Score: +6 (9/12/3)

Monterey County Grand Jury • 2022-2023

The Monterey County Coroner's Office*

Published: December 30, 2022 10 pages

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⚠️ 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 and Recommendations 9 findings

MCSO has no written recusal policy or procedure for when autopsies are to be sent out of the County, which could bring into question the integrity of the findings of an investigation or autopsy.

Related Recommendations (1)

Create and adopt written policy and procedures when the MCSO, or its staff, will recuse itself from an investigation

The CO's current dictation and transcription process is inefficient, contributing to the final autopsy report delay.

Related Recommendations (1)

Evaluate technological options to ensure dictation and transcription processes are efficient and timely

The lack of medical transcription training contributes to a delay in completing final autopsy reports.

Related Recommendations (1)

Provide ongoing resources for staff training and continuing education on transcription and emerging technologies in forensic science

CO detective investigative training is not a written requirement nor is there a timeline for completion despite its importance in ensuring investigations are conducted thoroughly and consistent with statewide standards.

Related Recommendations (1)

Ensure that death investigation training for each new detective assigned to the CO is mandatory and completed as soon as possible during their orientation

The CO relies on hiring temporary employees to fill full-time permanent positions, which could affect their ability to keep trained personnel on staff and may negatively affect the consistency of operations.

Related Recommendations (1)

Evaluate staffing needs and create permanent positions accordingly to minimize reliance on temporary staff

The MCSO has not enforced the provisions in the FP's contract requiring the prompt completion of autopsy reports, which could cause added, unnecessary distress to the families of the deceased.

Related Recommendations (1)

Evaluate the necessary forensic pathologist services needed by Monterey County and identify the best approach for meeting those needs

Collaborative purchasing arrangements between the MCSO and other County departments have not been explored where service needs are the same or similar.

Related Recommendations (1)

Monitor and enforce performance measures that are stipulated in the FP contract

Approved budgets and balances are not directly shared with individuals who control departmental expenditures, resulting in a lack of accountability and ownership.

Related Recommendations (1)

Explore optimizing existing or new contractual relationships with County Purchasing and other County of Monterey departments in areas where service or supply needs overlap

The CGJ acknowledges and appreciates the Coroner's Office staff for their ongoing commitment and service to the community.

No recommendations for this finding

Agency Responses 4

Government agencies' official responses to this report's findings and recommendations. Click on a response to see the structured breakdown.

County of Monterey's Response to Monterey County Coroner’s Office: A Matter of Life and Death

July 06, 2023 • 12 pages • 19 responses • Score: +1 (+1, 7, 0) View Details ▾

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19 responses to findings and recommendations

The Noise Complaint Hotline is only staffed for limited days and times; therefore, it is inadequately serving the community.

Response: Disagree Partially Score: 0

The Board disagrees with the finding. The Sheriff has taken steps to resolve previous issues and notes that all autopsy reports are current. For more information, please see the Sheriffs July 6, 2023 response to the Presiding Judge, which is attached. F3 The lack of medical transcription training contributes to a delay in completing final autopsy reports. F3 Response: The Board disagrees with the finding. The Sheriff has resolved issues related to delay in completion of autopsy reports. For more information, please see the Sheriffs July 6, 2023 response to the Presiding Judge, which is attache...

HCD assign additional code enforcement officers whose focus will be noise complaints during high frequency call periods

Response: Unknown

Score: 0

A single HCD code enforcement officer is insufficient to respond to all complaints submitted during peak call times.

Response: Unknown Score: 0

HCD extend the hours of the noise complaint hotline beyond 10 p.m. on weekends to accommodate the extended hours of special events

Response: Implemented

Score: 0

R2, R3, R4, R5, R6, R7 and RB RECOMMENDATIONS: Response With respect to each recommendations, pursuant to Penal Code, section 933 (c ) , the Department shall indicate one of the following: 1) That the recommendation has been implemented, with a summary regarding the implemented action; 2) That the recommendation has not yet been implemented, but will be implemented in the future, with a timeframe for implementation; or 3) That the recommendation requires further analysis, with an explanation and the scope and parameters of an analysis or study, and a time frame for the matter to be prepared fo...

The Sheriff's Office staffing is insufficient to respond to the number of noise complaints.

Response: Unknown Score: 0

HCD require code enforcement officers to consistently patrol areas known for noise complaints and unpermitted events

Response: Implemented

Score: 0

R3, R4, R5, R6, R7 and RB RECOMMENDATIONS: Response With respect to each recommendations, pursuant to Penal Code, section 933 (c ) , the Department shall indicate one of the following: 1) That the recommendation has been implemented, with a summary regarding the implemented action; 2) That the recommendation has not yet been implemented, but will be implemented in the future, with a timeframe for implementation; or 3) That the recommendation requires further analysis, with an explanation and the scope and parameters of an analysis or study, and a time frame for the matter to be prepared for di...

Because the MCSO considers noise complaints a lower priority than life, safety, and property calls, they are often unable to respond in a timely manner to noise complaints.

Response: Unknown Score: 0

Monterey County Sheriff prioritize filling currently budgeted sworn peace officer positions available for patrol in the Monterey County Sheriff’s Office

Response: Implemented

Score: 0

R4, R5, R6, R7 and RB RECOMMENDATIONS: Response With respect to each recommendations, pursuant to Penal Code, section 933 (c ) , the Department shall indicate one of the following: 1) That the recommendation has been implemented, with a summary regarding the implemented action; 2) That the recommendation has not yet been implemented, but will be implemented in the future, with a timeframe for implementation; or 3) That the recommendation requires further analysis, with an explanation and the scope and parameters of an analysis or study, and a time frame for the matter to be prepared for discus...

HCD community outreach regarding permit requirements is insufficient to reach those who may be unaware of the need for special event permits.

Response: Unknown Score: 0

HCD develop an outreach program to encourage residents to report any advertisements of planned special events and to call the hotline

Response: Implemented

Score: 0

R5, R6, R7 and RB RECOMMENDATIONS: Response With respect to each recommendations, pursuant to Penal Code, section 933 (c ) , the Department shall indicate one of the following: 1) That the recommendation has been implemented, with a summary regarding the implemented action; 2) That the recommendation has not yet been implemented, but will be implemented in the future, with a timeframe for implementation; or 3) That the recommendation requires further analysis, with an explanation and the scope and parameters of an analysis or study, and a time frame for the matter to be prepared for discussion...

Certain property owners are knowingly renting their land to others who host large, for profit, public events without proper permits, causing nuisance and safety issues to adjacent residents.

Response: Unknown Score: 0

MCSO develop a protocol with CHP to share information about large, possibly unpermitted events, to increase safe driving conditions in the area of the event, to be completed

Response: Implemented

Score: 0

R6, R7 and RB RECOMMENDATIONS: Response With respect to each recommendations, pursuant to Penal Code, section 933 (c ) , the Department shall indicate one of the following: 1) That the recommendation has been implemented, with a summary regarding the implemented action; 2) That the recommendation has not yet been implemented, but will be implemented in the future, with a timeframe for implementation; or 3) That the recommendation requires further analysis, with an explanation and the scope and parameters of an analysis or study, and a time frame for the matter to be prepared for discussion by ...

Certain property owners are repeat violators of permitting requirements and are undeterred by the current dollar amount of the fines placed against the property, creating a persistent nuisance. 10

Response: Unknown Score: 0

HCD develop a public outreach program to inform residents of permit requirements for special events by December 31, 2023. 11

Response: Implemented

Score: 0

R7 and RB RECOMMENDATIONS: Response With respect to each recommendations, pursuant to Penal Code, section 933 (c ) , the Department shall indicate one of the following: 1) That the recommendation has been implemented, with a summary regarding the implemented action; 2) That the recommendation has not yet been implemented, but will be implemented in the future, with a timeframe for implementation; or 3) That the recommendation requires further analysis, with an explanation and the scope and parameters of an analysis or study, and a time frame for the matter to be prepared for discussion by the ...

Event organizers renting property in unincorporated Monterey County have no penalty or fines levied against them for lack of permits, thus allowing them to host large events repeatedly without consequence from the County.

Response: Unknown Score: 0

Board of Supervisors impose stricter fines and penalties for repeat offenders of special event code violations

Response: Unknown

Score: 0

MCSO has an effective working relationship with CHP to patrol roads within unincorporated areas, providing an opportunity to acquire assistance with the road-related repercussions of large, unpermitted events.

Response: Agree Score: +1

The CGJ acknowledges and appreciates the Coroner's Office staff for their ongoing commitment and service to the community. F9 Response: The Board agrees with this finding. Ln l REPORT TITLE: 2022 -2023 Monterey County Civil Grand Jury Topic: "Monterey County Coroner's Office: A Matter ofL ife and Death" RESPONSE BY: Contracts & Purchasing RESPONSE TO: Recommendations and Response RI, R2, R3, R4, R5, R6, R7 and RB RECOMMENDATIONS: Response With respect to each recommendations, pursuant to Penal Code, section 933 (c ) , the Department shall indicate one of the following: 1) That the recommendat...

F10

Once a large, unpermitted event is underway in unincorporated Monterey County, it becomes virtually impossible for a code enforcement officer and/or Sheriff Deputy to intervene and shut down the event. This results in potential adverse health and safety issues for attendees and neighbors as well as the safety of the responding code enforcement officer and/or Sheriff’s Deputy.

Response: Unknown Score: 0

F11

The Board of Supervisors has been ineffective in resolving noise complaints and providing the necessary funding for outreach and enforcement, causing confusion and frustration to residents in unincorporated Monterey County.

Response: Unknown Score: 0

Monterey County Sheriff’s Office Response to The Monterey County Coroner's Office: A Matter of Life

July 06, 2023 • 5 pages • 17 responses • Score: +5 (+8, 5, -3) View Details ▾

PDF

17 responses to findings and recommendations

The Noise Complaint Hotline is only staffed for limited days and times; therefore, it is inadequately serving the community.

Response: Agree Score: +1

Agree Although a written policy is not in place at this time, I made the decision immediately after taking office to utilize outside Coroner Offices to perform the forensic post-mortem examination of decedents whose death occurs in which Monterey County Sheriff's Office personnel are involved. This decision was made to increase the transparency and integrity of the investigation into the cause, manner, and circumstances of the death. Staff are actively working to develop a written policy/procedure which will be implemented upon review and approval to codify my verbal order and directive.

HCD assign additional code enforcement officers whose focus will be noise complaints during high frequency call periods

Response: Will Implement

Score: +1

The recommendation has not yet been implemented but will be implemented in future prior to September 30, 2023.

A single HCD code enforcement officer is insufficient to respond to all complaints submitted during peak call times.

Response: Disagree Score: -1

Disagree with this finding. The Coroner's Office utilizes Forensic Autopsy Technicians to transcribe dictations provided by the contracted Forensic Pathologist. Coroner's Office personnel, at my direction, were tasked to prioritize and resolve delayed completion of final autopsy reports. At the time of this response, inefficient dictation, and transcription procedures existing when I took office have been resolved and all autopsy reports are current pursuant to the terms of the Forensic Pathologists contract with the Sheriff's Office. MONTEREY COUNTY, CALIFORNIA Tina M. Nieto Sheriff-Coroner

HCD extend the hours of the noise complaint hotline beyond 10 p.m. on weekends to accommodate the extended hours of special events

Response: Will Not Implement

Score: -1

The recommendation will not be implemented because it is not warranted. Staff assigned to the Coroner's Office were tasked to prioritize and resolve delayed completion of final autopsy reports. Emphasis was placed on ensuring the terms and conditions for completion of autopsy reports were prioritized. At the time of this response, inefficient dictation, and transcription procedures existing when I took office have been resolved and all autopsy reports are current pursuant to the terms of the Forensic Pathologist contract with the Sheriff's Office.

The Sheriff's Office staffing is insufficient to respond to the number of noise complaints.

Response: Disagree Score: -1

Disagree with the finding. Although medical transcription training will assist staff in performing their transcription duties in a more efficient manner, it does not contribute to a delay in the completion of final autopsy reports. Delays have been caused by failing to hold the Forensic Pathologist to the terms and conditions of her contract with the Sheriff's Office for the completion of autopsy reports. In addition, the lack ofp rioritizing the workload and time needed by staff to complete the required autopsy reports also contributes to delays in the completion of final autopsy reports. Sta...

HCD require code enforcement officers to consistently patrol areas known for noise complaints and unpermitted events

Response: Will Implement

Score: +1

The recommendation has not yet been implemented but will be implemented in the future prior to March 31, 2024.

Because the MCSO considers noise complaints a lower priority than life, safety, and property calls, they are often unable to respond in a timely manner to noise complaints.

Response: Disagree Partially Score: 0

I disagree partially with this finding. Currently, CO detective investigative training specific to coroner investigations is not necessitated due to a written Sheriff's Office requirement. Staff are working to develop a training matrix, identifying required and recommended training specific to coroner investigations, to ensure new detectives assigned to the CO receive assignment appropriate training within statewide standards. All current CO detectives have attended and completed the Statewide Coroner's Academy Coroners Course provided by the Orange County Sheriff's Office.

Monterey County Sheriff prioritize filling currently budgeted sworn peace officer positions available for patrol in the Monterey County Sheriff’s Office

Response: Unknown

Score: 0

Recommendation 4: Ensure that death investigation training for each new detective assigned to the CO is mandatory and completed as soon as possible during their orientation bv August 31, 2023.

HCD community outreach regarding permit requirements is insufficient to reach those who may be unaware of the need for special event permits.

Response: Disagree Partially Score: 0

I partially disagree with this finding. The Sheriff's Office is currently permanently budgeted for one sheriff's sergeant, four coroner detectives and two forensic autopsy technicians in the CO. The Sheriff's Office, prior to my taking office, hired temporary employees in excess of established full-time employee position allocations without an offsetting funding stream to cover their associated costs presenting an apparent reliance on them. At this time measures have been put in place within the CO to only utilize temporary employees when a position vacancy exists in the CO to allow for staffi...

HCD develop an outreach program to encourage residents to report any advertisements of planned special events and to call the hotline

Response: Requires Analysis

Score: 0

This recommendation needs further analysis. Staff have been tasked to work with Human Resources to fill vacant permanent positions in the CO and eliminate the use of temporary employees when an offsetting funding stream is eliminated due to the hiring of a permanent employee. I am in support of an evaluation of staffing needs to identify the most efficient long-term structure of the CO. Implementation of any change to the existing structure of the CO will require concurrence of the proposed staffing structure by the Human Resources Department and the Board of Supervisors. In addition, in the e...

Certain property owners are knowingly renting their land to others who host large, for profit, public events without proper permits, causing nuisance and safety issues to adjacent residents.

Response: Disagree Partially Score: 0

I partially disagree with this finding. MONTEREY COUNIY, CALIFORNIA Tina M. Nieto SHERIFF'S. OFFICE Sheriff-Coroner The Sheriff's Office was not regularly and routinely enforcing the provisions of its contract with the Forensic Pathologist prior to my taking office. Since taking office staff were tasked with working with the Forensic Pathologist to address the impacts on the families of the deceased due to the delayed completion of autopsy reports. Staff placed emphasis through accountability on ensuring the provisions of the contract were enforced and autopsy reports were completed within th...

MCSO develop a protocol with CHP to share information about large, possibly unpermitted events, to increase safe driving conditions in the area of the event, to be completed

Response: Will Implement

Score: +1

This recommendation has not yet been implemented but will be implemented in the future by January 31, 2024. Access to Forensic Pathologists across the United States is challenged due to not only the limited number Forensic Pathologists, but also to the limited number of Board-Certified Forensic Pathologists. Although the CO saw a reduction in case volume from 2021, where it handled over 1500 cases which included 475 autopsies, to 2022, where it handled 1,086 cases which included 423 autopsies, the use of this limited data would be inconclusive for an analysis of Forensic Pathologist services n...

Certain property owners are repeat violators of permitting requirements and are undeterred by the current dollar amount of the fines placed against the property, creating a persistent nuisance. 10

Response: Agree Score: +1

I agree with this finding.

HCD develop a public outreach program to inform residents of permit requirements for special events by December 31, 2023. 11

Response: Implemented

Score: 0

This recommendation has been implemented. Upon taking office as the Sheriff-Coroner I directed staff to take immediate action to address delays existing in the completion of autopsy reports. Staff worked with the Forensic Pathologist to ensure terms and conditions outlined in the contract with the Forensic Pathologist were adhered to. As of the writing of this response the Forensic Pathologist has resolved the backlog of delayed autopsy reports and is working within the terms and conditions of her contract. In addition, the Sheriff's Office extended the Forensic Pathologist's contract effectiv...

Response: Agree Score: +1

I agree with this finding. There are multiples layers in the supervisory and command structure of the Sheriff's Office. These layers allow for financial oversight of Sheriff's Office expenses specific to bureaus, divisions, and units. During my time in office, it was apparent fiscal training on responsibility and accountability of the budget had previously not been pushed to the division management or unit supervisory level of the Sheriff's Office. The lack of accountability and ownership at these levels was problematic in balancing the budget. Budget expenses were approved at bureau chief lev...

Board of Supervisors impose stricter fines and penalties for repeat offenders of special event code violations

Response: Will Implement

Score: +1

This recommendation has not yet been implemented but will be implemented on an ongoing basis as contractual issues are explored through December 31, 2023. Respectfully submitted, Cc: Sonia De La Rosa, County Administrative Officer Nick Chiulos, Assistant County Administrative Officer County of Monterey Board of Supervisors

Response: Agree Score: +1

I agree with this finding. The staff assigned to the CO are the utmost professionals who have shown a commitment to the community and a commitment to ensuring the deceased are represented through their actions.

Monterey County Sheriff's Response to The Monterey County Coroner's Office: A Matter of Life and Dea

March 04, 2024 • 2 pages View Details ▾

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(Spanish) - La Oficina del Forense del Condado de Monterey: Una Cuestión de Vida or Muerte

May 22, 2023 • 10 pages View Details ▾

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No Responses Found 1

Government entities assigned to respond to this report. No response documents have been linked in our database.

Monterey County Board of Supervisors Elected County Office

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