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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.
⚠️ 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 6 findings
F1
Page 29
The Sheriff’s Department failed to comply with GC §27520 when it did not facilitate an autopsy when one was requested in writing by an appropriate next-of-kin to the decedent. A major contributing factor to this failure was the lack of any mention of GC §27520 in the Sheriff’s Department Coroner P&Ps. 28
F2
Page 30
The Sheriff’s Department Coroner P&Ps are lacking in that they do not provide concrete guidance as to when the Coroner’s discretion should be exercised to obtain autopsies in connection with death investigations under GC §27491, nor do they reference best practices.
F3
Page 30
The sampled Coroner investigation reports lack necessary detail as to the determination of cause, manner and circumstances of death, and the basis for such determination, and did not shed light on the decision to forego autopsies in several instances in which best practices standards anticipate that autopsies would be obtained (including certain deaths involving fire, drowning, suicide, or alcohol or drug abuse).
F4
Page 30
The Sheriff’s Department did not fully comply with GC §27463(e) in the sample case reports insofar as they did not show cause of death or document how the cause of death was determined.
F5
Page 30
The Sheriff’s Department Coroner P&Ps risk becoming materially out of date in that they are not routinely reviewed and updated to ensure compliance with changing legal requirements.
F6
Page 30
The Sheriff’s Department failed to update the cause of death in the EDRS in six reviewed cases within a reasonable amount of time after receiving necessary information. RECOMMENDATIONS Based on the foregoing, the Grand Jury recommends:
Recommendations 6
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R1Page 30The Sheriff’s Department amend its Coroner P&Ps to provide better and more concrete guidance, consistent with best practices, as to the circumstances that govern when the discretion of the Coroner should be exercised to obtain an autopsy, particularly in connection with deaths subject to GC §27491.
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R2Page 30The Sheriff’s Department amend its Coroner P&Ps to point out the Department’s legal obligation under GC §27520, and to advise inclusion in a written communication to surviving next of kin of an advisory that an autopsy, if not otherwise obtained, will be conducted at their request and their expense.
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R3Page 30The Sheriff’s Department amend its Coroner P&Ps to add a directive to include in death investigation reports the determination as to cause, manner and circumstances of death for all deaths falling within GC §27491, and the reasons supporting such conclusions, as arrived at by the Coroner.
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R4Page 30The Sheriff’s Department amend its Coroner P&Ps to include a provision requiring annual reviews and updates of the Coroner P&Ps as needed to reflect changes in law and best practices.
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R5Page 30The Sheriff’s Department amend its Coroner P&Ps to include a policy ensuring that death records in a pending status are updated as soon as additional data is available to do so, and that investigation reports are supplemented promptly after receiving results of autopsies, toxicology reports and other procedures. 29
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R6Page 31The Sheriff’s Department institute yearly review of its Coroner P&Ps, to ensure compliance with updated legal requirements and best practices. REQUIRED RESPONSES Pursuant to Penal Code §933.05, the following responses are required: From the following Plumas County official ( ): • Plumas County Sheriff-Coroner (F-1 through F-6; R-1 through R-6) INVITED RESPONSES The Grand Jury invites the following responses: From the following Plumas County governing bodies and agency heads (requested and 60 days, respectively): • Plumas County Board of Supervisors (F-1 through F-6; R-1 through R-6) • Director, Plumas County Department of Public Health (F-1 through F-6) 30 BIBLIOGRAPHY Websites Plumas County Sheriff’s Department: https://plumascounty.us/Document Center/View/25145/Plumas-SO-GO-0-08-15-Revised-900-from-Grant Centers for Disease Control: https://www.cdc.gov/ and https://www.cdc.gov/nchs/data/misc/hb_me.pdf National Association of Medical Examiners: https://name.memberclick.net/ Commission on Peace Officer Standards and Training: https://post.ca.gov/basic-training- academies California State Association of Counties: https://www.counties.org/county-office/sheriff-coroner U.C. Davis, School of Medicine: https://health.ucdavis.edu/informatics/seminar_series/pdfs/EDRS- UCD_01_08_20064.2%20hogarth%20final.pdf 31