This appendix contains details from the two inquests observed by the Budget Analyst"s staff. This information is based on the observations and interpretations of the staff present as well as information contained in the transcripts from the inquests. This information is provided to give context for the conclusions and recommendations of the Budget Analyst. The information is not intended to characterize any participants, Medical Examiner"s staff or witnesses, negatively or positively, nor is the information intended to assert any culpability.

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 their testimony, the first witness did indicate that the deceased did appear 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 not 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 them 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 states 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 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 conversation 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 determined the manner of death to be suicide.