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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.
Los Angeles County Grand Jury
• 1981-1982
Department of Chief Medical Examiner-Coroner. . . . . . . . . . . . . . . . . .
⚠️ 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 19 findings
F1
Page 83
The extent to which the Department has taken action to respond to recommendations made by previous grand juries and the Auditor-Controller to enhance day-to-day operations
F2
Page 83
Whether contracts are awarded to outside concerns (for drayage, property management, auctions, estate maintenance, and the like) in an equitable manner
F3
Page 83
Whether opportunities exist to contract out services currently provided by the Department at a lower cost to the County without compromising service quality
F4
Page 83
Whether adequate management information capabilities exist within the Department 82 .
F5
Page 84
Whether the Department is maximizing the revenue it could 100 potentially receive for the services it provides 1000000
F6
Page 84
The extent to which the Department monitors its own activities to ensure that estates are closed expeditiously and in keeping with departmental policies and procedures. APPROACH The review was conducted by a two-person team over a period of approximately six weeks. TOTAL STREET The team conducted extensive interviews with numerous officials of the Department as well as representatives of the County Administrative Office, the Purchasing Department, the County Counsel's Office and the Auditor-Controller. The team reviewed numerous previous Grand Jury and Auditor-Controller reports, internal PA-PG reports, case files, budgets, and 7.770 other documents containing information regarding the areas outlined under "Objectives." The team reviewed its findings, conclusions and recommendations with Department officials prior to preparation of the final report. FINDINGS The Department provides specialized services to specialized groups of clients. In some re- spects, the work carried out by the Department closely resembles the work of executors and conservators in the private sector. The Department's role, however, differs markedly from that of private executors and conservators in two respects:
F7
Page 84
The Department provides services to thousands of clients rather than to one or a few as is the case with private executors and conservators.
F8
Page 84
The Department, in addition to having a fiduciary relationship with individual clients, also holds a position of public trust. These aspects of the PA-PG's role lead to some unusual arrangements and situations. For example, the Department is not required to follow County purchasing procedures in ob- taining services for its clients. Considerable discretion is allowed by the courts in how such services are obtained. The discretion allows for a great deal of flexibility in obtaining the best service at the best price, but also allows the Department to operate without the controls imposed by competitive bidding procedures and requirements for written contracts. The Department has developed innovative arrangements for some services, but has not, in some other cases, aggressively pursued competitive bidding to ensure that clients receive the best possible services at the lowest reasonable prices. From a financial standpoint, the Department has made important strides in improving the portion of expenditures for services which are derived from the estates of clients. Since 1978, the Department has increased the portion of costs covered by client assets by over 70 per- cent. It is continuing to identify and develop new and increased revenues while maintaining a ú., responsible and compassionate approach to individual clients' conditions. Service of the 83 The Department's existing management information system is outmoded and does not provide the type of data required for efficiently administering estates and managing the Department's workload. The Department is taking steps to replace the existing system with an improved one. In the important areas of written policies and procedures and development of workload measures and standards, the Department has not developed and maintained adequate manual or automated systems. Policies and procedures, when they exist in written form, are often out of date. Evaluation of employee workload and performance is often subjective and not based on written criteria and records. CONCLUSIONS The Grand Jury concludes the following regarding the Department: The Department has taken aggressive, imaginative and appropriate steps to increase
F9
Page 85
While the Department does not appear to be required to follow County purchasing procedures in obtaining outside services for clients, it does have a fiduciary responsibi- lity to those clients to obtain adequate services at reasonable costs. In some aspects and especially with regard to certain services, the Department has not been diligent in assessing the marketplace and establishing adequate contractual arrangements and monitoring procedures. At the same time, it is noted that the current PA-PG has taken several positive steps to improve the performance of some contractors hired to serve the Department's clients. The Department has not been aggressive in identifying and analyzing areas for which
F10
Page 85
The existing management information system, while adequate in terms of basic accounting functions, does not provide the Department with a sufficiently useful management tool for workload and performance monitoring, case management and other purposes for which it was designed. Needed changes in programs and files have not been made, with the result that certain system capabilities and reports are not used. Instead, the functions for which those capabilities were designed are accom- plished manually or not at all. The Department's planned approach for developing a new management information system and for financing it through maintenance of compensating balances at a bank which would in turn provide the system, is appro- priate and cost-effective.
F11
Page 85
The Department's existing approach to monitoring the workload, performance and productivity of its employees is inadequate. Written policies and procedures in this area are out of date, and there are insufficient reporting mechanisms and performance criteria in place. 84
F12
Page 84
The Department provides services to thousands of clients rather than to one or a few as is the case with private executors and conservators.
F13
Page 84
The Department, in addition to having a fiduciary relationship with individual clients, also holds a position of public trust. These aspects of the PA-PG's role lead to some unusual arrangements and situations. For example, the Department is not required to follow County purchasing procedures in ob- taining services for its clients. Considerable discretion is allowed by the courts in how such services are obtained. The discretion allows for a great deal of flexibility in obtaining the best service at the best price, but also allows the Department to operate without the controls imposed by competitive bidding procedures and requirements for written contracts. The Department has developed innovative arrangements for some services, but has not, in some other cases, aggressively pursued competitive bidding to ensure that clients receive the best possible services at the lowest reasonable prices. From a financial standpoint, the Department has made important strides in improving the portion of expenditures for services which are derived from the estates of clients. Since 1978, the Department has increased the portion of costs covered by client assets by over 70 per- cent. It is continuing to identify and develop new and increased revenues while maintaining a ú., responsible and compassionate approach to individual clients' conditions. Service of the 83 The Department's existing management information system is outmoded and does not provide the type of data required for efficiently administering estates and managing the Department's workload. The Department is taking steps to replace the existing system with an improved one. In the important areas of written policies and procedures and development of workload measures and standards, the Department has not developed and maintained adequate manual or automated systems. Policies and procedures, when they exist in written form, are often out of date. Evaluation of employee workload and performance is often subjective and not based on written criteria and records. CONCLUSIONS The Grand Jury concludes the following regarding the Department: The Department has taken aggressive, imaginative and appropriate steps to increase
F14
Page 85
While the Department does not appear to be required to follow County purchasing procedures in obtaining outside services for clients, it does have a fiduciary responsibi- lity to those clients to obtain adequate services at reasonable costs. In some aspects and especially with regard to certain services, the Department has not been diligent in assessing the marketplace and establishing adequate contractual arrangements and monitoring procedures. At the same time, it is noted that the current PA-PG has taken several positive steps to improve the performance of some contractors hired to serve the Department's clients. The Department has not been aggressive in identifying and analyzing areas for which
F15
Page 85
The existing management information system, while adequate in terms of basic accounting functions, does not provide the Department with a sufficiently useful management tool for workload and performance monitoring, case management and other purposes for which it was designed. Needed changes in programs and files have not been made, with the result that certain system capabilities and reports are not used. Instead, the functions for which those capabilities were designed are accom- plished manually or not at all. The Department's planned approach for developing a new management information system and for financing it through maintenance of compensating balances at a bank which would in turn provide the system, is appro- priate and cost-effective.
F16
Page 85
The Department's existing approach to monitoring the workload, performance and productivity of its employees is inadequate. Written policies and procedures in this area are out of date, and there are insufficient reporting mechanisms and performance criteria in place. 84
F17
Page 85
While the Department does not appear to be required to follow County purchasing procedures in obtaining outside services for clients, it does have a fiduciary responsibi- lity to those clients to obtain adequate services at reasonable costs. In some aspects and especially with regard to certain services, the Department has not been diligent in assessing the marketplace and establishing adequate contractual arrangements and monitoring procedures. At the same time, it is noted that the current PA-PG has taken several positive steps to improve the performance of some contractors hired to serve the Department's clients. The Department has not been aggressive in identifying and analyzing areas for which
F18
Page 85
The existing management information system, while adequate in terms of basic accounting functions, does not provide the Department with a sufficiently useful management tool for workload and performance monitoring, case management and other purposes for which it was designed. Needed changes in programs and files have not been made, with the result that certain system capabilities and reports are not used. Instead, the functions for which those capabilities were designed are accom- plished manually or not at all. The Department's planned approach for developing a new management information system and for financing it through maintenance of compensating balances at a bank which would in turn provide the system, is appro- priate and cost-effective.
F19
Page 85
The Department's existing approach to monitoring the workload, performance and productivity of its employees is inadequate. Written policies and procedures in this area are out of date, and there are insufficient reporting mechanisms and performance criteria in place. 84
Recommendations 27
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R1Page 79That the Department utilize "daily" transcribing procedures for recording inquest hearings that require immediate transcripts. Such option should be explained to all inquest parti- A STATE OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE The additional costs should be charged to the agency requesting the immediate cipants. transcript. That the Department develop performance standards for dictating and transcribing inquest
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R2Page 79In developing the proposed new management information system, the Department should ensure inclusion 200 in the system design of a capability to record and accumulate actual costs associated with the provision of all extraordinary services.
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R3Page 79That the Department develop a reporting system that tracks the workload of the Inquest Division and reports key operating data to management. Section of the last
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R4Page 79That the Department conduct a complete review of existing autopsy screening procedures to determine whether or not the number of complete autopsies presently performed needs to be increased. In performing this review, the professional opinions of qualified forensic A COLUMN 79 pathologists should be sought. Considering existing workloads, if additional autopsies need to be per- formed, staffing levels should be increased commensurately to maintain/enhance the quality of autopsies presently being performed. That the Department evaluate the workloads of investigators to determine if such workloads are too heavy in light of the need to conduct thorough investigations and in light of the overall duties performed. That the Department continue to use Coroner's Investigators to conduct inquest investigations. Efforts should be made whenever possible to use the original Coroner's Investigator assigned to the case.
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R5Page 79The Department should develop specific written procedures for monitoring the performance of contracted services and the accuracy of invoices submitted by contractors providing property cleanup and maintenance services. The Department should develop and adhere to written procedures for evaluating the appropriateness of
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R6Page 79property insurance coverage. The review of insurance placed should occur within a week to ten days of the broker's placement of such coverage in order to limit potential County loss liability. The Department should undertake detailed analyses of the following service areas for potential contracting out:
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R7Page 79That the Department continue to use outside contractors to perform embalming services based upon their evaluation of the most responsible bidder. That the Department enforce the formal personnel evaluation requirements set forth in the Department's Personnel Guidelines.
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R8Page 79The Department should seek a County Counsel opinion on the legality of contracting out property manage- ment services. Once a legal opinion has been rendered that the contracting of property management services is not pro- hibited by the Probate Code or County Charter, ordinances or other operating provisions, the Department should undertake a detailed analysis of this service area and either (a) develop and issue an RFP or, (b) recommend against contracting out the service. The Department should conclude its analysis of the administration of summary estates and adopt a formal position relative to providing the service in-house or contracting it out.
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R9Page 79That each Division develop quantitative standards of performance for major staff positions to serve as the basis for budget projection, staffing and performance evaluation. The final standards should continually be available to staff for reference.
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R10Page 79That the Department assign a Training Officer to develop formal training programs and a training budget for the continuing education of Departmental employees.
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R11Page 79That the County Personnel Department conduct an overall review/formal survey of positions and salaries within the Department. Such review should focus on the comparability of wages and duties within the overall County personnel structure and considering similar agencies in surrounding counties. The results of such review should be used in setting wages and salaries in the future.
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R12Page 79That the Department establish a specific retention policy for photographs, x-rays, bullets, death instru- ments, personal clothes, inquest reporter notes of inquest hearings, and other data and materials created in daily operations.
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R13Page 80That the Department improve storage practices by consolidating all storage areas of vital evidence into one central area. Storage bins should be secured and inventory records maintained.
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R14Page 80That the Department develop and submit to the County of Los Angeles Board of Supervisors a request for additional operating space to meet the immediate and long-term requirements.
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R15Page 80That the Department develop scheduling and parking arrangements for Coroner's vans and mortuary vehicles to accommodate reasonable peak loads.
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R16Page 80That the Department create and maintain a master log report (management information report) that reports the number of deferred certificates and final death certificates issued by examining pathologists and lists pending deferred death certificates and remaining tests and reports ordered by days outstand- ing.
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R17Page 80That the Department develop and implement performance standards for completion of internal medical tests (like histopathology) and, when necessary, secure additional support or overtime work to assure timely performance. Such standards should be developed with the help and input of outside agencies (e.g., law enforcement, hospitals, etc.) to develop mutually acceptable time standards for receipt of their respective reports that are critical to the completion of deferred death certificates.
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R18Page 80That the Department numerically order death certificates and maintain records to improve internal control procedures. 80
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R19Page 80That pathologists review copies of completed death certificates. If discrepancies are identified in review- STATE OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE PARTY OF THE P ing the death certificate, an amendment should be issued. That the Department strive to rigidly enforce the requirement for immediate notification of the Coroner. 100000000000000000000000000000000000000
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R20Page 80The Department should be requested to report to the 1982-83 Los Angeles County Grand Jury its progress toward implementing the recommendations contained in this report. 86
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R21Page 80That the Department accumulate in a single reference book a Departmental Policy and Procedures Manual; such manual should include tasks and standards for Coroner's Investigators and Senior Coroner's
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R22Page 80That the Department develop and monitor an evaluation system that tracks and enforces staff investi- gating performance against documented policies, procedures and standards. STOCK STOCK That the Department require payment in full before the preparation of inquest transcripts.
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R24Page 80That the Auditor-Controller develop a billing rate for first-time requests for inquest transcripts that is 200 consistent with the actual costs of preparation.
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R25Page 80That the Department work with other County departments requesting autopsy and transcript reports to determine if the volume of reports is excessive and if such volume cannot reasonably be reduced.
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R26Page 80That the Department's request for $85,000 in capital expenditures for the forensic laboratory equipment be approved. Such equipment is necessary to assure accurate and timely toxicology test results.
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R27Page 80That the Department develop a plan to implement the recommendations of this report that specifies
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R28Page 80That the Coroner's Office continue with the development of the "CAIN" system and the documenta- tion of its internal operating procedures. The detail design phase of "CAIN" development should be scheduled to begin after management changes in operating procedures resulting from this study have been made.