At the request of the San Francisco Board of Supervisors, the Budget Analyst conducted this management audit of the Medical Examiner"s Office of the City and County of San Francisco

Audit Scope

The scope of this management audit included a comprehensive examination of the operations, organizational structure, and staffing of the Medical Examiner"s Office and its interactions with other City departments, private mortuaries and the citizens of the City and County of San Francisco. The Medical Examiner"s Office is authorized by the California Government Code for the purpose of investigating and determining the manner and cause of death, and signing the death certificate in cases that fit the following criteria:

• The death is sudden, violent or unusual;

• The deceased has not been attended by a physician in the 20 days prior to death;

• The death is related to or follows a known or suspected self-induced abortion;

• The death is a known or suspected homicide, suicide, or accidental poisoning;

• The death is known or suspected to be the result of or related to an accident or injury;

• The death is due to drowning, fire, hanging, gunshot, stabbing, cutting, exposure, starvation, acute alcoholism, drug addiction, strangulation, aspiration, or where the suspected cause of death is Sudden Infant Death Syndrome (SIDS);

• The death in whole or in part is occasioned by criminal means; or,

• The death is known or suspected to be related to a contagious disease and constitutes a public health hazard, or is known or suspected to be related to an occupational disease or occupational hazard.

In addition, all deaths: occurring while an individual is in custody, or under sentence; resulting from involvement with a law enforcement action; involving a patient in a state hospital serving the developmentally disabled, and operated by the State Department of Developmental Services; or occurring under circumstances that afford reasonable grounds to suspect that the death was caused by the criminal act of another, fall under the jurisdiction of the Medical Examiner"s Office.

In order to assess the Medical Examiner"s Office"s fulfillment of its duties, the audit focused on the following areas:

• General operations and procedures with particular focus on the daily activities that are carried out to ensure that the Medical Examiner"s Office fulfills its duties and that the staff understands all processes and procedures;

• Organization and staffing to determine the Medical Examiner"s Office"s placement in the overall organization of the City and County, and the internal organizational structure of the Office, including, lines of authority and responsibility within the Medical Examiner"s Office, levels of staffing and management and the use of staff;

• Finance and budget to review current revenue and expenditure appropriations for the office and changes in appropriation levels over the past 5 years and the impact of those changes on the ability of the Medical Examiner"s Office to fulfill its functions for the City; and

• Interdepartmental relations and community perceptions to ascertain the actual and perceived levels of service the Medical Examiner"s Office provides for law enforcement and judicial agencies, the citizens of the City and County of San Francisco, private mortuaries, and private physicians.

Methodology

This audit was conducted in accordance with the generally accepted auditing practices established by Comptroller General of the United States and detailed in the United States General Accounting Office publication, Government Auditing Standards 1994 Revision. The following procedures were used to obtain information and verify the findings detailed in this audit report.

• Interviews with key personnel within the Medical Examiner"s Office, the District Attorney"s Office, the San Francisco Police Department, the Office of the Public Defender, and the Department of Health Services.

• Interviews with the staff of the Medical Examiner"s Office.

• Discussions with independent toxicologists, independent clinical laboratories in the Bay Area, and Medical Examiners" and Coroners" staff from the 10 largest California counties and selected jurisdictions around the United States.

• Review and analysis of documents outlining the roles and responsibilities of the various sections of the Medical Examiner"s Office, policy and procedure manuals outlining the expectations and steps of forensic examinations and pathology and toxicology testing, and previous audits and reports conducted by the Controller"s Internal Audit Division, the Office of the Chief Administrative Office, and the 1995-96 San Francisco Civil Grand Jury.

• A review of control procedures for processing and releasing the property of the deceased, the treatment and handling of evidence from crime scenes and specimen resulting from forensic examination procedures, including maintaining adequate chain of custody.

• Observations of administrative procedures, toxicology and pathology procedures for conducting required tests, responses to death scenes, processing bodies brought into the Medical Examiner"s Office and the work performed by the Medical Examiner"s Investigators at death scenes.

• A limited sampling of cases under the jurisdiction of the Medical Examiner"s Office to determine the process used to "sign out" the case and the completeness of the permanent file for each case including autopsy, pathology and toxicology reports.

• Observations of Medical Examiner"s Inquests and the disposition of such cases by the Medical Examiner, Police Department and District Attorney.

• The evaluation of rate schedules used by the Medical Examiner"s Office for various procedures that are performed for non-Medical Examiner cases including the costs of such procedures and the revenue generated.

• A formulation of recommendations to improve the operations, organizational structure, and management of the Medical Examiner"s Office for the City and County of San Francisco.

History and Overview of the Medical Examiner - Coroner Office
for the City and County of San Francisco

Establishing and Authorizing a Medical Examiner"s Office

As previously noted, the Medical Examiner"s Office is mandated and authorized by the California Government Code Section 24010 which states:

The Charter for the City and County of San Francisco (Charter) established and authorized the Office and the position of Coroner. As originally established the Medical Examiner/Coroner"s Office was under the jurisdiction of the Office of the Chief Administrative Officer (CAO). The individual appointed to serve is a Charter Officer of the City and serves at the pleasure of the CAO.

Under a provision of the 1996 Charter Reform, there is no longer a position of CAO and the Medical Examiner"s Office now reports to the Director of Administrative Services. The changes to the Charter have not affected the internal lines of authority and reporting for the Medical Examiner"s Office. Section VI of this report provides a detailed review of the organizational structure of the Medical Examiner"s Office, the lines of reporting, and current staffing configurations for each of the functional areas of the office.

Interaction with Other City Departments, Agencies and the Public

The changes to the Medical Examiner"s Office as a result of Charter Reform also has not changed the Office"s obligation to work cooperatively with other City departments and law enforcement and judicial agencies. It is essential that the Medical Examiner"s Office maintain open lines of communication with the Police Department"s Homicide and Criminal Investigation Units, and the Police Crime Lab and Photography Lab.

The work performed in concert with these units is a critical piece of investigating homicides and successfully charging individuals with Driving Under the Influence (DUI).

Interactions with State and other Public Agencies

The Medical Examiner"s Office provides crucial information used by the District Attorney"s Office (DA), and the Public Defender"s Office (PD) in the prosecution of suspects. Material gathered during the forensic examination can be requested by the District Attorney or Public Defender to be used as evidence during a trial. Therefore, a strict chain of custody must be established and verified to ensure that the evidence is not tainted and has not been tampered with. Establishing the chain of custody for items recovered during the forensic examination is the responsibility of the Medical Examiner"s Office. Sections: III Toxicology and V Medical Examiner"s Inquestsof this report provide information on the interactions of the Medical Examiner"s Office with the District Attorney and Public Defender, as well as the procedures used to establish and maintain the chain of custody.

The Public Administrator works in conjunction with the Medical Examiner"s Office to coordinate the investigation of the death of indigent individuals. If the Public Administrator has determined that the individual is indigent, next-of-kin can not be located and there are no assets in decedent"s estate, the deceased indigent will be placed under the jurisdiction of the Medical Examiner"s Office. The Medical Examiner, Administrative Coroner and Investigators provide information to the Public Administrator and arrange for removal of the deceased body.

The State Department of Health Services (DHS) and the City and County of San Francisco Department of Public Health (DPH), and Medical Examiner"s Office work in conjunction on several levels. Most basically, all death certificates signed by the Medical Examiner"s Office are forwarded to DPH to be recorded. From there, all death certificates are sent to Sacramento to the Death Registry for final recordation. The Medical Examiner"s Office also participates in two studies being conducted by the State Department of Health Services. One of the studies initiated by the State Department of Health Services tracks AIDS cases and AIDS related deaths in the City. Through the confidential testing of all decedents deemed Medical Examiner"s Office cases, information on the HIV status of the decedent is provided to the State Department of Health Services.

The Medical Examiner"s Office also participates in a state-wide study and program tracking the incidence of Sudden Infant Death Syndrome (SIDS). The Medical Examiner"s Office and DHS employ a prescribed protocol when investigating and responding to the needs of families when there is a death of an infant for "no known cause." The protocol used includes the completion of a 22-page questionnaire that provides information on the circumstances of the birth, life and death of the infant, as well as autopsy procedures to obtain certain types of information. Through the implementation of these protocols, the State and DHS hope to gain valuable information on the causes and prevention of SIDS. The information can then be used in educational and promotional materials for the "Back to Sleep" Program. For participation in this state-wide program the Medical Examiner"s Office receives revenue from the State. The funds have been used to upgrade computer equipment, decreasing requests for General Fund support for such items.

Survey of Entities Interacting with the Medical Examiner"s Office

As part of this study, the budget analyst audit team conducted a survey of other City departments and governmental agencies to assess the level of service provided by the Medical Examiner"s Office and how knowledgeable Medical Examiner"s Office staff are of policy and procedures. Specifically, the survey was designed to address the issue of whether Medical Examiner"s Office staff, who interface with the public, are knowledgeable and execute appropriate procedures and policies when interacting with next of kin, especially in regards to meeting the cultural and religious needs of families.

The survey consisted of contacting 15 agencies by telephone, of which 13 agencies responded to questions by phone or via fax. The 13 respondents included ten funeral homes, one hospice, and two public programs (see Appendix II). These types of agencies were chosen because they interact both with the Medical Examiner"s Office and the public at-large (with the exception of the Department of Public Health"s AIDS Project), and these agencies have the opportunity to observe the Medical Examiner"s Office staff interact with the public. Individuals or families who have had interaction with the Medical Examiner"s Office due to a death of a friend or family member were not contacted to participate in this survey. The Budget Analyst"s audit team determined that direct communication with such individuals or families may infringe upon their privacy, as well as cause them unnecessary personal hardship.

The ten funeral homes and the one hospice, which are located in San Francisco, were chosen randomly. The two public agencies, the City and County of San Francisco Department of Public Health AIDS Project, and the Public Administrator/Public Guardian, specifically were chosen because they are able to observe or receive feedback from the public regarding the Medical Examiner"s interaction with the public. In summary, all 13 respondents stated that Medical Examiner"s Office staff had adequate knowledge of procedures and policies; although, one funeral home indicated that administrative staff who answer the telephone and interact with the public were not as well informed about procedures as the investigators. In addition, all 13 respondents indicated that the Medical Examiner"s Office meets families" cultural and religious needs, and 12 of the 13 respondents indicated they were satisfied with the performance of the Medical Examiner"s Office. Therefore, based on our survey results, the Budget Analyst concluded that Medical Examiner"s Office is meeting its obligation to work cooperatively with these agencies and providing an adequate level of service to the public.

Major Accomplishments

The main objective of a management audit is to identify opportunities for improvement and cite areas where improvements on efficiency, effectiveness and economy can be achieved. However, the accomplishments of the Medical Examiner"s Office should not be overlooked. Some of the recent accomplishments include:

• Cost reductions of approximately $100,000 per year resulting from canceling an outside contract to provide indigent burial and cremation services and bringing the program in-house.

• The conversion of the old WANG computer system to a Local Area Network (LAN) which has helped the Medical Examiner"s Office improve the quality of the Medical Examiner"s Office"s records and created the ability to develop data retrieval and problem-solving applications;

• Reductions in Hazardous Chemical Waste, which has won awards for staff members. In 1991-1992 and before, the department generated 36 gallons of liquid hazardous chemical waste and 30 pounds of solid hazardous chemical waste. Through careful management and utilization of non-hazardous chemicals, the department reports that it has reduced such waste to 18 gallons or less of liquid chemical waste and 5 pounds or less of solid chemical waste per year

• The Chief Medical Examiner has been a pioneer in Sudden Infant Death Syndrome (SIDS) research, with studies since the 1970"s. The Chief Medical Examiner is one of the authors of what has become the standard in SIDS Investigations and Autopsy protocols for the State. The Chief Medical Examiner"s participation in the "Back to Sleep" program and recognition as a leader in the efforts to reduce the number of deaths due to SIDS is commendable. During Fiscal Year 1994-95, there were only six SIDS cases. This was a substantial decrease from the previous Fiscal Year"s 15 cases. By working in conjunction with the State and the DPH, the Chief Medical Examiner is personally committed to work on isolating the causes of SIDS and making SIDS a rare to nonexistent occurrence;

• The Medical Examiner"s Office has received Peace officers Specialized Training certification which allows Peace Officer Standard Training of certified staff at no cost to the taxpayers of San Francisco;

• The Medical Examiner"s Office, with the assistance of the Police Department has instituted a background check for Investigators;

• The Medical Examiner"s Office, in conjunction with the Employee Assistance Program, has set up a Cultural Diversity Program to educate the staff and community, and build a stronger understanding on both sides of how the community can best be served by the Medical Examiner"s Office. Several other counties have expressed an interest in setting up similar programs; and

• The Chief Medical Examiner also serves as the chair of the City"s Child Death Committee. Even though this committee is mandated by law, the City and the Medical Examiner conducted meetings prior to this mandate to review the deaths of all individuals under the age of eighteen. The Child Death Committee meets monthly to share information available on the deaths of children, the services available to the families and the resources needed by the community to address concerns surrounding the deaths of juveniles and surviving siblings and family members. The Committee also assesses the state of the Mayor"s Rapid Intervention Program and its ability to respond to crises and provide additional resources to schools and other groups needing additional resources.

In addition to these accomplishments, the Budget Analyst found, through interviews with other medical examiner and coroner offices in California and selected jurisdictions across the United States, that the current Chief Medical Examiner is very well respected in the forensic pathology community, and is certified by a majority of the western states and western Canada as a forensic expert. The recognition the Chief Medical Examiner receives as an expert is of great value to the City and County of San Francisco, and has been a key factor in generating the City"s reputation for providing the highest quality forensic work.

The Medical Examiner"s Office staff is an extremely dedicated group of individuals who are committed to providing high quality and compassionate service to the citizens of San Francisco. This is a group of individuals who must interact with people at a very difficult and emotional time in their lives. The staff is concerned with ensuring that any contact citizens must have with the Medical Examiner"s Office is as humane as possible under the circumstances, and that the information provided is accurate, helpful and affords the individuals some degree of solace.

The Budget Analyst"s staff found the Medical Examiner"s Office Investigators to be an extremely professional group of individuals who handle very intense and stressful situations. There are reported incidents of citizens who were not pleased with the outcome of their interaction with the Medical Examiner"s Office, and the Medical Examiner"s Office Investigators in particular. Upon reviewing and investigating incidents that were brought to our attention, we found that the Medical Examiner"s Office Investigators responded appropriately, and acted in accordance with established laws of the State of California and existing Medical Examiner"s Office policies and procedures.

Acknowledgments

Management audits must rely heavily on key personnel within the organizations under review to provide information and identify opportunities for improvement. We wish to acknowledge the assistance of the Forensic Pathologists, Drs. Trent, Ferenc, Frisby, and Nazareno for explaining autopsy and toxicology procedures, and generally, for their cooperation and assistance during this audit. We would also like to acknowledge and thank the Investigators from the Medical Examiner"s Office, Police Department, District Attorney"s Office, Public Defender"s Office, and Department of Health for their cooperation and assistance. Their assistance and cooperation significantly assisted the Budget Analyst"s efforts to complete this management audit.