Photographs taken of Liam Johns' crib by the Sacramento County Coroner's Office clearly show where it came apart.
The drop rail had detached from its plastic track, creating a gap through which the 9-month-old boy slipped feet-first.Instead of falling to the floor, Liam got his head stuck between the rail and the mattress. Trapped in a hanging position, the boy asphyxiated.
Liam's April 2005 death prompted an investigation by a federal watchdog agency and a family lawsuit against the crib's manufacturer, Simplicity Inc.
But the company and the Consumer Product Safety Commission didn't warn parents across the country about the potentially fatal flaw in Simplicity cribs--not after Liam suffocated, not after more complaints about the crib rails and not after two more infants died.
Once the Tribune began questioning the company and the agency this month, a massive recall of Simplicity cribs followed.
On Friday, the CPSC took action on 1 million cribs, including the model that the Johns family used for Liam. It is the largest recall of full-size cribs in the agency's history.
In its Hidden Hazards series, the Tribune has documented how the understaffed and sluggish CPSC fails to protect children from dangers in toys and other products. The paper's examination of Simplicity's popular cribs underscores that, even in the aftermath of a child's death, the agency can fall short in its watchdog role, leaving children vulnerable to a documented hazard.
Interviews and records show that the federal investigator assigned to Liam's death failed to inspect the crib in his initial inquiry and didn't track down the model or manufacturer.
"We get so many cases," the investigator, Michael Ng, said in an interview this month. "Once I do a report, I send it in and that's it. I go to the next case. We could spend more time, but we are under the gun. We have to move on."
Only last week, after inquiries by the Tribune, did Ng return to California to find the crib. It had first been held as evidence by sheriff's police and later was put in storage by a lawyer retained by the family.
Even with the recall, it remained unclear why it took so long to address the problem. The CPSC often gets bogged down in negotiations with companies over recalls because fedx eral law limits its powers and its ability to disclose details of its investigations into dangerous products.
Nancy Cowles, a child-product safety advocate and executive director of Kids In Danger, called for congressional hearings to look into the delay. "Was it because the CPSC has no power and the company was able to stall?" she asked.
When first presented with the Tribune findings this month, Julie Vallese, spokeswoman for the CPSC, said the agency could not comment about Simplicity. "We have more than one investigation open, and that's why I can't answer any questions," she said.
In announcing the recall Friday, the CPSC blamed a flawed crib design and hardware that allowed parents to install the drop rails upside down, which can cause the rail to detach from the frame. The agency said it was aware of seven non-fatal cases of infants being trapped and 55 other cases of drop-rail problems.
It also linked the Simplicity cribs to three deaths but did not release the names of those children or the dates of the fatal accidents.
One of those children was Liam Johns, records show. Another was 6-month-old Edward Millwood, who died in November 2006 in Georgia. The third was 8-month-old Royale Arceneaux, who died in February in Houston. All three children fell between the mattress and a separated drop rail.
The drop rails in those deaths had been installed upside down. But the agency also found two incidents in which correctly installed drop rails failed to work properly.
Ken Waldman, president of Simplicity Inc., said in an interview Friday that the company makes safe products and works closely with the CPSC to fix any problems. He would not say why the recall did not occur earlier.
"This is the thing to do and that's why we decided to do it now," he said.
The Aspen 3 in 1, once Simplicity's best-selling crib, accounted for the bulk of the recall. About 600,000 of those models, which are no longer made, were recalled.
It was the same one the Johns family chose for Liam.
Reached at her home in Northern California, Nicola Johns, Liam's mother, began to weep when she learned about the recall.
"I feel like there is a stone or weight off my chest," she said. "So many kids' lives can be potentially saved because they took the right action finally.
"Nothing will bring Liam back, but if this saves one baby's life, it will mean so much to me."
Haven or danger?
A baby's crib is supposed to be the safest place in the home. It's considered a haven, the one place where the parents of a child, whether a newborn or a wriggling infant learning to roll over, can leave their babies for hours at a time without worry of harm.
That's why parents were so upset and contacted the CPSC when they began to notice problems with the drop rails on their Aspen 3 in 1 cribs. That model had features allowing it to be converted into a toddler bed and later a regular bed as a child grew.
According to records obtained from the agency through the federal Freedom of Information Act, the first complaint to the CPSC about a drop-rail problem with the crib came in July 2003 from a woman in Meridian, Miss. It involved the rail suddenly falling down, but not separating from the crib.
A CPSC investigator tried to find the crib in December, five months later. By then the woman had returned it to the store for a refund. The crib was gone, according to a copy of the investigator's report.
The investigator then called Simplicity. "During our conversation, the customer service representative for Simplicity indicated that the manufacturer is aware of some issues with drop sides of this model crib. He said that all cases of which [the company] is aware have involved improper assembly of the drop side by the consumer," the report said.
Then, in February 2004, a mother complained about a more serious drop-rail issue: separation from the crib.Julie Heath, who was living with her husband at the Ft. Stewart, Ga., Army base, reported to the CPSC that an hour after she put her 5-month-old daughter into the crib, she came into the nursery and found that one end of the drop rail had come loose. She said she also contacted Simplicity.
"I called the company, and they said it was no big deal," Heath said in an interview. "They said there were no problems with it. I thought it was scary and wondered if there were any kids who were hurt that they weren't telling us about."
Heath said she ultimately got rid of the crib and instructed her husband to put it into a trash bin in separate pieces. "I see them [Simplicity cribs] a lot at yard sales on the base," she explained. "I was worried if we just left it out that someone would pick it up and some baby would die."
Many of the parents who complained about their Simplicity cribs weren't worried just about their own children. They also wanted action to avert tragedy for other families.
The drop rail on the Aspen 3 in 1 owned by Christina Zimmerman of Bloomington, Ind., separated from the headboard of the crib the day after New Year's 2005. The thought that her son could have fallen through the resulting gap terrified her, and she contacted the CPSC.
"It had a huge gap," Zimmerman said. "I thought my son could fall through or get his head stuck in there."
She said she returned it to the store where she purchased it. "I stressed to them--I don't know how the procedure works, but these need to be removed from the shelf. I thought it should be taken off the market."
Zimmerman said she was saddened, but not surprised, to hear of Liam's death.
"I have five children," she said. "I was just afraid something like that was going to happen. You don't think just about your child. "As a mother, I don't want anyone to lose their child like that. I can't imagine how [Liam's] parents feel."
Feds miss link to flawed crib
Nicola Johns put her son Liam to bed about 8 p.m. on April 11, 2005, in their apartment in Citrus Heights, Calif.
She last checked on him about five hours later, just before she and her husband, Chad, went to bed. She was roused by her 2-year-old son, Logan, around 6:30 a.m. and got up to make breakfast.
"I went in to check on Liam and I couldn't see him at first," she said. "When I walked closer, I could see he was hanging. I lifted him up by his arms. He wasn't breathing."
Paramedics worked on the boy, but he was pronounced dead at a nearby hospital.
According to police reports and a lawsuit filed by the family, sometime in the early-morning hours, one end of the drop rail on Liam's crib had come off its track.
Liam, who could sit up with pillows behind him and was just learning to roll over, either rolled or slid feet-first into the opening. His head was caught between the rail and the mattress.
A coroner's office investigator photographed the crib and notified the CPSC. Sheriff's police impounded the crib while they conducted a death investigation. Child welfare authorities temporarily removed the Johns' other son from the parents' care while they investigated.
The CPSC dispatched investigator Ng. When he went to the sheriff's police, he was told the crib was in the evidence room and couldn't be examined while the investigation was pending, according to his report.
Ng noted in his report that the coroner's investigator had failed to record the correct model number of the crib but did record the Graco brand name. Mistakenly believing that Graco had manufactured the crib--it was made by Simplicity under the Graco brand name--Ng went to Graco's Web site.
"A search of ... www.gracobaby.com did not reveal any models similar to the crib involved in the incident," Ng's report stated. A superior reviewed it on July 29, 2005, and in the box calling for a model number put "UNKNOWN."
Three days later, after sheriff's police determined that Liam's death was an accident, the crib was released to the family.
In an interview, Ng acknowledged he did not follow up to try to determine the crib model.
Asked if he would have gone back to find the crib if a supervisor had requested, he said: "Well, that's possible. But that didn't happen."
As a result, Liam's death was not linked to the Aspen 3 in 1.
Charles Kelly, a San Francisco product liability attorney, filed a lawsuit on behalf of the family, alleging the crib was to blame. "The dangers of the crib included the risk of the drop side becoming loose from the plastic track," the lawsuit read in part.
The suit was settled out of court earlier this year. As part of the agreement, Kelly said, lawyers for Simplicity required that the terms be sealed.
Complaints pile up
After Liam's death, more consumers filed complaints with the CPSC about problems with the drop rails on their Aspen 3 in 1 cribs.
Lisa Smith of Sherwood, Ark., told the agency in October 2005 that her 10-month-old daughter had fallen to the floor between the drop rail and the mattress after the rail detached.
"I was out of the room for about 40 minutes and I heard a thud," Smith said in an interview. "She was screaming. My child rolled against it and rolled right on through."
Smith said she tried to contact Simplicity, but the company never returned her calls. "I stopped using the crib," she said. "It was dangerous, and it could have killed my child."
The CPSC sent out an investigator. Smith said she told him, "A child could have been suffocated."
A year later, the Millwood family in Georgia had no idea a crib could pose such a danger.
On Nov. 19, 2006, Robert and Amanda Millwood went out to celebrate their one-year wedding anniversary and dropped off their 6-month-old son, Edward, at his aunt and uncle's home in Woodstock, Ga.
The aunt put the boy to bed in a Simplicity Nursery-in-a-Box crib. It was a new crib purchased six months earlier, and her husband had put it together.
She would later tell police that Edward fussed for a while but eventually fell asleep in the crib. She left the nursery door open just in case the boy cried out during the night.
At 6:45 a.m., she got up to check on Edward and found him hanging by his head between the drop rail and the mattress.
The drop rail, which had been installed upside down, cracked open at a joint and separated far enough from the crib that the baby slipped through feet-first and suffocated.
This past February, 8-month-old Royale Arceneaux was found suffocated between an improperly installed drop rail on a Crib N Changer Combo in Houston.
"The parents had no idea it was installed upside down," said Mark Weycer, a lawyer for the family. "That was a death sentence for their child."
The Millwood and Arceneaux families both filed lawsuits against Simplicity.
On Saturday, CPSC spokesman Scott Wolfson said the agency was reinvestigating Liam's death and would open an investigation into a fourth death in a Simplicity crib just this past Wednesday.
Two-year-old Serenity Bergey was asphyxiated in Boca Raton, Fla., in a Crib N Changer Combo. The child's mother, Connie Bergey, said drop-rail hardware had broken and the rail was being held by duct tape.
"CPSC is deeply saddened by each one of the deaths involving children in Simplicity cribs, including the tragic death of Serenity Bergey just last week," Wolfson said.
The CPSC issued Friday's recall with a strong sense of urgency. Wolfson stated bluntly that parents should keep their children out of the cribs until they are examined for flaws or fixed.
Cowles, the consumer advocate, also emphasized the high stakes in such a recall. "We don't want another baby to be harmed," she said.
She was left to wonder, however, why it took so long for the cribs to be recalled, dating back to Liam Johns' 2005 death.
"Two-and-a-half years is not acceptable," she said. "There is no room for tolerance in the safety of a crib."
Tribune staff reporter Patricia Callahan contributed to this report.