The value of a nationwide ME/C surveillance system was dramatically illustrated with respect to a previously unknown and preventable public health problem: children’s deaths from entrapment in car trunks. Over a 2- month period in 1998, 11 child deaths were identified through death investigations in three states: New Mexico, Utah, and Pennsylvania. The cluster of cases triggered a broader investigation, which uncovered a total of 21 deaths nationwide from 1987 to 1999. That investigation led to identification of the major risk factor: children’s inability to get out of a car trunk. An expert panel was convened by the National Highway Traffic Safety Administration (NHTSA), and it recommended an interior trunk release. NHTSA responded by setting a new safety standard for automobile manufacturers in September 2001. That example illustrates that over a 3-year period surveillance can be actively translated into a new public health intervention, once a risk factor is found. If the case cluster had not been identified by pooling data from many jurisdictions, an opportunity to prevent deaths of children would have been lost.

There are major impediments to the development of a national surveillance system with ME/C data: variability in data quality with respect to training and experience, investigation procedures, and reporting requirements (for example, common nomenclature); variability in technology and standards; and the lack of policies for data interchange. To determine the extent of the child-entrapment problem, for example, CDC searched media databases because there was no standardized means of tallying the cases across all ME/C offices.

An IOM study could help to spearhead standards for death investigation. Standards are the key to reducing the high variability in data quality. They could cover death investigation practice and data collection, storage, and exchange of data. IOM could assess the feasibility of an integrated information system, including how long it would take to establish and what types of resources and steps would be necessary. IOM could also provide an independent and systematic assessment of the benefits and costs of a national system to improve all death investigations. IOM’s credibility comes from its expertise and its independence. For almost a century, there has been widespread agreement that the current system is inadequate. An IOM study could



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