County of Plumas Civil Grand Jury Report

Conclusions 2

• CL1
  26 Based on the reports reviewed, autopsies were obtained in 20% of the sample cases (5 of 25, not including the partial autopsy in Case 8). Autopsies were not obtained in connection with certain deaths where NAME Standards best practices suggest they ordinarily should be obtained— including death by fire, involving thermal injuries (Case 5), death by drowning (Case 24) and death resulting from alcohol or drug abuse (Cases 7, 14, 18, 21, 23, 26). Moreover, in only one of the suicides was an autopsy performed. Similarly, no autopsy was obtained in certain cases deemed “accidents” that were not observed—Cases 5, 17, 24. The reports do not indicate why it was felt there was no need for an autopsy in any of these instances. It is the view of the Sheriff’s Department that the decision to obtain an autopsy is simply discretionary, and that this discretion is exercised by appropriate members of the Sheriff’s Department. The Grand Jury does not dispute that the decision to undertake an autopsy in California is (with the two exceptions noted above) one for professional judgment under the circumstances, but such discretion does not mean there is a complete absence of standards to be applied, or that the decision can be made arbitrarily or for inappropriate reasons, such as saving costs. Accordingly, it is appropriate for third parties such as the Grand Jury to try to assess the Sheriff’s Department performance in this area. Under the terms of the Coroner P&Ps, if an autopsy is not ordered, investigating deputies must obtain a blood sample. Based on the review of the reports, there were seven instances where, although an autopsy was not ordered, no blood sample was taken. These cases included all three exposure cases as well as one suicide and the death during a structure fire. In the majority of these cases, the decedent hadn’t been seen for a while prior to death and the narratives usually only set forth how the victim was found. In about a third of the sample cases, the reports did not indicate whether medical records had been requested. The Coroner P&Ps provide that medical records should be obtained in all Coroner Cases. Particularly in cases lacking an autopsy, blood sample results, and review of medical records (as in Cases 5, 13, 16), it is difficult to tell from the investigation report how the Sheriff’s Department determined with confidence the manner and cause of death. Case Closures and Updating Pending Death Certificates As noted above, near the beginning of the investigation, there were six cases in the sample listed as “Pending” in the EDRS. Follow up with the Sheriff’s Department revealed that these cases were considered “closed”. The EDRS system was not updated and it was determined that the Sheriff’s Department relied on the copies of medical records, toxicology or autopsy results as attachments to the report instead of referencing the findings in the report. Based on the data provided by Public Health, on the dates the cases were recorded with the final determined cause and manner of death, there were multiple cases that took an extended amount of time to update. While cases that included an autopsy could expect to be delayed depending on how quickly the autopsy is completed, it would be reasonable to expect to wait no longer than 27 three months for results. Six of the 25 cases took longer than three months to update; one took nearly five years before it was updated, two took nearly two years to update and the other three were updated within a year from the date of death. Only one of these cases had an autopsy performed and one other case had a blood sample taken. There were no other circumstances documented in the reports to indicate why there were such lengthy delays. The CDC Handbook states that the cause of death should be updated “immediately” when known. By the end of the Grand Jury’s investigation, it made a repeat inquiry and learned that five of the six cases originally classified as ‘pending’ in EDRS had been updated since January 2020. It may or may not be a coincidence that the Grand Jury had at that point been conducting interviews on this topic for some months. A Final Note The Grand Jury wishes to make abundantly clear that it is not averring that the Sheriff’s Department reached the determinations it apparently did in the 25 sample cases without reason, or that its death investigations were conducted negligently or inappropriately. Such a determination would require the input of experts in the relevant disciplines, which the Grand Jury did not seek or obtain as part of this particular investigation. Instead, the conclusion reached by the Grand Jury is that the coroner investigation reports that it reviewed did not contain sufficient detail or explanation to allow an outside observer to verify what conclusions the Sheriff’s Department arrived at as to cause, manner and circumstance of death, how it arrived at those conclusions, and where it seemingly did not comply with best practices or its own policies and procedures, what reasons it may have had for so doing. These information gaps are, in the view of the Grand Jury, significant and substantive, given the function and importance of coroner investigation reports. These reports, which are public documents, are the principal means members of the public have to assess the adequacy and care taken by the Sheriff’s Department in investigating the deaths of loved ones, and gauging whether there was uncertainty as to any of the determinations made. If these reports do not contain clearly articulated conclusions as to the cause, manner and circumstances of death, backed up by clear and persuasive reasoning and sources, the eventual result could well be loss of confidence by the public in the Coroner’s functions and processes. This would be in no one’s interest.
• CL2 Page 73
  The Grand Jury appreciates all departments and agencies that replied to the 2018-2019 Grand Jury’s findings. It is important for responses to be complete and responsive so the public can know when to expect actions to be taken to address highlighted issues. 72

No Responses Found 1

Government entities assigned to respond to this report. No response documents have been linked in our database.