Medical Examiner's Office Report of the 1999-2000 San Francisco Civil Grand Jury

Recommendations 5

• R1
  a death with police officers at the scene;
• R2
  death in a hospital emergency room;
• R3
  death in a hospital, convalescent hospital room, rest home or board and care
• R4
  home; indigent cases.
• R5
  C. Delayed Response The CGJ closely reviewed with the MEO the issue of delayed response to a call regarding a death. This was an area where the CGJ received anecdotal information. The Chief of the Police Department advised the CGJ that representatives of the MEO are more often than not on the scene before the police arrive. However, the Chief Medical Examiner did acknowledge that there were often delays with respect to representatives of the Investigation Section arriving at a home where family members were on the scene. As noted above, this chiefly involved a situation where the Investigation Team was required to attend to a homicide case or a situation where there was a decedent in public view. As noted above, these situations have a higher order of response than the situation involving a death with family members on the scene. The MEO Administrative Guidelines Manual does provide that if the investigation representatives are going to be delayed, the investigators should telephone the MEO to advise of the delay. The CGJ recommended to the MEO that if the investigator cannot arrive at the scene of the death within one hour of advising the parties on the scene, (particularly the situation involving deaths with family members present), they should telephone the individuals at the scene, explain the delay and give an approximate time of arrival. It is recommended that the investigator's ambulance contain a cell phone. D. Public Information There is available at the MEO in the Hall of Justice several brochures in different languages delineating in a very sensitive and informative manner the duties and functions of the MEO and providing other information to survivors. It is recommended that this literature also be available in the investigator's ambulances so that it may be distributed to the survivors or friends of the deceased at the time the investigators visit the scene. The CGJ raised with the Chief Medical Examiner the issue of how members of the public may secure help in cleaning a premises that has been the scene of a violent crime. The Chief Medical Examiner advised that it is against the policy of the MEO to steer people to certain crime-scene cleaners. The MEO suggests that people look in the phone book for such services. The CGJ feels that this reticence to inform victims of violent crime as to cleaning services is not warranted. The CGJ does understand that the MEO does not want to be accused of steering members of the public to a particular vendor. Indeed there is a clear policy prohibiting referrals to a particular funeral home. However, it does seem a bit abrupt to advise people who are quite naturally in a state of shock to "look in the phone book." It is the CGJ's recommendation that a master list of crime-scene cleaning services be prepared and made available on request. E. Cultural and Language Concerns In that the population of San Francisco is so diverse in incorporating the number of recent immigrants from cultures that do not or may not understand the duties and functions of the MEO, it is particularly appropriate that the MEO be sensitive to difficulties in dealing with family members in such situations including the refusal of family members to allow access to the decedent or refusal to allow removal of the remains. The MEO Administrative Guidelines Manual provides that where access to the decedent is denied or the family or others refuse to allow removal of the decedent various procedures are to be followed. If the death is by natural causes, the investigators should explain to the family the ramifications of removal and the difficulty of certification of death. The investigators are cautioned to try to talk to one family member. If there is continued refusal it is suggested that the Investigator call the MEO. Contact with a clergyman or physician is suggested. Attempts should be made to get an outside friend, relative or professional involved. Finally, the investigators are instructed to be courteous and polite at all times. The CGJ has determined that the inability of certain members of the public to speak English has not presented a significant problem to the effective operations of the MEO. In those situations where there is not present a family member or friend who can translate, the MEO calls upon translators from the Police Department or the Department of Public Health. F. Sudden Infant Death The very traumatic situation involving sudden infant death syndrome cases is treated in detail in the Administrative Guidelines Manual. The investigators are specifically instructed to never leave a mother by herself. There should be an attempt to ascertain when the husband or partner will be home. Either a neighbor or friend should be present. The investigators must leave SIDS literature with the family and explain that a San Francisco County Public Health Nurse will be calling. Section 462 of the California Health and Safety Code requires in SIDS cases that the County Health Officer or designated agent immediately contact the person or persons who had custody of the infant and explain to such persons the nature and causes of SIDS to the extent that current knowledge permits. It is the policy of the MEO to send a letter to the parents of a SIDS victim. This letter is extremely sensitive, tactful and informative. After initially conveying the utmost sympathy on the loss of the child the letter discusses the state of the knowledge regarding SIDS, appropriate support groups and services and the MEO's particular attention to examining the circumstances of the death in question. A copy of this excellent letter is attached to this CGJ report (Attachment 2). G. Care of Personal Property Section 27491.3 of the California Government Code provides that the Coroner or Medical Examiner may take charge of any and all personal effects, valuables and property of a deceased at the scene of death and hold or safeguard the property until lawful disposition thereof can be made. The MEO Administrative Guidelines Manual details treatment of personal effects and property and treats the subject with sensitivity. If a legal next of kin is present at the scene any personal property or effects of the deceased will be removed and a receipt will be given to the next of kin. In a case of solitary deaths, all searches must be conducted by the investigating deputy only. It is emphasized that the investigator must always have a civilian witness at the scene such as the hotel manager, friends, the person who found the deceased, etc. It is specified that clothing should not be destroyed indiscriminately. Any clothing that is clean and appears serviceable should be removed, appropriately wrapped and stored and placed with the deceased. The guidelines note that the staff is to be especially careful with belt buckles or other such accouterments. The one thrown away will be the one "Uncle Harry had for 100 years and is irreplaceable." H. Complaint Procedures - Responses The subject of complaints received from the public or other agencies is treated exhaustively in the Administrative Guidelines Manual. Any complaint received must be immediately reported to the Administrator. The caller must be informed that the Administrator will return their call as soon as possible. The person receiving the call shall provide the Administrator with a written statement of the facts concerning the complaint or any alleged deviation from MEO policy. The Department Head or the Chief Medical Examiner may hold a fact-finding session with the employees concerned in order to establish the facts. Every month, ten cases are selected at random from cases investigated by the MEO. Form response letters are sent to the survivors. This is a one page document wherein the following questions are asked: (1) Were the investigators who came into the death scene courteous, dressed appropriate, helpful; (2) Did the investigators recommend a specific funeral director; (3) Did the investigators recover the deceased jewelry in front of you; (4) Did the investigators explain why they were taking the family member to the MEO; (5) Comments. The cover letter with this form states that the office: ...recently investigated the death of your loved one. In order to monitor and improve our service to the community, we ask that you take a few moments to complete the enclosed questionnaire and return it in the self-addressed, stamped envelope provided. If you have any questions or concerns that you would like to address to me directly, please feel free to contact me at the number listed below. Signed, [Chief Medical Examiner] As noted earlier, the CGJ reviewed literally hundreds of response letters received following solicitation by the MEO. There were only a very few complaints. One complaint had to do with the number of police cars in front of the house and officers laughing, etc. Another complaint concerned what was on the death certificate. The respondent felt that the death certificate appeared to make out the deceased as a drug addict which he was not. The respondent wanted the death certificate changed to "natural causes." One response did indicate that the staff was not sympathetic or helpful. However, the respondent indicated that she was in a state of shock and did not understand what was going on. She complained that no one later followed up with a telephone call and that she had to call the MEO. However, the great majority of the responses indicated that the investigators were "dignified," "courteous," "professional," "sensitive," and "went out of their way to locate relatives." Several individuals wrote lengthy comments and indeed some were specifically typed out on a separate page. It is of note that there were no responses that would indicate language or communication difficulties. I. Public Information The Administrative Guidelines Manual details regulations pertaining to public information. To foster cooperation and mutual respect between the public, the news media and the MEO, the Chief Medical Examiner or his authorized representatives are designated as the only personnel authorized to release any information regarding decedents. No information regarding a decedent or the circumstances of the death shall be released to the media unless the immediate next of kin has been notified. To assure that authorized personnel are communicating with a relative, the appointed representative of the family, or a member of a law enforcement agency, proper identification will be required before the MEO will release any information. Finally, the Administrative Guidelines Manual provides that, notwithstanding the MEO's cooperative attitude with the public and the media, certain information must be withheld from the public and the media in order to protect the rights of the next of kin. J. Identification of the Deceased The visual identification of a deceased friend or loved one is perhaps one of the most traumatic experiences a human being may be called upon to endure. The MEO is extremely sensitive to this issue. It is the policy of the MEO, as addressed definitively in the Administrative Guidelines Manual that, if a decedent is traumatized or in post- mortem decomposition, visual identification should not be utilized. If a family insists on viewing the traumatized and/or post-mortem decomposed decedent, and in the opinion of the investigator/pathologist that decedent is unviewable, every option should be taken to dissuade the viewing. If the family still insists, a waiver should be signed before viewing. It is of note that the Administrative Guidelines Manual specifically states that "common sense should prevail! The viewing room is for identification only, but the office is here to serve the public, and as such each case should be served on its individual merit." The CGJ investigated the possibility that unauthorized third persons might enter areas of the MEO, specifically the autopsy room or storage area and view the remains of decedents. Indeed there was concern that unauthorized personnel might even photograph the remains. The CGJ is confident that appropriate security now exists to prevent such a happening. Some time ago the Chief Medical Examiner was working late and heard noises in the autopsy room. He investigated and found that the janitor had brought certain friends in to see the autopsy room. The MEO now cleans or otherwise attends to all janitorial services with respect to the autopsy room and other sensitive areas. There is a potential problem with the door utilized by the investigators' ambulances and funeral director's vehicles. This is the original door that was constructed at the time the Hall of Justice was built. While locked and made of steel, the Chief Medical Examiner is concerned that it could be crowbarred open. Were someone to do this and gain access to the MEO and photograph or otherwise take inappropriate action with respect to human remains, the uproar and potential liability to the City would be horrendous. It is strongly recommended that an appropriate requisition be made for the replacement of the existing door with a door matching all appropriate standards for security. CONCLUSIONS AND RECOMMENDATIONS Issues raised in the 1997 Budget Analyst audit The CGJ has concluded that many of the critical items set forth in the 1997 audit have been corrected. Other criticisms were either not warranted or were not in need of further review or recommendation on the part of the CGJ. More specifically, past OSHA violations have been corrected. The MEO Written Exposure Control Plan and the training of employees ensures employees regarding the particular hazards inherent in their duties at the MEO. The lawsuits resulting from alleged testing of employees without their written consent were unmeritorious. All appropriate laws and regulations regarding consent for testing are in place. The MEO is meeting all regulations and requirements regarding sanitation and cleanliness. The 1997 audit's criticisms of the Toxicology and Pathology Departments were not warranted. What problems presently exist in those departments result from salary constraints inhibiting the retention of qualified professionals. The MEO is acting appropriately with respect to cooperating with other departments on the subject of inquests. The investigation division is not overstaffed but is in fact understaffed. Utilizing part-time drivers to handle certain duties of the investigation could result in serious legal exposure to the City and County of San Francisco. Sensitivity and interaction with the public With respect to interaction with the public, the CGJ concludes that the MEO acts with sensitivity and in accordance with established laws and existing policies and procedures of the office. The investigators, the first person or persons from the MEO that the family or a member of the public will have contact with present an initial visual impression of professionalism and act with sensitivity and kindness. While there have been occasions of delayed response those have been relatively few in number and were generally the result of the investigators being diverted to a higher priority call. The CGJ does recommend that appropriate contact be made with family members where a scheduled visit must be delayed. The CGJ also recommends that written information be left with survivors and survivors be advised as to appropriate assistance in cleaning a premises that has been the scene of a violent crime. The inability of certain members of the public to speak English does not appear to present a significant problem to the effective operations of the MEO. The MEO acts with great sensitivity in the area of Sudden Infant Death Syndrome cases. Regulations governing the handling of personal property are detailed and appear to be adhered to. The primary focus of MEO operations is dedicated to dealing sensitively and with kindness towards the survivors of the deceased. The Chief Medical Examiner San Francisco is fortunate indeed to have the benefit of the services of the present Chief Medical Examiner. He is a dedicated public servant. As noted earlier in this Report, the CGJ concurs with the impressions expressed in the 1997 audit concluding that the Chief Medical Examiner was very well respected in the Forensic Pathology community which recognition was of great value to San Francisco and is the key factor in generating San Francisco's reputation for providing the highest quality forensic services. The CGJ has noted the extensive time that the Chief Medical Examiner spends at the MEO, including weekends and evenings and the fact that he is subject to being called in at any time. Budgetary constraints require his participation in the Toxicology and Pathology Departments at the expense of his being able to give more attention to general managerial and supervisory duties. Recommendation (1) If representatives of the Investigation Team are going to be delayed and cannot arrive at the scene of a death within one hour of advising the parties of the scheduled arrival, the investigators should telephone the individuals at the scene, explain the delay and give an approximate time of arrival. The investigator's ambulance should contain a cell phone.