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* Departments of Pediatrics
Epidemiology and Public Health, University of Miami School of Medicine, Miami, Florida
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Methods. ME and police records for all pediatric firearm fatalities in Miami-Dade County from 1994 to 1998 were reviewed. The ME’s assignment of manner of death as homicide, suicide, or accident was compared with an intent-based classification of intentional homicide, intentional suicide, and unintentional firearm death based on expressed or implied evidence of intent to harm.
Results. There were 123 pediatric firearm deaths in Miami-Dade County from 1994 to 1998. A significant difference between ME coding and the intent-based classification was found for homicide (94 vs 78) but not for suicide. A significant difference was also found between the ME’s coding for "accident" and the investigator’s classification of "unintentional" firearm death (4 vs 26).
Conclusions. The incidence of unintentional pediatric firearm deaths is significantly underreported by the Miami-Dade County ME when the classification of "accidental" firearm death is used. Reviewing the manner of death classification criteria or establishing an intent code on official death documentation is recommended. Furthermore, clinicians should be aware that the true incidence of unintentional gun death may be higher than that reported as accidental.
Key Words: pediatric firearm death • manner of death • unintentional • homicide • suicide • medical examiner
Abbreviations: ME, medical examiner
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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A key epidemiologic source for fatal firearm injuries is medical examiner (ME) reports, completed for each firearm-related death. In Florida, the manner of death reported by the Office of Vital Statistics on death certificates is determined by the ME except in cases in which there is a pending police investigation. MEs determine and code the cause, mechanism, and manner of death. In the case of firearm fatalities, manner of death is typically coded by the ME as homicide, suicide, or accident. (Note: "Accident/accidental" are terms generally used by the ME and in this article refers to such ME manner of death classification.)
Manner of death determination is a subjective conclusion based on facts concerning the circumstances surrounding the death, the autopsy findings, and laboratory tests.5 Previous studies have documented notable differences of opinion among MEs regarding manner of death classification.6–9 A 28-year review of pediatric firearm fatalities revealed that individual MEs vary considerably in their classification of accidental manner of death.6 A review of adolescent self-inflicted deaths suggested racial and age-related bias in manner of death determination.9 ME and coroner criteria for manner of death also differ by jurisdiction and death investigation practices.10 Thus, individual subjectivity and regional variation in manner of death classification may affect the reporting of unintentional pediatric firearm fatality incidence.
The definition of manner of death classification accounts for intent, wherein homicide and suicide are deliberate and unintentional death is not, regardless of evidence of negligence.11 However, in practice, intent is not uniformly considered in manner of death coding of firearm fatalities in Miami-Dade County (Joseph Davis, MD, Miami-Dade County ME, personal communication, November 30, 2000). Barber et al12 also found differences between ME manner of death coding policy and practice in Massachusetts.
Unintentional firearm death is estimated to be 2.82% of all firearm deaths.13 This translates to 824 unintended gun deaths annually. This figure may lead clinicians to discount the importance of prevention counseling and minimize recommendations to parents regarding risk of unintentional injury, yet, as with many unintentional injuries, children and adolescents are disproportionately involved: unintentional gun death among 0- to 19-year-olds is 2.5 times higher than for the general population.13 The aim of this study was to compare the proportion of pediatric unintentional gun death in Miami-Dade County based on manner of death coding by the ME with an intent-based classification approach.
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METHODS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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The ME and police departments record information that includes medical history, autopsy reports, police reports, toxicology screens, summaries of detectives’ and MEs’ communications with family, documentation of previous Department of Children and Families investigations, suicide notes, photographs, and press clippings. The records reviewed included cases investigated by several different MEs and investigators employed by the Miami-Dade County Medical Examiner’s Office and detectives from 3 different police departments within Miami-Dade County (Miami-Dade County, City of Miami and Hialeah Police Departments). Extracted variables included demographics of victims and suspects; details of the incident circumstances, including the preceding and subsequent historical accounts; the victim’s medical and mental health well-being; and social history information, including drug use or gang involvement by the victim or shooter.
The investigators used an intent-based classification of the deaths according to whether intent to harm or intent to threaten harm was expressed or implied.14 A threat to harm would include a situation in which a gun was used by a perpetrator to intimidate, such as during an argument, even if the actual firing of the weapon was unintended. Such a death would be considered intentional, in that the weapon was used to threaten harm.
Unintentional deaths were determined to occur when the person who fired the gun did not intend harm or intend to threaten anyone with a firearm, and included deaths that occurred when the shooter believed that the gun was unloaded, was engaged in cleaning the gun, was in play, or otherwise demonstrated curiosity or bravado. Russian roulette deaths were excluded from the analysis, as determination of intent in such fatalities remains controversial.
The first 3 authors conducted the record review and independently classified the deaths as intentional or unintentional. Classification of intent required unanimity among the 3 authors. When there was a discrepancy of opinion between the reviewers, full records were independently reviewed again. When disagreement still remained, the investigating police department would be queried regarding determination of intent, and this was to be accepted as final. Interclassifier reliability was high: the 3 reviewers agreed unanimously on 97.5% of the cases on the first review. Agreement was reached on the remaining 3 cases when the complete records were reexamined.
All deaths coded as unintentional, intentional homicide, and intentional suicide by the investigators were compared with those coded as accidents, homicides, and suicide by the ME. For comparing these proportions, the 
2 test of hypothesized proportions was used.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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The mean age of pediatric firearm deaths was 13.9 (±3.9), and the median age was 16. Seventy-one percent of the deaths occurred among children between 14 and 17 years of age, 21% occurred in children between the ages of 6 and 13 years, and 8% occurred in children 5 years of age or younger. Twenty-three percent of the victims were female. More than half (52.8%) of pediatric gun deaths occurred in black children, and 35% of the deaths occurred in children with Spanish surnames (includes both black and white). This is a proxy variable for Hispanic ethnicity, which is not required and only occasionally recorded by the ME.
Among the 123 pediatric gun deaths enrolled, a total of 22 cases previously classified by the ME as homicide (n = 16) or suicide (n = 6) were reclassified as "unintentional." In those cases, there was no evidence of intent to harm or to threaten harm. A significant difference between the ME’s coding and our intent-based classification was found for homicide (94 vs 78; P = .037) but not for suicide (25 vs 18; P = .175). A significant difference was found between the ME’s category of accident and our reclassified "unintentional" deaths (4 vs 26; P < .0001).
The ME had coded 4 deaths as accidental, and our review concurred that they were unintentional; these cases were not different in circumstance from the reclassified cases (Table 1). In each of the 4 cases, manner of death was coded by a different ME. Two cases (1.6%) of Russian roulette were placed in their own category (Table 2).
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Determining the shooter’s intent is particularly important when the shooter is a child. Children are less likely to understand the dangers of lethal weapons and require more protection from adults and firearm manufacturers.15 Determination of intent must take into account the shooter’s age and developmental stage. Normal adolescent development includes risk taking and a sense of invulnerability. The intent of an adolescent who loads a single cartridge, spins the chamber, and kills himself in a "game" of Russian roulette may not be suicide. As ill conceived as his actions may be, in some cases, circumstances reveal that he meant only to demonstrate manliness or bravado, not to end his life. Toddlers have tantrums and preschoolers engage in fantasy play. An angry preschooler who "acts out" with a gun in hand is unlikely to be aware of the full consequences of her actions and cannot be said fully to intend to kill or maim.
The difficulty in determining intent must not be minimized. Witness statements, even from well-intentioned family members, are often helpful but may not always be reliable. The family of a child who committed suicide may prefer that it be recorded as unintentional to avoid social or religious stigma. Conversely, the family of a child who unintentionally shot herself with a parent’s gun may prefer that it be reported as an intentional act potentially to avoid prosecution in a state with a child access prevention law (which holds the gun owner responsible if a child uses his or her firearm).16
The resultant difference between our intent-based classification and the ME’s coding is considerable. The assumption that ME reporting of firearm homicide represents only intentional interpersonal violence may misguide the efforts of community and public health agencies engaged in violence prevention. During a coalition meeting in Miami to reduce youth gun injury, several prevention partners protested a focus on unintentional gun deaths because no "accidental" firearm deaths had been reported by the ME during the previous year ("Not One More" coalition meeting, March 17, 1999). Without accurate information about how many pediatric firearm fatalities are unintentional, an entire community might fail in its planning to address an unrecognized yet sizable portion of preventable firearm injury. Given that unintentional firearm injury in Miami-Dade County results in more pediatric deaths than asthma (Florida Department of Health, Office of Vital Statistics, Table 18U: 1994–1998), such an oversight is significant.
As additional tragedies involving children who die from gunshot wounds—especially children killed by themselves or other children—come to public light, the need for accurate and reliable data on which to base prevention efforts becomes increasingly important. We must focus on identifying preventable factors and work with our local MEs, coroners, and police investigators to report intent when determining the manner of death in cases that involve children and firearms. One possibility is to add intent as a required and distinct category in ME reports and death certificates. Physicians, particularly those in emergency and intensive care settings, should also carefully consider their role in documenting intent on death certificates and at the time of evaluation for a firearm injury. Documentation of circumstance in the medical record may be the primary source for such information.
Child fatality teams can contribute to the understanding of pediatric gun death circumstances and help inform violent death statistics systems regarding intent. Although local child fatality review teams have been recommended nationwide to identify patterns and assist in prevention of future deaths,17 they may miss most pediatric firearm deaths if, for example, the team reviews only cases of documented child abuse. Expansion of the team’s scope of reviewed cases will help to detect and characterize the problem of unintentional child gun death.
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CONCLUSIONS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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The creation of a national violent death reporting system has been endorsed by numerous medical and public health organizations, including the American Academy of Pediatrics.18–20 ME records are a primary data source for the proposed system.21 As the database will be used to guide prevention and policy development and to evaluate interventions,12,22–24 consistent and accurate coding of firearm data are essential. Revising the method of manner of death classification by the ME or adding a new coding requirement for intent may improve the utility of future injury statistics and thereby better inform local prevention strategies. Pediatricians and family practitioners should not discount the occurrence of unintentional firearm injury—more than 20% in our study—when counseling families about safety.
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ACKNOWLEDGMENTS |
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FOOTNOTES |
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Reprint requests to (J.S.) Department of Pediatrics, University of Miami School of Medicine, Miami, FL 33101. E-mail: jschaech{at}med.miami.edu
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REFERENCES |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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This article has been cited by other articles:
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  R D Comstock, S Mallonee, and F Jordan A comparison of two surveillance systems for deaths related to violent injury Inj. Prev., February 1, 2005; 11(1): 58 - 63. [Abstract] [Full Text] [PDF]
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L J Paulozzi, J Mercy, L Frazier Jr, and J L Annest CDC's National Violent Death Reporting System: background and methodology Inj. Prev., February 1, 2004; 10(1): 47 - 52. [Abstract] [Full Text] [PDF]
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