CHICAGO -- 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 death in April 2005 in a Simplicity crib prompted an investigation by a federal consumer watchdog agency and a family lawsuit against the manufacturer.
But Simplicity and the Consumer Product Safety Commission didn't warn parents across the country about this potentially fatal flaw - not after Liam's death, not after more complaints about the crib rails and not after another infant died last year.
Once the Chicago Tribune began questioning the company and the agency this month, a major 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.
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 federal 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 said.
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 nonfatal cases of infants being trapped and 55 other cases of drop-rail problems.
It also linked the Simplicity cribs to three deaths.
One of those children was Liam Johns, records show. Another was 6-month-old Edward Millwood, who died in November 2006 in Georgia. He, too, fell between his mattress and a separated drop rail. A suit filed by Edward's family alleges not only negligence by Simplicity but shoddy manufacturing in China.
The drop rail in each child's cribs was 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.
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 called the company, which said all such cases involved improper assembly by the consumer.
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 Fort Stewart, Ga., Army post, 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.
"I called the company, and they said it was no big deal," Heath said. "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."
Maurice Possley writes for the Chicago Tribune.