February 5, 2016
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2001 Final Report:
Reengineering the San Mateo County Coroner's Department
2001 Final Report:
Reengineering the San Mateo County Coroner's Department
2001-2002 Grand Jury studied the San Mateo County Coroner's Department
to determine how productive it is, given its current organization and
practices. In order to gain perspective, the Grand Jury also reviewed
the operation of several other coroners' departments around the state.
All members of the San Mateo County Coroner's Department with whom we
spoke seemed dedicated and interested in providing a quality service to
The Grand Jury found
that the county Coroner's Department has significant conflicts, both within
the department and with other departments, that result in reduced effectiveness.
The Pathology Section is in need of greater management support to properly
address facilities and equipment problems. The overall distribution of
staff positions in the department and their schedules should be evaluated
to determine best use of resources and maximize departmental cohesiveness.
If San Mateo County
wishes to be on a technological par with other California counties of
comparable size and sophistication, it should carefully evaluate the benefits
of restructuring the department to be headed by a medical examiner, who
would have training in all areas of forensic science and be able to provide
the most comprehensive approach to the position of coroner.
defined responsibility of a coroner's department is determining the causes
of all manners of deaths, unless the decedent has been under a physician's
care within the last 20 days. This is accomplished by a combination of
investigations and autopsies. The 2001-2002 Grand Jury undertook an investigation
of the organization of the San Mateo County Coroner's Department, its
operation and its interaction with the Sheriff's Crime Lab. For comparison,
the Grand Jury reviewed the organization and operations of neighboring
counties that have filled the coroner's position with a medical examiner.
Unlike the position of coroner, where no special technical certification,
credentialing or experience is required, a medical examiner must be a
board-certified forensic pathologist.
In San Mateo County,
the coroner is an elected position. The office was held for nearly 40
years from 1953 to 1991 by Paul Jensen. Adrian "Bud" Moorman
held the position for 10 years from 1991 until his death in 2001. Beginning
in April 2001, Chief Deputy Coroner Robert Foucrault assumed the duties
of coroner. In March 2002 he was elected to the position.
The department has
16 full time equivalent positions on staff, as well as two independent
forensic pathologists who provide services through a contract with the
county. These staff members and contractors work out of two locations.
The coroner, administrative support staff and the Investigative Division
are located at Veterans Boulevard in Redwood City. The Pathology Support
Section is located at San Mateo County Family Health Center (the Hospital)
on 39th Avenue in San Mateo.
Staff work schedules
are nonstandard, ostensibly to enable greater round-the-clock coverage.
Pathologists work alternating weeks, and investigators work two 20-hour
shifts distributed during the week to allow them the greatest continuous
number of days off. Toxicology testing is provided by contract with an
independent laboratory in Fresno. The department has a budget of $2,225,593
for 2001-2002 and an adopted budget for 2002-2003 of $2,251,293.
In addition to interviewing key department members, crime lab personnel, and other interested county management in San Mateo, the Grand Jury spoke with and reviewed organizational and budgetary information from officials at coroner's and medical examiner's departments in Los Angeles, San Diego, San Francisco, Santa Clara, Santa Cruz, Shasta, Sonoma, and Ventura counties. Among the documents reviewed by the Grand Jury were "Comparative Analysis of Coroner's Services" prepared by the San Mateo County Coroner's Services Task Force, dated March 2001, and "The Report on Coroner-Administrator Organizational Options and Update on Various Issues", prepared by Solano County Administrator, dated May 1996.
fact that the office was held for nearly 50 years by only two people led
to continuation of practices long after they were useful. There are significant
structural and organizational problems within the department, such as:
to issues within the department, there seems to be little connection between
the Coroner's Department and the Sheriff's Crime Laboratory. The following
statement is made in the Coroner's Department Adopted Budget, FY 2001-2002,
FY 2002-2003: "The County is currently planning the construction
of the new crime laboratory for the Sheriff's Office at the Tower Road
Facilities and will include space for the Investigation and Administration
Divisions of the Coroner's Department. This new location will increase
collaborative efforts of the Coroner and Sheriff's Offices as well as
provide Coroner's Investigators with better access to crime lab services,
resulting in quicker turnaround time on Investigation Reports." There
was no discussion, however, between the two groups during the planning
process for construction of the new laboratory facility. Potential cost
reductions in this area and other areas of synergy between these two groups
are only just now beginning to be discussed. Crime Lab officials told
the Grand Jury that with the proper training, little or no additional
staff, and very minor additions to equipment they could process Coroner's
Department samples (currently being sent to an independent contract lab
for testing) for many drugs of abuse.
considerations of the relative merits of having a medical examiner in
the position of coroner, the Grand Jury found that medical examiners are
most common in counties with higher populations and greater technological
awareness. In California, these include Los Angeles, San Diego, San Francisco,
Santa Clara, and Ventura counties. Unlike coroners, medical examiners
must be trained forensic pathologists. According to the Ventura County
Medical Examiner, "The medical examiner is able to provide a comprehensive
approach to an investigation in order to determine the cause of death.
A coroner often relies on a pathologist to determine cause of death. The
reality of a coroner/pathologist team is that neither has a complete understanding
of the case at hand and may be making incorrect assumptions as to cause
of death by not having all case facts available." This sentiment
was echoed by the San Francisco County Medical Examiner. Medical examiners
are trained in all areas of forensic medicine including toxicology as
well as evidence collection and processing and are, therefore, qualified
to testify about the technical aspects of the determination of the cause
of death. They are trained in, and generally personally perform, some
significant portion of a county's autopsies.
When the Grand Jury raised the option of a medical examiner overseeing the Coroner's Department, interviewees were concerned with: (1) whether the number of autopsies performed (workload) warranted a medical examiner, and (2) the likelihood that department costs would increase. The Grand Jury's review of counties that have medical examiners did not support those concerns. As an example, Table 1, below, shows comparative information from Santa Clara County and Ventura County that have medical examiners.
the relative high cost of the San Mateo County Coroner's Department under
its current structure.
"Report on Coroner-Administrator Organizational Options and Update
on Various Issues," an extensive comparison prepared by the Solano
County Administrator, dated May 1996, the Administrator states, "Solano
County is on the cusp of the caseload size needed for such a system."
That statement was made in a county that at the time had a population
of 340,000 residents and an autopsy caseload of approximately 263. While
budgetary information was not available from San Francisco in a comparable
form , full time positions (exclusive of their toxicology lab) numbered
38 in a department that handles approximately 1,500 autopsies.
restructuring the department with a medical examiner at the helm need
not lead to a larger departmental budget or a higher cost per autopsy.
Redistributing personnel among investigative, pathology, and administrative
groups could offset any increased costs.