9. Audit Committee

The Los Angeles County Coroner should have a better staffing of Forensics’ Pathologist, Technologist, Attendants, and mortuary attendants and aids. The Decedent Services Unit (DSU) This section is part of the Investigations Division of the Operations Bureau.19 DSU is largely staffed by Forensic Attendants and is charged with transporting decedents from death scenes and hospitals (that fall under the jurisdiction of the coroner), to the Forensic Sciences Center (FSC). Location type can vary widely from hospitals and residences, to hillsides and burnt out structures. The DSU staff will pick up medical records, x-rays and relevant samples, such as blood and tissue in hospital deaths. They will collect and package property and clothing, as well as, collect and book the evidence. They assist the Coroner Investigator with packaging and movement of the deceased. DSU staff will process incoming cases to include fingerprinting, undressing and documenting height and weight of the deceased. They are responsible for crypt management and releasing decedents, once the Department has concluded its examination. This requires a review of the documentation provided by the mortuary, a confirmation of the legal next of kin and a verification of the deceased being released. DSU staff provides transportation for indigent cases and veteran burials that the Department arranges. The DSU also staffs a twenty-four hours per day operation that receives calls from Los Angeles Police Department, Los Angeles County Sheriff Department, Los Angeles City Fire Department, Los Angeles County Fire Department, Los Angeles County Hospitals, and Mortuaries, within and outside of the Coroner’s jurisdiction. The Decedent Services Unit is responsible for crypt management of human remains prior to release for photograph, x-ray and autopsy. These services include preparation of “Proof of Death” letters to verify that a death is being investigated by the Coroner. As well as “Port of Entry” letters to confirm that a decedent had no communicable disease, which are necessary when a decedent is transferred into the United States after a death has occurred outside of the United States. Department of Medical Examiner-Coroner Personnel County of Los Angeles – Department of Medical Examiner-Coroner Budgeted allocated positions Fiscal Year (FY) 2017-2018 Unit Description Budget/Allocated Vacant Administration 58 5 Operations Bureau – Investigations 78 13 Operations Bureau – Forensic Services 29 2 Forensic Laboratory Services 29 3 Forensic Medicine 28 7 Forensic Medicine – Photo and Support 26 1 TOTAL 248 31 There are extensive processes for vetting new hires of Coroner Investigator Trainees (CITs). The process can take up to a year from the time an individual applies to the time they are hired. DME-C Organization chart 196 2017-2018 LOS ANGELES COUNTY CIVIL GRAND JURY FINAL REPORT After hiring, there is a training period for CITs that takes approximately one year. This would equal a total processing time of up to 2 years. In the last Coroner Investigator Trainee (CIT) exam administered in 2017 out of a total of 979 applications, there were a total of 7 candidates hired. The reason for disqualification were, failing the willingness questionnaire, incomplete applications, failure to appear for the exam, failing the written exam, failing the oral exam, and one candidate withdrew. Finally, 163 candidates were added to the certification list. However, of the 163 candidates, only 30 candidates were classified in the primary acceptable bands of the “V” (Veteran) or Band 1. These “bands” represent 5 selection groups the highest being “V” and Bank 1, extending down to Band 4. Usually the “V” Band and Band 1 are the bands from which candidates are selected, with difficulty reaching down into the other Bands to select additional candidates. All 30 were invited to the selection interview. During that time, there were 12 CIT vacancies. Thirteen (13) offers were made and seven (7) candidates mentioned above were hired. The remaining candidates either withdrew (3) or failed the background (3) process.20 This demonstrates the difficulty in recruitment and hiring, especially in the Investigative Division and in Forensic Medicine, which currently have the most important needs. Criminalist positions, such as administrative or other support positions can typically be brought on board within four months depending on the size of the eligible list. With a population of over 10 million people in Los Angeles County, approximately 78,000 to 80,000 residents die each year. The coroner’s office investigates about 20,000 to 22,000 of those deaths. The Coroner’s office received a total of 5418 requests for documents (Proof of Death Letters, Autopsy Reports, and Investigator Reports). This includes calls, mail, e-mail, walk-ins and online. The present DME-C case management system does not have an area in the document request screen (DRS) to note how a request was made, which prevents them from specifying how many calls were received.21 The coroner’s office conducts about 8,500 case examinations each year. There are four levels or types of examinations ranging from an external cursory examination to a full-scale autopsy. 1. Type I – Medical-Legal (performed as prescribed by law) 2. Type II – Clinical or Pathological (particular disease or research) 3. Type III – Anatomical or Academic (med-school anatomy students) 4. Type IV – Virtual or Medical Imaging autopsies. The coroner operates from a single central location in downtown Los Angeles and two small satellite offices located in the Antelope Valley and in San Fernando22 . The enormous size and constant congestion of Los Angeles County require the coroner staff to travel at least 30 to 90 minutes, and sometimes up to three hours, to investigate a scene of death and remove bodies. A body cannot be moved from an accident or crime scene until the coroner arrives and gives permission.23 20 DME-C Senior Staff regarding banding Los Angeles County.gov hiring process for (CIT) 21 DME-C Senior Staff 22 Ibid 23 Ibid 2017-2018 LOS ANGELES COUNTY CIVIL GRAND JURY FINAL REPORT 197

There is a strong need to replace the cremation retort and or outsource unclaimed remains. ODA County Morgue The Los Angeles County and University of Southern California Medical Center’s (LAC&USC Medical Center) Office of Decedent Affairs (ODA) is located on the grounds directly across from the Coroners Facility. The ODA processes all deaths that occur at the LAC&USC Medical Center. ODA also is comprised of the county morgue, the crematory, and the Los Angeles County Cemetery (Evergreen Cemetery)24. The ODA Manager reports up the chain of command to the Associate Hospital Administrator, who reports to the Hospital Chief Operations Officer, who reports to the Hospital CEO, who reports to the Director of Department of Health Services (DHS), who reports to the Board of Supervisors (BOS). The LAC+USC is responsible for all unclaimed and indigent deceased that do not come under the Coroner’s jurisdiction. The decedents are picked up by the Morgue staff or brought in by private mortuaries for storage in the County Morgue awaiting final disposition (cremation)25. The morgue itself holds only 43 decedents. Any in excess of this number are stored in refrigerated outdoor containers. The morgue processes all deaths that occur in LAC+USC Medical Center, as well as, indigent and unclaimed persons throughout the County as reported by hospitals, nursing homes, convalescent homes and law enforcement agencies. The remains are taken to the LAC+USC Medical Center by Decedent Affairs Office Mortuary Attendants. If no estate or family is available to assume the responsibility of the deceased, the County takes responsibility for cremating the decedent. The ODA also manages and operates the crematory and receives on average 8 cases daily. The crematory’s single functioning retort can only process 2 decedents per working day or 8 to 10 decedents per week, therefore 60 to 80 percent of decedents are outsourced. The current County Crematory Retorts and Decedent Refrigeration Units are at the end of their useful life26. The ODA does not have reliable options should a natural disaster or mass casualty situation arise. The 911 call flow process is that all law enforcement agencies, nursing and convalescent homes call directly to the Coroner to report a death27. The call is then screened by the coroner to determine name, age, family contact, address and to determine if there is a physician to sign the Death Certificate. If the death does not come under the Coroners jurisdiction, the County Mortuary Attendant is dispatched for pick-up, if no morgue staff is available. If the individual remains unclaimed after thirty days, they are cremated at the county crematory at county expense. Transporting creates an added burden, especially in the north area of the county which is distant to the morgue. 24 https//www.laconservancy.org/locations/evergreen-cemetery 25 Senior Administrator at LAC+USC 26 Ibid 27 Flow chart for DME-C 198 2017-2018 LOS ANGELES COUNTY CIVIL GRAND JURY FINAL REPORT