approach has resulted in a tremendous sharing of expertise across agencies. For example, Heger clues Durfee in on the metaphyseal knee chip, an inflicted bone injury that shows up on X-rays. Deputy Dist. Atty. Amy Suehiro suggests that an LAPD detective scan medical reports for a “torn ferenulum”--something she has learned from Heuser--which is a rip in the fleshy arch inside the upper lip, a classic sign of a baby who’s been punched in the face or had something forced in the mouth.

“Everywhere that has a good death review team,” says Deputy Dist. Atty. Scott Gordon, “there’s also a renaissance of interdisciplinary learning. You’ll walk into a detective’s office and see a paper by Durfee, or into a prosecutor’s office and see the Straus and Gelles’ ‘Survey on Interpersonal Violence.’ ”

Bobby Smith knows of police who once dismissed dead children as “kiddie cases” but now ask to attend special courses. He says: “When a parent looks an LAPD officer in the eye and says, ‘My 3-month-old baby crawled into the kitchen, and I tripped and spilled hot oil on the baby,’ we would’ve bought that once. But because of the team, every officer gets child-development classes. They know a 3-month-old can’t crawl one inch. So that’s not a bereaved parent. That’s a parent under arrest.”

Yet, others need educating. Heuser, back in her office, talks in angry staccato bursts about a recent case in which a lightly bruised baby arrived DOA at a suburban emergency room and the doctor wrote in his report, “no evidence of trauma.” Emergency room generalists, often lacking awareness of the field, still sometimes want to believe that fatal abuse is just SIDS.

“Our investigator had a fit!” Heuser crows. “In yellow pen all over, she writes, ‘No! Wrong!’ Then during autopsy we found this child had been crushed on the back near the kidneys. Sexually assaulted. And severely punched. A Godforsaken mess. No evidence of trauma, indeed.”

IT IS PERHAPS NATURAL THAT THE TEAM IS TURNING, MORE AND MORE, TO PREVENTING child deaths. Billie Weiss, a team member and director of the county’s violence prevention program, solved a puzzling iron-poisoning case when she held up a bottle of prenatal iron pills at a meeting once and said, “Don’t these look just like red and green M&Ms;?”

The team discovered that adult ignorance and easy-open bottles of tasty-looking but dangerous pills had killed several children. The federal Food and Drug Administration, at the urging of L.A. and other child death review teams, ordered safety changes. Now the team is pressing for county regulations to fence in home swimming pools to end a rash of accidental drownings.

Team members cite as one of their major accomplishments the requirement that police physically check all children when called to homes for domestic violence, child abuse, drug abuse and other complaints. Many battered children have been discovered. The practice stems from the Me No Breathe Case, in which deputies found the preschooler peacefully “sleeping.” Had they peeked beneath his blanket, they would have found a dying child, beaten and lashed with ropes. He was later suffocated by his grandmother. Another major improvement came last year, when district attorney officials, Block, death review team members and others persuaded Sacramento to pass a felony murder child abuse law. When a fatal assault on a child occurs and a reasonable person would know that the act would cause serious injury, then that assailant can be found guilty of homicide.

Change is perhaps most evident at the children and family services department. Director Digre hired 30 nurses after becoming convinced that social workers alone could not determine medical clues to abuse. His and other L.A. agencies are creating a computerized Children’s and Family Index so that social workers “can find out at 2 a.m. if a family was visited by police last week for domestic violence or drug abuse” or whether hospitals or others are aware of situations critical to assessing danger to a child.

But the team searches, still, for a way to stop the killing. “Next month,” Durfee says, “a messed-up parent in Los Angeles is going to kill a kid for being afraid of the dark. And because we still haven’t figured out why they do it, we won’t be able to head them off.” For Heger, it begins by getting inside homes to understand families. Durfee, who is having his radical thoughts again, wants to create a system in which all cases of suspiciously injured living children are as thoroughly reviewed as those of the dead. Tilton Durfee wants to persuade neighbors to report children they suspect are endangered. Heuser would like everybody to witness a child autopsy. Smith believes parenting education must start in grade school.

Despite the leaps forward, however, even in Los Angeles, an unofficial “cold case file” of undetermined deaths and unprosecuted cases grows each year, and homicidal parents still go free. From 1989 through 1993, 29 known homicides of children were rejected by the district attorney, 15 of them because it was impossible to prove which caretaker was the attacker. In addition, in 1993, 14 mysterious child deaths were ruled “undetermined cause” even after review by the team.

In states such as New York, Connecticut, Michigan and Florida, where little child death review is under way, experts believe that hundreds of deaths, which in L.A. would be obvious, go undetected each year.

“We used to think falls were killing children, but we got wise,” says Heuser, after fielding a call from an inexperienced coroner in a smaller county seeking advice. “Then we called a lot of homicides SIDS or pneumonia, but we got wise. Then a few parents tried to say CPR, and we shut that down. So, now, we have to ask: What are we calling it today, and when are we going to get wise?”