Dutch forensic doctors miss fatal child abuse in up to 10 cases a year

Dutch forensic doctors fail to detect fatal child abuse in an estimated five to 10 cases each year, sometimes issuing death certificates for natural causes even though children died from violence, according to the national Forensic Medical Research and Expertise Office, known as LOEF. One such missed case involved a 4-month-old girl later found to have died from severe head and brain injuries inflicted by her father, De Telegraaf reports.

LOEF says the problem stems largely from the limits placed on forensic doctors who are only allowed to perform an external examination with parents' permission or if there are clear signs of a crime. In young children, fatal abuse reportedly often leaves no visible marks. Based on earlier scientific research and its case experience, LOEF estimates that a small number of fatal abuse cases go unnoticed each year. After death, children no longer develop bruising or swelling, further complicating assessments.

“On the outside, there is often nothing to see,” Guido Reijnen, a forensic doctor and medical director at LOEF, told De Telegraaf. “One of the problems is that forensic doctors usually cannot see from an external examination that young children died as a result of abuse.”

A widely cited case illustrates the risk. On a Sunday morning three years ago, a mother identified as Linda called the emergency number 112 in panic, saying her 4-month-old daughter, Noa, showed no signs of life. On the dispatcher’s advice, she began resuscitation until police and ambulance crews arrived. The baby was already dead.

Because there were no visible injuries, the forensic doctor initially concluded Noa had died from sudden infant death syndrome and issued a certificate of natural death. A day later, the doctor learned that Veilig Thuis, the national child protection service, had previously been involved with the family. Noa’s 1-year-old brother had earlier been removed from the home because of suspicions of serious child abuse.

That information prompted the forensic doctor to reverse the decision and issue a certificate of non-natural death. The Public Prosecution Service ordered an autopsy. Linda supported that decision.

The autopsy showed that Noa died from severe head and brain injuries caused by violent shaking and a powerful blow to the head. Forensic investigation established that she had already died the evening before the emergency call, at a time when her father was alone with her. A court later sentenced him to 10 years in prison. He was also suspected of severely abusing the couple’s 1-year-old son, but that charge was not proven. The boy now lives with his mother.

“If I had never known this, that would have been so much worse,” Linda said. “Then my life would forever have been based on a lie.”

Reijnen said he has personally experienced at least five cases recently in which parents refused to cooperate with medical examinations after their child’s death. In those cases, he wanted to arrange a CT scan or MRI because he could not determine a cause of death. “But if parents are involved in the death of their child, the chance that they will cooperate is minimal,” he said.

Without concrete evidence of a crime, forensic doctors cannot force criminal investigations or additional medical tests. As a result, they may have no option but to issue a certificate of natural death. “That still bothers me,” Reijnen told De Telegraaf.

Figures from the Dutch Children’s Ombudsman show that about 50 children die each year as a result of abuse. In theory, that number should result in a similar number of requests from forensic doctors to the Public Prosecution Service for criminal investigations, said Ingeborg Doves, the national public prosecutor for child abuse cases. That is not happening.

“This means we are missing cases every year,” Doves said. She said such deaths amount to at least manslaughter. Once a natural death certificate is issued, a case no longer comes to the attention of police or prosecutors. “And with that, we let a child down,” Doves said. “Then what exactly happened is no longer investigated.” Doves wants forensic doctors to contact police and prosecutors more often when a child’s death is unexpected or unexplained.

LOEF is also calling for routine medical testing after child deaths, including CT or MRI scans and blood tests. “That largely rules out abuse or poisoning,” Reijnen said. According to Doves, a change in the law would be required to make such examinations standard practice.