San Joaquin Sheriff Opens Death Inquiries to Public

2 min
Decades ago the California State Coroners Association and the Orange County Sheriff's Department recognized the need to standardize training for the job of conducting death investigations. (Getty Images)

The sheriff-coroner of San Joaquin County came under scrutiny late last year after two physicians who conducted autopsies for his office quit in protest.

Dr. Bennet Omalu and Dr. Susan Parson accused Sheriff Steve Moore of pressuring them to change medical findings, especially in cases involving law enforcement officers.

“Recently, questions have been raised about death investigations that were, in some way, connected to law enforcement action,” Moore acknowledged in a Facebook post Friday.

Moore responded with a promise to conduct public inquests of all deaths that occurred in custody or during a pursuit or arrest. Moore wrote that he modeled his new policy on a coroner's inquest system in neighboring Contra Costa County “that has proved successful, transparent, cost-effective, and can be completed in months, not years.”

Contra Costa County Benefits from Coroner’s Inquests

During the inquest hearing the coroner, a designated deputy or an independent hearing officer -- typically an attorney -- will select and question witnesses.


Either the hearing officer or a nine-member jury of county residents can consider the evidence to decide whether the deceased person died as the result of an accident, homicide, suicide or natural causes.

“I am a fan of it,” said attorney Matthew Guichard, who has conducted coroner's inquests for Contra Costa County for 15 years. He says the hearing “puts out into the open the circumstances of the death and it doesn't get into whether there's criminal or civil responsibility on the part of anyone -- either the policeman, the dead person or anyone else.”

Contra Costa County began conducting coroner's inquests for all deaths that occurred in custody in the 1980s. The proceedings are open to the general public and the press. Families of the deceased may have attorneys submit questions on their behalf to the hearing officer.

Guichard believes the inquests have made a difference in how the public views fatalities involving officers.

“Putting it out into the open -- the circumstance -- in my view has significantly reduced the number of lawsuits afterwards because parties, families oftentimes listen and go ‘OK.’ This is the first time they really hear an exhaustive story of precisely what happened.”

Some See Bias With Inquests Controlled by a Sheriff-Coroner

Critics say the inquest system gives the public a false sense of impartiality because the sheriff-coroner runs the operation, selects the witnesses and jury.

A forensic pathologist who has worked in several Bay Area counties in California said the only way to completely avoid conflicts of interest or bias is to have the deaths reviewed by an outside expert.

Some officials in San Joaquin County are pushing to replace the sheriff-coroner system with an independent medical examiner's office headed by a physician trained in forensic pathology.

San Joaquin County officials have hired a consultant to look into how Moore runs the coroner’s operation and to provide a cost-benefit analysis of replacing it with a medical examiner’s office.

That report is due in April.