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Findings and Recommendations 4 findings
F1
Upon reviewing the supplemental page of Coroner’s Packets #2013- 10639 (Attachment #1) and #2013-11723 (Attachment #2), it was observed that each contained a similar misleading statement. They both read, on the applicable date, Riverside County Sheriff-Coroner Stanley Sniff conducted a Coroner’s Review in the matter of the death of the decedent. After the facts were presented, Sheriff-Coroner Stanley Sniff certified the death. These written statements are misleading as Sheriff-Coroner Stanley Sniff was not present at either review. Delay of Files/Documents
Related Recommendations (1)
R1
The supplemental page of all Coroners’ packets recommending the cause, mode, and manner shall be reworded to reflect that a Coroner’s Review was conducted on behalf of Sheriff-Coroner Stanley Sniff. Delay of Files/Documents
F2
On October 30, 2014, members of the Grand Jury attended Coroner’s Review of Coroner’s Case File #2013-11723. The Sheriff-Coroner Representative certified this death as: • Cause of death: Acute methamphetamine and heroin intoxication • Mode of death: Administered illicit drugs to self • Manner of death: Accident At the conclusion of the review, the Grand Jury requested a Coroner’s Packet for this case file. On November 5, 2014, a follow-up telephone call was made to the Coroner’s Office inquiring into the status of the requested Coroner’s Packet. Later that day, the Grand Jury Foreperson received a voice mail message advising the packet was not complete and the cause of death was still undetermined, even though the cause of death was certified on October 30, 2014. A second follow-up telephone call was placed on November 24, 2014. This time the Grand Jury was advised that the requested Coroner’s packet was awaiting final approval. A third follow-up call was placed on December 4, 2014, this time the Grand Jury was advised the packet was awaiting a signature. The requested packet was finally received on December 15, 2014. Inaccurate Information
Related Recommendations (1)
R2
The Sheriff-Coroner shall not hold Coroner’s Reviews until cause, mode, and manner of death have been verified. Inaccurate Information
F3
On two occasions, members of the Grand Jury met with a city chief of police. During these meetings, the chief expressed concerns, as he was advised by the Sheriff that the Grand Jury only attends three Coroner’s Reviews a year. The chief felt that this left his officers in a state of anxiety. He further stated he understood that if the Grand Jury was not present, a Coroner’s Review could not be conducted. The Grand Jury is invited to attend Coroner’s Reviews as the watchdog, representing the citizens of Riverside County. Accuracy/Amending Files
Related Recommendations (1)
R3
Sheriff-Coroner personnel shall not advise anyone that the Grand Jury must be present for a Coroner’s Review to take place, and shall be written into the Sheriff-Coroner’s Policy and Procedure Manual. Accuracy/Amending Files
F4
The Grand Jury requested a Coroner’s Packet for Coroner File #2013-
Related Recommendations (1)
R4
Coroner Investigation Reports shall be amended as new information becomes available. Subpoenas
Additional Recommendations 1
These recommendations are not explicitly linked to specific findings.
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R5The Sheriff-Coroner shall comply with the delivery date and time as mandated within a Grand Jury Subpoena. Report Issued: 06/30/15 Report Public: 07/02/15 Response Due: 09/28/15 5 Attachment #1 6 Attachment #2 7