8. On the Street

Accreditation. The Los Angeles County Coroner should be accredited. Accreditation demonstrates compliance with acceptable professional standards and performance criteria providing assurance of competence in carrying out medicolegal death investigations. There are two nationally recognized organizations that set accepted standards for accreditation, The NAME11 and The International Association of Coroners and Medical Examiners (IAC&ME)12. NAME is a national professional organization representing physicians, investigators and administrators, who are active in medicolegal death investigations. The IAC&ME is a similar, but an international organization. Both organizations have standards that are accepted as national accreditation standards by multiple medicolegal professional associations. Accreditation is given at two levels: Full Accreditation is given to those organizations that have no major deficiencies and less than fifteen minor deficiencies and is granted for five years. Provisional Accreditation is given with less than five major and less than twenty-five minor deficiencies and is granted for a twelve month period. There is an expectation of significant improvement during that time that can result in another twelve-month extension. The primary reason for DME-C’s downgrade from Full to Provisional Status was its difficulty in recruiting and retaining personnel, especially forensic pathologists, investigators, and criminalists/forensic toxicologists. Inadequate numbers of personnel have resulted in excessive overtime, employee redeployment, and employee burnout. Most importantly, the overall effect has been rapidly growing backlogs in final autopsy reports that have resulted in failure to meet the accreditation standard of 90% final autopsy reports completed in 90 days or less. Another requirement by NAME is that 90% of autopsies and external examinations are to be performed within 72 hours from the time: 1. the medical examiners’ jurisdiction is accepted 2. the coroner’s authorization is granted 3. or the receipt of an externally referred decedent The inability to attain the above requirements, threatens the DME-C’s ability to achieve Full Accreditation status, when they are re-evaluated by NAME in 2020. The NAME Inspection and Accreditation Program has the purpose of improving the quality of the forensic/medicolegal investigation of deaths. NAME’s accreditation applies to forensic death investigations. It does not apply to individual forensic practitioners. Accreditation issues may also be associated with the condition of their facilities. Facilities are only a part of the accreditation evaluation and NAME does not accredit facilities alone. The accreditation standards emphasize policies and procedures, not the professional work product. The accreditation standards represent minimum standards for an adequate medicolegal death investigation system, not guidelines. NAME accreditation is an endorsement by NAME that the system or office provides an adequate environment, in which a medical examiner/forensic pathologist may practice his or her profession and provides reasonable assurances that the office or system well serves its jurisdiction. NAME accreditation is not a guarantee of proper 11 https://netforum.avectra.com/eweb/DynamicPage.aspx?Site=NAME&WebCode=AboutNA... 1/8/2018 12 IAC&ME https://www.theiacme.com 2017-2018 LOS ANGELES COUNTY CIVIL GRAND JURY FINAL REPORT 193 medicolegal death investigations or forensic pathology diagnoses. It is the goal of NAME that application of these accreditation standards will aid materially in developing and maintaining a high caliber of forensic medicolegal death investigations for the communities and jurisdictions they serve. Discussion of DME-C Organization Presented below are significant divisions or units within the DME-C organizational structure. The Operations Bureau and Call Center The Operations Bureau represents the largest segment of the DME-C13. This bureau consists of the disaster community services, decedent services, coroner investigation, identification, notification services, background coordinator, Sudden Infant Death Syndrome Program and Peace Officers Standards and Training (POST),14 and The Special Operations Response Team (SORT),15 which provides response in the event of any mass fatality or high explosive incident. The Public Information Officer also falls under this bureau. This Bureau is responsible for the 24-hour a day, 7 day a week operations of many direct services provided by the department.16 The Bureau oversees the Investigations and Forensic Services Divisions.

The Los Angeles County Coroner should implement a better case management system. The Operation Bureau’s Call Center receives all incoming calls which include emergency calls, non-emergency calls and dispatches all outgoing calls utilizing a case assignment screen. The present version utilizes the Case Management Enterprise CME2.2 (a 1997 version). This system is antiquated and its operational area is challenged when processing all such calls through their Case Management System (CMS). The system crashes giving a ‘run-time-error’ message which obviously interrupts the normal flow of work placing all work productivity at a complete standstill. As calls come in, case numbers are assigned manually and recorded on paper logs until the system comes back up. When this system (CMS) goes down, it does not have a ‘save’ or backup data entry function or capability. When the system comes back up the user/operator must input the records into the CMS system effectively handling the same record twice. The CMS has a limited search function, only the name or date field can be searched. In both cases it can only match the exact match. For example, Jon Smith would not yield options for John Smith. The term “case management system” also refers to two computer applications. First, an application called CMS which has been in place for over 15 years, is not secure and cannot be changed or upgraded. Second, ECFS (Electronic Case Filing System) is a more recently developed application that is being used for object tracking (autopsy specimens and evidence) and document storage. These two systems are separate and synchronized daily. An Information Technology (IT) manager has been hired and this should prove helpful improving the functionality of the present system. DME-C Organization chart 14 Peace officers’ (POST) Training Manual 15 Ibid 16 DME-C Senior Staff Report 194 2017-2018 LOS ANGELES COUNTY CIVIL GRAND JURY FINAL REPORT

or the receipt of an externally referred decedent The inability to attain the above requirements, threatens the DME-C’s ability to achieve Full Accreditation status, when they are re-evaluated by NAME in 2020. The NAME Inspection and Accreditation Program has the purpose of improving the quality of the forensic/medicolegal investigation of deaths. NAME’s accreditation applies to forensic death investigations. It does not apply to individual forensic practitioners. Accreditation issues may also be associated with the condition of their facilities. Facilities are only a part of the accreditation evaluation and NAME does not accredit facilities alone. The accreditation standards emphasize policies and procedures, not the professional work product. The accreditation standards represent minimum standards for an adequate medicolegal death investigation system, not guidelines. NAME accreditation is an endorsement by NAME that the system or office provides an adequate environment, in which a medical examiner/forensic pathologist may practice his or her profession and provides reasonable assurances that the office or system well serves its jurisdiction. NAME accreditation is not a guarantee of proper 11 https://netforum.avectra.com/eweb/DynamicPage.aspx?Site=NAME&WebCode=AboutNA... 1/8/2018 12 IAC&ME https://www.theiacme.com 2017-2018 LOS ANGELES COUNTY CIVIL GRAND JURY FINAL REPORT 193 medicolegal death investigations or forensic pathology diagnoses. It is the goal of NAME that application of these accreditation standards will aid materially in developing and maintaining a high caliber of forensic medicolegal death investigations for the communities and jurisdictions they serve. Discussion of DME-C Organization Presented below are significant divisions or units within the DME-C organizational structure. The Operations Bureau and Call Center The Operations Bureau represents the largest segment of the DME-C13. This bureau consists of the disaster community services, decedent services, coroner investigation, identification, notification services, background coordinator, Sudden Infant Death Syndrome Program and Peace Officers Standards and Training (POST),14 and The Special Operations Response Team (SORT),15 which provides response in the event of any mass fatality or high explosive incident. The Public Information Officer also falls under this bureau. This Bureau is responsible for the 24-hour a day, 7 day a week operations of many direct services provided by the department.16 The Bureau oversees the Investigations and Forensic Services Divisions. Finding 2: The Los Angeles County Coroner should implement a better case management system. The Operation Bureau’s Call Center receives all incoming calls which include emergency calls, non-emergency calls and dispatches all outgoing calls utilizing a case assignment screen. The present version utilizes the Case Management Enterprise CME2.2 (a 1997 version). This system is antiquated and its operational area is challenged when processing all such calls through their Case Management System (CMS). The system crashes giving a ‘run-time-error’ message which obviously interrupts the normal flow of work placing all work productivity at a complete standstill. As calls come in, case numbers are assigned manually and recorded on paper logs until the system comes back up. When this system (CMS) goes down, it does not have a ‘save’ or backup data entry function or capability. When the system comes back up the user/operator must input the records into the CMS system effectively handling the same record twice. The CMS has a limited search function, only the name or date field can be searched. In both cases it can only match the exact match. For example, Jon Smith would not yield options for John Smith. The term “case management system” also refers to two computer applications. First, an application called CMS which has been in place for over 15 years, is not secure and cannot be changed or upgraded. Second, ECFS (Electronic Case Filing System) is a more recently developed application that is being used for object tracking (autopsy specimens and evidence) and document storage. These two systems are separate and synchronized daily. An Information Technology (IT) manager has been hired and this should prove helpful improving the functionality of the present system. DME-C Organization chart 14 Peace officers’ (POST) Training Manual 15 Ibid 16 DME-C Senior Staff Report 194 2017-2018 LOS ANGELES COUNTY CIVIL GRAND JURY FINAL REPORT