Santa Barbara County Coroner's Bureau Still a Substandard Facility

Conclusions 11

• CL1
  Discharged air from the autopsy room ventilation system is not monitored, resulting in air-borne pathogens being discharged to the atmosphere. 2019-20 Santa Barbara County Grand Jury Page 3
• CL2
  The bodies are placed in the refrigeration room in body bags and stored on racks.
• CL3
  An industrial scale is located outside the Sheriff-Coroner’s building.
• CL4
  There is no stainless steel dissecting table with wash down equipment in the autopsy room.
• CL5
  The residue from autopsies drains into a sink, which is discharged into the public sewer system.
• CL6
  In Santa Barbara County, the Sheriff is also the Coroner.
• CL7
  The current building, constructed in 1987 and adapted to be the Sheriff-Coroner’s Bureau in 1988, does not meet National Association of Medical Examiners standards.
• CL8
  There is one autopsy room, no toxicology lab and no isolation room dedicated to handle high risk cases.
• CL9
  All instruments are manually cleaned with soap and water. This is a safety hazard and cross- contamination between autopsies cannot be avoided.
• CL10
  The Santa Barbara County Sheriff-Coroner’s Bureau is not accredited by the National Association of Medical Examiners. 2019-20 Santa Barbara County Grand Jury Page 4
• CL11
  As has been reported by many previous Grand Juries in 2012-13, 2014-15 and 2015-16, and reconfirmed by the 2019-20 Santa Barbara County Grand Jury, the Santa Barbara County Sheriff-Coroner’s facility should be replaced as soon as possible. The Jury finds that the serious inadequacies of the facility jeopardize the health and safety of the staff and the public. The Grand Jury recommends that the Santa Barbara County Board of Supervisors establish an independent Coroner’s Bureau, one that can be accredited by the National Association of Medical Examiners. Santa Barbara County has recently faced many deaths from natural disasters, man-made emergencies, accidents and pandemics. There should be a new, fully accredited facility to meet the challenges of the 21st century. FINDINGS AND RECOMMENDATIONS Finding 1 The current building, constructed in 1987 and adapted to be the Sheriff-Coroner’s Bureau in 1988, does not meet National Association of Medical Examiners standards. Recommendation 1 That the Santa Barbara County Board of Supervisors allocate funding for a facility specifically designed as a Coroner’s Bureau, built to meet the current recommended standards of the National Association of Medical Examiners. Finding 2 There is one autopsy room, no toxicology lab and no isolation room dedicated to handle high risk cases. Recommendation 2 That the Santa Barbara County Board of Supervisors specify that the Coroner’s facility be designed with two autopsy rooms, a toxicology lab, an isolation room, and a refrigeration room. Finding 3 Discharged air from the autopsy room ventilation system is not monitored, resulting in air-borne pathogens being discharged to the atmosphere. 2019-20 Santa Barbara County Grand Jury Page 3 Recommendation 3 That the Santa Barbara County Sheriff-Coroner monitor discharged air and ensure that no air- borne pathogens are discharged into the atmosphere. Finding 4 The bodies are placed in the refrigeration room in body bags and stored on racks. Recommendation 4 That the Santa Barbara County Sheriff-Coroner provide a more modern method of body storage such as refrigerated drawers. Finding 5 An industrial scale is located outside the Sheriff-Coroner’s building. Recommendation 5 That the Santa Barbara County Sheriff-Coroner install a body scale within the Sheriff-Coroner’s building to determine accurate weight, without consideration of the weight of the body bag or the gurney. Finding 6 There is no stainless steel dissecting table with wash down equipment in the autopsy room. Recommendation 6 That the Santa Barbara County Sheriff-Coroner install a stainless steel dissecting table with dedicated drainage in the autopsy room. Finding 7 The residue from autopsies drains into a sink, which is discharged into the public sewer system. Recommendation 7 That the Santa Barbara County Sheriff-Coroner handle residue from autopsies as biological hazardous waste. Finding 8 All instruments are manually cleaned with soap and water. This is a safety hazard and cross- contamination between autopsies cannot be avoided. Recommendation 8 That the Santa Barbara County Sheriff-Coroner install an autoclave to ensure all instruments are sterilized after cleaning. Finding 9 The Santa Barbara County Sheriff-Coroner’s Bureau is not accredited by the National Association of Medical Examiners. 2019-20 Santa Barbara County Grand Jury Page 4 Recommendation 9 That the Santa Barbara County Board of Supervisors require that the Sheriff-Coroner’s Bureau meet the standards for accreditation set by the National Association of Medical Examiners and the National Academy of Sciences, as recommended by the U.S. Department of Justice. Finding 10 In Santa Barbara County, the Sheriff is also the Coroner. Recommendation 10 That the Santa Barbara County Board of Supervisors separate the Santa Barbara County Coroner position and make it independent from the Santa Barbara County Sheriff when the current Sheriff-Coroner’s term expires. REQUEST FOR RESPONSE Pursuant to California Penal Code Section 933 and 933.05, the Santa Barbara County Grand Jury requests each entity or individual named below to respond to the enumerated findings and recommendations with the specified statutory time limit: Responses to Findings shall be either:  Agree  Disagree wholly  Disagree partially with an explanation Responses to Recommendations shall be one of the following:  Has been implemented, with brief summary of implementation actions taken  Will be implemented, with an implementation schedule  Requires further analysis, with analysis completion date of no more than six months after the issuance of the report  Will not be implemented, with an explanation of why Santa Barbara County Board of Supervisors – 90 days Finding 1, 2, 9, 10 Recommendation 1, 2, 9, 10 Santa Barbara County Sheriff-Coroner – 60 days Finding 3, 4, 5, 6, 7, 8 Recommendation 3, 4, 5, 6, 7, 8 2019-20 Santa Barbara County Grand Jury Page 5

Observations 1

• OB1
  The Santa Barbara County Sheriff is the Sheriff-Coroner. Santa Barbara County joined 40 other counties using the Sheriff-Coroner model in 1947. The remaining 17 counties have either a medical examiner or a lay coroner. The Sheriff-Coroner is not subject to mandatory state or national accreditation. A medical examiner model operates under more stringent regulations and must meet national accreditation and quality assurance standards. Moreover, the Sheriff-Coroner is not independent from law enforcement supervision. The Santa Barbara County Coroner’s Bureau is currently staffed by a sergeant who is the supervisor, four coroner’s investigators, one full-time pathologist, two extra-help technicians, and one administrative office professional. The Bureau staff state that they review approximately 1500 deaths and conduct between 700 and 800 death investigations annually. The Pathologist, on behalf of the Sheriff-Coroner, determines a deceased person's time and cause of death, often in the case of sudden or unexpected deaths. The Bureau staff identify bodies, notify the next of kin, and return personal belongings to the family. They work with the Santa Barbara County Sheriff and city police departments within the County to investigate suspicious or violent deaths. The Santa Barbara County Coroner creates death records that can be used in criminal investigations, to resolve insurance claims or to monitor Santa Barbara County public health. In Santa Barbara County, all autopsies are done in one room. The Bureau does not have an isolation room to handle high risk cases to prevent the possible transmission of air-borne pathogens. After many reports from previous Grand Juries, the ventilation system in the autopsy room was finally updated in 2017. It is now designed to cause negative air pressure in the autopsy room to prevent pathogens from entering other parts of the building from the autopsy room. However, the discharge from the ventilation system, installed on the roof above the autopsy room, is not monitored and possible aerosolized pathogens might be discharged into the atmosphere. Autopsies are performed on gurneys, not on a stainless-steel table, and there is no dedicated dissection table. It was observed that the gurney used for the autopsy is cleaned by hand and drained by lifting and tilting the gurney in order to drain the residue into the sink in the autopsy room. The Bureau lacks other preventive measures to safely protect staff and equipment. There is no transition room for staff to remove protective clothing and clean up. There is no equipment to sterilize instruments used in performing autopsies. Although instruments are cleaned with soap and water, cross-contamination cannot be avoided. It was observed that there was no eye-wash 2019-20 Santa Barbara County Grand Jury Page 2 station located in the autopsy room when this Jury inspected the Coroner’s Bureau in October 2019. However, that has since been rectified and there is now an eye-wash station in the autopsy room. There is a refrigerated room where bodies are placed in body bags and stored on racks within the room. The facility has a back-up generator in the event of a power failure. Outside the main building in a secure area there is an additional refrigerated unit capable of storing two bodies and an industrial scale to weigh bodies. The weight of the body is determined after deducting allowance for the body bag and the gurney. Recently, the Bureau has acquired a machine to analyze DNA for identification of victims. This saves time and money by eliminating the need to send samples to an outside lab, which could take weeks to obtain results. This valuable resource can now perform the identification and obtain results in a few hours.

Agency Responses 2

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