⚠️ Translation Notice: This content has been automatically translated. The original English text is the official version. Translation may contain errors.
⚠️ Este contenido ha sido traducido automáticamente. El texto original en inglés es la versión oficial. La traducción puede contener errores.
Findings 16 findings
F1
Death investigation historically has been folded into law enforcement duties. This combination is inappropriate in the face of advanced medical knowledge in the diagnosis of 10 unnatural and violent deaths. Death investigation is a medical science and should be performed by medically qualified people. Death certification is a healthcare issue.
F2
In the United States there has been a trend in large population centers to convert to a medical examiner system of death investigation. Such a system now serves 48 percent of the population of the United States and 40 percent in California.
F3
Coroners with few exceptions are administrators and/or peace officers with no medical qualifications or training. Very few are physicians. Medical Examiners are licensed physicians who have completed medical school, four to six years of postgraduate training in pathology, including forensic pathology fellowship. They are board certified in anatomic, clinical, and forensic pathology.
F4
Death investigation should be performed by an independently funded, autonomous office unrelated to law enforcement or prosecutorial agencies, answering only to the governing board of the jurisdiction. There should be clear separation of scientific medical decisions from non-qualified individuals, agencies and political interests.
F5
The performance of death investigation does not require law enforcement background. Forensic pathology fellowship includes this training, and forensic board certification requires this knowledge.
F6
There is no legal impediment to a medical examiner discharging all functions of death investigation. In Sacramento County the authority for death investigation would be conveyed by creation of the Office of Medical Examiner.
F7
In Sacramento County the Office of the Coroner is within the Public Protection Agency and operates under the administrator of that agency and the county executive. It is defined as an administrative position with no formal medical qualifications required. It is frequently combined with other county positions.
F8
In Sacramento County, on an annual basis, a deputy coroner with no formal medical qualifications authorizes the signature of death certificates in approximately 4500 reportable deaths without consultation or knowledge of the department forensic pathologists. The assistant coroner, also with no formal medical training, is empowered to determine the extent of death investigation and the final manner of death and cause of death of the approximately 1400 decedents transported to the office for evaluation. This provision can include overruling the judgment of the pathologist. The compromise of medical autonomy is not just theoretical; cases confirming have been documented.
F9
On September 11, 2001 the Board of Supervisors authorized change in the coroner’s office from contractual pathology and morgue services to county employees, further compromising medical autonomy and discharging a pathology group that by all accounts was professionally excellent. The transition may have created problems with respect to recruitment 11 of pathologists and homicide testimony. The decision was made despite significant opposing written advice and testimony from the local medical community. The chief forensic pathologist continues to be a contractual employee.
F10
On December 11, 2001 the Board of Supervisors created a conflict of interest in the investigation of in-custody deaths by placing the coroner in charge of correctional health. This conflict was in place at a time of intense scrutiny regarding inmate deaths/suicides. There is pending litigation. The conflict was only partially resolved by an autopsy contract with San Joaquin County and the very recent transfer of correctional health to the Sheriff ‘s Department. This action was also the subject of major objection in the medical community. Investigation of in-custody deaths by an independent medical examiner’s office in concert with a district attorney’s investigator will resolve this conflict.
F11
Coroner and Medical Examiner systems operate outside the usual medical oversight and control. There are no national standards or guidelines. Therefore voluntary review and certification by organizations such as NAME and ABMDI are desirable. Affiliation with the UCD Department of Pathology would facilitate subspecialty consultation, development of policy and quality assurance.
F12
With the above review and affiliation, the excellent physical plant already in place and conversion to a medical examiner system assuring medical autonomy, Sacramento County will attract excellent forensic pathologists and be in position to develop a state of the art death investigation program.
F13
Conversion to a medical examiner system would not be difficult from an operational standpoint. The coroner’s staff would not have to be replaced and would adapt quickly to medical emphasis and supervision.
F14
A financial analysis of the transition has been reviewed by the jury and thought to be neutral, with no additional funding necessary for the operation of a medical examiner system.
F15
Change to a medical examiner system requires a charter amendment and electorate participation.
F16
There have been complaints of inappropriate pressure by deputy coroners placed upon attending physicians to certify deaths when the physicians had inadequate knowledge as to the cause of death. This problem appears resolved.
Recommendations 21
-
R1The citizens of Sacramento County should be served by a medical examiner system headed by a board certified forensic pathologist appointed by the governing board. The Office of the Medical Examiner is autonomous, independently funded, and responds only to the Board of Supervisors.
-
R1aThe EGUSD should take immediate disciplinary action against responsible staff.
-
R1bThe Superintendent and Board of Education should provide oversight to the staff responsible for the purchase of school sites.
-
R1cThe California State Government Code Section 2609 should be amended to eliminate Section 2609(f) providing for audits to be performed less frequently than once a year. The code should require all districts to perform annual audits.
-
R1dThe California State Legislature should enact a statute requiring the State Controller to independently verify accuracy and completeness of district audits.
-
R2To establish this office the Board of Supervisors should propose and place on the ballot a charter amendment to abolish the Office of Coroner and replace it with the 12 Office of Medical Examiner. Failing that, the board should propose and place on the ballot a charter amendment to require the coroner to be a forensic pathologist. Failing that, the board should appoint a forensic pathologist to be coroner at the earliest opportunity.
-
R2aThe district should require staff members responsible for the purchase of property, supplies, or services to sign a fiduciary responsibility statement. District staff should also be accountable under the EGUSD conflict of interest policy.
-
R2bThe district should develop policies and procedures for the purchase of school sites that protect the financial interests of taxpayers.
-
R3The Chief Medical Examiner should be selected by a search committee of medical experts utilizing non-political and strictly professional criteria, including prior administrative experience. All staff pathologists should be board certified in forensic pathology. They can be contractual or county employees.
-
R3aGive the public what it wants and issue letter grades to restaurants inspections, which must be prominently displayed. Certificates or awards of excellence could also be given to restaurants consistently receiving a letter grade of A over 3 consecutive inspections.
-
R3bThe county Environmental Health Division should establish its own Web site to post all food inspections results including grades, enforcement or closure actions, follow-up inspections, and complaint remedies.
-
R4The Medical Examiner System of Sacramento County should establish a strong relationship with the UCD Medical Center for development of lines of consultation, quality assurance and continuing education programs. The system should utilize professional organizations for review, certification and guidelines of operation. There should be medical emphasis in the recruitment and continuing education of staff. A forensic pathologist should supervise each reported decedent investigation and sign the death certificate of all those studied in the medical examiners office. A pathologist should supervise all morgue functions.
-
R4aThe county Environmental Health Division should encourage inspection staff development by allowing staff to attend training programs sponsored by government agencies and leaders in the food safety industry. 33
-
R4bThe County Environmental Health Division should consider establishing an apprenticeship program to encourage recent college graduates to enter the field. Such a program would allow these individuals to move up to staff positions after they become registered Environmental Health Specialist.
-
R5The investigation of in-custody deaths should be separate from correctional health and the Sheriff’s Department. It should be performed by an independent medical examiner and district attorney investigator.
-
R5aEnforcement actions with severe implications should require immediate closure of the facility and mandatory re-inspections, paid for by the violator. Increase education for minor violations.
-
R5bIncreased enforcement should lead to administrative hearings for repeat violators with ultimate license revocation.
-
R6That the safety of students be recognized by including the school resource officers program in the budgets of the San Juan Unified School District, the Elk Grove Unified School District and the Center Unified School District for 2003-2004. Commendation The Sheriff’s Department’s fiscal support of the SRO program in 2002-2003 in the unincorporated areas is recognized as positive and necessary.
-
R7Are directors attending water industry conferences required to submit reports to the water district? Is the report written or oral? Is the item placed on the district’s meeting agenda?
-
R8What is the district’s policy on the acceptance of gifts by district directors and staff personnel? Please provide a copy of the policy.
-
R9What is the district’s policy on the payment of overtime to management personnel? Please provide a copy of that policy. After reviewing the responses, Grand Jurors interviewed the general managers and/or directors to elicit additional information. The following is a summary of what the Grand Jury found: Carmichael Water District Carmichael Water District is an urban water supply serving 11,063 customers in the Carmichael area with a population of 40,000 in a 6 square mile area. Water sources include 9 ground water wells (37%) and surface water supplied from the American River (63%). The average monthly rate for unlimited water is $39.80 for one connection of a ½ acre or less. The district’s operating budget for 2002-2003 is $7.9 million. The general manager’s annual salary is $100,614 and the assistant manager’s annual salary is $82,000. The district’s written response to questions by the Grand Jury:
Commendations 15
-
CM1Does your district have written policies on staff travel? Please provide a copy of that policy.
-
CM2Who has the responsibility to audit travel records to assure compliance with those policies?
-
CM3How are district directors compensated for time spent on district business? Please include forms of compensation other than cash, i.e., meals, use of vehicles, etc.
-
CM4What authority determines which water district industry conferences directors will attend? When more than one director attends a conference, what justification is needed to provide for more than one participant?
-
CM5What practices exist for directors' travel? Please provide a copy.
-
CM6When was the last travel audit performed on your district? Please provide a copy of that audit.
-
CM7Are directors attending water industry conferences required to submit reports to the water district? Is the report written or oral? Is the item placed on the district's meeting agenda?
-
CM8What is the district's policy on the acceptance of gifts by district directors and staff personnel? Please provide a copy of the policy.
-
CM9What is the district's policy on the payment of overtime to management personnel? Please provide a copy of that policy. After reviewing the responses, Grand Jurors interviewed the general managers and/or directors to elicit additional information. The following is a summary of what the Grand Jury found: Carmichael Water District Carmichael Water District is an urban water supply serving 11,063 customers in the Carmichael area with a population of 40,000 in a 6 square mile area. Water sources include 9 ground water wells (37%) and surface water supplied from the American River (63%). The average monthly rate for unlimited water is $39.80 for one connection of a ½ acre or less. The district's operating budget for 2002-2003 is $7.9 million. The general manager's annual salary is $100,614 and the assistant manager's annual salary is $82,000. The district's written response to questions by the Grand Jury:
-
CM10The Sacramento City Unified School District
-
CM11The Elk Grove Unified School District
-
CM12The Center Unified School District
-
CM13The Sacramento Police Department
-
CM14The Sacramento County Sheriff's Department
-
CM151 A comprehensive school is a regular 4-year school that offers a full range of curriculum.