Appendix III: A Limitied Survey of Medical Examiner's Offices in California and Selected Jurisdictions Across the United States.
Based on population statistics for the areas surveyed, the number of deaths annually, the number of deaths reported to the Medical Examiner"s Office and the number of deaths determined to be under the jurisdiction of the Medical Examiner, the statistics reported by San Francisco appear to be reasonable. The major differences, with regard to the jurisdictions outside of California, are:
- Organizational Structure;
- Responsibility for notification of the next of kin;
- Time needed to sign-out a case;
- The manner in which toxicology cases are handled; and
- Conducting Coroner/Medical Examiner Inquests.
The most comparable jurisdiction, with regard to the philosophy used to manage cases is King County, Washington. Despite its placement as a division of the Department of Public Health, the King County Medical Examiner"s Office maintains strong alliances with local and County police agencies. King County is a jurisdiction that has a little more than twice the population of San Francisco, has slightly more than twice the number of deaths annually, and just under twice the number of cases reported to the Medical Examiner"s Office on an annual basis. However, both King County, Washington and San Francisco have approximately the same number of cases under the Medical Examiner"s jurisdiction on an annual basis.
As in San Francisco, the King County Medical Examiner"s Office has a policy to conduct full autopsies if a dissection is warranted, and that all motor vehicle accidents, and suicides should be fully autopsied. Death investigations are handled by the Medical Examiner"s Investigation staff with accidents and homicide investigations conducted jointly by the Medical Examiner"s Office and the Police.
The annual appropriation for FY 1995-96 for the King County Medical Examiner"s Office was approximately $2.1 million. This level of appropriation is approximately $1.2 million less than the appropriation for the San Francisco Medical Examiner"s Office during the same time period. However, the difference in appropriation levels can be attributed to the fact that the King County Medical Examiner"s Office does not conduct any toxicology analysis in-house, has 10 fewer funded positions, and is not responsible for conducting inquests, or paying any costs associated with inquest proceedings.
The information gathered on each jurisdiction surveyed is included as part of this appendix. It provides interesting information for comparative purposes as well as insight into to vast differences in the organizational structure of medical examiner offices, reporting responsibilities and total processing time for cases.
Case #1
The first case involved the death of an individual as a result of methamphetamine poisoning. The cause of death was determined prior to convening the inquest. The Chief Medical Examiner"s questions focused on obtaining information to help determine the circumstances and manner of the individual"s death. Due to the high levels of methamphetamine found in the deceased, the Chief Medical Examiner was trying to determine whether the manner of death should be listed as a suicide, or an accident, or at the hands of another.
In total, three witnesses provided testimony regarding the psychological state of the deceased. The witnesses were characterized as a friend/counselor, an acquaintance, and a boyfriend.
The first witness, the friend/counselor, described a troubled person who, over a period of time, had become somewhat delusional and had begun to exhibit behaviors that would indicate the presence of some mental health issues. During testimony, the first witness indicated that the deceased appeared to show signs of depression. This witness also indicated that the deceased used illegal substances, specifically "crack" and "speed", and that "speed", or methamphetamine was the deceased"s drug of choice.
The friend/counselor indicated that they referred the deceased to an emergency room on one occasion for depression and that the deceased was reportedly under psychiatric care. Even though the deceased evidenced signs of depression and was reportedly under psychiatric care, this witness indicated that suicide was never mentioned and the deceased had never taken overdoses of medication with the intention of harming themselves.
The second witness, the acquaintance, indicated that they knew the deceased for a period of two or three months as a friend of the third witness. This witness also indicated that they saw the deceased daily, in passing, and only had extended conversations on a couple of occasions. This witness was not aware of any medical or psychiatric problems, or drug use by the deceased. However, this witness was in the same building when the deceased allegedly overdosed on methamphetamine. The building was described as a shared living space with one way to enter and exit the building. Therefore, for anyone to enter or exit, they had to pass by the area where the second witness lived.
The second witness indicated that the third witness told them to let the ambulance in when it arrived. The second witness did not recall if the third witness was in a hurry, or agitated, or upset. The second witness alleges letting the paramedics in, but not following them. The witness learned about an hour later that the deceased overdosed and was surprised. This witness did describe the deceased as moody and emotional, but not necessarily inappropriate or unreasonable. This witness was also not aware of any reasons, nor did they suspect that the deceased would intentionally end their life.
The third witness, the boyfriend, had known the deceased for approximately six months and had lived with the decedent for approximately three months. This witness did describe routine use of methamphetamine and indicated that the deceased had been a user prior to meeting them. The relationship was characterized as good and everything in the deceased"s life was going well. All indications were that an intentional overdose would not have been something the deceased thought about or attempted. Finally, this witness vouched that no one else was on the premises and that he had no idea or understanding of the reasons for the deceased"s actions.
This witness stated that they did not have large quantities of methamphetamine at their home, and that the deceased did not typically obtain the drug on their own. The witness described the events of the evening as unremarkable and indicated that things happened quickly with regard to the apparent overdose.
After hearing the testimony of the witness, and based on the facts of the case, the Medical Examiner determined the manner of death to be an accident.
Case #2
The second case involved the death of an individual from secobarbitol-and-morphine-type alkaloid poisoning. Again, the circumstances and manner of death were at issue in this case. Also at issue in this case was whether or not the health care professional responsible for reporting the death knowingly omitted information from the attending physician and Medical Examiner"s Office staff.
Two witnesses were called to provide testimony that would give the CME enough information to make some decisions regarding the circumstances and manner of death. One witness was characterized as a friend who was providing some level of home care for the deceased along with the witness"s mother. The second witness was a health care worker responsible for monitoring the condition of the deceased, who was, at the time of his death, under hospice care.
The first witness, indicated that they had known the deceased for a period of five to six years and considered the person a friend and at times a confidant of the deceased. This witness was aware that the deceased was HIV positive and for the past several years exhibited progressive symptoms of the disease. The witness was aware of the recent hospitalization of the deceased and that at the time of death, was in hospice care.
The first witness also characterized the deceased as being able to move around their environment with assistance and being strong enough to sit, upright. The deceased had help with chores from the witness and from family members who had come to be of assistance. In the month prior to death, the deceased was described as lucid, able to follow conversations and able to remember things from the past. However, the deceased was characterized as extremely depressed and as having a long history of depression. The deceased had also told this witness that suicide was an option.
The second witness, indicated that they were a licensed healthcare worker in the State of California, and had been employed as such since 1993. This witness began working with the deceased approximately two weeks prior to their death. This witness also confirmed that individuals assigned to hospice support are generally thought to have approximately six months to live. The duties of the witness were to manage the patients" medications, monitor their condition and report any changes to the physician, and ensure the patient"s comfort and safety.
This witness stated that they could not remember all of the medications that the deceased was on, but did recall the deceased self-administering morphine that had not been prescribed by the doctor. The deceased was again described as rational, lucid and interactive. The second witness stated that the deceased did not discuss suicide, nor did the deceased give the impression that they were stock-piling medication to commit suicide.
After hearing the testimony and based on the facts of the case, the Medical Examiner determines the manner of death to be suicide.
| Los Angeles County | San Diego County | Santa Clara County | Alameda County | Ventura County | Marin County | Cook County | King County | Bexar County | Hennepin County | Milwaukee County | |
| Organizational Information: | |||||||||||
| Type of Office | Medical Examiner/Coroner | Medical Examiner | Medical Examiner/Coroner | Sheriff-Coroner | Medical Examiner/Coroner | Coroner | Medical Examiner | Medical Examiner | Medical Examiner | Medical Examiner | Medical Examiner |
| Place in Overall Organization | under CAO | under CAO | under County Executive | No answer | under Health Dept. | Separate elected office | under Bureau of Administration | Under Dept. of Public Health | Report to County Commissioners | Under County Administrator | Under County Executive/County Board |
| Organizational Structure | 3 bureaus: Administrative; Operations (Investigative) & Forensic Labs headed by Director; plus Forensic Medicine section (headed by CME) | 2 divisions: Operations (Investigations; autopsy assts/evidence; support svcs) & Chief Deputy ME (autopsies; tox; histology) | 3 divisions (clerical; autopsies & investigations) headed by admin coroner, who reports to CME & Asst MEs | No answer | Chief ME; Asst Chief ME; clerical, investigative and autopsy divisions | 1 coroner; 1 Asst Coroner; 3 Investigators; 2 clerical; 1 contract pathologist | 6 Divisions: X-ray/Histology/Consultants; Autopsies; Toxicology; Admin/ Investigations/ Medical Records; Photo/ Transcription; Autopsy Service/ Intake Desk | 3 Divisions: Admin; Investigations/Autopsies (headed by PhD Chief Medical Investigator); Pathologists | 5 Divisions: Investigative (7); Medical (5); Medical Support (7); Toxicology (6); Administrative/Clerical (8) | 3 Divisions: Autopsies; Admin; Investigations | 5 divisions: Pathology Services; Laboratory Services; Investigative Services; Autopsy Services; Administrative Services |
| Statistics: | |||||||||||
| Population | 2,700,000.00 | 1,500,000.00 | 670,000.00 | 230,000.00 | 1,613,600.00 | 968,200.00 | |||||
| No. of Deaths Annually | 65,000.00 | 18,000.00 | 9,300.00 | 10,000.00 | 4,500.00 | 1,750.00 | 50,000.00 | 12,337.00 | 10,000.00 | 10,000.00 | 10,425.00 |
| Mortality Rate per 1,000 | #DIV/0! | 6.67 | 6.20 | #DIV/0! | 6.72 | 7.61 | #DIV/0! | 7.65 | #DIV/0! | #DIV/0! | 10.77 |
| No. of Deaths Reported to C/ME | 19,000.00 | 8,400.00 | 3,000.00 | 3,500.00 | 2,500.00 | 1,200.00 | 18,000.00 | 5,864.00 | 7,000.00 | 3,300.00 | 5,308.00 |
| % of Deaths | 29.2% | 46.7% | 32.3% | 35.0% | 55.6% | 68.6% | 36.0% | 47.5% | 70.0% | 33.0% | 50.9% |
| No. of Cases under C/ME"s Jurisdiction | 13,000.00 | 2,550.00 | 1,200.00 | 1,600.00 | 1,200.00 | 750.00 | 12,000.00 | 1,504.00 | 2,000.00 | 1,575.00 | 3,109.00 |
| % of Deaths Reported | 68.4% | 30.4% | 40.0% | 45.7% | 48.0% | 62.5% | 66.7% | 25.6% | 28.6% | 47.7% | 58.6% |
| No. of Full Autopsies | 4,500.00 | 1,760.00 | 1,000.00 | 1,200.00 | 450.00 | 300.00 | 4,000.00 | 1,118.00 | 1,300.00 | 700.00 | 1,109.00 |
| % of C/ME Cases | 34.6% | 69.0% | 83.3% | 75.0% | 37.5% | 40.0% | 33.3% | 74.3% | 65.0% | 44.4% | 35.7% |
| No. of Partial Autopsies | 800.00 | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 | 75.00 | 0.00 | 0.00 |
| % of C/ME Cases | 6.2% | 0.0% | 0.0% | 0.0% | 0.0% | 0.0% | 0.0% | 0.0% | 3.8% | 0.0% | 0.0% |
| No. of External Examinations | 5,000.00 | 770.00 | 200.00 | Unknown | 20.00 | 200.00 | 8,000.00 | 189.00 | 700.00 | 50.00 | 29.00 |
| % of C/ME Cases | 38.5% | 30.2% | 16.7% | N/A | 1.7% | 26.7% | 66.7% | 12.6% | 35.0% | 3.2% | 0.9% |
| Demographic Categories Used | Age, sex, race, ethnicity, zipcode, type of death | Manner of death; sex; race; age; place of death; occupation; marital status | Records not maintained | location; manner of death; type of accident | sex; age; ethnicity; location | Records not maintained | Race, sex, age, cause, manner | Manner; Age; Gender; Race; Marital Status; Month; Location; Cause | Age, sex, race, cause of death, manner, day, time, year; circumstances | Name; Case # | Manner, cause; sex; age;race; marital status |
| # of Authorized Positions | 247.00 | 46.00 | 21.00 | 27.00 | 9.00 | 8.00 | 110.00 | 27.00 | 34.00 | 25.00 | 34.00 |
| # of Funded Positions | 173.00 | 46.00 | 21.00 | 27.00 | 9.00 | 8.00 | 110.00 | 27.00 | 34.00 | 285.00 | 34.00 |
| Annual appropriation | $12,000,000 | $3,029,810 | $1,805,000 | $2,500,000 | $1,070,000 | $970,000 | $7,000,000 | $2,100,000 | $2,068,925 | $2,100,000 | |
| Investigations: | |||||||||||
| Responsibility for Investigative Function | POST certified Coroner"s investigators | ME Investigators (formerly Deputy Coroners) | ME/Coroner Investigators | Deputy Coroner Peace Officers | Coroner/ME personnel | Coroner"s Investigator | ME Investigators | ME Investigators | ME Invesitgators | ME Investigators | ME Investigators |
| Training Requirements for Investigative Staff | POST Death Investigative Course and PC 832 training; must have AA/BS degree | 80 hour Deputy Coroner"s course at Orange County Sheriff Coroner"s Office | HS diploma; 3 years experience in medical, nursing, medical examiner, coroner, investigative or law enforcement field | Must meet POST requirements; 832 PC; 2 week death investigation course & entry level requirements | On-the-job training | POST training; Mortuary College; OJT | 5 months in-house | In-house training for 3 months | 40 quarter credits of biology, chemistry, criminal justice OR 2 years of forensic medical investigation experience for Investigator; 20 quarter credits & 1 year morgue or mortuary experience for Invest. Asst | 3 months on-scene training; monthly in-service training sessions | |
| Body Removal Services | In-house Forensic Attendants | by contract | by contract | Police Department | Contracted out | In-house | Contracted out | ||||
| Homicides contaminated because investigators not properly trained | A few | No answer given | None | Unknown | Unknown | ||||||
| Responsibility for Notification of Next of Kin | Coroner staff | Investigative staff; in person if possible | Investigators; in person or by phone | in person; by phone; other agency (in person) | In person by ME investigator | In county-in person; out of county - other agency | Police function | Police agency with jurisdiction | Chaplain; Police; ME personnel | Local Police Agency | |
| No. of Investigative Staff | 33 Investigators (I & II); 20 Forensic Attendants | 1 Chief Investigator; 14 Investigators | 8 Investigators | 3 supervising investigators; 12 investigators; 4 coroner aides | 5 investigators | 3 investigators | 1 Chief; 1 Asst Chief; 23 Investigators (I, II & III); 3 Investigator Aides | 1 Chief Medical Investigator (PhD) &12 Investigators | 7 Investigative staff | 1 Invest Supv.; 8.2 Investigators; 5.4 Investigative Assts; 1 ME Tech | 1 Investigative Coordinator; 12 Forensic Investigators |
| Responsibility for Investigating Accidents/Homicides | Law enforcement-criminal aspects; coroner-death aspects | Accidents-ME investigators; MV accidents-Police Traffic Div; Homicides-Police Dept | ME investigators | Criminal - Police; Death - Coroner | ME and Police | Police/ME | Police/ME | Police/ME | |||
| Pathology: | |||||||||||
| Time Needed to sign out case | 1 - 1.5 hours for mortuary sign-out exams and 1 - 3 months for autopsied cases | Autopsy reports - 30 days; Toxicology 3 - 6 weeks | 2 - 6 weeks | 6 - 8 weeks | Hours to months; determined by ME | 1 day - 2 weeks | Usually within 24 hours | 1 - 2 months | 2 days to several weeks | 3 - 6 days | |
| Use of protocols for labs, etc. | Yes | Yes | Yes | Yes | No | Yes | Yes | No answer | Yes | Yes | |
| Use of Universal Precautions | Yes | Yes | Yes | Yes | No | Some | Yes | No | most | Yes | |
| Licensure Required | Pathologists are Board-certified in forensic pathology; physicians are State-licensed | State-licensed & Board-certified forensic pathologists; Forensic Autopsy Techs are licensed embalmers | None | None | None as a department | Coroner is licensed MD | Doctors must be licensed in Illinois | Physicians licensed by State; Certified by NAME | None | ME & Asst MEs are licensed MDs; inspected & certified by NAME | CME, Deputy CME & Asst. MEs are licensed physicians |
| Laws regarding Inquests | Inquests no longer performed | None conducted | No inquests | Government Code | No inquests | Very seldomly held | No inquests | Inquests performed by County Executive Office, usually for in-custody deaths | No inquests | No inquests | ME does not conduct inquests; inquests are conducted by circuit court judge or cour commissioner & ordered by DA |
| Pathologists called to accidents/homicides | Only if needed | Homicides-Yes | No | No, but may request one | No - discretionary | On-call Pathologists | |||||
| Problems caused by not having pathologist at scene | No major problems | Very helpful to have pathologists at scene | None | Sometimes | Rarely | ||||||
| Cases miscalled because pathologist not at scene | Occasionally | Unknown | None | None | None | ||||||
| Do benefits of having pathologists on-call outweigh costs? | Not feasible to do this in LA | Yes | No | No | No extra cost for pathologists to be on-call | ||||||
| Criteria for determining full or partial autopsy/external exam | Circumstances and exam findings | External exams-over 50 yrs old: past medical history sufficient for explanation & no trauma or suspicion; over 60: no trauma or suspicion, even without medical history | External exam: seen by physician in last 30 days & good medical history; attending physician not avail.;family objects to autopsy (incl. SIDS) | Medical history & circumstances | At discretion of Physician ME | Limited autopsy - by family request | Very few partial autopsies | Full autopsy on all traffic, homicides & most suicides; external on suicides (e.g. hanging), heart attack or if family objection | Partial autopsy on gunshot wounds of the head and unquestionable suicides | No partial autopsies | External exam - suicide w/ note; passengers in MV accidents; non-criminal deaths |
| Who makes this determination? | Chief ME | Deputy ME | Pathologist | Pathologist | see above | Coroner/Asst Coroner | CME | Pathologist | |||
| No. of Autopsy Staff | 17 Physician Specialists; 3 Post Graduate Physicians; 16 Forensic Technicians (I & II); 1 Radiologic Technologist | 1 ME; 1 Deputy CME; 4 Deputy ME; 1 Forensic Pathology Fellow; 1 Chief Autopsy Asst; 6 Forensic Autopsy Assts | 4 pathologists; 4 forensic pathology technicians | Contracted out | 2 Physician MEs; 1 autopsy assistant | Contracted out | 1 Chief Radiologist; 1 X-Ray Tech; 1 Chief Technologist & 2 Medical Lab Techs (Histology); 5 consultants; 11 Asst Medical Examiners; 1 Pathology Resident; 1 Chief Autopsy Tech; 1 Asst Chief Autopsy Tech; 10 Autopsy Techs; 3 Photogs (1 Chief) | 2 Assoc. MEs; 2 Asst MEs; 1 Pathology Asst; 4 Autopsy Asst; 1 Medicolegal Coordinator | 5 Medical; 7 Medical Support; Contract out histology | 1 Asst CME; 1 Assoc. Physician; 1 Sr Assoc. Physician; 1 Forensic Fellos; Pathology testing contracted out | 1 Deputy CME; 3 Asst MEs; 2 Forensic Fellows; 4 consultants; 4 Forensic Assts; Histology & Radiology contracted out |
| Toxicology: | |||||||||||
| Cost per year for toxicology analyses | $709,380 | $625,108 | $60,000 | $110,000 | None | Criminal cases done by State Police; ME cases by ME | |||||
| Minimum Qualifications of toxicologists | Entry level - Bachelor"s Degree in Science and 3 semesters of quantitative analysis; Journeyman - Master"s | BS in Chemistry or Certified Lab Technologist | N/A | N/A | N/A | N/A | N/A | N/A | |||
| Types of Screens | T (Traffic); H (Homicide); S (SIDS); C (Comprehensive); Extended C | Not provided | Auto; Homicide; Drug Overdose (illicit drugs); Drug Overdose (prescription drugs); Fetal Death; SIDS; Child Abuse; Work-related; High Profile/Police-involved Deaths | Same as Santa Clara | Not provided | Not provided | Not provided | Alcohol; CO; etc. | |||
| Tox Screens ordered for external exams | Natural death - from nothing to C screen; overdose - C screen | None routinely; occasional alcohol | Nothing routine | No answer | None | None | Whatever the doctor wants | Suicides where manner of death clear - will run toxicology tests & do external exam | Same as for autopsies | Ordered on a case-by-case basis | CO, alcohol |
| No. of Toxicology Staff | 8 Senior Criminalists; 3 Evidence & Property Custodians | 1 Tox Lab Mgr; 1 Supv. Toxicologist; 4 Toxicologists; 1 Lab Asst | Contract w/ IFS | Contract w/ IFS | Performed by Sheriff"s Crime Lab | Contract w/ DOJ | 1 Chief; 1 Asst Chief; 9 Toxicologists (I, II & III); 3 Medical Lab Techs; 1 Lab Asst | Contract w/ State Tox Lab | 6 Toxicology staff; Chief ME is also director of Crime Lab for Bexar Co. and City of San Antonio | Contracted out | 1 Forensic Lab Technical Director 1 Scientific Director 3 Forensic Chemists; physical evidence testing by State Crime Lab |
| Other Staff | 12 Records/Subpoena/Medical Support clerical positions | 4 clerical; 1 MIS; 1 Administrator; 1 Admin Svcs Mgr; 1 Custodian; 2 student workers | 1 Administrator; 2 clerical; 2 transcriptionists | 3 clerks; 1 property clerk; 1 sergeant; 1 lieutenant; 2 medical transcribers | 1 clerical | 2 clerical | 1 CME; 2 Asst CME;1 Executive Director; 1 Business Mgr; 5 Admin Assts; 1 Medical Record Librarian; 2 Property Custodians;1 Telephone Operator; 3 Transcribers (1 Supv); 11 Intake Attendants; 11 Clerical | 1 CME; 1 Admin Asst; 2 Office Techs (II & III); 1 LAN Administrator | 8 Admin/Clerical staff | 1 CME; 1 Admin Svc. Supv.; 1 Sr. Med. Secretary; 1 Principal Office Specialist; 3.5 Office Specialists; 1 Medical Transcriber | 1 ME; 1 Admin Manager; 3 clerical; 1 transcriber; 1 Office Systems Coordinator; 1 consultant |