Is SF's COVID-19 Death Count the Complete Picture?

An aerial view shows painted circles in the grass to encourage people to social distance at Washington Square Park in San Francisco, California, on May 22, 2020, amid the novel coronavirus pandemic. (Josh Edelson/AFP via Getty Images)

So far, San Francisco has had a relatively small number of deaths from COVID-19, compared to most other large Bay Area counties. But hundreds of deaths in San Francisco are still being investigated by the medical examiner’s office, raising questions about whether the true death count is as low as it seems.

As of Friday, 40 people had died from COVID-19 in San Francisco, according to the city’s public health department. But the cause of 243 other deaths, reported to the county morgue from December through April, remain unresolved. And the medical examiner’s office had exceeded a 90-day deadline for closing more than a quarter of those cases.

San Francisco Supervisor Aaron Peskin suspects those pending results could push the COVID-19 death rate closer to other Bay Area counties, including Alameda, Santa Clara and San Mateo.

“I've been asking the same questions that many people are wondering: how many un-processed cases at the medical examiner's office that are pending investigation could be due to COVID-19?” said Peskin, who sits on the committee that oversees the medical examiner. “We have seen cities and countries around the world that have actually raised their official COVID-19 death counts as they've slowly gone back through unknown deaths.”

Backlogs at the medical examiner’s office have been a problem in the past.

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In 2014 then-Chief Medical Examiner Amy Hart stepped down from the top position after families complained of having to wait six months for the final results of autopsies on their loved ones. Dr. Hart is now the acting chief, since her boss took a job in another county.

Bill Barnes with the San Francisco City Administrator’s Office, said the cases pending now should not be considered a backlog.

“To the extent that in the past, the medical examiner had a fairly extensive backlog in services, I don't think this shows that,” Barnes said. “What it shows is that there are lots of cases that are actively being investigated.” Barnes said most of the pending cases are waiting on lab tests, which can take weeks to complete.

“You have a situation where the toxicologist has to review it, sign off on it, and then the forensic pathologist, a medical doctor has to review it,” Barnes explained. “People rely on the final cause of death to settle their family's affairs and so it's important that the final report be correct.”

Supervisor Peskin thinks that shouldn’t preclude the medical examiner from providing details about the pending cases. He said sharing information about the kinds of people who died, and the kinds of places they lived, could help San Francisco officials better respond to the pandemic.

“Were they people from congregate settings — be they nursing homes or S.R.O's (Single-Room Occupancy Hotels) — from the streets of San Francisco or other places?” Peskin asked. “The public has a right to know.”

At the start of the pandemic, the medical examiner’s office had to send tissue samples to the overwhelmed Centers for Disease Control and Prevention in order to find out if a person who died had COVID-19. But in March, officials began testing post mortem samples at the county’s own lab, which allowed for quicker results.

The San Francisco Department of Public Health is compiling the complete list of COVID-19 deaths, including those reported by hospitals and funeral homes, as well as those cases that are handled by the medical examiner, whose job is to investigate violent, sudden and unexplained deaths.

The first San Francisco resident confirmed to have died from the virus — on March 27 — was identified by the medical examiner. But most coronavirus deaths have been reported by doctors.

As of Thursday, the medical examiner had submitted 40 specimens for COVID-19 testing and four had come back positive, according to a spokeswoman for the city’s Department of Public Health.

One of those four cases is not being counted as a COVID-19 death because the person died of another cause, according to Barnes.

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For now the confirmed COVID-19 fatalities in San Francisco remain far below some other Bay Area counties. In Santa Clara County 138 people had succumbed to the virus as of Friday, while San Mateo County reported 76 fatalities, and Alameda County reported 86.

“I suspect that San Francisco's COVID-19 death rate is higher than we know,” said Peskin, who pointed out that, in other countries, additional cases of coronavirus have been identified months later. “I suspect that there were a number of deaths as early as February and into March that were attributable to coronavirus that we have yet to discover.”

Public health officials say that if a person suspects their relative died from COVID-19, they should ask the attending physician to conduct a post mortem test for the virus and then report the result to their county’s public health department.

Lisa Pickoff-White contributed to this report.

Matt Kiefer, a John S. Knight Journalism Fellow at Stanford, contributed to this report as part of COVID Public Info, a non-profit news collaboration.