Office of the County Administrator Monica Nino, County Administrator
April 12, 2018
Board of Supervisors County Administration Building Stockton, CA Dear Board Members: Accept the San Joaquin County Coroner Review and Audit Report, Provide Staff Direction and/or Select Option for the Delivery of Coroner Services and Accept County Counsel’s Report Regarding the Allegations of Doctors Omalu and Parson Recommendation It is recommended that the Board of Supervisors: 1. Accept the San Joaquin County Coroner Review and Audit Report. 2. Provide staff direction and/or select an option for the delivery of Coroner services. a. Sheriff-Coroner/Morgue b. Elected Coroner/Appointed Coroner c. Medical Examiner 3. Accept County Counsel’s report regarding the allegations of Doctors Omalu and Parson. Reason for Recommendation As a result of the County’s two full-time Pathologists resigning and submitting a number of documents addressing concerns with the Sheriff-Coroner’s operations, the County Administrator and County Counsel retained the professional services of RAM Consulting, LLC. The consultant assessed the Sheriff-Coroner’s operations in the following areas and provided recommendations improving operations to best serve the citizens of San Joaquin County.
Evaluated the operations against a set of objective standards and best practices. Assessment of the level of performance in current operations. Compared and contrasted the Sheriff-Coroner and Medical Examiner models.
One of the recommendations from the audit report (Attachment A) is that the organizational structure ensure individuals with the most knowledge and experience are providing leadership and the office must be independent, objective, and timely in the services it provides to the community. 44 N. San Joaquin Street, Suite 640 | Stockton, California 95202 | T 209 468 3203 | F 209 468 2875
Board of Supervisors CAO - Accept the San Joaquin County Coroner Review and Audit Report
April 12, 2018 Page 2
Options for the Delivery of Coroner Services The current organization of an elected Sheriff-Coroner is responsible for determining the circumstances, manner, and cause of all deaths reportable to the Coroner. Recently, the Sheriff has implemented the Coroner’s Inquest Policy. The proceeding allows a jury or hearing officer to make the decision as to the manner of death, while the cause of death would remain with the pathologist who performed the autopsy. This practice will be used with law enforcement involved deaths. If the Board chooses to separate the Coroner’s responsibility from the Sheriff’s Office, Government Code 24009 allows for the public to vote on whether to have an elected or appointed coroner. There are no qualifications specified in State law for the position of coroner. In the event the public voted for an appointed coroner, your Board could define the requirements and qualifications of the position. The Board can choose to adopt an ordinance abolishing the Office of the Coroner and creating the Office of the Medical Examiner, in accordance with Government Code 24010. It specifies that the Medical Examiner must be a “licensed physician and surgeon duly qualified as a specialist in pathology.” Should your Board choose to select this option, taking into consideration the County’s past experience in finding qualified physicians for specialty areas with strong leadership skills, this option will take time. Since early March 2018, the County has been working with an outside consultant for the recruitment of a forensic pathologist. The recruiter reports being contacted by 20 interested individuals, however, many of the candidates have declined to pursue employment with San Joaquin County due to on-line searches revealing the media presence reporting on this issue, as well as the negative reaction to the location. The remaining candidates do not meet the minimum qualifications. The recruiter continues to reach out and indicates the pool of available candidates with the required skills is limited. The recruitment is at the annual rate range of $250,000-$320,000. The annual salaries of the two most recent full-time pathologists were $358,377 and $257,877, respectively, and an annual cost for contract pathologist of $47,257 within that same twelve-month period, for a total cost for pathology services of $663,511. The County Administrator’s recommendation is for the Board to have the ability to appoint a Coroner on behalf of San Joaquin County. In the last four years, this Board and recent past Boards have experienced positive outcomes in the caliber of candidates applying for appointed leadership positions. Finding a path forward for the Board to approve the establishment of the qualifications and experience for an appointed Coroner position will create an independent and accountable Coroner to lead a department separate from other segments of the criminal justice system. The County does an incredible job of collaborating between the elected and appointed Departments Heads. In 2017-2018, your Board approved the rebudgeted amount of $8.9 million for the design, engineering, and construction of a new morgue. The project accommodates
Board of Supervisors CAO - Accept the San Joaquin County Coroner Review and Audit Report
April 12, 2018 Page 3
future growth for forensic staff. The design is 50% complete and construction is anticipated to start in fall 2019. The current budget and staffing allocation of the Sheriff-Coroner is the following, along with the cost of the proposed increase in staffing from the consultant’s report. FY 2017-2018 Adopted $2,786,474
San Joaquin County (Population: 745,424) Current Positions: Sergeant Deputy Sheriff Deputy Sheriff* Office Assistant Sr Office Assistant Physician Manager Physician Medical Technician Private Contract - Pathologists (3) *Assigned to Patrol Total Positions
Additional Cost
Consultant Proposed Additions Proposed Positions:
1 3 2 2 1 1 1 3 0
7 1 1 1 -
Death Investigators Staff Assistant
Forensic Pathologist Lead Morgue Technician
$850,850 64,020 328,061 78,793 -
282,271 14
$3,068,745
Total Positions
$1,321,724
10
Proposed Grand Total: 24 Total Positions
$4,390,469
The following are examples of four Counties, including San Joaquin County, of SheriffCoroner, Appointed Coroner, and Medical Examiners total budgets for 2017-2018 and allocated positions. County San Joaquin County Sheriff-Coroner (Population: 745,424) Positions
Positions
Allocated FY 2017-2018 Adopted Budget
Sergeant Deputy Sheriff Deputy Sheriff* Office Assistant Sr Office Assistant Physician Manager Physician Medical Technician Private Contract - Pathologists (3)
282,271 Total
756
$ 2,786,474
1 3 2 2 1 1 1 3
*Assigned to Patrol
Autopsies Performed
Budget
14
$ 3,068,745
Board of Supervisors CAO - Accept the San Joaquin County Coroner Review and Audit Report
County Sacramento County Appointed Coroner (Population: 1,530,615) Positions
April 12, 2018 Page 4
Positions
Allocated FY 2017-2018 Adopted Budget
Coroner Supervising Deputy Coroner Chief Forensic Pathologist Administrative Services Officer II Forensic Pathologist Deputy Coroner II Senior Coroner Technician Coroner Technician I/II Account Clerk I/II Account Clerk I/II (Conf) Senior Office Assistant Total
Autopsies Performed Santa Clara County Medical Examiner (Population: 1,938,153) Positions
Ventura County Medical Examiner (Population: 854,223) Positions
$ 7,942,545
1 2 1 1 3 12 1 8 1 1 2 33
785 FY 2017-2018 Adopted Budget Admin Serv Mgr III
1
Admin Support Officer I
1
Exec Assistant I
1
Office Specialist III
1
Medical Transcriptionist
0
Chief Medical Exam-Coroner-U
1
Asst Medical Examiner-Coroner
4
Forensic Pathology Technician Forensic Pathology Tech Trn
4 0
Chief Coroner Investigator Medical Examiner Coroner Invst
1 11
Sr Office Specialist
2 Total
Autopsies Performed
Budget
$ 6,312,757
27
700 FY 2017-2018 Adopted Budget Medical Examiner Investgr I Medical Examiner Investgr II Chief Medical Examiner Sr Medical Examiner Investigtr Assist Chief Medical Examiner
$ 2,949,000 1 3 1 2 1
Board of Supervisors CAO - Accept the San Joaquin County Coroner Review and Audit Report
County
April 12, 2018 Page 5
Positions Management Assistant III Forensic Pathology Technician Total
Autopsies Performed
Allocated 1 2 11
Budget
Unknown
County Counsel’s Report In December 2017, County Counsel was asked to examine the allegations that were contained in the memoranda delivered by Doctors Omalu and Parson. Counsel reviewed the memoranda, solicited responses from the Coroner’s Office, researched the law governing operations of the Coroner’s Office, reviewed other pertinent publications, and interviewed Doctors Omalu and Parson, Sheriff-Coroner Steve Moore, Assistant Sheriff Annette Mondavi, Chief Deputy Coroner Mike Reynolds, and the autopsy technicians. The findings and conclusions drawn from that analysis are contained in Counsel’s report (Attachment B). Fiscal Impact In any option the Board chooses, there will be a fiscal impact to the General Fund to address best practices and staffing requirements to better serve the community of San Joaquin County. Board direction will be included as part of the 2018-2019 Proposed Budget. Action To Be Taken Following Approval Upon Board approval, the County Administrator, County Counsel, and Human Resources will work with the Sheriff on implementing Board action. Sincerely,
Monica Nino County Administrator Attachments: A. Consultant’s Report - Coroner Review and Audit B. County Counsel Report c:
County Counsel Human Resources Sheriff-Coroner-Public Administrator Clerk of the Board for 4/24/18 Agenda
Board of Supervisors CAO - Accept the San Joaquin County Coroner Review and Audit Report
BL04-01 Reviewed by County Counsel’s Office:
April 12, 2018 Page 6
ATTACHMENT A
2018 San Joaquin County Coroner Review and Audit
Submitted By: RAM Consulting LLC 4/10/2018
ATTACHMENT A
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ATTACHMENT A
TABLE OF CONTENTS INTRODUCTION
4-5
METHOD
5-6
FINDINGS ORGANIZATIONAL STRUCTURE AND MANAGEMENT
7-11
DEATH INVESTIGATIONS
12-16
MORTUARY SERVICES
16-17
FORENSIC PATHOLOGY
18-20
AUTOPSY REPORTS
21-22
MORGUE FACILITY
23-24
BUDGET
24-25
RECOMMENDATIONS
25-28
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ATTACHMENT A
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ATTACHMENT A
San Joaquin County Coroner Review and Audit Scope of Work: The County of San Joaquin desires a Coroner’s Office that performs the coroner functions honestly, efficiently and effectively. For this reason, the County desires to retain independent consultants to: a. Evaluate the operations of the coroner’s office against a set of objective standards and best practices. b. Provide a report based on the evaluation indicating level of performance, current operations assessment, including areas where the office meets or exceeds standards, areas needing improvement and recommendations for the improvements that should be made. c. Compare and contrast the coroner/sheriff and medical examiner models including staffing, training, operations and costs. The comparison will not express a preference for one system over the other but will provide the Board of Supervisors with sufficient information so that the Board can make an informed decision.
INTRODUCTION Medicolegal death investigations in the United States of America can take on many forms. There are two primary medicolegal death investigations systems operating in the United States. One is the coroner system; the other is the medical examiner system. The coroner system revolves around an elected or appointed coroner who, in most jurisdictions, is not required to be a physician or forensic pathologist. The medical examiner system revolves around an appointed forensic pathologist, who is almost always board-certified in, at a minimum, anatomic and forensic pathology. Both systems have a process of investigation that responds to calls of death reportable by some specific legislative mandate. These systems may be legislated from the state, county, or even local city levels. The administration of medicolegal death investigation systems in this country are not regulated by any federal agency or office. The coroner system may be administered by an elected professional, physician, or law enforcement official. The latter is often defined as a Sheriff Coroner System. The Sheriff Coroner System usually requires the elected Sheriff to not only provide leadership to death investigations but also other responsibilities that may include criminal investigations and/or guard and security operation (i.e. courts and prisons). Death investigators employed by the coroner system are often law enforcement who may or may not have other public safety related responsibilities. Most Sheriff Coroner Systems either contract with or employ forensic pathologists who are responsible for the post mortem examination. In these jurisdictions, the 4|Page
ATTACHMENT A forensic pathologist is responsible for generating an autopsy report and the medical cause of death. The manner of death (in other words, how the death arose) is often determined by the Sheriff Coroner or his/her designee in consultation with the forensic pathologist. The medical examiner system is administered by a pathologist as Chief Medical Examiner. The Chief Medical Examiner is appointed by the local leadership. Day-to-day death investigations usually are conducted by staff with a diverse background including, but not limited to, nursing, physician assistant, master’s in forensic science, bachelor’s in criminal justice or the natural sciences, emergency medical technicians (EMTs) or paramedics and/or a background in law enforcement. Most medical examiner offices promote participation of their investigators with the American Board of Medicolegal Death Investigation (ABMDI) certification. ABMDI certifies individuals who have the proven knowledge and skills necessary to perform medicolegal death investigations as set forth in the National Institutes of Justice 1999 publication Death Investigation: A Guide for the Scene Investigator. ABMDI is not relegated only to the medical examiner system but is increasingly becoming part of all medicolegal death investigations, including investigations conducted by coroner’s offices. The Medical Examiner System utilizes forensic pathologists who are contracted with or directly work for the office. These physicians are responsible for the certification of both cause and manner of death and producing the corresponding autopsy report. High functioning medicolegal death investigation systems participate in national accreditation and standards set forth by the National Association of Medical Examiners (NAME) or the International Association of Medical Examiners and Coroners (IACME). These organizations not only support individual forensic pathologists, investigators, or scientists, but similar to ABMDI, set forth guidelines for the proper staffing, training, organization, implementation, and reporting of death investigation in this country. The San Joaquin Sheriff Coroner’s Office is a coroner system with an elected Sheriff Coroner and Public Administrator. This report is intended to incorporate findings regarding the Coroner operations, including areas where the office meets or exceeds standards, areas of deficiency, if any, and recommendations for improving the existing operations to best serve the needs of the citizens of San Joaquin County.
METHOD A brief audit of the San Joaquin County Coroner’s Office was performed for the purposes of identifying strengths, weaknesses, and opportunities to inform recommendations for improvement. The audit required both document review and in-person staff interviews to evaluate the operations of the coroner’s office. Document review and interviews were centered on evaluating Six Core Management Areas generally required to operate a medicolegal death investigations system. The six core areas include Organizational 5|Page
ATTACHMENT A Management and Structure, Death Investigations, Morgue Services, Forensic Pathology, Facilities, and Budget. The six areas were evaluated for both process and personnel. Documents reviewed included: •
Organizational charts from the County and the San Joaquin Coroner’s Office
•
Position descriptions and salaries for all staff
•
Law and Justice – Sheriff-Coroner/Morgue Budget from 2013-2016
•
Law and Justice – Sheriff-Coroner/Morgue Proposed Budget for 2017-2018
•
2016 Annual Report of the Coroner
•
San Joaquin County Coroner’s Office Reference Binder
•
San Joaquin County Coroner’s Office Morgue Procedures
•
San Joaquin County Grand Jury Final Report on Morgue Facility 2010-2011
•
San Joaquin County Grand Jury Final Report on Morgue Facility 2011-2012
•
Autopsy Report Time and Duration Data by Physician
•
2017 Physician Activity Data
•
Forensic Pathology Budget Cost Analysis
Detailed interviews were conducted on the following personnel: a Sergeant Coroner; all office assistant support staff; a sample of available Sheriff Deputy Coroners; all medical technicians; two full-time forensic pathologists; one contract pathologist; the Assistant Sheriff; and the elected Sheriff-Coroner. Additional interviews were conducted on the following individuals: Chief of Stockton Police Department, the District Attorney; support Attorney; Investigator; and the Chief Executive Officer of San Joaquin County General Hospital. In addition to the six (6) core management areas for medicolegal death investigation, we initiated a review of ten percent (10%) of the investigative and autopsy reports for 2016. The case identification and review were performed in a random fashion. The following cases were reviewed: fifty (50) declined case reports, twenty (20) natural cases, thirty (30) accident cases, seven (7) homicides, seven (7) suicides, five (5) deaths in the custody of jail/law enforcement, four (4) infants, and two (2) undetermined cases. The autopsy reports were evaluated along the following five (5) areas: Organization/Legibility; Content; Cause and Manner of Death; Linkages; and Quality. Each is measured against a scale of 1 to 3: 1- Poor, 2 – Satisfactory, 3 – Excellent.
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ATTACHMENT A FINDINGS Organizational Structure and Management The Coroner at San Joaquin County, California is organized within the Law & Justice Division of County Government. The Law & Justice Division includes the District Attorney, Child Support, Probation, the Public Defender, and the Sheriff-Coroner-Public Administrator. The SheriffCoroner-Public Administrator is one of four elected department/agency directors outside of the elected Board of Supervisors. The District Attorney is also elected. The remaining agency directors are appointed by the County Administrator, appointed by the Board of Supervisors, or appointed by a non-governmental agency. In San Joaquin County, the Sheriff-Coroner-Public Administrator is generally responsible for preserving the peace; enforcing laws of the county; administering contract policing for Lathrop/Mountain House; serving court processes ; operating correction & detention facilities; providing bailiff services for the Superior Court; supporting animal services; serving as the agent for the county; investigating and administering estates of persons who die with no appropriate person willing or able to administer the estate; and determining and classifying causes of death. The Coroner’s Office is further organized with a Sergeant who functions as the supervisor of the Office. The office is made up of thirteen (13) staff which includes five (5) deputy sheriffs, three (3) medical technicians, three (3) office assistants, and two (2) forensic pathologists. The Coroner Sergeant is tasked with being the direct supervisor for all staff. Functionally all staff report directly to the Coroner Sergeant except for the forensic pathologists. The forensic pathologists do not have a functional supervisor and are self-governed. The Sergeant reports up through the Investigation Unit supervisory structure that includes a Lieutenant, Captain, Assistant Sheriff and Undersheriff — all of which report to the SheriffCoroner.
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ATTACHMENT A
Vision and Mission Mission Statement: “The mission of the San Joaquin County Coroner’s Office is to serve and protect the interests of the community by determining the cause, circumstances and manner of sudden or unexplained deaths that occur within our jurisdiction. We identify the deceased and notify their next of kin, regardless of where in the world they may live, while insuring that the deceased and their property are treated with the utmost respect and dignity. We accomplish our mission through the use of pathologists, consultants, and other methods of inquiry. We serve as an independent finder of fact in a manner as prescribed by law.” The Coroner’s Office is responsible for determining the circumstances, manner, and cause of all deaths reported to the Coroner. Field death investigations, postmortem examinations, and related forensic tests are used to establish a medical cause of death. Work is performed by County forensic pathologists with assistance from medical technicians. The technicians assist with autopsies, clean the morgue, take tissue and fluid specimens, and maintain inventories of remains and supplies.
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ATTACHMENT A Communication The communication method is based upon the basic hierarchal law enforcement structure. This communication model is based upon “orders” being delivered to the Deputy Sheriff Coroner Investigators from the Sergeant. The communication model for the office assistant and the medical technicians is ad-hoc and task based. Within the last ten (10) months, the Sergeant has initiated a morning meeting that allows exchange among most staff. This meeting is primarily for the investigative staff and does not include the forensic pathologists. There are no quarterly or annual meetings between staff and executive leadership. The Sheriff-Coroner does not have regularly schedule meetings with Coroner Office leadership and/or front-line staff. All meetings between the Sheriff-Coroner and the Coroner Office staff is on an ad-hoc basis or in emergent situations. The preferred communication model would ensure the following: (A) daily scheduled communications between investigation staff, physician staff, and mortuary staff to discuss the cases of the day; (B) weekly meetings between physician leadership and administrative leadership to ensure clarity surrounding budget, operations and personnel-related issues; and (C) monthly meetings for all leadership to discuss the performance of the agency Performance Measurement Performance management allows leadership the ability to evaluate staff based upon an agreed upon uniform criteria. The majority of performance management programs evaluate an individual’s ability to work with others, leadership, technical skills, job knowledge, dependability, and/or adaptability. Most performance management programs also utilize S.M.A.R.T (Specific, Measurable, Achievable, Relevant, Time limited) goals as performance measures and individual goal setting. The Coroner’s Office of San Joaquin County does not have a comprehensive performance management program. Both positive and negative feedback are provided on an ad-hoc basis. The agency also does not have a county-based performance mandate as would be established by the County Administrator and/or Board of Supervisors. The Coroner’s Office is currently not accredited by any of the national accrediting bodies including the National Association of Medical Examiners (NAME) or the International Association of Coroners and Medical Examiners (IACME). Accreditation provides uniform measures of performance and outcomes. Accreditation also establishes objective standards and agreed upon best practices in death investigation, forensic pathology, staffing levels, facility infrastructure, autopsy reporting, turn-around time, and records retention.
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ATTACHMENT A Standard Operating Procedures Standard Operating Procedures (SOPs) are documents that govern how an organization carries out the day to day activities to meet its legislative or statutory mandate. The San Joaquin County Coroner’s Office has what is called the Coroner’s Reference Binder. The Reference Binder is a set of documents including memorandums, field response directives, and background information that most closely resembles the SOPs for the agency. The reference binder includes the following: • • • • • •
• • • • • • • • • • • • • • • • • •
Deaths that should be reported to the Coroner – Memorandum dated May 23, 2017 Duty of the Coroner Field Response Directive – dated January 10, 2011 Coroner’s Property – dated June 25, 2007 Coroner’s Case Recording and Format – dated January 23, 2013 o With forms, diagrams, and examples Dictaphone Field Change for Coroner’s Supplement – Memorandum dated January 23, 2007 Fetal Death Investigation – dated February 4, 2011 o Supporting Infant Death Memorandum dated September 24, 1976 o Supporting SIDS Memorandum dated March 27, 2007 SIDS Protocol – dated April 17, 2007 Coroner’s Identification Bracelet – dated June 25, 2007 Report of Cancelled Investigation/Doctor Referral – dated January 10, 2011 Death Notification Procedure for Next of Kin – dated July 1, 1999 X-ray and CT Scans – dated June 25, 2015 Kaiser Patients – Memorandum dated October 3, 2003 Viewing of Autopsy – dated January 2000 Notification of Death to a Police Agency – dated January 2000 Monthly Traffic Report – dated April 17, 2007 Unidentified Persons – not dated Toxicology – dated November 4, 2011 Retention of Decedent Tissue – not dated Indigent – dated August 10, 2016 Decedent Intake – dated August 10, 2016 Decedent Release – dated August 10, 2016 Payment Cancellation – dated August 10, 2016 Coroner’s Office Policy – Investigative Guidelines – 485-495 Lexipol LLC 2017 Morgue Procedures – not dated o Morgue Tracking System, Body and Property Intake, Specimen, Toxicology Request, Fingerprints, Case Notes, DNA Cards, Histology Process, Morgue Tech Standard Set Up, Medicine Disposal, Doctor’s Set-up, and Supply Cabinet (why is this formatted in this way?)
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ATTACHMENT A Review of the Coroner’s Reference Binder revealed that much of the content has not undergone regular review to ensure that the current process best represents the information found within the written procedure. Many of the procedures are out of date and may contain information that should be updated to reflect best or promising practice in forensic medicine. The following are the strengths, weaknesses, and opportunities within the Organizational Management and Structure.
Organizational Management and Structure Strength • Coroner’s Office organized within the County Government Structure • Clear legislated mandate to investigate and certify cause and manner of death • Established Vision and Mission within the organization • Established Personnel Reporting Structure • Established Standard Operating Procedures Weakness • Hierarchical Personnel Reporting Structure • Ad-hoc Issued based Communication Model • Poor leadership messaging and communication • Rudimentary Performance Management Program • Incomplete Standard Operating Procedures • Outdated Standard Operating Procedures Opportunity • Develop a Functional/Knowledge Based Personnel Reporting Structure • Develop an intentional consensus-based Communication Model • Develop messaging/communication strategy from leadership to front line staff • Improve Performance Management to include the S.M.A.R.T Goal Model • Improve and update all Standard Operating Procedures
Death Investigations Cases are reported to the Coroner’s office through central dispatch at the request of the local police department, emergency medical services, or hospital. The reporting of cases is based upon the California Health and Safety Code’s Section 102850 and Section 27491 of the Government Code that sets the legal requirements for reporting deaths the Coroner. Deaths that occur under any of the following circumstances must be reported: California Health and Safety Code Section 102850 a.
Without medical attendance;
b.
During the continued absence of the attending physician;
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ATTACHMENT A c.
Where the attending physician is unable to state the cause of death;
d.
Where suicide is suspected;
e.
Following an injury or an accident; or
f.
Under such circumstances as to afford a reasonable ground to suspect that the death was caused by the criminal act of another.
Government Code Section 27491 1.
All violent, sudden, and unusual deaths;
2.
No physician in attendance;
3.
Wherein the deceased had not been attended by a physician in the twenty days before death;
4.
Related to or following known or suspected self-induced or criminal abortion;
5.
Known or suspected homicide;
6.
Accidental poisoning (food, chemical, drug, therapeutic agents);
7.
Known or suspected as resulting in whole or in part from or related to accident or injury either old or recent;
8.
Deaths due to drowning, fire, hanging, gunshot, stabbing, cutting, exposure, starvation, acute alcoholism, drug addiction, strangulation, or aspiration;
9.
Deaths associated with a known or alleged rape or crime against nature;
10.
Deaths in prison or while under sentence;
11.
Deaths known or suspected as due to contagious diseases and constituting a public hazard;
12.
Deaths from occupational diseases or occupational hazards;
13.
All deaths of unidentified persons;
14.
Where the suspected cause of death is Sudden Infant Death Syndrome;
15.
Deaths of patients in State mental hospitals serving the mentally disabled and operated by the State Department of Mental Health;
16.
Deaths of patients in State hospitals serving the developmentally disabled and operated by the State Department of Developmental hospitals; and/or
17.
Deaths under such circumstances as to afford a reasonable ground to suspect that the death was caused by the criminal act of another.
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ATTACHMENT A Coroner death cases are reported through central dispatch to Patrol Sheriff Deputies or Coroner Sheriff Deputies. Prior to October 2017, the Patrol Deputies responded to Coroner calls twenty-four (24) hours a day and seven (7) days a week. However, since October 2017, as part of a new pilot program, death cases have been reported to the Coroner Sheriff Deputies from 0900 to 1700 Monday through Friday and Patrol Sheriff Deputies from 1700 to 0900 (overnight) Monday through Friday. On Saturday and Sunday, Patrol Sheriff Deputies respond to all calls for the 48-hour period. According to the 2016 Annual Report there were 5,308 deaths recorded in San Joaquin County with 2,703 deaths reported to the Coroner’s Office. 1,536 cases (57%) were reported from a medical facility (hospice, hospital, and nursing home) and 1,167 cases (43%) from a scene of death (i.e. roadway, home, park, field, etc.). All 2,703 deaths including those occurring in a medical facility received an on-scene response by Sheriff’s Deputies. This is an overrepresentation of scene visits to medical facilities (1,536 cases). Deaths that occur at a medical facility (i.e. under the care of medical professionals) do not require a scene visit. In these instances, death investigation can occur telephonically. By performing the death investigations over the phone for those deaths that occur at a licensed medical facility, the agency can focus its field operation resources on scene cases, therefore decreasing costs and decreasing the risk of investigator “burn-out”. It is important to point out that, of the 2,703 deaths reported to the Coroner’s office, only 738 deaths (27.3%) were certified by the Coroner. Further analysis should be performed on cases accepted and certified by the Coroner to evaluate additional need for process improvement. Death scene investigations performed by either the Coroner or Patrol Sheriff Deputies do not include photography. Photographs taken at death scenes are taken by the local law enforcement agency and therefore are not available for the majority of cases. For infant death investigations, there are no doll reenactments performed. Information gathered during the death investigation is gathered by the Patrol or Coroner Sheriff Deputies. A coroner case number is not generated at the time the investigation is initiated. The body carries the law enforcement case number until the investigation report is dictated and transcribed. The information gathered is formulated into a Coroner’s report. The report is dictated by the Sheriff Deputies and made available to forensic pathologists no earlier than the next business day. For cases investigated on Friday thru Sunday, the dictated investigation report is not available to the forensic pathologist until the following Monday. Depending upon the case load over the weekend, investigation case reports may not be available to the forensic pathologist until Monday afternoon. Much of the process on what cases to accept and what cases to decline are not described within the existing Standard Operating Procedures. The declined cases are not reviewed and signed by a physician prior to final disposition. Identification and Next of Kin (NOK) determination is governed by the Coroner’s Reference Binder. Identification occurs mostly in the field through confirmation of visual identity by friends, family, or NOK. NOK notification occurs in person by Sheriff Deputies. When visual 13 | P a g e
ATTACHMENT A identification cannot occur, fingerprints and/or dental X-rays are the next preferred form of identification. Ink prints and dental X-ray are performed by Morgue staff and submitted by the Sheriff Deputies for proper comparison utilizing fingerprint databases and forensic odontology, respectively. On occasion, Sheriff Deputies report having to remove decedent hands to confirm identity — a practice that is and should be rarely performed. Tattoos are often documented and compared. DNA is also taken for all decedents and is a rare form of scientific identification. Chest X-ray comparison and contextual identification are not used to confirm identity. The San Joaquin County Coroner’s Office does not currently participate in the National Missing and Unidentified Persons System (NamUs). NamUs is a national database that gives opportunity for families, law enforcement agencies and investigators to search nationwide for missing persons using a variety of powerful search features. Anyone may search the database; however, registering in the system will enable law enforcement professionals and the general public to: •
Add new missing persons cases;
•
Add physical and circumstantial details, photographs, dental contacts and other critical pieces of information to a case;
•
Create and print missing persons posters; and
•
Track multiple cases as information is added to the system.
There is a total of five Sheriff Deputies that serve as death investigators for the Coroner’s Office (three full time Coroner Deputies and two Sheriff Deputies who were recently added as part of the pilot program). There are only five (5) Sheriff Deputies who have the sole responsibility of death investigations in the entire San Joaquin County. The average education attainment of the deputies is a high school diploma. The most senior deputies of the group have amassed eight (8) years of experience. Each deputy undergoes an 80-hour training in Basic Death Investigation offered by the California State Coroners Association (CSCA) at the beginning of the Coroner assignment. There is minimal continuing education training offered to the Coroner Deputies during their professional tenure including 32 hour annual training for select investigators. The unit does not participate in the American Board of Medicolegal Death Investigation (ABMDI) requirements, certification, or continuing education program. None of the Coroner Deputies are certified by ABMDI. It is important to note that the Patrol Deputies have even less formal education in death investigation. Patrol Deputies are not required to attend the CSCA course. All death investigation experience occurs in real-time without specific measurable criteria. There is no evidence that the Patrol or Coroner Deputies consult with physicians on difficult death scene investigations. In addition, the forensic pathologists are not required nor encouraged to visit complex death investigation scenes. In addition to responding to calls of death in San Joaquin County, the Coroner Deputies provide case management and provide follow-up for death investigations in the county. Regardless of 14 | P a g e
ATTACHMENT A whether a Patrol or Coroner Deputy initiated the death investigation, the Coroner Deputies are responsible for all subsequent case management including identification, request and receipt of medical records, finalization of the coroner’s report, and the certification of cause and manner of death. The Coroner Deputies are also responsible for overseeing body release process. There are approximately 3 to 5 decedents that are released daily at two separate times per day. The body release process requires authorization from three persons: a medical technician, a Coroner Deputy, and a funeral director. The fact that the Coroner Deputy is mandated in the body release process is reported as often taking away (unnecessarily diverting) the Coroner Deputy from important investigative tasks. The following are the strengths, weaknesses, and opportunities within Death Investigations. Death Investigations
Strength • Death investigation is the jurisdiction of the Coroner’s Office • Comprehensive jurisdictional investigative categories • Coroner Deputies are performing on-scene death investigations • Coroner Deputies are passionate and motivated Weakness • Coroner Deputies cover only 25% of the investigative week • Lack of Coroner Deputy Investigative staff • Patrol Deputies investigate deaths on nights and weekends • Unnecessary hospital scene response in greater than 50% of cases • Photography is not performed by Deputies during death investigation • Coroner Deputies and Patrol Deputies have limited training and continuing education • Coroner Deputies are not certified by ABMDI • Coroner office does not utilize well-recognized forms of identification comparison (chest x-ray, contextual) • Coroner office does not subscribe to the NamUs Program • Investigative case reports are dictated
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ATTACHMENT A
Death Investigations Continued Weakness Continued • Investigative case reports are delayed • Coroner Deputies are utilized for the body release procedure • Physicians are not required to respond to complex death scenes • SOPs are outdated and incomplete Opportunity • Update and Improve Standard Operating Procedures • Hire additional Coroner Deputies (death investigators) • Cover greater percentage of the investigative work week • Prioritize death scene response by not mandating visits to medical facilities during the death investigation • Develop comprehensive training and education program for Sheriff Deputies responsible for death investigations • Participate in both ABMDI and NamUs programs • Follow best practices for post-mortem identification procedures • Ensure completion of Coroner Investigative Reports before the end of any given shift • Allow physicians to respond to complex death investigation scenes
Mortuary Services The decedents are transported by a contract service to the Morgue unit. The contract service has unsupervised access to the body coolers. The contract service utilizes hand-written logs to log-in the name of the decedent and time the decedent is transported to the coroner’s office Morgue unit. This is done without the use of a unique coroner generated case number. The body is checked-in the next morning by the medical technician utilizing the morgue tracking system. The morgue tracking system is used to track most activities within the Morgue service but does not interface with the coroner case management system. It was reported that in any given morning the Morgue staff may not know the case specific information required to prepare for autopsy examination by the forensic pathologists. This creates some delay in when and potentially how autopsies are performed. The Morgue body storage capacity is approximately fifty (50) bodies. This includes both fixed facility and mobile body storage. There are three medical technicians that serve as autopsy assistants. The role of the medical technician is to assist the forensic pathologist during the autopsy by coordinating post-mortem radiology, preparing the autopsy station for examination, transporting decedents from storage to autopsy table, preparing bodies for dissection, writing down organ weights and physical findings, assisting with head dissection, preparing specimen for testing and preparing bodies for final disposition and body release.
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ATTACHMENT A The training of the medical technicians is performed “on the job” in an ad-hoc manner. There are no skill checklists to ensure proficiency in autopsy support. The medical technicians report not ever receiving training in Blood Borne Pathogens, training in the proper use of personal protective equipment (PPE), fitting for N95 face masks, Occupational, Safety and Health Administration (OSHA) training in lifting and moving bodies, and verification of Hepatitis B testing. There are no personal formalin monitors issued to the staff and no environmental air monitoring for hazardous chemicals. There has been recent tuberculosis (TB) testing but there is no annual Health Safety Program for the office. The medical technicians are also directly supervised by the Coroner Sergeant. There are no lead technicians who are responsible for ensuring the completion of daily tasks. The physical morgue facility is not directly connected to the administrative building and therefore creates significant barriers to the management of the morgue unit by the Coroner Sergeant. The staff reports not having sufficient direct guidance by management. The following are the strengths, weaknesses, and opportunities within Morgue Services. Mortuary Services Strength • Dedicated Morgue Facility • Written Standard Operating Procedures for the Morgue Services • Established criteria to support physicians • Adequate Morgue Unit Staffing • Adequate body storage for routine day-to-day cases • Medical Technicians are passionate and motivated Weakness • Lack of medical technician training in morgue operations • No on-site supervisory structure among the medical technician staff • No Health and Safety Program for the Morgue and Medical Technician Staff • No Occupational Health Monitoring (Blood Borne Pathogens, TB, Formalin, etc.) • Morgue Tracking System does not interface with the Coroner Case Management System • Delay in Case Number assignment for accepted cases • Delay in daily examination schedule • Outdated and Incomplete Standard Operating Procedures Opportunity • Establish comprehensive Occupational Health Monitoring Program • Establish comprehensive Health and Safety Program • Establish Lead Medical Technician Position • Establish uniform Medical Technician Training Program • Assign Coroner case numbers upon acceptance of jurisdiction • Fully integrate Morgue Tracking System and Coroner Case Management • Update and Improve the Standard Operating Procedures
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ATTACHMENT A Forensic Pathology The forensic pathology unit has historically utilized both contract and full-time pathologists. In October 2016 the Coroner’s office utilized primarily two full-time forensic pathologists on salary by San Joaquin County both of whom were board certified in at least Anatomic and Forensic Pathology. In 2016, there were examinations of 738 cases including: 515 autopsies, 154 inspections, and 69 investigations. Autopsy:
A full examination, both external and internal, to determine the pathological cause of death.
Inspection:
There is sufficient medical data to determine the cause of death by physical inspection of the body without an autopsy.
Investigation: Investigation and review of the medical records without the presence of the body. Although one of the forensic pathologists is designated as physician manager in the Coroner’s Office Organizational Chart, functionally this physician does not operate in that capacity. Physician management is therefore relegated to a peer-to-peer model. Cases are assigned based upon the physician pathologist schedule. No more than one physician are on the autopsy schedule for any given day. The physician schedule at some point was the responsibility of the forensic pathologists, however at the time of this report the Coroner Sergeant set the physician schedule. There is a morning meeting hosted by the Coroner Sergeant that is not attended by the forensic pathologist. Criteria for autopsy examinations are largely at the discretion of the individual pathologist. There is no SOP for autopsy vs. inspection criteria. The individual forensic pathologist can set his/her own start time. In as much, the pathologists report that case investigative information is often not complete and, therefore, unavailable at the time of autopsy. The delay in case investigation information can often result in delayed examination. Start times range from 0830 to 1500. On average the physicians can begin many of the autopsy case examinations by 1000. Each physician performs approximately thirty (30) autopsy examinations per month. It is important to note that forty seven percent (47%) of the case examinations in 2017 occurred within twenty-four (24) hours of receipt of the decedent. More importantly fifty-three percent (53%) of examinations were performed up to seven (7) days after the receipt of the decedent (Figure 2). This is crucial because autopsy examination findings can and will change after seven (7) days due to post-mortem changes and may impact the physician’s ability to diagnose disease or injury. The physicians interviewed suggested that much of these delays are due to decreased availability of medical or law enforcement case information necessary to perform the examination. In 2017, the autopsy report turnaround time averaged one hundred sixty-two (162) days for one physician and one hundred sixteen (116) days for the other. It was suggested that there is 18 | P a g e
ATTACHMENT A not a routine schedule for autopsy report transcription. Dictated autopsy reports are transcribed on an ad-hoc basis and upon request.
The physicians report adequate support in the Morgue unit during autopsy examination and have described uniform support of individual medical technician staff. However, delays can often occur when radiology (x-ray or CT-scan) are required for the evaluation including penetrating trauma, decomposed, and pediatric cases. Radiology is currently performed outside of the Morgue unit, at the San Joaquin County General Hospital. There is currently no portable x-ray system in the San Joaquin Coroner’s Office for rapid required forensic radiology. Post-mortem testing support in the form of toxicology, histology, and microbiology are provided for case examination. Toxicology and histology are more uniformly available. However, microbiology testing appears to only be available to the full-time forensic pathologist due to contractual affiliation with the San Joaquin General Hospital. Currently, the San Joaquin Coroner’s Office is utilizing three contract forensic pathologists who do not have contract
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ATTACHMENT A privileges with the hospital and report that they, as a result, do not have ready accessibility to microbiology testing. Access to additional ancillary testing or specialized consultation is also underrepresented. Although neuropathology consult service is available due to the expertise found among the fulltime forensic pathology staff, other consult services such as cardiac pathology, pediatric pathology, and forensic anthropology are not readily utilized. With the impending change in full-time forensic pathology staff, even the availability and access to neuropathology will become a challenge. Like the Morgue unit, the forensic pathology staff report never receiving training in Blood Borne Pathogens, training in personal protective equipment (PPE), fitting for N95 face masks, OSHA training in lifting and moving bodies, and verification of Hepatitis B testing. There has been recent tuberculosis (TB) testing but there is no annual Health Safety Program for the office. The following are the strengths, weaknesses, and opportunities within Forensic Pathology. Forensic Pathology Strength • Forensic Pathologists are board certified in at least Anatomic and Forensic Pathology Weakness • Case load too much for two forensic pathologists • Unavailable death investigation information at the time of autopsy • Consistent delays in autopsy examinations (53% beyond 24 hours) • No uniform start and stop time for autopsy examination • Delays in dictation transcription • Autopsy Reports completed in an average of 139 days • Physician management needs to be improved • Lacks comprehensive Standard Operating Procedures • No official case consensus conferences • No in-house X-ray system • Reliability of access to ancillary testing • Lacks Health and Safety Program for the Morgue and Physician Staff • Lacks Occupational Health Monitoring (Blood Borne Pathogens, TB, Formalin, etc.) Opportunity • Hire one additional board certified forensic pathologist • Improve quality and timeliness of investigative report • Perform case examinations within 24 hours of notification • Develop consistent start and stop time for morgue operations • Require transcription of case report dictations within 5 days • Require autopsy report completion to 90% within 90 days • Improve physician management • Develop comprehensive Standard Operating Procedures • Purchase portable digital x-ray system • Solidify access to necessary ancillary testing • Establish comprehensive Occupational Health Monitoring Program • Establish comprehensive Health and Safety Program 20 | P a g e
ATTACHMENT A Autopsy Reports The autopsy report file generally had all requisite information. The autopsy report is dictated by the attending forensic pathologist after the examination. When that dictation occurs is variable. The dictation is transcribed by administrative staff. Transcription of reports also occurs anywhere from days to months after dictation. All report files include a data sheet filled out and signed by the attending forensic pathologist indicating the preferred cause and manner of death. The layout of the report file however did not include any sectional tabs to direct the reader to the location where he/she could find the toxicology report, microbiology report, medical records, or other ancillary reports. The autopsy reports reviewed from the San Joaquin Coroner’s Office were generally well organized. All of which had the necessary demographics (name, age, race, and gender) of the decedent as well as the date of death, date of autopsy, and name of the attending forensic pathologist. The reports were properly separated into the external examination and the internal examination sections. Each report had a Final Diagnosis/Pathological Diagnosis section that summarized the most important autopsy findings. Where there was some organizational variability was in the location that the Final Diagnosis/Pathological Diagnosis section appeared in the report. In some reports it appeared in the beginning and in others it appeared at the end. Each report was signed by the attending pathologist; however, not all forensic pathologists provided a date next to the signature. Upon review of each manner category the reports indicated that some cases received an external examination only, a partial examination, or a full autopsy. It was not clear through the review of the report nor the review of the standard operating procedures as to what type of case receives what type of examination. What also was not as readily apparent was when an autopsy report required the review and signature of two forensic pathologists. Several autopsy reports, particularly homicide cases, had signatures of both the attending forensic pathologist and his/her colleague. In order to ensure reliable quality, it is important for the autopsy report to undergo peer review. Peer review can include quality review by a second pathologist for all homicides and undetermined cases as well as a yearly 10 percent random review of all cases. A quality review should also extend to the coroner’s investigative report. There was no indication that the investigators report undergoes a peer review. In addition, the investigators report of those cases where coroner’s jurisdiction is not established are not reviewed by the attending forensic pathologist. Review of investigators reports by the attending forensic pathologist should occur on every case within 24 hours of the report. The majority of the autopsy reports reviewed were natural and accident cases. The general organization, content, cause and manner of death, and quality scored high with an average score of 2.8 out of 3.0. What was variable was the use of microscopic analysis/histology. Many physicians did not use microscopic analysis for determining cause of death. Even more concerning, the review of several of the infant autopsy reports also did not reveal the use of the 21 | P a g e
ATTACHMENT A microscopic analysis. Microscopic analysis for infant deaths are standard for all infant death examinations. Review of the homicide and suicide autopsy reports revealed also an average high score of 2.6 out of 3.0 for organization, content, cause and manner of death, and quality. The main issues are the lack of photographs/photographic CD available in the paper record on all homicide cases as well as the lack of post-mortem diagrams in all cases, particularly in homicide case reports. Upon review of the sample reports for deaths in the custody of law enforcement, the manner of death recorded by the forensic pathologist on the data sheet was not the manner of death certified by the coroner in several of the cases reviewed. In cases where there was a direct physical altercation with law enforcement, the forensic pathologist indicated the manner as homicide. The ultimate coroner manner of death was certified as accident for the aforementioned cases. There were, however, other examples where manner of death indicated by the forensic pathologist was different than the manner of death certified by the coroner. Many of the cases where there was a difference between the manner of death of the coroner and the forensic pathologist revealed a need for improved communication prior to final certification. Autopsy Reports Strength • Well written and organized autopsy reports Weakness • Variability of dictation time frame • Variability of transcription time frame • Uniformity and layout of report case file • Variability of autopsy report layout • Absence of microscopic analysis/histology sections • Absence of autopsy examination diagrams • Absence of peer quality review by second forensic pathologist • Absence of investigator report review by forensic pathologist • Correlation and communication surrounding cause and manner death Opportunity • Develop clear policy for autopsy report dication and transcription • Outsource autopsy transcription service • Develop a uniform layout for the coroner case file • Identify staff dedicated to manage case reports • Standardize autopsy report layout • Develop clear policy on the inclusion of autopsy examination diagrams • Develop clear policy on the inclusion of photographs • Develop quality review procedures for both investigator and autopsy reports • Develop policy on cause and manner of death determination • Develop communication model for manner of death determination
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ATTACHMENT A Morgue Facility According to Grand Jury documents from 2010, “the County Morgue was built in the late 1930's as a crematory for the San Joaquin County Hospital. It was converted in the mid 1980's to a morgue facility. The morgue is small and outdated for a county in excess of 640,000 residents. The facility has a capacity of twenty three (23) decedents in the morgue and six in temporary storage located in back of the morgue. The rooms in the Morgue include: an entry way with a floor scale, six roll out wall compartments, a walk-in refrigerator, the autopsy/preparation room, one bathroom, two offices that were once crematories and a Columbarium.” The Grand Jury established that “the building is deteriorating due to wear and tear and dry rot. Testimony verified the building has asbestos. Exposure to asbestos is a health risk for all staff and visitors to the facility. The ventilation in the autopsy/preparation room lacks proper airflow and employees have to rely on a portable ventilator. Due to a lack of space, Formalin-filled jars with tissue samples from autopsies are stored on shelves in the Columbarium that are kept for one year and one day. The Grand jury found that the San Joaquin County Coroner’s Office morgue building is also small for the amount of cases handled by the Sheriff/Coroner; and the use of asbestos and formalin and other chemicals creates a health hazard to all persons working in or visiting the morgue.” In 2011, the San Joaquin County responded to the Grand Jury findings by working to isolate the asbestos and ensuring that formalin monitors were available for the mortuary staff. During the in-person evaluation and interviews, this evaluator identified the lack of space described in the Grand Jury Report including formalin-filled jars stored in the Columbarium. Formalin monitors were, however, not observed. What was most compelling is the distant location of the morgue unit from the administrative office. The morgue unit is approximately 200 feet from the main administrative office. The main administrative office was built in 1992 and has a modern configuration. The office building houses all additional Sheriff as well as Public Administrator responsibilities. Because of the deterioration of the current morgue facility, there are plans to build a new morgue facility complete with a larger autopsy suite, improved ventilation, a larger cooler capacity, as well as improved office and meeting spaces. Phase 1 of this project does not include the development of associated administrative space. Therefore, management leadership will still be in a separate building. It is important to note there are a total of 5,574 indigent cremains that have not been relocated or claimed. They are still stored in a 30 x 25 feet Columbarium and date back to 1935 within the current morgue. It has been reported that it would cost the County approximately $600,000 to legally and respectfully dispose the cremains. The cremains are currently being properly stored and would remain stored in this location even after the building of the new morgue facility. The following are the strengths, weaknesses, and opportunities within the Morgue Facility.
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ATTACHMENT A
Morgue Facility Strength • Plan to construct brand new forensic morgue facility • Budget set aside to construct brand new forensic morgue facility Weakness • Current facility has been designated a health hazard by the San Joaquin Grand Jury 2010 • Management leadership not under the same roof as the Morgue staff Opportunity • Continue with the plans of building a new forensic morgue facility • Expand plans to include the construction of associated administrative offices
BUDGET The San Joaquin County Government’s 2017-2018 budget was adopted at $1.63 billion. The County’s General fund totaled $887 million. The Law & Justice Division makes up 20% of the budget at $326.2 million. The Sheriff’s Division makes up approximately 49% of the Law & Justice Budget at $159.8 million. The Coroner’s Office budget is approximately $2.8 million, which represent 1.8% of the overall Sheriff’s budget. The budget plan for 2017-2018 included $8.9 million allocated to the construction of the new morgue facility. Supplemental budget requests that were funded for the Sheriff’s Office totaled approximately $1.6 million including only $62,793 going to the Coroner’s Office for the addition of a new Senior Office Assistant.
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ATTACHMENT A Communication with the Sheriff-Coroner revealed approximately 838 total positions including approximately 343 sworn officers within the Division. At the time of this report, there were approximately 94 vacancies for the entire Sheriff-Coroner Division. As projected at midyear, December 31, 2017, the Sheriff’s Department projected year-end general fund budget savings totaled $1.9 million.
RECOMMENDATIONS The San Joaquin County Coroner’s Office has highly motivated and dedicated staff who want to perform timely and accurate death investigations. Nonetheless, there is great opportunity to improve the office and how it functions. The San Joaquin County Coroner’s Office must adapt a new structure to properly serve the citizens of San Joaquin County. The organizational structure must ensure that the individuals with the most knowledge and experience in conducting medicolegal death investigations provide the ultimate management and leadership for the office. The office must be and appear to be independent of law enforcement particularly when investigating deaths in the custody of law enforcement or while in jail/prison. This requires a complete shift towards a Medical Examiner System. The Medical Examiner System gives the County the best opportunity and tools required to establish the necessary standards for an improved level of service, maintain independent objectivity, and rebuild the public trust. The recommendations listed below represent an initial list of the most critical issues to be addressed while attempting to transition to a Medical Examiner System for medicolegal death investigation. With the proper training, management and oversight, many of the current staff can be utilized in the path forward. In addition, with intentional use of general fund savings and the yearly variance within the overall Sheriff budget at $1.9 million, the existing County-Wide budget can cover the initial and future expenses of such an undertaking.
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ATTACHMENT A The recommendations are as follows: 1. Immediately develop a comprehensive Occupational Health and Safety Program for the agency and staff 2. Develop an improved system for reporting and documentation of deaths in the jurisdiction 3. Develop an organizational structure that ensures that those with the most knowledge and experience are providing leadership 4. Participate in agency accreditation process by the National Association of Medical Examiners (NAME) 5. Establish a Chief Administrator for the office who is responsible for budget and human resource management and general office compliance 6. Ensure that the forensic pathologist structurally and functionally provides management over all medicolegal death investigations 7. Hire seven (7) additional death investigators 8. Hire one (1) additional forensic pathologist 9. Hire one (1) additional Morgue technician 10. Hire one (1) additional staff assistant 11. Ensure death investigations are conducted exclusively by full-time and trained death investigators a. Require forensic photography for all death scene visits 12. Participate in staff certification by the American Board of Medicolegal Death Investigation (ABMDI) 13. Ensure there are lead positions among the staff assistants, Morgue technicians, and death investigators 14. Update IT Case Management system to incorporate Morgue Tracking 15. Update and Improve all Standard Operating Procedures and Agency Policies a. Set policy for what types of death investigations receive scene visits b. Exclude deaths that occur while under the care of a medical facility c. Set policy to ensure that all cases receive a unique identifying death investigation case number at the time the case is accepted d. Set policy to ensure better oversight over body intake by contractor personnel e. Set policy to require death investigation reports be available to the forensic pathologist within 1 business day of the notification of death require death investigators to type their own investigations report f. Set policy to ensure that all examinations occur within 3 days of receipt of the body g. Set policy for uniform identification methods to include best practices h. Set policy to ensure that autopsy report dictation occurs within 5 days of autopsy examination
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ATTACHMENT A i.
Set policy to ensure that autopsy report dictation is transcribed within 1 week from dictation j. Set policy that promotes improved autopsy report turn-around time to 90% within 90 days k. Set policy to ensure that forensic pathologists have input into final cause and manner of death 16. Develop uniform standard for the Autopsy Report 17. Develop comprehensive communication model for cause and manner of death development and certification. 18. Outsource autopsy report transcription service to ensure proper records management 19. Develop dedicated Records Management Staff 20. Develop comprehensive Quality Program for the agency a. Introduce Performance Management of both the entire staff and agency as a whole b. Regular quality review of death investigation reports c. Regular quality review of autopsy reports 21. Ensure consistency between Cause of Death and Manner of Death a. Annual review and revision of the Standard Operating Procedures b. Ensure that forensic pathologist is present during morning meetings 22. Ensure that ancillary testing (microbiology, histology) and consultation services (anthropology, pediatric pathology, cardiac pathology, and neuropathology) consistently is available to forensic pathologists for all relevant cases. 23. Ensure that radiology is available at the onsite morgue by the purchase Portable Digital X-ray https://newbethel.ccbchurch.com/goto/forms/38/responses/newSystem
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ATTACHMENT A
Chief Medical Examiner
Current Positions Positions Recommended
Chief Administrator
Administration
Death Investigations
1 Lead Staff Assistant
2 Lead Death Investigator
3 Staff Assistants Records Management
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10 Death Investigators
Forensic Pathology
2 Forensic Pathologists
Morgue Services
1 Lead Morgue Technician
3 Morgue Technicians Includes 5 current death investigators
ATTACHMENT B OFFICE OF THE
COUNTY COUNSEL COUNTY OF SAN JOAQUIN 44 NORTH SAN JOAQUIN STREET, SUITE 679 STOCKTON, CA 95202-2931 TELEPHONE: (209) 468-2980 FAX: (209) 468-0315
J. MARK MYLES COUNTY COUNSEL
DEPUTY COUNTY COUNSEL: LAWRENCE P. MEYERS MATTHEW P. DACEY KIMBERLY D. JOHNSON JASON R. MORRISH QUENDRITH L. MACEDO ROBERT E. O’ROURKE LISA S. RIBEIRO ZAYANTE (ZOEY) P. MERRILL ERIN H. SAKATA KIRIN K. VIRK CHILD PROTECTIVE SERVICES COUNSEL: (209) 468-1330 DANIELLE DUNHAM-RAMIREZ SHANN S. KENNEDY ALISTAIR SHEAFFER NIKOLAS ARNOLD
RICHARD M. FLORES ASSISTANT COUNTY COUNSEL
KRISTEN M. HEGGE CHIEF DEPUTY COUNTY COUNSEL
April 13, 2018
Board of Supervisors 44 N. San Joaquin Street, Suite 627 Stockton, CA 95202 Dear Board Members: In December 2017, County Counsel (Counsel) was asked to review the memoranda of Drs. Omalu and Parson, and to provide a report to the Board of Supervisors. This report examines only the allegations raised in the memoranda and responses from the Coroner’s Office (Office). This report does not evaluate the operations of the Office, and does not attempt to determine whether the Office employs best practices. Counsel prepared this report by reviewing the memoranda of Drs. Omalu and Parson; obtaining responses from the Coroner’s Office to each of the memos; interviewing Drs. Omalu and Parson; interviewing Sheriff-Coroner Steve Moore, Assistant Sheriff Annette Mondavi, Chief Deputy Coroner Sgt. Mike Reynolds, and the autopsy attendants. Counsel researched statutes, case law, and other authorities pertaining to the Office. Counsel also researched publications by the Department of Justice and the National Association of Medical Examiners. Background: In July 2005, the County Administrator completed an evaluation of the Coroner’s Office and presented its report to the Board of Supervisors recommending that the Board reaffirm the elected office of the Sheriff/Coroner/Public Administrator. The report principally examined the fiscal realities of separating the offices. The report indicated that the consolidation of the Sheriff-Coroner offices may represent the original configuration of the offices in San Joaquin County, though no records could be found for verification.
ATTACHMENT B April 13, 2018 Page 2
In 2007, Dr. Bennett Omalu was hired by San Joaquin County as a part-time physician working as a forensic pathologist under the direction of the San Joaquin County SheriffCoroner and the chair of the Department of Surgery. In hiring Dr. Omalu, the County sought to reduce its expense incurred through the use of contract physicians. In October 2016, Dr. Susan Parson was hired by the County as a part-time physician working as a forensic pathologist under the direction of the San Joaquin County SheriffCoroner and the chair of the Department of Surgery. By hiring Dr. Parson, the County sought to further reduce its expense for contract physicians. In November 2017, Dr. Parson tendered her resignation to the County Administrator. Subsequently, she provided the County with a 50-page memorandum she had prepared over the course of six months, detailing her criticisms of the Coroner’s Office. In December 2017, Dr. Omalu tendered his resignation and also provided a 50-page memorandum detailing his criticisms of the Coroner’s Office. Legal Authority for the Office of the Coroner: The office of the coroner is created by the Legislature which specifically made it an elected office. The Legislature also provided that the office may be changed from an elected office to an appointed office by submitting the question to the electorate. (Government Code § 24009.) 1 The Legislature also granted to the Board of Supervisors the authority to abolish the office of the coroner and replace it with a medical examiner “who shall be appointed by the Board.” (§ 24010.) There have been numerous representations to the Board of Supervisors that California is the only State that maintains a Sheriff-Coroner system. This is neither an accurate description of State law, nor an accurate description of how coroner systems work in other states. California law does not require that the offices of sheriff and coroner be held by the same person. Nor does it require that the Coroner’s Office function through the Sheriff’s Office. Those are decisions made at the local level for a variety of reasons, including cost and organizational efficiency. While a majority of California counties maintain sheriffcoroner offices, some counties have an independent coroner office, while others have abolished the office in favor of a medical examiner system. According to the Center for Disease Control, California is 1 of 14 states with a county-based mixture of coroner and medical examiner offices. There are another 14 states that have a county, district or parish-based coroner system. Counsel was able to find examples of combined sheriff-coroner offices in Nevada, Montana and South Dakota.
1 All code references are to the Government Code, unless noted otherwise.
ATTACHMENT B April 13, 2018 Page 3
Duties of the Coroner: The duties of the Coroner are specified in State law and include: “the duty to inquire into and determine the circumstances, manner, and cause of all violent, sudden, or unusual deaths; unattended deaths; deaths where the deceased has not been attended by either a physician or a registered nurse, who is a member of a hospice care interdisciplinary team, as defined by subdivision (g) of § 1746 of the Health and Safety Code in the 20 days before death; deaths related to or following known or suspected self-induced or criminal abortion; known or suspected homicide, suicide, or accidental poisoning; deaths known or suspected as resulting in whole or in part from or related to accident or injury either old or recent; deaths due to drowning, fire, hanging, gunshot, stabbing, cutting, exposure, starvation, acute alcoholism, drug addiction, strangulation, aspiration, or where the suspected cause of death is sudden infant death syndrome; death in whole or in part occasioned by criminal means; deaths associated with a known or alleged rape or crime against nature; deaths in prison or while under sentence; deaths known or suspected as due to contagious disease and constituting a public hazard; deaths from occupational diseases or occupational hazards; deaths of patients in state mental hospitals serving the mentally disabled and operated by the State Department of State Hospitals; deaths of patients in state hospitals serving the developmentally disabled and operated by the State Department of Developmental Services; deaths under such circumstances as to afford a reasonable ground to suspect that the death was caused by the criminal act of another; and any deaths reported by physicians or other persons having knowledge of death for inquiry by coroner.” (§ 27491) The San Joaquin County Coroner carries out these functions through the Coroner’s Office and the Sheriff’s patrol division. The patrol division is not reflected in the Coroner’s budget but is tasked with the initial response to, and investigation of a reported death. The patrol deputy gathers initial information about the decedent and the death scene, obtains information where available about known medical conditions, relatives, and the circumstances of the death. The patrol deputy dictates a coroner’s report, which is later transcribed by the Coroner’s Office. The patrol deputies respond to an average of four to five cases per day. On average, cases take 300 minutes each to process. The Chief Deputy Coroner is responsible for the daily administration of the office, and ensuring the duties of the office are properly executed. He is assisted by five coroner investigators responsible for completing the death investigation, and three senior office assistants who are responsible for transcribing the coroner’s reports, the autopsy reports, and maintaining the files. The Coroner’s Office also employs two forensic pathologists and three autopsy technicians who assist the physicians and maintain the morgue, which is physically separate from the Coroner’s Office.
ATTACHMENT B April 13, 2018 Page 4
In September 2017, the Coroner instituted a new program tasking the coroner investigators with the duty to respond to death cases during regular duty hours (M-F, 0600 to 1500) and patrol deputies to respond during the remaining hours. The goal of this program is to increase the quality of the death investigations performed by the County. It has already decreased the average time on scene from 300 minutes to 100 minutes. Analysis of Complaints: The memoranda of Drs. Omalu and Parson chronicle their criticisms of the Office over a six-month period. To prepare a cogent report, without unnecessarily repeating the facts of each incident, I have analyzed the memoranda and believe they can be distilled into four major themes: I. II. III. IV.
Interpretation of Duties and Responsibilities Training Mismanagement of Resources/Insufficient Resources Hierarchical Structure of the Office/Infringement of Physician Independence
This report will address each of these themes, and will also analyze the issue of the authority of the Coroner to order the removal of hands from “DOE” decedents for the purposes of identification. I. Interpretation of Duties and Responsibilities: The duties of the coroner are prescribed in the Government Code and generally include the duty to identify the decedent, the duty to determine the cause of death, and the duty to determine the manner of death. The criticisms relating to interpretation of duties and responsibilities principally revolve around: 1. the duty to determine the manner of death 2. the duty to consult with the physician who performed the forensic autopsy The Coroner is generally required to “inquire into and determine the circumstances, manner, and cause of all violent, sudden, or unusual deaths…” (§ 27491.) The Coroner has a duty “ … on being informed of a death and finding it to fall into the classification of deaths requiring his inquiry, may immediately proceed to where the body lies, examine the body, make identification, make inquiry into the circumstances, manner and means of death…” (GC 27471.2)
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The authority for the coroner to take possession of a body and make or cause to be made a postmortem examination or an autopsy is found in § 27491.4. “Forensic autopsy” is defined in State law as an examination of the body of a decedent to generate medical evidence from which the cause of death is determined. It defines the postmortem exam as the external exam of the body where no manner or cause of death is determined. (§ 27522) The statute requires that an autopsy include all positive and negative findings pertinent to establishing the cause of death, and also requires that all postmortem exams and autopsies include the taking of all available fingerprints and palm prints. (27521 (b)(1).) State law also expressly allows for the removal of the maxilla and mandible or other bone sample from unidentified persons and requires that the agency retain the samples for one year after positive identification or indefinitely. (GC 27521 (f)). The duty to consult arises from GC 27522 (d) which states “The manner of death shall be determined by the coroner or medical examiner of a county. If a forensic autopsy is conducted by a licensed physician or surgeon, the coroner or medical examiner shall consult with the licensed physician or surgeon in the determination of the manner of death.” 1.
Duty to Determine the Manner of Death.
There are two primary duties of the Office – determine the cause of death and determine the manner of death. The law is absolutely clear that an autopsy may only be performed by a licensed physician and surgeon. The law is also absolutely clear that in a Coroner’s Office, the duty to determine the manner of death falls on the coroner. (§ 27522.) Additionally, in instances where an autopsy has been performed, the coroner must consult with the physician when determining the manner of death. (§ 27522(d). See discussion below.) There are five possible outcomes for the manner of death determination: natural, accident, homicide, suicide, or undetermined. Dr. Omalu criticizes the Coroner for considering intent when determining the cause of death. Dr. Omalu and Dr. Parson criticize the Coroner for selecting a manner of death that was different from the manner of death they recommended without consulting them. (Omalu pg. 4, 6; Parson pg. 19-20.) The National Association of Medical Examiners published a guide in 2002 titled A Guide for Manner of Death Classification. Among the caveats contained in the preface are “The recommendations contained herein are not standards and should not be used to evaluate the performance of a given certifier in a given case. Death certification and manner-of-death classification require judgment, and room must be allowed for discretion on a case-by-case basis. It must be recognized that when differing opinions occur regarding manner of death classification, there is often no ‘right’ or ‘wrong’ answer or specific classification that is better than its alternatives.” It also states that there is a “fundamental premise that manner of
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death is circumstance-dependent, not autopsy-dependent” meaning that the manner of death must consider all of the circumstances that resulted in the death, not just those that are reflected in the autopsy. As to the role of intent when classifying the manner of death, the guide states that while the concept of intent in manner of death determinations differs from the concept of intent in the law, “one cannot escape the need to consider intent when classifying manner of death.” (Id at 5.) Because injuries are often classified as intentional or unintentional “…assessment of ‘intent’ does relate to manner-of-death classification: it necessarily underlies the quasi-judicial responsibility derived from the enabling law in the relevant jurisdiction of the death certifier.” (Id at 8.) The guide provides general principles to be applied to the five manners of death. It states “Accident applies when an injury or poisoning cause death and there is little or no evidence that the injury or poisoning occurred with intent to harm or cause death. In essence, the fatal outcome was unintentional.” (emphasis added.) The guiding principle for homicide states “Homicide occurs when death results from a volitional act committed by another person to cause fear, harm or death. Intent to cause death is a common element but it is not required for classification as homicide… It is to be emphasized that the classification of homicide for the purposes of death certification is a ‘neutral’ term and neither indicates nor implies criminal intent, which remains a determination within the province of the legal processes.” The guide recommends that where intent is difficult to determine “the concept of volition or voluntary act may be useful.” (Id at 8.) It states “In general, if a person’s death results at the hands of another who committed a harmful volitional act directed at the victim, the death may be considered a homicide from the death investigation standpoint.” (Id.) Dr. Omalu’s criticisms regarding intent arise in the context of officer-involved deaths. He acknowledges in his memoranda that the Coroner has the discretion and authority to classify the deaths as he deems appropriate, yet criticizes how the coroner exercises his discretion. The Coroner, classifying the manner of death in officer-involved deaths, considers the intent of the involved officer as evidenced by the conduct of the officers. If the officer uses force which was likely to result in serious bodily harm or death, the Coroner has classified those deaths as homicides. When the evidence is that the officer has used an intermediate level of force not likely to result in serious bodily harm or death, the Coroner has classified those deaths as accidents. Conclusion: The Coroner has the duty to determine manner of death. The Coroner applies a standard methodology to determining manner of death in officer-involved deaths which includes consideration of the circumstances and intent. The National Association of Medical Examiners guide plainly states that the manner of death is a “circumstancedependent” analysis and that intent is a relevant factor to consider. It further recognizes that
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when differing opinions occur as to the manner of death, there is no “right” or “wrong” answer or specific classification that is better than the alternatives. 2.
Duty to Consult
Both Dr. Omalu and Dr. Parson complained about the Coroner reaching a manner of death determination different from the one they reached and not consulting with them. Senate Bill (SB) 1189 was adopted by the Legislature and signed into law in 2016, becoming effective on January 1, 2017. The bill modified several existing statutes regarding the duties of the coroner and medical examiner. It also added Gov’t Code § 27522(d) which states in full “For purposes of this section, the manner of death shall be determined by the coroner or medical examiner of a county. If a forensic autopsy is conducted by a licensed physician and surgeon, the coroner or medical examiner shall consult with the licensed physician and surgeon in the determination of the manner of death.” Thus, imposing on coroners and medical examiners a duty to consult with the physician who performed the forensic autopsy when determining the manner of death. (GC 27522(d).) The statute does not contain a definition of what it means to consult, nor are there any cases interpreting this code section. The statute requires that the person responsible for determining the manner of death “consult with” the person responsible for determining the cause of death. Dr. Omalu explained in his interview that one of the processes he instituted when he came to the County, was the use of the Autopsy Summary form which is completed by the physician performing the autopsy. The form allows the physician to check a box indicating the manner of death recommendation. The doctor shared that he did this to make it easier for the coroner investigators and so they could ask questions, if they had any. SB 1189 does not presume the existence of a report that contains a manner of death recommendation by the physician, and it does not limit the duty to only those cases where there is disagreement regarding the manner of death. A strict interpretation of the statute requires “consultation” in all cases where a forensic autopsy has been performed. What does it mean “to consult with” the physician who performed the autopsy? Generally accepted principles of statutory interpretation require that in the absence of a definition in the statute, words are given their common meaning. Webster’s defines consult as a transitive verb meaning “a. to ask the advice or opinion of” or as an intransitive verb meaning: “1. to consult an individual; 2. to deliberate together; or 3. to serve as a consultant.” The statute does not propose that the decision on the manner of death be made jointly when a forensic autopsy is performed. It plainly states that it is the responsibility of the
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coroner to make that decision. The purpose of consult[ing] with the physician who performed the forensic autopsy then must be to ensure that the coroner or medical examiner understands the cause of death as determined by the forensic autopsy. If there was no summary of the autopsy and no recommendation on the manner of death, it would be appropriate for the coroner or medical to discuss the results of the autopsy in every case. If the physician has provided a summary of the cause of death, and a recommendation on the manner of death, and the coroner considers the report, summary, and recommendation, and has no questions and agrees with the recommendation based on his consideration of all of the circumstances, there is little to be gained by further consultation. If the physician has provided a summary of the cause of death and a recommendation on the manner of death, and the coroner considers the report, summary, and recommendation, and has questions or based on his consideration of all of the circumstances, disagrees with the recommendations, consulting with the physician would ensure that the coroner understood why the physician reached the conclusions he or she did. Dr. Parson is of the belief that “shall consult,” as used in the statute means that there must, at minimum, be a conversation about the autopsy. The Chief Deputy Coroner is of the opinion that “shall consult” requires him to consider the determinations reached by the physicians, and if he has questions regarding the determinations, he should discuss those with the physicians. Conclusion: The coroner has a duty to consult with the physician performing the forensic autopsy. The autopsy summary form with recommendation on the manner for death completed by the physician performing the autopsy is a valuable tool for the Coroner. If the Coroner reaches a conclusion that is different from the conclusion reached by the physician, the Coroner and the physician should deliberate together regarding the determination of the manner of death so that each understands the other’s perspective. There is no requirement that they agree as to the manner of death. II. Death Investigation Training of Coroner Investigators and Patrol Deputies Drs. Parson and Omalu both complain about the absence of credentialed, trained and certified investigators to perform competent death investigations. (Omalu p. 18, Parson p. 2) Additionally, Dr. Parson complained: 1. Of an absence of official coroner protocols and policies including policies governing CT scans and the handling of SIDS cases. 2. That the investigative narratives are incomplete and often fail to include specific facts regarding the manner of death.
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1.
Absence of credentialed, trained and certified death investigators.
Within San Joaquin County, the duties of death investigation have historically been split between the patrol deputies and the coroner investigators. The patrol deputies respond when notified of a death and conduct the initial investigation. The coroner investigators are responsible for gathering additional information, requesting and obtaining medical records, obtaining information from investigating agencies, identifying the body, and investigating the manner of death. Patrol deputies are provided a four-hour block of coroner training at the mini-academy when they are initially hired by the Sheriff’s Department. This is followed by hands-on training under the supervision of a field training officer for six months. Each deputy is provided with a coroner’s binder containing the coroner’s forms and policies. Patrol deputies routinely respond to up to five deaths daily. Priority is given to those deputies in training. The Chief Deputy Coroner has attended the 80-hour POST Basic Death Investigation course and has attended the Advanced Coroner Death Investigator Symposium consisting of 32 hours of training each year for the past two years. 2 Two of the five coroner investigators have attended the Basic Death Investigator course and the Advanced Coroner Death Investigator Symposium. Two more investigators are projected to attend the Basic Death Investigation Course in Fiscal Year 2018-2019. The fifth investigator will attend the following year. The Chief Deputy Coroner and two investigators will attend the Advanced Death Investigator Symposium each year. Conclusion: The Chief Deputy Coroner, the coroner investigators and the patrol deputies are not certified by an independent credentialing organization like the American Board of Medicolegal Death Investigators (ABMDI). The Chief Deputy Coroner and two of the coroner investigators have attended the 80-hour POST basic coroner course and the Advanced Death Investigator Symposium. 3 As to the representation by Dr. Parson of an absence of coroner protocols and policies, including policies governing CT scans and the handling of SIDS cases, Counsel finds the allegations unsubstantiated. The Coroner’s Office has an extensive policy and procedure manual which includes a policy addressing when to obtain CT scans, procedures for identifying DOE decedents, a ten-page pamphlet in English and Spanish explaining SIDS and a 34-page policy and reference material for fetal death investigation, duties, responsibilities, and authority of the Coroner. 4 2 Sgt. Reynolds was appointed the Chief Deputy Coroner in October 2015. 3 I was unable to obtain course curriculum for the basic coroner course or the Advanced Death Investigator Symposium and therefore was unable to compare the training provided with the accreditation standards of the ABMDI. 4 The adequacy and sufficiency of those policies is addressed in Dr. Mitchell’s evaluation.
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2. Investigative narratives are incomplete, and often fail to include specific facts regarding the manner and mechanism of death. Drs. Omalu and Parson complain that the investigative narratives are incomplete and often fail to include specific facts regarding the manner or mechanism of death. As to the sub-issue that the narratives often fail to include specific facts regarding the manner and mechanism of death, the department responded that the information identified in Dr. Parson’s memo did not pertain to the cause of death, and would typically be included in the investigating agency’s report, which would be available to the physician. Conclusion: There is insufficient information to determine that the reports were incomplete. There are specific instances where the narratives were incomplete. When those instances have been brought to the Chief Deputy Coroner’s attention, additional training has been provided to the deputy who prepared the narrative. Additionally, there are instances where the reports failed to contain specific facts regarding the manner and mechanism of death. The coroners are not qualified to determine what information is or isn’t necessary for the physician to determine the cause of death. If the physicians believe that the reports lacked information necessary for them to function in an efficient manner, it was incumbent on the physicians to make the coroner aware of their need for additional information. III. Mismanagement of Resources/Insufficient Resources Drs. Omalu and Parson criticize the Coroner because cases are unnecessarily brought to the morgue, when they should have been signed off by the physician and taken to a funeral home. Dr. Omalu also complained about bodies being brought to the morgue and the physicians not being made aware they were there. (Omalu p. 48.) They have criticized the Coroner’s Office regarding the allocation of resources resulting in the transcription of reports not being completed in a timely manner. Further, they have criticized delays in acquiring medical records, alleging that once the bodies are brought to the morgue they are “compelled most times” to complete an external examination or partial autopsy because of delayed investigation reports or medical records, which increases costs and decreases efficiency. 1. Cases brought to the morgue, which should have been signed off by the physician; Physicians not aware of the bodies in the morgue. Both Drs. Omalu and Parson complained about decedents being transported to the morgue when the death should have been certified by the physician and the body transported to a funeral home. However, there are often extenuating circumstances that cause the Coroner to bring the decedent to the morgue. These include the inability to locate a physician to sign the death certificate; inability to locate next of kin; and the family being unable to make funeral arrangements at that moment.
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When families do not have funeral arrangements or lack funds to provide for services, the decedent is transported and stored at the morgue to assist the family. The families are always advised of the cost associated with the transport and are informed of the County’s indigent program to assist with the costs of removal if the family lacks financial resources. Decedents are brought to the morgue by a transportation company. The drivers leave documentation notifying the autopsy technicians of the delivery. It is historically the practice of the physicians to call the autopsy technicians each morning to learn about new cases that had come in. Conclusion: In some instances, decedents are brought to the morgue when the cause of death could have been signed off by the treating physician. Often decedents are brought to the morgue because the family is unprepared to cope with the situation at that moment. As to the claim that decedents are brought to the morgue and the physicians are unaware that the body is there, if the physicians were unaware of the presence of a body it was the result of a breakdown in the communication process the physicians had established. 2.
Transcription of Reports Not Being Completed in a Timely Manner
Dr. Omalu and Dr. Parson criticize the allocation of resources resulting in delayed transcription of coroner’s reports. The physicians opined that coroner reports must be transcribed before the physicians can evaluate the case and determine the level of examination required. When the deputies respond to a call reporting a dead body, the deputies prepare a coroner’s report. This report is dictated for transcription at a later time. In 2007, when Dr. Omalu was first employed by the County, the transcription was performed by staff working nights. As a result, all of the reports were ready when the physicians arrived in the morning. During the economic downturn, the unit that provided the overnight transcription was eliminated and the service was no longer available. Subsequently, the reports were transcribed by office assistants in the Coroner’s Office each morning. One office assistant would start her shift at 6:00 a.m. to transcribe the coroner reports before the physicians arrived. They also transcribed the autopsy reports of Dr. Omalu. With the hiring of Dr. Parson in October 2016, the Coroner requested the addition of a third office assistant in the 2017-2018 budget. In April 2017, one of the two office assistants transferred to SJC Probation, leaving just one office assistant to transcribe all of the coroner reports and the autopsy reports. The office assistant would start her shift at 6:00 a.m. Additionally, over three-day-weekends, the
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office assistant would come into the office to transcribe the pending reports to ensure the most efficient workflow given staffing limitations. On June 26, 2017, a replacement office assistant was hired and trained on the transcription program. A third office assistant was hired on August 7, 2017. According to the Coroner’s Office, it takes three to four months for new office assistants to become proficient in the transcription of reports. Conclusion: All coroner’s reports are not completed before the beginning of the physician’s day. For a significant portion of Dr. Omalu’s tenure with the Coroner’s Office, overnight transcription has not been available. This issue appears to have become critical when the office was short-staffed due to vacancies. Due to the vacancies, there was a delay in the daily transcription of reports. Not having the reports complete at the beginning of the shift affected the ability of the physicians to schedule their workload. 3.
Delays obtaining medical records.
Drs. Omalu and Parson both complained about delays receiving medical records. They allege that in some cases bodies were delivered to the morgue and nothing was done to obtain records for several days. They contend that if medical records are not received in a timely manner it can delay the evaluation and determination of whether an autopsy is necessary. When a body is brought to the morgue, the Coroner investigators review the Coroner case report to identify the decedent’s physician. Often this is accomplished by reviewing prescription bottles, or obtaining information from a family member. In those cases where the investigator is able to identify the physician, the investigators call the physician’s office and make a verbal request for the records. The verbal request is followed with a written request. If the records are not extensive, they are often faxed to the Coroner’s Office. If they are extensive, the physician’s office will usually save them to a disc and deliver it to the Coroner’s Office. In most cases, the medical records are received the same day they were requested. On occasion, the physician’s office has not provided the records on the same day, and in some cases have not provided the records in a timely manner. When the records are received, they are included in the case file or uploaded to the system and the autopsy technicians are advised to inform the physicians. When the identity of the treating physician is unknown, the investigators contact all of the area hospitals and urgent care centers to attempt to locate records. On occasion, they have been unable to obtain medical records for a decedent. With regard to the claim that bodies were delivered to the morgue and nothing was done for days, the Coroner’s Office records indicate that those statements are not accurate. Records were requested in a timely manner, although in some cases the records were not
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provided in a timely manner. In other cases, the records were provided in a timely manner and were added to the file. The reason the physicians were not aware of the records delivered is undetermined. Conclusion: There have been delays obtaining medical records, but the delays are not to the extent alleged, and are not the result of negligence within the Coroner’s Office. IV. Hierarchical Structure of the Office/Infringement of Physician Independence 1.
Morning Briefings
Drs. Omalu and Parson alleged that the Sheriff’s Office was infringing on their independence and attempting to influence how they did their work, and the type of exam they performed, by having them attend an office meeting with the Chief Deputy Coroner, coroner investigators, and autopsy technicians at 9:00 each morning to review the pending cases. Prior to the implementation of the morning briefings, the Chief Deputy Coroner had been informed that there was a level of animosity developing among the autopsy attendants and a concern that work was not being evenly distributed. To address these concerns and to facilitate the timely dissemination of information regarding the cases and the actions and other materials that were required for each case, the Chief Deputy Coroner instituted the morning briefings. Although the physicians purposefully limited their participation in the meetings, Dr. Parson acknowledged in her interview that during the meetings, no one attempted to influence how the physicians performed their work or the types of examinations performed. 2.
Physician Scheduling
Drs. Omalu and Parson complain that physician scheduling can only be performed by a physician, and that the Coroner’s attempt to take over the scheduling was a total disaster. Prior to the hiring of Dr. Omalu, the County relied exclusively on contract physicians. When Dr. Omalu was hired, the need for contract physicians was reduced but not eliminated. The justification for hiring Dr. Parson was that it would further reduce the reliance on contract physicians. The contracts of both Drs. Omalu and Parson state that they were hired as “part-time physicians” who “1. … shall work as forensic pathologists under the direction of the San Joaquin County Sheriff-Coroner and the Chairperson of the Department of Surgery… 3. The Employee shall be hired as a part-time employee working a 95% schedule, which will
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provide that Employee will work 19 days out of every 20 days he is scheduled to work. The employee work schedule shall be determined by the Sheriff-Coroner in consultation with Employee in accordance with the 95% part-time status…” (Emphasis added.) In 2017, a financial analyst at the Sheriff-Coroner’s Office noted that the use of contract physicians was increasing and brought it to the Coroner’s attention. Based on the records, it appears that when Dr. Omalu was preparing the schedule he was not accounting for the 95% status. Because of the contractual requirements to account for the 95% schedule and to ensure the availability of one of the two employee physicians instead of the contract physicians, the Chief Deputy Coroner was directed to take over scheduling. This was not implemented until October 2017. The doctors both wrote that the scheduling by the Coroner was a disaster and that it failed to account for their activities outside of the Coroner’s Office, such as meetings with the District Attorney and Dr. Omalu’s teaching duties at U.C. Davis. To prepare the schedule, the Chief Deputy Coroner requested that the physicians provide a list of any days they were not available for autopsies. They did not identify any personal or professional days when they would be unavailable. The Sergeant prepared a schedule based on the information available. The physicians failed to inform the Chief Deputy Coroner of commitments they had outside of the office that would conflict with the autopsy schedule. Conclusion: The contracts of Drs. Omalu and Parson state “The employee work schedule shall be determined by the Sheriff-Coroner in consultation with Employee in accordance with the 95% part-time status…” The schedule prepared by the Chief Deputy Coroner was consistent with the contractual requirements. The schedule prepared by the Chief Deputy Coroner did not reflect outside commitments Drs. Omalu and Parson had because they failed to provide that information. 3.
Sergeant-Coroner ordering when autopsies are to be performed.
Both Drs. Omalu and Parson recite incidents where they allege that the SergeantCoroner was ordering when the autopsies were or were not to be performed. Oftentimes, the investigating agency will request to attend the autopsy. The request is made to the coroner investigator who conveys it to the physician who provides the start time. Typically, the physicians try to give at least an hour notice of the start of the autopsy. At times, the investigating agency will ask that the autopsy be delayed until they can attend. Dr. Parson alleged that in one incident, the Chief Deputy Coroner requested that the two autopsies be delayed until the next duty day. She alleges that one of the cases was a homicide, which should have been completed within 24 hours, and alleges that the Sergeant failed to identify it as such. She alleges that his explanation for delaying the autopsies was
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due to staff reassignment in the office. She also alleges that he characterized the homicide as a case “that required more information.”(Parson pg. 14.) Dr. Parson states in the memorandum that she received other requests for delays and that at times she rejected those requests. The Chief Deputy Coroner reported that the request for the delay was made by the investigating agency because their staff had been on duty for 24 hours. He also reported that while he did not recall if he specifically identified it as a homicide, it was his practice to provide the physician with the circumstances of the death, and that it was through that process that Dr. Parson told him that she needed additional records. Dr. Omalu reports similar incidents where he alleges he was ordered not to do an autopsy at a certain time. He writes that the deputy called the autopsy technician who relayed to him that the Chief Deputy Coroner was ordering that the autopsy not be conducted. (Omalu pg. 24) The Chief Deputy Coroner reported that he received a request from the investigating agency to delay the autopsy so the investigators could attend and relayed that request through the staff. The Chief Deputy Coroner is adamant that only the physicians can schedule the autopsies. He acknowledges making the requests to delay the autopsies but denies ever ordering that autopsies be done or not done at certain times. Conclusion: The Chief Deputy Coroner asked that autopsies be delayed at the request of the investigating agency. Dr. Parson acknowledges having received such requests and having denied them on occasion. In the incident identified by Dr. Omalu, he did not speak with the coroner investigator himself, but only reports what he was told. In none of the reported instances did the physicians reject the request. There is insufficient evidence to support the allegation that the Chief Deputy Coroner ordered when autopsies would or would not be done. Removal of Hands and Digits for Purposes of Identification One of the most salacious and controversial portions of the memoranda related to the removal of hands for the purposes of identification. Drs. Omalu and Parson have criticized the practice of removing digits or hands for the purposes of identification. Drs. Omalu and Parson expressed concern with the loss of their medical license should they participate in the removal of hands for the purposes of identification. Dr. Omalu has also written that the activity of the removal of hands was undertaken “on a whim” by the Chief Deputy Coroner. He has also written that it is mutilation and illegal.
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The Coroner has a duty to identify the body. (§ 27491.2.) Government Code § 27491(b) provides the Coroner with discretion to determine the “extent of inquiry” that will be made. (§§ 27491.2; 27491.) Additionally, the law expressly allows for the removal of the jaw if the Coroner is unable to identify the body by other means. (§ 27522(f).) When a death occurs and it falls within the class of deaths, the Coroner is required to investigate. The normal legal requirement of consent is removed by operation of law. There are no cases interpreting §§ 27491 et seq. with regard to the duty to identify bodies, but the attorney general addressed this specific question and held that the Coroner has the authority to remove digits for the express purpose of identifying bodies. (44 Ops Cal Atty Gen 26.) To the accusation that the Chief Deputy Coroner engaged in this activity on a whim, the following information is provided: Hands or digits are only removed when the body is in an advanced state of decomposition so that visual identification is not possible and the office is unable to obtain fingerprints through conventional methods. When the hands or digits are removed, they are sent to a specialized Department of Justice laboratory for fingerprinting and then the hands are returned to the body. This is a long-standing practice, which predates Sheriff Moore and Sgt. Reynolds, is not limited to the County, and has occurred throughout Dr. Omalu’s tenure. According to the Department of Justice Sacramento Laboratory, over the past five years, the percentage of identification cases originating from the County constituted less than 20% of all cases processed by the lab, which required the removal of hands or digits. In the Coroner’s exercise of discretion granted under Government Code Section 27491, the Coroner has determined that there is a value in having the decedent identified with 100% certainty and ensuring that every conceivable measure has been exhausted to that end. Dr. Parson wrote in her memo that she was objecting to the procedure because it was not a coroner case and because the law stipulates that only a licensed physician may perform an autopsy. The Coroner is required to inquire into any unattended death. The Coroner has the discretion to determine the extent of inquiry to be made into any death occurring under natural circumstances, and falling within the scope of the deaths he is required to inquire into. (GC 27491 (b).) This was an unattended death; therefore, it was a coroner’s case. As to Dr. Parson’s second point regarding whether only a forensic pathologist could remove the hands, Dr. Parson refers to SB 1189, which implements GC 27522. GC 27522 states that a forensic autopsy shall only be performed by a licensed physician and surgeon. It further defines “forensic autopsy” as a procedure for determining the cause of death. The purpose of removing the hands was to determine identity, not to determine the cause of death.
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Even assuming that Dr. Parson is correct, and that no incision should be made except under the supervision of the physician – the Coroner was not ordering otherwise. The process established at the request of the physicians was for the Coroner’s Office to convey the request – whether for hands, digits, or DNA – to the autopsy technicians. The Coroner assumed the autopsy technicians were being properly supervised by the physicians. Conclusion: The Coroner has a duty to identify the body. The Coroner has the discretion to determine the depth of inquiry that will be made in a case. The Coroner has the authority to order the removal of digits or hands for the purpose of identification. The removal of hands or digits is a long standing, but rarely used process. CONCLUSION: As is always the case, there are two sides to every story. Usually the truth lies somewhere in between. While there is certainly room for improvement as identified above, Counsel has not found any facts to support nefarious or callous motives ascribed to the Chief Deputy Coroner or the Coroner. Aside from the lack of formal training in death investigation for the patrol deputies conducting death investigations, I believe that the majority of the remaining allegations could have been avoided, addressed, or remedied in an atmosphere of mutual respect and effective communications. Examples: • Dr. Omalu wrote about an incident where he requested an anthropologic autopsy which was never completed because as he wrote, “the lieutenant overrode his decision”. This was on an unidentified decedent. The lieutenant’s experience was that anthropologic autopsies were intended to help identify the person. Before the bones were sent to the anthropologist, the identity of the person was determined. For that reason, the anthropologic autopsy was not performed. This situation could have been avoided by the lieutenant checking with Dr. Omalu before making that decision. • Dr. Omalu wrote that Sgt. Reynolds authorized an organ harvest. The facts are that Dr. Parson authorized the organ harvest. • The Duty to Consult. An atmosphere encouraging mutual effective communication could have resulted in an understanding and agreement as to how the duty to consult would be carried out in practice. • Physician schedules. Effective communication would have ensured that the Chief Deputy Coroner was aware of all activities outside of the Office, which would have conflicted with the scheduled autopsy days.
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Finally, effective communication would have improved the overall operations of the Coroner’s Office. If the forensic physicians would have engaged with the Chief Deputy Coroner or Coroner as problems were encountered, much of these complaints could have been resolved. Respectfully submitted,
J. Mark Myles County Counsel
JMM:kr
Before the Board of Supervisors County of San Joaquin, State of California
B-
MOTION: Accept the San Joaquin County Coroner Review and Audit Report, Provide Staff Direction and/or Select Option for the Delivery of Coroner Services and Accept County Counsel’s Report Regarding the Allegations of Doctors Omalu and Parson
THIS BOARD OF SUPERVISORS DOES HEREBY: 1. Accept the San Joaquin County Coroner Review and Audit Report. 2. Provide staff direction and/or select an option for the delivery of Coroner services. a. Sheriff-Coroner/Morgue b. Elected Coroner/Appointed Coroner c. Medical Examiner 3. Accept County Counsel’s report regarding the allegations of Doctors Omalu and Parson.
I HEREBY CERTIFY that the above order was passed and adopted on by the following vote of the Board of Supervisors, to wit:
AYES: NOES: ABSENT: ABSTAIN: MIMI DUZENSKI Clerk of the Board of Supervisors County of San Joaquin State of California
__________________ Board Order Template October 2015