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Extracted from Consolidated Report

This investigation was originally published as part of a larger consolidated report containing multiple investigations. View the consolidated PDF for the complete document.

Los Angeles County Grand Jury • 2011-2012

Medication for Inmates

8 pages
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Findings 11 findings

F1 Page 169
The Coroner has enlarged its morgue space and has built an adjacent building with a 500 slab capacity for the storage of bodies.
F2 Page 169
The Coroner transfers unclaimed remains to Los Angeles County+USC Hospital for cremation services and no longer performs these services.
F3 Page 169
The Emergency Operations Plan provided to the CGJ was a comprehensive plan adopted on March 22, 2011. The EOP appeared to be a plan written and adopted by a state wide organization. Many of the positions of responsibility are not specific to the personnel currently employed by the Coroner. Even though job descriptions are specified, actual responsibilities are difficult to determine.
F4 Page 169
The EOP does not provide training or continued education programs with key per- sonnel. Continued formal training is a key component for success in implementation of the EOP.
F5 Page 169
The position of Director is scheduled to become vacant as of March 2012 due to the retirement of the current Director. The Chief Medical Examiner is also scheduled to retire at the end of 2012. However, the Succession Plan does not provide the search progress, the qualifications, or the possible candidates for the filling of vacant positions at the Coroner nor does it provide a direct succession plan for the key posi- tions such as the Chief Medical Examiner or Director.
F6 Page 169
The Coroner currently uses an antiquated, non-web based, non-secure file man- agement system that can no longer be upgraded. Intake of bodies and evidence is currently tracked manually, not electronically. This leaves evidence open to error in criminal cases and identification matters. These handwritten documents are filed in individual folders in cabinets. Currently, in the event of a fire or flood, all records could be lost or destroyed.
F7 Page 167
The Coroner Forensic Science Laboratories have been accredited since 1993. New requirements for accreditation are being adopted by ISO and the need for a special- ist to ensure the accreditation process is met is critical.
F8 Page 169
Budget restrictions have eliminated the replacement of vehicles in the last three years and several vehicles have exceeded the 100,000 mileage marker.
F9 Page 169
The Coroner has no power back-up generators to use in the event of power outages.
F10 Page 169
The Antelope Valley Regional Office of the Coroner is over 25 years old. It does not meet the need for Coroner services in the high desert.
F11 Page 169
The Coroner’s security system should be updated in light of the extreme sensitivity of the Coroner’s forensic operations. 2011–2012 LOS ANGELES COUNTY CIVIL GRAND JURY FINAL REPORT 149 CORONER

Recommendations 9