📋
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.

Merced County Grand Jury • 2004-2005

Merced County Coroner's Office — Complaint #04-05-03

3 pages
View PDF View Full Original

Findings and Recommendations 7 findings

F1 Page 21
The Committee found that the complaint had merit. As of January 17, 2005, the complainant still had not received the final death certificate.
No recommendations for this finding
F2 Page 21
Cases pending final death certificates are identified with an orange circle label. Upon issuance of the final amended death certificate, the peel-off label is removed
No recommendations for this finding
F3 Page 21
The Coroner’s Office has over 100 pending cases covering a two year period. The oldest case has been outstanding for over two years. The pathologist report had been received, yet the case was still without the final cause of death.
No recommendations for this finding
F4 Page 21
Evidence of systematic review and follow up were not apparent in the files. It was difficult to determine the last time a file had been reviewed and/or what action had been taken.
No recommendations for this finding
F5 Page 21
There was an inordinate amount of responsibility assigned to a sole employee.
No recommendations for this finding
F6 Page 21
The review of the official records and their record keeping practice demonstrated a drastic need for improvement. It is a contributing factor to a much greater problem. Utilization of a manual system versus up-to-date technology delayed a chronological updating of pending and final reports.
No recommendations for this finding
F7 Page 21
It was also noted that the cost of the contracted pathologist had increased substantially over the years.
No recommendations for this finding