WHO Cares for the Dead When the Dead Don’t Vote?

The DMEC Workload With more than 10 million residents, Los Angeles County is the most populous county in the nation. It covers 4,752 square miles and, significantly, is congested with nearly 8 million registered vehicles.11 DMEC’s sole facility is located in downtown Los Angeles, although there are three satellite facilities out of which a handful of investigators operate.12 No one is allowed to touch or move a body at an accident or crime scene unless the Coroner gives them permission to do so or until a Coroner’s Investigator arrives.13 The CGJ has been informed that the average time for an investigator to travel through traffic from the downtown headquarters to a death scene in most areas of the county is usually 30 to 90 minutes and sometimes nearly three hours. Thus, distance and population density both affect the effective conduct of DMEC’s work. DMEC processes about 9,000 – 10,000 bodies and performs about 4,000 autopsies per year. While its workload is comparable to that of the medical examiner offices in New York City (all boroughs are organized under one medical examiner) and Cook County (Chicago), which report performing more than 5,000 and about 3,700 autopsies per year, respectively, those other jurisdictions are physically smaller, serve smaller populations, and employ more critical staff per capita than DMEC. California Department of Motor Vehicles Forecasting Unit: total for 2014 was 7,719,360. https://www.dmv.ca.gov/portal/wcm/connect/add5eb07-c676-40b4-98b5- 8011b059260a/est_fees_pd_by_county.pdf?MOD=AJPERES 12Two investigators are assigned to a small office in Lancaster, CA, four investigators are assigned to office space in Lomita, CA, and two investigators are assigned to an office in the San Fernando Police Department. In Lancaster there is a small office and non- working refrigerated space that could accommodate six bodies. In some cases, because of lack personnel, DMEC must depend on a local funeral company to transport bodies from Antelope Valley to the Los Angeles office, the only location in the county where autopsies are performed. Neither the Lomita nor the San Fernando offices contain anything other than desks for the investigators who work there. These regional offices allow DMEC to more rapidly respond to a scene of death which mitigates traffic obstructions. Cal.Govt.Code § 27491.2 (b) “For purposes of inquiry, the body of one who is known to be dead from any of the causes or under any of the circumstances described in Section 27491 shall not be disturbed or moved from the position or place of death without permission of the coroner or the coroner's appointed deputy. Any violation of this subdivision is a misdemeanor.” 2015-2016 LOS ANGELES COUNTY CIVIL GRAND JURY INTERIM REPORT 7 Table 1: Population Served Per Critical Staff Member Population Population Area served per served per Population Total Served in Forensic Coroner served per Population Square Pathologist Investigator * Toxicologist Served Miles Los Angeles 434,700 222,200 769,200 10,000,000 4,752 New York 242,800 293,100 386,400 8,500,000 303 (5 Boroughs) Cook County 385,700 337,500 385,700 5,400,000 945 (Chicago) *Put another way, each of the 46 investigators in Los Angeles County can be said to “cover” 103 square miles, while 29 investigators in New York each cover 10.5 square miles and 16 investigators in Cook County each cover 59 square miles. The Medical Examiner-Coroner informed the CGJ that DMEC, despite severe understaffing, is committed to provide a 48-hour turnaround time with regard to preliminary results in cases in which it accepts jurisdiction.

The Investigation and Examination Process According to the standard of care applied by medical examiners across the country autopsies are completed within 48 hours of death. The forensic pathologist cannot begin an autopsy or even an external examination, however, until the investigator completes a report detailing the scene at which a body is found, including personal effects gathered there. In each case determined to be within the jurisdiction of DMEC, the deceased is taken to DMEC’s facility and examined by a deputy medical examiner to determine the cause and manner of death. That physician assesses whether an autopsy and/or laboratory tests are required as part of the investigation. At its present rate DMEC takes on average much longer than 90 days to complete final autopsy reports, the minimum standard for completion required by NAME for full accreditation of a forensic death investigation facility. This substantial period of time can be attributed to a lack of sufficient staff, including professional and direct and indirect support personnel. During an autopsy the decedent’s body is examined for external wounds. A detailed internal examination is conducted during which organs are examined and weighed. Bodily fluids are collected. Tissue samples are taken and retained to determine if there 8 2015-2016 LOS ANGELES COUNTY CIVIL GRAND JURY INTERIM REPORT is a presence of drugs, poison, and/or disease(s) and to preserve DNA. Forensic pathologists work closely with law enforcement but conduct their investigations independently to reach scientific conclusions as to cause of death. Moreover, toxicology samples are very time and temperature sensitive. A body lying on ninety (90) degree asphalt will begin to decompose within an hour. Samples retrieved more than two weeks after death likewise will have degraded and therefore may not be optimally reliable.14 The DMEC toxicology lab currently requires six or seven months to analyze samples taken in routine autopsies,15 jeopardizing accreditation of the entire facility. The Forensic Laboratory standards, which are international standards of analysis, are higher now than were expected even five years ago. They are much more time consuming and labor intensive than previous standards. DMEC continues to have on average more than 400 bodies stored in its crypt and is incapable of meeting, in the vast majority of its cases, the minimum acceptable standard autopsy report completion time of 90 days. Some 160 bodies await external examination and/or autopsy, and more than 250 additional bodies are stored for further testing (about 10 percent of the number), to be identified (delayed because there are not enough coroner investigators to do the statutorily-required work), or have been abandoned by survivors and therefore are left for final disposition by Los Angeles County.

Accreditation DMEC has maintained its accreditation -- a measure of acceptable standards in management, personnel, operations, procedures, instruments, physical site, and safety -- although it currently is so far behind the minimum standards that losing accreditation is a likelihood in 2016.16 Such accreditation has been attained by only 82 medical examiner or coroner offices, including DMEC, out of the more than 2,000 counties across the nation. Los Angeles County DMEC worked hard to attain this elite status among peer facilities. The volume of cases for which DMEC is responsible overwhelms a staff that is significantly smaller than recommended in standards set by NAME. The budget provided to DMEC also has been flat in the past two fiscal years and the CEO’s recent proposed budget reduces the level of funding for FY 2016-2017. 14 “Factors such as delay in autopsy, sampling technique, and specimen preservation contribute more to inaccuracies associated with toxicological testing than do the testing procedures themselves, but procuring and storing toxicology specimens under optimal conditions mitigate these factors.” Dr. G. G. Davis and the National Association of Medical Examiners and American College of Medical toxicology Expert Panel on Evaluating and Reporting Opioid Deaths, “National Association of Medical Examiners Position Paper: Recommendations for the Investigation, Diagnosis, and Certification of Deaths Related to Opioid Drugs,” (March 2013), p.

DMEC prioritizes cases in a particular order.  First, cases involving infants and young children, because their bodies rapidly decompose.  Second, homicides.  Third, unidentified individuals.  Fourth, all others.

The budget reflects investment in DMEC of about $3.55 per resident of the county.

DMEC strives to provide quality services to all of its customers, including decedent’s families, funeral directors, law enforcement, courts, the District Attorney, the Public Defender, and other justice agencies, foreign consulates, and the news media, in a timely, accurate, efficient, and usable manner.

The workload/caseload of DMEC in Los Angeles County compares with that in other very large urban counties, including New York City (all five boroughs) and Cook County (Chicago). Although their service areas are physically smaller and they serve smaller populations, those jurisdictions employ more critical staff per capita than DMEC.

The professional field of forensic pathology is quite small and very few medical students pursue residencies, and later careers, in the field.

There are numerous job listings for forensic pathologists across the nation that offer starting salaries comparable to those offered in Los Angeles County, but the workload is much less (as is the cost of living).

There is a vacancy in the most senior budgeted investigator position, Chief of Coroner’s Investigations. 2015-2016 LOS ANGELES COUNTY CIVIL GRAND JURY INTERIM REPORT 17 12. There are three vacancies in the most senior positions in the forensic laboratory.

Los Angeles County does not engage in recruitment battles for scarce professionals by offering bonuses or other incentives.

DMEC will lose its professional accreditation, and expose the County and DMEC to attacks on their credibility in criminal cases, if the workload cannot be handled by staff in a timely manner.

Los Angeles County might preserve at least a “provisional” accreditation for DMEC if NAME examiners, expected to inspect DMEC in August 2016, are aware that concrete steps have been taken by Los Angeles County and by DMEC to permanently rectify severe staffing deficiencies.

Due to traffic congestion and distance from the medical examiner’s facility in downtown Los Angeles, travel times for investigators to the scene of a death can vary widely, but are generally 30 to 90 minutes and sometimes more than three hours. Law enforcement and paramedics must wait for DMEC staff to arrive on scene.

Two DMEC investigators are located in the Antelope Valley and work out of a small building (about 4,000 square feet) adjacent to the now closed High Desert Hospital. Bodies are no longer able to be refrigerated prior to transfer to DMEC’s Forensic Science Center in downtown Los Angeles because that equipment is not operating. In the rear of the hospital there is an autopsy suite, out of use for at least 10 years.

Ambulances are prohibited by law from transporting deceased individuals.

In New York City mortuary services, including autopsy facilities, are located in Manhattan, Brooklyn, and Queens. The medical examiner there is in the process of reopening similar facilities in the Bronx and Staten Island.

DMEC sends hundreds of bodies per year to private facilities for cremation at a net cost of about $350 per body.

The ODA morgue staff is overworked in both transport and administrative positions. There are unfilled, budgeted positions available for additional staff.

The Los Angeles County morgue would continue to be located in LAC+USC Medical Center regardless of which department is responsible for its operation.

Only two of five existing retorts in the county crematory are operational. One of these lacks a functioning thermostat. DHS workers at the crematory are able to process only two bodies per day. 18 2015-2016 LOS ANGELES COUNTY CIVIL GRAND JURY INTERIM REPORT 24. DHS has a policy of contracting with private crematories if the diminished capacity at the county crematory results in a backlog of ten or more bodies.

https://netforum.avectra.com/public/temp/ClientImages/NAME/a8f3230e-d063-4681-8678-e3d15ce9effb.pdf 15 Interview with DMEC staff. The minimum standard is that 90 percent of toxicology tests will be completed in 90 days. NAME, “Inspection and Accreditation Checklist for Autopsy Services, Adopted February 2013,” p. 16. https://netforum.avectra.com/public/temp/ClientImages/NAME/c43b8bca-ad7b-4a40-990b-7f45283a66ab.pdf 2015-2016 LOS ANGELES COUNTY CIVIL GRAND JURY INTERIM REPORT 9 Table 2: DMEC Budget CEO Proposed FY 2012-2013 FY 2013-2014 FY 2014-2015 FY 2015-2016 FY 2016-2017 Net County $31,704,000 $31,789,000 $35,656,000(a) $35,515,000 $33,583,000 Cost Budgeted 216 217 244(b) 227 227 Positions (a) The majority of the $3.8 million increase over the 2013-2014 budgeted amount reflects the county-wide salary and benefit increases as a result of a Memoranda of Understanding (MOU) and one-time miscellaneous equipment funding. (b) The 27 additional positions over the 2013-2014 budgeted numbers reflect 20 volunteer (non-paid) positions (added in error to the 2014-2015 Adopted Budget ordinance), six positions added at the time of Chief Medical Examiner-Coroner’s appointment, and one position added in exchange of reduced expense funds. Critical staff and the challenges in recruiting and retaining them include:  Forensic Pathologists: At present there are only about 500 - 600 board-certified forensic pathologists in the United States,17 although NAME estimates, significantly, a need for double that number.18 In 2015 just 43 doctors passed the examination to become board certified forensic pathologists.19 Each year there are 15,000 new medical students, but only 37 of the 131 medical schools provide accredited training programs in forensic pathology. On average, just 47 medical students from all schools go on to become forensic pathology residents.20 Los Angeles County each year offers two residency positions in DMEC but cannot always fill both. The starting salary for forensic pathologists in Los Angeles County was recently set by the CEO. “All new employees would start at an annual salary of $187,728 unless they had outside experience and then they would start at a higher step commensurate with their experience.”21 17 “Between 2007 and 2013, a total of 290 people were trained in forensic pathology, an annual average of 41 per year. . . . Considering an annual creation rate of 21 FPs per year [who attain board certification], and given the current work force of 500 FPs, it would take approximately 25 years to create enough FPs to serve the current U.S. population, assuming no population growth during that time. Compounding this issue, the FP workforce is annually decreasing due to attrition from retirement, death, and other factors, including job dissatisfaction because of the stressful nature of political, legal, and media encounters; poor working conditions; the nature of the work, and/or low salaries.” National Institute of Standards and Technology, National Commission on Forensic Science, “Increasing the Number, Retention, and Quality of Board-Certified Forensic Pathologists,” p. 3. http://www.justice.gov/ncfs/file/641646/download 18 Ibid. Denise McNally, Executive Director of NAME, telephone interview February 2, 2016. Scientific Working Group on Medicolegal Death Investigation (SWGMDI), “Increasing Forensic Supply of Forensic Pathologists in the United States,” (December 5, 2012), p. 2. http://www.swgmdi.org/images/si4.fpsupplyreportpublisheddecember2012.pdf National Institute of Justice, Forensic Death Investigation Symposium, June 7-9, 2010, National Academy of Sciences Report, p. 5. https://www.ncjrs.gov/pdffiles1/nij/249252.pdf 21 Email from Senior Manager, Benefits and Compensation Policy, Los Angeles County Chief Executive Office, March 17, 2016. 10 2015-2016 LOS ANGELES COUNTY CIVIL GRAND JURY INTERIM REPORT As a result of this dearth of practicing forensic pathologists it is difficult to fill pathologist positions as senior physicians resign or retire. Los Angeles County employs 23 forensic pathologists. The Medical Examiner-Coroner just resigned and there is a critical need for two additional doctors. NAME statistics suggest a median staffing level of 3.2 forensic pathologists per million of population,22 translating into a staffing level of 32 forensic pathologists at DMEC.  Coroner investigators are sworn law enforcement officers who lead the crime scene investigation and coordinate all evidence collection at the scene of a death. The investigator takes charge of physical evidence, including the personal belongings and evidentiary samples taken from the deceased, making sure that it is properly cataloged and handled. He or she helps to move the body and may be in attendance at the autopsy as well. Coroner investigators are also involved in disposition or release of the body once DMEC's investigation has been concluded. DMEC has 46 budgeted investigator positions for a total caseload of about 10,000 incidents per year, which does not include the 10,000 - 15,000 additional cases in which a coroner investigator is called to a scene of death but determines there to be no jurisdiction for DMEC. There are four vacancies, including Chief of Coroner Investigations, at this time. Investigations inevitably lag behind the steady flow of cases for which DMEC is statutorily responsible and autopsies are delayed, producing stress and heartache in survivors. NAME statistics suggest a median staffing level of 5.9 investigators per million of population,23 translating into a staffing level of 59 investigators at DMEC.  Criminalists/forensic toxicologists are extremely critical to DMEC’s operation. They examine tissues, bodily fluids, and blood to determine the cause and manner of death, and frequently provide expert testimony in court proceedings, which requires these staff to be specifically board certified, for example, in opioids, alcohol or some other area. These positions are highly specialized and require several years of experience and training. The American Board of Toxicology requires the following criteria for certification: a doctorate and at least three years full time experience in toxicology; a master’s degree and at least seven years full time experience in toxicology; or a bachelor’s degree and at least ten years full time experience in toxicology. All the degrees must be in a life or chemical science. Drs. M. Weinberg, V. Weedn, S. Weinberg, and D. Fowler, “Characteristics of Medical Examiner/Coroner Offices Accredited by the National Association of Medical Examiners,” Journal of Forensic Sciences, Vol. 58, No. 5 (September 2013), p. 1196. Ibid. 2015-2016 LOS ANGELES COUNTY CIVIL GRAND JURY INTERIM REPORT 11 BOS has budgeted 13 forensic toxicology positions for DMEC. NAME-suggested levels, however, suggest a staff significantly larger. There are six vacancies in the unit, including Chief of Forensic Laboratories, two supervising criminalists, and three senior criminalists. Four additional positions are held by employees on leave so that currently only three toxicologists are handling an overwhelming workload. The inability to fill even the budgeted positions is based largely on the failure of Los Angeles County to offer competitive salaries for the severe workload involved in these positions. NAME statistics suggest a median staffing level of 3.5 toxicologists per million of population,24 translating into a staffing level of 35 toxicologists at DMEC. DMEC is understaffed in forensic pathology, investigator, and criminalist (laboratory) positions, due in part to difficulties recruiting and retaining staff in all of these professional areas in a hyper-competitive market. It is that much more difficult to recruit and retain these specialized personnel in Los Angeles County where the cost of living is very high25 and DMEC has not been able to offer salaries high enough to compete with other locations. Ibid. Experian Data Quality, “The Cost of Living in America,” https://www.edq.com/data-quality-infographics/cost-of-living-in-america/ 12 2015-2016 LOS ANGELES COUNTY CIVIL GRAND JURY INTERIM REPORT Table 3: Starting Salaries Offered For Forensic Pathologists in Selected Jurisdictions26 $300,000 $250,000 $200,000 $150,000 $100,000 Low-end of Salary $50,000 Range $0 High-end of Salary A 1 2 L V A A I R N A E T L Range C , s e le g n A s o L L , Y N , k r o Y w e L , Y N , k r o Y w e I , y t n u o C k o o C N , o n e R V , d n o m h c iR C , y t n u o C a t s a , e c n e d iv o r P M , s ilo p a e n n iM C , e s o J n a S D , n w o t e g r o e G U , y t iC e k a L t la F , e lliv n o s k c a J N N h S S Table 4: Workload (Number of Autopsies and External Examinations) For Forensic Pathologists in Selected Jurisdictions 9000 8000 7000 6000 5000 4000 3000 2000 No. of Autopsies and External Examinations 1000 0 26 Salaries listed were available as job offerings on-line as of March 7, 2016. New York provided information for two subcategories of “city medical examiners,” level I and level II. 2015-2016 LOS ANGELES COUNTY CIVIL GRAND JURY INTERIM REPORT 13 B. Office Of Decedent Affairs The Office of Decedent Affairs (ODA) is a division of the Department of Health Services (DHS) with headquarters located at the LAC+USC Medical Center. It comprises the morgue, the crematory, and the county cemetery. ODA performs a function that is remote from the core mission of the hospital, operating at a distance of three managerial levels from the administration of the hospital (which, in turn, reports to the Director of DHS). Its problems are frequently overlooked. For example the county crematory is barely able to process the remains of the county’s indigent. The CGJ investigation found a disturbing backlog of about 250 bodies stored in “temporary” refrigerated trailers at the county morgue on the LAC+USC Medical Center campus. When our concerns were noted on February 17, 2016, the problem was rectified in fewer than two weeks and no backlog currently exists. A new policy was immediately put in place to keep such a backlog from ever occurring again. The ODA’s remote existence as part of DHS, however, does not add to its oversight and effective provision of services.