Source: Medical Examiner"s Inquest Log and individual case files for 1993, 1994, 1995 and 1996.
See Work Papers for additional details.
(1) data for 1996 includes inquests held from January 1, 1996 through November 30, 1996.

Observation of Coroner"s Inquest Proceedings

As part of the fieldwork for this audit, the Budget Analyst"s staff observed the proceedings of two inquests. Both inquests were held by the Chief Medical Examiner and neither was attended by representatives from any law enforcement or court agency. As such, the Chief Medical Examiner served as the sole arbiter of the facts presented and the reliability of the witnesses providing testimony.

In opening the inquests, the Chief Medical Examiner explained that the inquest is a California courtroom of inquiry, but not a courtroom of law. The Chief Medical Examiner further explained that the purpose of the inquest is not to assess criminality nor make charges against any particular individual. In accordance with the laws of California, these inquests were held by the Chief Medical Examiner for the purpose of determining the cause, circumstances and manner of death.

Purpose of the Medical Examiner"s Questions

In both cases, the Chief Medical Examiner posed question to help determine:

• The circumstances surrounding the individual"s death;

• The behavior of the decedent in the time period leading up to their death;

• The actions of individuals who were present at the time of death or shortly before the death occurred;

• The forthrightness of the witnesses statements regarding the circumstances of the death of each individual inquested; and,

• Whether the actions of the decedent or any person present at, or near the time of death, could have caused or contributed to the death.

Budget Analyst"s Staff Observations of Inquest Proceedings

As previously noted, the Budget Analyst"s staff attended two inquests. One involved the death of an individual as a result of methamphetamine poisoning and the other a suicide. In the first case the Chief Medical Examiner needed to determine whether the manner of death should be recorded as an accident or a suicide. In the second case the Chief Medical Examiner was trying to determine if the suicide was assisted and if parties reporting the death knowingly gave false information to the Medical Examiner. Details of these cases can be found in Appendix III.

The audit staff was informed during an interview with the Chief Medical Examiner that inquests are not legal proceedings. The general parameters of the process were explained at the opening of the proceeding for each case. Despite this prior knowledge, several aspects of the two inquests observed by the audit staff caused concern.

• First, there were not representatives from the Police Department Criminal Investigation Unit present at either inquest. Upon further discussion with the Chief Medical Examiner, he indicated that the Police would have been interested in Case #1 only if there was evidence of a methamphetamine laboratory or the processing of methamphetamine. In Case #2, the Police would have been interested if the alleged suicide had been advised, assisted or encouraged in any way.

• Second, there were not representatives from the District Attorney"s Office present at either inquest. Again, the Chief Medical Examiner indicated that there were no criminal charges pending and the interest of the District Attorney would have been with regard to possibly charging individuals with violations of the law.

• Third, a behaviorist trained in interpreting typical human responses and behavior was not in attendance at either inquest.

• Fourth, the Chief Medical Examiner is the sole arbiter of the information presented.

• Fifth, there is no cross examination of the witnesses. The family, and others in attendance who have some standing in the case are allowed to submit questions for a particular witness. However, the Chief Medical Examiner can rephrase or omit the questions at his discretion.

The Chief Medical Examiner"s statements regarding the interest of the Police in the two cases inquested are reasonable. However, the Chief Medical Examiner reported to the Budget Analyst"s staff that, Case #1, he believed that the decedent had ingested liquid methamphetamine, or methamphetamine oil. He further stated that the presence of methamphetamine oil suggested the presence of a methamphetamine lab. He also questioned how someone who was possibly involved in the production of methamphetamine could accidentally ingest such a large quantity of the substance. On the basis of the Chief Medical Examiner"s questions regarding this case, it seems that the conditions under which he believed the Police Department would have been interested in the case existed.

Case #2 was even more clear cut with regard to the Chief Medical Examiner"s criteria to notify the Police Department and the District Attorney"s Office. The decedent was known to have died from "Secobarbital and Morphine-type Alkaloid Poisoning [1]. The Chief Medical Examiner and the Administrative Coroner both indicated that the hospice worker in attendance had withheld information from the Medical Examiner"s Office that would place the death under their jurisdiction. Furthermore, it was believed that the information had been withheld intentionally. Finally, assisted suicide is not legal in the State of California and as such, any person who participates in or encourages a suicide is in violation of the laws of the State.

During the questioning of the witnesses for this inquest, all of the Chief Medical Examiner"s questions were crafted to determine: 1) whether the decedent would have been capable of committing suicide without assistance; 2) how and where the decedent obtained the secobarbital used in the overdose since it was not prescribed by the decedent"s physician; 3) what types of actions were taken by hospice staff and others in attendance at the scene of the apparent suicide; 4) whether anyone in attendance actively participated in the act; and 5) whether hospice staff knew that any death that did not result from natural causes was to be reported to the Medical Examiner and that State law prohibits a private physician from signing a death certificate if the manner of death could not be reported as "Natural". The beliefs of the Chief Medical Examiner and the Administrative Coroner and the nature of the questions asked of the witnesses meet the criteria given by the Chief Medical Examiner for determining when the District Attorney"s Office should have be notified of the Chief Medical Examiner"s suspicions and afforded the opportunity to attend the Inquest to make their own assessments with regard to this case.

Since the law clearly states that only one inquest can be held, it is important to make sure the process is as thorough as possible. Also, all parties having any interest in the outcome of the inquest, should be notified and given the opportunity to attend the proceedings. Interviews with the District Attorney"s staff revealed that the District Attorney"s Office is not routinely notified of inquests. Interviews with the Police Department staff revealed that they also do not receive notice of inquests held by the Medical Examiner"s Office. While neither the District Attorney"s Office nor the Police Department were particularly concerned about being notified of pending inquests, providing such notification would alert both departments of possible concerns regarding Medical Examiner"s cases and allow them to make decisions on whether or not their presence at the proceeding is advised.

The one exception regarding advance notification of Medical Examiner proceedings is a monthly meeting held to review the deaths of juveniles. These meetings are convened by the Chief Medical Examiner and attended by representatives of the Child Protective Services, Police Homicide Unit, Department of Social Services, Public Health, District Attorney"s Office and other agencies. However, these meetings are not inquests; and it is not clear that these meetings result in the scheduling of inquests on any of the deaths that are reviewed. If the Medical Examiner does hold inquests as a result of these meetings, the Police and the District Attorney are not notified.

Practices in Other Jurisdictions Regarding Coroner"s Inquests

As part of the survey conducted regarding the practices of Coroner and Medical Examiners in California and selected locations in the United States, practices regarding convening inquests were questioned. All six of the California jurisdictions that responded operate under the same statues as the City"s Medical Examiner. Los Angeles, San Diego, Santa Clara and Ventura Counties all indicated that Inquests are not held. Upon further investigation, both Los Angeles and San Diego indicated that inquests are not cost efficient. Los Angeles County found that the majority of the questions surrounding the manner of death were related to whether the death was the result of an accident or a suicide. As such, Los Angeles County has adopted a practice of conducting Psychological Autopsies.

The County of Los Angeles has contracted with trained psychiatrists, psychologists from USC Medical Center who investigate the circumstances surrounding a questionable death. During the investigative process, the psychologist interviews persons known by the decedent to determine behavior, state of mind, lifestyle and other characteristics that would be helpful in assessing the circumstances that were present at the time of death. Based on the psychologist"s analysis of the information obtained, the Medical Examiner, and a panel of Deputy Medical Examiners will hear the information presented by the psychologist, deliberate, vote and ascribe the manner of death.

None of the Medical Examiners in jurisdictions outside of California (Cook County, Illinois; King County, Washington; Bexar County, Texas; Hennepin County, Minnesota; and Milwaukee County, Wisconsin) conduct inquests. Cook, Bexar and Hennepin County indicated that no inquests are conducted at all. Inquests in King County are performed by the County Executive"s Office and are conducted, usually, for in-custody deaths. Inquests in Milwaukee County are conducted by Circuit Court judges or court commissioners and are ordered by the District Attorney.

Changes in San Francisco Medical Examiner"s Office"s Inquest Policy

The practice of conducting psychological autopsies, used in the County of Los Angeles, reportedly costs approximately $1,000 per case. Medical staff estimates that approximately six to eight psychological autopsies are conducted annually at a cost of approximately $6,000 to $8,000. In San Francisco, Medical Examiner"s Inquests are conducted with known costs of approximately $34,914, (the cost of the salary and benefits for the 0.6 FTE Court Reporter). With an average of 20 inquests per year, the unit cost of conducting each inquest is approximately $1,724, excluding the cost of the Chief Medical Examiner"s and Investigator"s time. Changing current practices of conducting inquests to using psychological autopsies could result in savings of $724 per case inquested using the psychological autopsy process.

Information contained in Table V.1 shows that the majority of the cases in the four year period investigated resulted in a determination that the manner of death should be listed as an accident. The Budget Analyst"s staff found that in 72 percent of the cases, the question to be answered was in fact whether the manner of death should be recorded as an accident or suicide. Only one cases in the four period investigated resulted in the listing of homicide as the manner of death. The remaining cases resulted in a determination that the manner of death was natural or indeterminate. As such, the conclusions reached by Los Angeles and San Diego County that psychological autopsies are more cost efficient, is reasonable.

Based on the above information, the Budget Analyst"s staff has concluded that the practice of conducting Medical Examiner"s Inquests should be limited. Instead, the Chief Medical Examiner should continue utilizing information from the Investigator"s reports and the Forensic Pathologist"s autopsy report and increase the use of information gathered by professionals trained in human behavior and mental health, where appropriate, to make determinations regarding the manner of death. By adopting a policy of using psychological autopsies, these determinations can be made in a more efficient and less costly manner. Over the four-year period investigated for this report, the approximate cost of conducting 81 Medical Examiner"s Inquests was $139,656 ($34,914 X 4 = $139,656). The same 81 cases could have been handled as psychological autopsies at an approximate cost of $81,000 (81 cases X $1,000 per case = $81,000) for a savings of $58,656.

Conclusions

California law gives the Chief Medical Examiner the authority to conduct Coroner"s Inquests to answer questions surrounding the circumstances of a death which may provide valuable information in determining the manner of death. Over the past four years, 81 such Inquests have been held in the City and County of San Francisco. Fifty-four percent of those inquests (44 of the 81) resulted in the manner of death being ascribed as "Accident".

In making the determination on the manner of death, the Chief Medical Examiner is usually the sole arbiter of the facts and information presented during the inquest. This is the result of a loss of funding for jury panels, and the authority granted to the Medical Examiner by the California Government Code. Since the California Government Code grants such authority to the Medical Examiner, he is not required to notify the Police or District Attorney of the intent to hold an inquest nor ask them to attend the proceedings. However, due to the nature of some of the questions surrounding the circumstances of death, in inquested cases, notification of the Police and District Attorney may be prudent.

During this audit, the Budget Analyst"s staff was present as two such cases were inquested. The failure to notify the Police and the District Attorney of the pending inquests appeared to directly contradict the Chief Medical Examiner"s explanations of when it would be prudent to alert those entities of the planned proceedings. While technically meeting the requirements of the statues and maintaining compliance with the Government Code, this practice does not allow the Police or the District Attorney to make independent assessments of the possible legal issues surrounding an individual"s death.

Based on the results of our limited survey, the practice of holding inquests is waning throughout the Country. In the limited survey of Medical Examiner"s Offices in California and elsewhere in the United States, only three of the eleven jurisdictions responding indicated that inquests of any kind were held. Only one of the eleven indicated that the inquests, when held, were conducted by the Medical Examiner. One jurisdiction, Los Angeles County, indicated that Psychological Autopsies are now used to determine between "Suicide" and "Accident" as the manner of death. Los Angeles County finds this practice much more efficient and economical than conducting inquests.

Recommendations

The Medical Examiner"s Office should:

V.1 Use psychological autopsies to make determinations between accident and suicide as the manner of death. This could result in savings of $724 per case inquested using the psychological autopsy process.

V.2 Develop a method of estimating the cost of conducting an inquest so it is possible to determine what portion of the Medical Examiner"s Office resources are dedicated to this function and the viability of alternatives based on cost, time and informational value of the proceedings.

V.3 Develop a policy of formally notifying the Police Department and District Attorney"s Office of inquests so they can make their own assessments regarding the need to send an observer.

Cost/Benefits

Implementation of these recommendations could result in net savings of up to approximately $14,480 per year. Additionally, implementing these recommendations would allow the Police and District Attorney to make independent assessments regarding the potential legal issues surrounding the circumstances of the death of the individual being inquested. In the event that legal proceedings are required, a much stronger case could be presented by the Police and District Attorney.

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Footnotes

1. See Register Page for Medical Examiner"s Case Number 1073-96 Pathologists Report Section; Page 5, of the City and County of San Francisco Chief Medical Examiner Necropsy Department Report dated September 25, 1996 stating cause of death; and City and County of San Francisco Office of the Chief Medical Examiner-Coroner Toxicology Division Report received August 6, 1996 and completed August 19, 1996 indicating the presence of Secobarbital and Morphine in the blood and urine samples drawn from the decedent.