Monterey County Grand Jury • 2022-2023 • Agency Response
Response to: Monterey County Coroner's Office: A Matter of Life and Death

Monterey County, California Tina M. Nieto 's Office Sheriff-Coroner Keeping the peace since 1850 July 6, 2023 Honorable*

Published: July 06, 2023 5 pages
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Findings and Recommendations 9 findings

F1
county, which could bring into question the integrity of the findings of an investigation or autopsy. Response: Agree Although a written policy is not in place at this time, I made the decision immediately after taking office to utilize outside Coroner Offices to perform the forensic post-mortem examination of decedents whose death occurs in which Monterey County Sheriff's Office personnel are involved. This decision was made to increase the transparency and integrity of the investigation into the cause, manner, and circumstances of the death. Staff are actively working to develop a written policy/procedure which will be implemented upon review and approval to codify my verbal order and directive. The CO's current dictation and transcription process is inefficient, contributing to the final
Related Recommendations (1)
R1
Create and adopt a written policy and procedures when the MCSO, or its staff, will recuse itself from an investigation by September 30, 2023. The recommendation has not yet been implemented but will be implemented in future prior to Response: September 30, 2023.
F2
autopsy report delay. Disagree with this finding. Response: The Coroner's Office utilizes Forensic Autopsy Technicians to transcribe dictations provided by the contracted Forensic Pathologist. Coroner's Office personnel, at my direction, were tasked to prioritize and resolve delayed completion of final autopsy reports. At the time of this response, inefficient dictation, and transcription procedures existing when I took office have been resolved and all autopsy reports are current pursuant to the terms of the Forensic Pathologists contract with the Sheriff's Office. 1414 Natividad Road, Salinas CA 93906 (831) 755-3700 www.montereysheriff.org MONTEREY COUNTY, CALIFORNIA Tina M. Nieto 'S OFFICE Sheriff-Coroner Keeping the peace since 1850
Related Recommendations (1)
R2
Evaluate technological options to ensure dictation and transcription processes are efficient and timely by March 31, 2024. 1414 Natividad Road, Salinas CA 93906 (831) 755-3700 www.montereysheriff.org MONTEREY COUNTY, CALIFORNIA Tina M. Nieto F'S OFFICE Sheriff-Coroner Keeping the peace since 1850 The recommendation will not be implemented because it is not warranted. Response: Staff assigned to the Coroner's Office were tasked to prioritize and resolve delayed completion of final autopsy reports. Emphasis was placed on ensuring the terms and conditions for completion of autopsy reports were prioritized. At the time of this response, inefficient dictation, and transcription procedures existing when I took office have been resolved and all autopsy reports are current pursuant to the terms of the Forensic Pathologist contract with the Sheriff's Office.
F3
The lack of medical transcription training contributes to a delay in completing final autopsy reports. Disagree with the finding. Response: Although medical transcription training will assist staff in performing their transcription duties in a more efficient manner, it does not contribute to a delay in the completion of final autopsy reports. Delays have been caused by failing to hold the Forensic Pathologist to the terms and conditions of her contract with the Sheriff's Office for the completion of autopsy reports. In addition, the lack of prioritizing the workload and time needed by staff to complete the required autopsy reports also contributes to delays in the completion of final autopsy reports. Staff, working with the Forensic Pathologist, have resolved the delayed completion of autopsy reports which existed when I took office as the Sheriff-Coroner. CO detective investigative training is not a written requirement nor is there a completion
Related Recommendations (1)
R3
Provide ongoing resources for staff training and continuing education on transcription and emerging technologies in forensic science by March 31, 2024. The recommendation has not yet been implemented but will be implemented in the future prior to Response: March 31, 2024.
F4
despite its importance in ensuring investigations are conducted thoroughly and consistent with statewide standards. I disagree partially with this finding. Response: Currently, CO detective investigative training specific to coroner investigations is not necessitated due to a written Sheriff's Office requirement. Staff are working to develop a training matrix, identifying required and recommended training specific to coroner investigations, to ensure new detectives assigned to the CO receive assignment appropriate training within statewide standards. All current CO detectives have attended and completed the Statewide Coroner's Academy Coroners Course provided by the Orange County Sheriff's Office. The CO relies on hiring temporary employees to fill full-time permanent positions, which could
Related Recommendations (1)
R4
Ensure that death investigation training for each new detective assigned to the CO is mandatory and completed as soon as possible during their orientation by August 31, 2023. This recommendation has been implemented. Response: All current CO detectives have attended and completed the Statewide Coroner's Academy Coroners Course provided by the Orange County Sheriff's Office. All other training specific to coroner investigations would be considered recommended and not required. Recommended coroner specific training courses are provided at the Statewide Coroner's Academy hosted by the Orange County Sheriff's Office with limited presentations and limited capacity for students annually. All future personnel assigned to the CO will be required to attend the Statewide Coroner's Academy Coroners Course provided by the Orange County Sheriff's Office. This course is provided two times per year with one course provided in the spring and the other provided in the fall. Enrollment in the course will be prioritized by the Sheriff's Office, but actual attendance will be limited by course availability. Staff will be developing a training matrix identifying required and recommended training specific to coroner investigations to ensure new detectives receive assignment appropriate training within statewide standards.
F5
affect their ability to keep trained personnel on staff and may negatively affect consistency of operations. I partially disagree with this finding. Response: The Sheriff's Office is currently permanently budgeted for one sheriff's sergeant, four coroner detectives and two forensic autopsy technicians in the CO. The Sheriff's Office, prior to my taking office, hired temporary employees in excess of established full-time employee position allocations without an offsetting funding stream to cover their associated costs presenting an apparent reliance on them. At this time measures have been put in place within the CO to only utilize temporary employees when a position vacancy exists in the CO to allow for staffing coverage while the Sheriff's Office works with the Human Resources Department to conduct a recruitment to fill the vacant position on a permanent basis at which time the temporary employee would be no longer utilized. The MCSO has not enforced the provisions of the Forensic Pathologist's contract requiring the
Related Recommendations (1)
R5
Evaluate staffing needs and create permanent positions accordingly to minimize reliance on temporary staff by March 31, 2024. Response: This recommendation needs further analysis. Staff have been tasked to work with Human Resources to fill vacant permanent positions in the CO and eliminate the use of temporary employees when an offsetting funding stream is eliminated due to the hiring of a permanent employee. I am in support of an evaluation of staffing needs to identify the most efficient long-term structure of the CO. Implementation of any change to the existing structure of the CO will require concurrence of the proposed staffing structure by the Human Resources Department and the Board of Supervisors. In addition, in the event proposed changes to the structure of the CO lead to increased operational costs then the increased funding would have to be approved by the Board of Supervisors. 1414 Natividad Road, Salinas CA 93906 (831) 755-3700 www.montereysheriff.org 4 MONTEREY COUNTY, CALIFORNIA Tina M. Nieto 'S OFFICE Sheriff-Coroner Keeping the peace since 1850
F6
prompt completion of autopsy reports, which could cause added, unnecessary distress to the families of the deceased. I partially disagree with this finding. Response: 1414 Natividad Road, Salinas CA 93906 (831) 755-3700 www.montereysheriff.org MONTEREY COUNTY, CALIFORNIA Tina M. Nieto F'S OFFICE Sheriff-Coroner Keeping the peace since 1850 The Sheriff's Office was not regularly and routinely enforcing the provisions of its contract with the Forensic Pathologist prior to my taking office. Since taking office staff were tasked with working with the Forensic Pathologist to address the impacts on the families of the deceased due to the delayed completion of autopsy reports. Staff placed emphasis through accountability on ensuring the provisions of the contract were enforced and autopsy reports were completed within the terms and conditions of the contract. At this time all overdue delayed reports have been completed and the Forensic Pathologist working with CO staff are terms and conditions of the contract are adhered to.
Related Recommendations (1)
R6
Evaluate the necessary forensic pathologist services needed by Monterey County and identify the best approach for meeting those needs by January 31, 2024. This recommendation has not yet been implemented but will be implemented in the future by January Response: 31, 2024. Access to Forensic Pathologists across the United States is challenged due to not only the limited number Forensic Pathologists, but also to the limited number of Board-Certified Forensic Pathologists. Although the CO saw a reduction in case volume from 2021, where it handled over 1500 cases which included 475 autopsies, to 2022, where it handled 1,086 cases which included 423 autopsies, the use of this limited data would be inconclusive for an analysis of Forensic Pathologist services needed. To determine the necessary pathologist services needed by the CO, due to the COVID Pandemic, an analysis of approximately 8 years of data will need to be conducted to evaluate to trends in case volume to establish annual averages for the CO. The Sheriff's Office Fiscal Year 24 budget is fully allocated at the time of this response and completion of the analysis and review of accumulated data may require supplemental augmentation funding from the Board of Supervisors to conduct and complete.
F7
Collaborative purchasing arrangements between MCSO and other County departments have not been explored where service needs are the same or similar. I agree with this finding. Response:
Related Recommendations (1)
R7
Monitor and enforce performance measures that are stipulated in the Forensic Pathologist's contract by December 31, 2023. Response: This recommendation has been implemented. Upon taking office as the Sheriff-Coroner I directed staff to take immediate action to address delays existing in the completion of autopsy reports. Staff worked with the Forensic Pathologist to ensure terms and conditions outlined in the contract with the Forensic Pathologist were adhered to. As of the writing of this response the Forensic Pathologist has resolved the backlog of delayed autopsy reports and is working within the terms and conditions of her contract. In addition, the Sheriff's Office extended the Forensic Pathologist's contract effective July 1, 2023, placing a per case escalating financial penalty into the agreement it could charge the Forensic Pathologist for delayed autopsy reports.
F8
Approved budgets and balances are not directly shared with individuals who control departmental expenditures, resulting in a lack of accountability and ownership. Response: I agree with this finding. There are multiples layers in the supervisory and command structure of the Sheriff's Office. These layers allow for financial oversight of Sheriff's Office expenses specific to bureaus, divisions, and units. During my time in office, it was apparent fiscal training on responsibility and accountability of the budget had previously not been pushed to the division management or unit supervisory level of the Sheriff's Office. The lack of accountability and ownership at these levels was problematic in balancing the budget. Budget expenses were approved at bureau chief levels without a lack of accountability or ownership for approved expenses which then impacted the overall Sheriff's Office budget. Staff have developed and are currently implementing a plan to push accountability and ownership of the budget to the division management and unit supervisory levels for increased oversight of day-to-day expenditures thus addressing this finding. The CGJ acknowledges and appreciates the Coroner's Office staff for their ongoing
Related Recommendations (1)
R8
Explore optimizing existing or new contractual relationships with County Purchasing and other County of Monterey departments in areas where services or supply needs overlap by December 31, 2023. This recommendation has not yet been implemented but will be implemented on an ongoing basis as Response: contractual issues are explored through December 31, 2023. Respectfully submitted, Tina M. Nieto Sheriff-Coroner Cc: Sonia De La Rosa, County Administrative Officer Nick Chiulos, Assistant County Administrative Officer County of Monterey Board of Supervisors 1414 Natividad Road, Salinas CA 93906 🔳 (831) 755-3700 🔳 www.montereysheriff.org
F9
commitment and service to the community. I agree with this finding. Response: The staff assigned to the CO are the utmost professionals who have shown a commitment to the community and a commitment to ensuring the deceased are represented through their actions.
No recommendations for this finding

* This report's PDF did not contain easily extractable text and required Optical Character Recognition (OCR) for analysis. There may be minor errors in the extracted findings and recommendations due to OCR limitations with scanned documents.