The San Joaquin County Coroner's Office is within the county's Sheriff's Operation Center. (Julie Small/KQED)
When a young Sacramento man died in a struggle with Stockton police in 2016, San Joaquin County Sheriff-Coroner Steve Moore labeled the death an accident, overriding the opinion of his principal forensic pathologist.
Last month, a full two years later, the discrepancy was exposed, and the sheriff reclassified the death of Abelino Cordova-Cuevas as a homicide.
The reversal raises questions about the integrity of death investigations conducted under Moore, especially whether the sheriff appeared to use his power to shield officers of the law from prosecution, even if they killed people. In San Joaquin County, as in the vast majority of California counties, the sheriff also serves as coroner and is responsible for investigating sudden, violent and suspicious deaths.
“Let’s not lose sight of the fact that this is an officer-involved death,” said Greg Bentley, an attorney for the Cordova-Cuevas family. “There needs to be independence, objectivity and competency in county-performed autopsies. The public would expect nothing less.”
But in the case of Cordova-Cuevas, Bentley says the sheriff betrayed that public trust by violating a subpoena for all records on the case. He says Moore’s agency withheld a key document that would have showed that the forensic pathologist who conducted the autopsy, Dr. Bennet Omalu, had indicated the death was a homicide.
The lawyer discovered the omission during a deposition of Omalu, who noted that the cover sheet was missing from his autopsy report.
The sheriff’s decision to reclassify Cordova-Cuevas’ death was made shortly after that revelation and just one day before Moore implemented a new policy that would provide greater transparency in death investigations.
Going forward, all officer-involved deaths would require a coroner’s inquest where the sheriff appoints a hearing officer or a nine-member jury of county residents to consider evidence to decide whether the deceased person died as the result of an accident, homicide, suicide or natural causes.
“Recently, questions have been raised about death investigations that were, in some way, connected to law enforcement action,” Moore wrote in a statement last month, referring to allegations made by Omalu and the county’s other forensic pathologist, Dr. Susan Parson, who both resigned in December.
Omalu, renowned for his discovery of a deadly brain disease related to concussions in professional football players, served as the county’s chief forensic pathologist for a decade. In a memo documenting his reasons for resigning he wrote, “The sheriff was using his political office as the coroner to protect police officers whenever someone died while in custody or during arrest.”
Deadly Traffic Stop
On March 7, 2016, Cordova-Cuevas was driving home from his job at a Stockton meat market, when police pulled him over for what they called “erratic driving,” according to a wrongful-death complaint filed for the family.
In the complaint, witnesses reported seeing the 28-year-old standing on the sidewalk, his hands in the air, while repeatedly telling officers, “I have no weapons.” When one of the officers triggered his taser gun, making a “crackling sound,” Cordova-Cuevas ran away. Police quickly cornered him at a nearby business.
Security camera footage from a nearby business obtained by Bentley, the family’s attorney, showed Cordova-Cuevas was backing up slowly with his hands in the air when police tackled him.
That footage also showed Stockton officers using either a chokehold or carotid restraint on Cordova-Cuevas. Police in California are not allowed to use a chokehold that cuts off the air by compressing the windpipe, but they are allowed to use a carotid restraint where they squeeze a person’s neck to restrict blood flow to the brain, causing them to lose consciousness briefly.
When Cordova-Cuevas became unresponsive, officers called for medics and tried to resuscitate him. He was taken to a local hospital and pronounced dead.
Coroner Overrode Doctor’s Opinion on Homicide
Omalu conducted the autopsy the day after Cordova-Cuevas’ death, but did not finalize his report for nearly a year. The pathologist said it took that long to convince the Stockton Police Department to let him view footage from the officers’ body cameras.
The Jan. 26, 2017, autopsy form filled out by Omalu states that Cordova-Cuevas died from mechanical asphyxiation, compression of the neck and blunt force trauma to the head, face, neck and trunk. Acute amphetamine toxicity is listed as a significant contributing factor. The doctor concluded that the man had died at the hands of another -- the medical definition of a homicide. On a cover sheet for the autopsy report, Omalu checked a box next to the word “homicide,” and circled it.
Months later, Omalu told KQED the sheriff called him into his office and asked him to change the manner of Cordova-Cuevas’ death to “accident,” and wanted the same change made in another 2016 officer-involved fatality.
“We went into this long back and forth,” Omalu said, “that he doesn't think it was a homicide because they didn't mean to kill him. And I said to him, ‘Sir, it doesn't matter what you and I think, we have to adhere to the standards of practice.’”
Omalu said he told the sheriff that a medical determination of homicide indicates that someone died at the hands of another, but it does not ascribe motive or guilt.
Four months later, on May 4, 2017, the coroner's office issued a death certificate for Cordova-Cuevas, identifying the manner of his death as an accident.
Omalu found out after the Cordova-Cuevas family asked an outside pathologist to review the autopsy report, and that doctor called Omalu and asked why had he had designated the manner of death an accident.
In an Aug. 22, 2017 memo documenting that call, Omalu wrote, “I had made it a homicide but the Sheriff had apparently overruled my opinion, without even consulting me.”
A KQED investigation found other examples in which Sheriff Moore overrode Omalu’s assessment and ruled deaths accidents instead of homicides. One is the case of Daniel Humphreys, who died in 2008 after a CHP officer tased him 31 times.
An independent audit of San Joaquin County coroner operations, released last week by RAM Consulting LLC, confirmed “several cases” in 2016 where Moore labeled an officer-involved fatality an accident, against the opinion of the forensic pathologist who conducted the autopsy.
Moore declined to be interviewed for this story, but has repeatedly denied that he interfered with his doctors’ findings.
In a Dec. 6 Facebook post, Moore stated, “I would never try to control, influence or change the opinions of Dr. Omalu or any other physician working on a case, but I still have the responsibility of making the final determination.”
In a legal review of the doctors’ allegations, San Joaquin County Counsel Mark Myles concluded that “the Coroner and the physician should deliberate together regarding the determination of the manner of death so that each understands the others’ perspective. There is no requirement that they agree as to the manner of death.”
Controversy over Sheriff Moore’s handling of death investigations became public when Omalu and Parson resigned last December.
Addendum to Homicide
In the Cordova-Cuevas case, an addendum to the coroners’ investigative report, obtained by KQED, shows that Chief Deputy Coroner Mike Reynolds reviewed the autopsy file on Omalu’s final day on the job.
In the March 23, 2018 addendum, Reynolds wrote that he conducted a follow up after learning that Omalu had reviewed a case synopsis of the incident from the Stockton police that was never shared with the coroner. Reynolds wrote that he obtained and “read the documented report, which includes detailed statements from both of the involved Stockton Police Department officers who took the decedent into custody, including the manner in which a carotid control hold was applied.” Based on his reading of the officers statements, Reynolds explained, “I reclassified the manner of death as ‘homicide,’ which is defined as ‘death at the hands of another.’”
But attorney Greg Bentley said it’s telling that the sheriff’s revised report made no mention of the form that Omalu had filled out two years earlier, indicating that he considered Cordova-Cuevas’ death a homicide.
“They completely disregarded that,” Bentley said.
Bentley asked San Joaquin County’s district attorney to investigate all officer-involved deaths dating back 10 years to make sure this hasn’t happened before.
The district attorney launched an investigation into Moore’s office last year, which is ongoing.