Sacramento County Grand Jury June 30, 2003 Death Investigation in Sacramento County: The Coroner’s Office

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.

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.

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.

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.

The performance of death investigation does not require law enforcement background. Forensic pathology fellowship includes this training, and forensic board certification requires this knowledge.

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.

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.

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.

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.

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.

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.

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.

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.

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.

Change to a medical examiner system requires a charter amendment and electorate participation.

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.