Governor Vetoes Bill That Sought Independence in Death Investigations
Sheriff Accused of Interfering in Death Investigations Loses Re-Election Bid
Coroner Training Seeks to Raise Standards for California Death Investigations
Reports of Sheriff's Interference in Death Investigations Spur Change in Santa Clara County
Stephon Clark Autopsy Controversy: As Coroner Points to Errors, Private Doctor Defends His Findings
San Joaquin County Sheriff Stripped of Role in Death Investigations
Reversal on Death Ruling for Man Killed by Police Raises Doubts in San Joaquin County
San Joaquin County Should Install Independent Medical Examiner, Audit Finds
San Joaquin Sheriff Opens Death Inquiries to Public
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"content": "\u003cp>Gov. Jerry Brown vetoed a bill Tuesday that would have required six counties in California to change how they investigate sudden, suspicious or violent deaths, including deaths that happen during arrest or in jail or prison.\u003c/p>\n\u003cp>State Senate Bill \u003ca href=\"https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=201720180SB1303\" target=\"_blank\" rel=\"noopener\">1303\u003c/a> would have forced non-charter counties with more than 500,000 residents to establish a medical examiner’s office to investigate deaths.\u003c/p>\n\u003cp>But in his Sept. 18 veto \u003ca href=\"https://www.gov.ca.gov/wp-content/uploads/2018/09/SB-1303-Veto-Message.pdf\" target=\"_blank\" rel=\"noopener\">message\u003c/a>, Brown wrote, “Counties have several options when delivering coroner services to the public. This decision is best left to the discretion of local elected officials who are in the best position to determine how their county offices are organized.”\u003c/p>\n\u003cp>The bill’s author, state Sen. Richard Pan, \u003ca href=\"https://sd06.senate.ca.gov/news/2018-09-19-governor-vetoes-senate-bill-1303-which-would-have-required-medical-experts-conduct\" target=\"_blank\" rel=\"noopener\">responded\u003c/a> Wednesday, “I am disappointed in the veto because it would have been an important step in ensuring the integrity of autopsy reports and achieving justice for people across California.”\u003c/p>\n\u003cp>In seven of California's largest counties — including San Francisco, Santa Clara and San Diego — a medical examiner, who is also a physician, investigates deaths. In the majority of other counties, that job falls to a \u003ca href=\"https://www.kqed.org/news/11670624/coroner-training-seeks-to-raise-standards-for-california-death-investigations\" target=\"_blank\" rel=\"noopener\">coroner\u003c/a>, who is also the elected sheriff.\u003c/p>\n\u003cp>[ad fullwidth]\u003c/p>\n\u003cp>Dr. Pan, a pediatrician, believes that having the sheriff-coroner investigate deaths involving officers is a conflict of interest.\u003c/p>\n\u003cp>“Because of that, they can influence the findings of the autopsy,” Pan said. “They can even modify the reports.”\u003c/p>\n\u003cp>Pan introduced SB 1303 in response to accusations late last year that a county sheriff had in fact meddled in death investigations and altered findings.\u003c/p>\n\u003cp>\u003cstrong>Death Investigation Scandal in San Joaquin County\u003c/strong>\u003c/p>\n\u003cp>The chief forensic pathologist for San Joaquin County, Dr. Bennet Omalu, \u003ca href=\"https://www.kqed.org/news/11634689/autopsy-doctors-sheriff-overrode-death-findings-to-protect-law-enforcement\" target=\"_blank\" rel=\"noopener\">accused\u003c/a> Sheriff Steve Moore of overriding autopsy findings in cases where an officer of the law appeared to have killed someone.\u003c/p>\n\u003cp>Omalu, known for his discovery of the debilitating brain disease CTE in professional football players, resigned from his position as chief forensic pathologist Dec. 4, after a decade holding the position.\u003c/p>\n\u003cp>Among the reasons he said he could no longer work for Moore were several instances where he had determined a person’s death was a homicide, only to watch Moore override his findings and label the death an accident.\u003c/p>\n\u003cp>Omalu testified in support of Pan's bill, which was sponsored by the California Medical Association. The \u003ca href=\"https://www.calsheriffs.org/about-us/about-cssa-our-mission.html\" target=\"_blank\" rel=\"noopener\">California State Sheriffs' Association\u003c/a>, currently led by Moore, opposed the measure as costly and unnecessary, and the California State Association of Counties objected to the measure's interference with local autonomy.\u003c/p>\n\u003cp>While the legislation ultimately failed, San Joaquin County supervisors moved to \u003ca href=\"https://www.kqed.org/news/11664465/san-joaquin-county-sheriff-stripped-of-role-in-death-investigations\" target=\"_blank\" rel=\"noopener\">strip\u003c/a> the sheriff of his coroner duties and establish an independent medical examiner’s office. That effort is ongoing.\u003c/p>\n\u003cp>Moore \u003ca href=\"https://www.kqed.org/news/11672974/sheriff-accused-of-interfering-in-death-investigations-loses-re-election-bid\" target=\"_blank\" rel=\"noopener\">lost\u003c/a> his re-election in June.\u003c/p>\n\u003cp>Omalu recently opened new \u003ca href=\"https://www.bennetomalu.com/\" target=\"_blank\" rel=\"noopener\">offices\u003c/a> and is providing autopsies for several local entities and expert witness testimony in cases throughout the U.S.\u003c/p>\n\u003cp>Pan plans to keep trying to improve death investigations in California. Contrary to the governor’s veto message, the senator thinks that local officials are unlikely to challenge the sheriff-coroner system.\u003c/p>\n\u003cp>\u003c/p>\n\u003cp>“Sheriffs have tremendous political power in counties,” Pan said. “That’s why many counties have been very slow to address this issue.”\u003c/p>\n\n",
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"content": "\u003cdiv class=\"post-body\">\u003cp>\u003cp>Gov. Jerry Brown vetoed a bill Tuesday that would have required six counties in California to change how they investigate sudden, suspicious or violent deaths, including deaths that happen during arrest or in jail or prison.\u003c/p>\n\u003cp>State Senate Bill \u003ca href=\"https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=201720180SB1303\" target=\"_blank\" rel=\"noopener\">1303\u003c/a> would have forced non-charter counties with more than 500,000 residents to establish a medical examiner’s office to investigate deaths.\u003c/p>\n\u003cp>But in his Sept. 18 veto \u003ca href=\"https://www.gov.ca.gov/wp-content/uploads/2018/09/SB-1303-Veto-Message.pdf\" target=\"_blank\" rel=\"noopener\">message\u003c/a>, Brown wrote, “Counties have several options when delivering coroner services to the public. This decision is best left to the discretion of local elected officials who are in the best position to determine how their county offices are organized.”\u003c/p>\n\u003cp>The bill’s author, state Sen. Richard Pan, \u003ca href=\"https://sd06.senate.ca.gov/news/2018-09-19-governor-vetoes-senate-bill-1303-which-would-have-required-medical-experts-conduct\" target=\"_blank\" rel=\"noopener\">responded\u003c/a> Wednesday, “I am disappointed in the veto because it would have been an important step in ensuring the integrity of autopsy reports and achieving justice for people across California.”\u003c/p>\n\u003cp>In seven of California's largest counties — including San Francisco, Santa Clara and San Diego — a medical examiner, who is also a physician, investigates deaths. In the majority of other counties, that job falls to a \u003ca href=\"https://www.kqed.org/news/11670624/coroner-training-seeks-to-raise-standards-for-california-death-investigations\" target=\"_blank\" rel=\"noopener\">coroner\u003c/a>, who is also the elected sheriff.\u003c/p>\n\u003cp>\u003c/p>\u003c/div>",
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"content": "\u003cdiv class=\"post-body\">\u003cp>\u003c/p>\n\u003cp>Dr. Pan, a pediatrician, believes that having the sheriff-coroner investigate deaths involving officers is a conflict of interest.\u003c/p>\n\u003cp>“Because of that, they can influence the findings of the autopsy,” Pan said. “They can even modify the reports.”\u003c/p>\n\u003cp>Pan introduced SB 1303 in response to accusations late last year that a county sheriff had in fact meddled in death investigations and altered findings.\u003c/p>\n\u003cp>\u003cstrong>Death Investigation Scandal in San Joaquin County\u003c/strong>\u003c/p>\n\u003cp>The chief forensic pathologist for San Joaquin County, Dr. Bennet Omalu, \u003ca href=\"https://www.kqed.org/news/11634689/autopsy-doctors-sheriff-overrode-death-findings-to-protect-law-enforcement\" target=\"_blank\" rel=\"noopener\">accused\u003c/a> Sheriff Steve Moore of overriding autopsy findings in cases where an officer of the law appeared to have killed someone.\u003c/p>\n\u003cp>Omalu, known for his discovery of the debilitating brain disease CTE in professional football players, resigned from his position as chief forensic pathologist Dec. 4, after a decade holding the position.\u003c/p>\n\u003cp>Among the reasons he said he could no longer work for Moore were several instances where he had determined a person’s death was a homicide, only to watch Moore override his findings and label the death an accident.\u003c/p>\n\u003cp>Omalu testified in support of Pan's bill, which was sponsored by the California Medical Association. The \u003ca href=\"https://www.calsheriffs.org/about-us/about-cssa-our-mission.html\" target=\"_blank\" rel=\"noopener\">California State Sheriffs' Association\u003c/a>, currently led by Moore, opposed the measure as costly and unnecessary, and the California State Association of Counties objected to the measure's interference with local autonomy.\u003c/p>\n\u003cp>While the legislation ultimately failed, San Joaquin County supervisors moved to \u003ca href=\"https://www.kqed.org/news/11664465/san-joaquin-county-sheriff-stripped-of-role-in-death-investigations\" target=\"_blank\" rel=\"noopener\">strip\u003c/a> the sheriff of his coroner duties and establish an independent medical examiner’s office. That effort is ongoing.\u003c/p>\n\u003cp>Moore \u003ca href=\"https://www.kqed.org/news/11672974/sheriff-accused-of-interfering-in-death-investigations-loses-re-election-bid\" target=\"_blank\" rel=\"noopener\">lost\u003c/a> his re-election in June.\u003c/p>\n\u003cp>Omalu recently opened new \u003ca href=\"https://www.bennetomalu.com/\" target=\"_blank\" rel=\"noopener\">offices\u003c/a> and is providing autopsies for several local entities and expert witness testimony in cases throughout the U.S.\u003c/p>\n\u003cp>Pan plans to keep trying to improve death investigations in California. Contrary to the governor’s veto message, the senator thinks that local officials are unlikely to challenge the sheriff-coroner system.\u003c/p>\n\u003cp>\u003c/p>\n\u003cp>“Sheriffs have tremendous political power in counties,” Pan said. “That’s why many counties have been very slow to address this issue.”\u003c/p>\n\n\u003c/div>\u003c/p>",
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"content": "\u003cp>The San Joaquin County sheriff-coroner, who was \u003ca href=\"https://www.kqed.org/news/11634689/autopsy-doctors-sheriff-overrode-death-findings-to-protect-law-enforcement\" target=\"_blank\" rel=\"noopener\">accused last year of meddling in death investigations\u003c/a>, fell short in his bid for re-election.\u003c/p>\n\u003cp>Three-term incumbent Sheriff Steve Moore trailed his opponent \u003ca href=\"http://withrowforsheriff.com/\" target=\"_blank\" rel=\"noopener\">Pat Withrow\u003c/a> by 17 points Wednesday, with 100 percent of precinct votes reported.\u003c/p>\n\u003cp>Moore conceded defeat Wednesday morning in a phone call to Withrow, congratulating him on his win even as the county registrar was still tallying 50,000 vote-by-mail and provisional ballots.\u003c/p>\n\u003cp>Moore lost support after two forensic pathologists in the coroner's office alleged that the sheriff interfered with autopsy findings and used his political office to shield officers who killed civilians. The \u003ca href=\"https://www.kqed.org/news/11633330/autopsy-doctor-quits-alleges-sheriff-interfered-in-death-probes\" target=\"_blank\" rel=\"noopener\">allegations\u003c/a> were first reported by KQED.\u003c/p>\n\u003cp>\u003ca href=\"http://www.bennetomalu.com/\" target=\"_blank\" rel=\"noopener\">Dr. Bennet Omalu\u003c/a>, a nationally renowned forensic pathologist famous for his discovery of a concussion-related disease in football players, worked for the sheriff for a decade.\u003c/p>\n\u003caside class=\"alignright\">\n\u003ch3>\u003ca href=\"https://www.kqed.org/news/11634689/autopsy-doctors-sheriff-overrode-death-findings-to-protect-law-enforcement\">Autopsy Doctor Resigns, Says Sheriff Overrode Death Findings to Protect Officers\u003c/a>\u003c/h3>\n\u003cfigure>\u003ca href=\"https://www.kqed.org/news/11634689/autopsy-doctors-sheriff-overrode-death-findings-to-protect-law-enforcement\">\u003cimg src=\"https://ww2.kqed.org/wp-content/uploads/sites/10/2017/12/coroner_1920-1180x632.jpg\" alt=\"\">\u003c/a>\u003c/figure>\n\u003c/aside>\n\u003cp>Shortly after his colleague Dr. Susan Parson quit in November, Omalu tendered his own resignation. Together the doctors submitted over 100 pages of documentation to county officials that they said showed Moore had repeatedly violated medical and ethical standards in his role as coroner.\u003c/p>\n\u003cp>[ad fullwidth]\u003c/p>\n\u003cp>Moore denied he did anything wrong, a claim backed up by a county \u003ca href=\"https://www.kqed.org/news/11663351/san-joaquin-county-should-install-independent-medical-examiner-audit-finds\" target=\"_blank\" rel=\"noopener\">audit\u003c/a> that concluded he broke no laws.\u003c/p>\n\u003cp>However, the audit also identified so many problems with the way Moore ran death investigations that supervisors \u003ca href=\"https://www.kqed.org/news/11664465/san-joaquin-county-sheriff-stripped-of-role-in-death-investigations\" target=\"_blank\" rel=\"noopener\">voted unanimously in April\u003c/a> to strip the sheriff of his coroner duties and establish an independent medical examiner to investigate deaths, independent of law enforcement.\u003c/p>\n\u003cfigure id=\"attachment_11673167\" class=\"wp-caption aligncenter\" style=\"max-width: 800px\">\u003cimg class=\"size-medium wp-image-11673167\" src=\"https://ww2.kqed.org/news/wp-content/uploads/sites/10/2018/06/PatWithrow-800x550.jpg\" alt=\"San Joaquin County Sheriff-Elect Pat Withrow (second from left) and supporters celebrate the June 5 primary results.\" width=\"800\" height=\"550\" srcset=\"https://ww2.kqed.org/app/uploads/sites/10/2018/06/PatWithrow-800x550.jpg 800w, https://ww2.kqed.org/app/uploads/sites/10/2018/06/PatWithrow-160x110.jpg 160w, https://ww2.kqed.org/app/uploads/sites/10/2018/06/PatWithrow-1020x701.jpg 1020w, https://ww2.kqed.org/app/uploads/sites/10/2018/06/PatWithrow-1200x825.jpg 1200w, https://ww2.kqed.org/app/uploads/sites/10/2018/06/PatWithrow.jpg 1920w, https://ww2.kqed.org/app/uploads/sites/10/2018/06/PatWithrow-1180x811.jpg 1180w, https://ww2.kqed.org/app/uploads/sites/10/2018/06/PatWithrow-960x660.jpg 960w, https://ww2.kqed.org/app/uploads/sites/10/2018/06/PatWithrow-240x165.jpg 240w, https://ww2.kqed.org/app/uploads/sites/10/2018/06/PatWithrow-375x258.jpg 375w, https://ww2.kqed.org/app/uploads/sites/10/2018/06/PatWithrow-520x358.jpg 520w\" sizes=\"(max-width: 800px) 100vw, 800px\">\u003cfigcaption class=\"wp-caption-text\">San Joaquin County Sheriff-Elect Pat Withrow (second from left) and supporters celebrate the June 5 primary results. \u003ccite>(Courtesy Tracy Spencer)\u003c/cite>\u003c/figcaption>\u003c/figure>\n\u003cp>Withrow, who served as the deputy sheriff of San Joaquin County for nearly three decades, quit to run against Moore in 2014. Moore beat Withrow that year, drawing on strong support from county ranchers and farmers.\u003c/p>\n\u003cp>Despite the allegations against him, Moore became president of the influential \u003ca href=\"https://www.calsheriffs.org/about-us/board-of-directors/presidents-message.html\" target=\"_blank\" rel=\"noopener\">California State Sheriffs' Association\u003c/a> in April, a title he will have to forfeit when Withrow takes office next year.\u003c/p>\n\u003cp>\u003c/p>\n\u003cp>As of 2 a.m. Wednesday, Withrow had won 58 percent of the vote, with Moore taking 41 percent.\u003c/p>\n\n",
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"excerpt": "San Joaquin County Sheriff Steve Moore won't be coming back for a fourth term. Allegations that he interfered with death investigations and autopsy findings may have cost him crucial votes.",
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"content": "\u003cdiv class=\"post-body\">\u003cp>\u003cp>The San Joaquin County sheriff-coroner, who was \u003ca href=\"https://www.kqed.org/news/11634689/autopsy-doctors-sheriff-overrode-death-findings-to-protect-law-enforcement\" target=\"_blank\" rel=\"noopener\">accused last year of meddling in death investigations\u003c/a>, fell short in his bid for re-election.\u003c/p>\n\u003cp>Three-term incumbent Sheriff Steve Moore trailed his opponent \u003ca href=\"http://withrowforsheriff.com/\" target=\"_blank\" rel=\"noopener\">Pat Withrow\u003c/a> by 17 points Wednesday, with 100 percent of precinct votes reported.\u003c/p>\n\u003cp>Moore conceded defeat Wednesday morning in a phone call to Withrow, congratulating him on his win even as the county registrar was still tallying 50,000 vote-by-mail and provisional ballots.\u003c/p>\n\u003cp>Moore lost support after two forensic pathologists in the coroner's office alleged that the sheriff interfered with autopsy findings and used his political office to shield officers who killed civilians. The \u003ca href=\"https://www.kqed.org/news/11633330/autopsy-doctor-quits-alleges-sheriff-interfered-in-death-probes\" target=\"_blank\" rel=\"noopener\">allegations\u003c/a> were first reported by KQED.\u003c/p>\n\u003cp>\u003ca href=\"http://www.bennetomalu.com/\" target=\"_blank\" rel=\"noopener\">Dr. Bennet Omalu\u003c/a>, a nationally renowned forensic pathologist famous for his discovery of a concussion-related disease in football players, worked for the sheriff for a decade.\u003c/p>\n\u003caside class=\"alignright\">\n\u003ch3>\u003ca href=\"https://www.kqed.org/news/11634689/autopsy-doctors-sheriff-overrode-death-findings-to-protect-law-enforcement\">Autopsy Doctor Resigns, Says Sheriff Overrode Death Findings to Protect Officers\u003c/a>\u003c/h3>\n\u003cfigure>\u003ca href=\"https://www.kqed.org/news/11634689/autopsy-doctors-sheriff-overrode-death-findings-to-protect-law-enforcement\">\u003cimg src=\"https://ww2.kqed.org/wp-content/uploads/sites/10/2017/12/coroner_1920-1180x632.jpg\" alt=\"\">\u003c/a>\u003c/figure>\n\u003c/aside>\n\u003cp>Shortly after his colleague Dr. Susan Parson quit in November, Omalu tendered his own resignation. Together the doctors submitted over 100 pages of documentation to county officials that they said showed Moore had repeatedly violated medical and ethical standards in his role as coroner.\u003c/p>\n\u003cp>\u003c/p>\u003c/div>",
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"content": "\u003cdiv class=\"post-body\">\u003cp>\u003c/p>\n\u003cp>Moore denied he did anything wrong, a claim backed up by a county \u003ca href=\"https://www.kqed.org/news/11663351/san-joaquin-county-should-install-independent-medical-examiner-audit-finds\" target=\"_blank\" rel=\"noopener\">audit\u003c/a> that concluded he broke no laws.\u003c/p>\n\u003cp>However, the audit also identified so many problems with the way Moore ran death investigations that supervisors \u003ca href=\"https://www.kqed.org/news/11664465/san-joaquin-county-sheriff-stripped-of-role-in-death-investigations\" target=\"_blank\" rel=\"noopener\">voted unanimously in April\u003c/a> to strip the sheriff of his coroner duties and establish an independent medical examiner to investigate deaths, independent of law enforcement.\u003c/p>\n\u003cfigure id=\"attachment_11673167\" class=\"wp-caption aligncenter\" style=\"max-width: 800px\">\u003cimg class=\"size-medium wp-image-11673167\" src=\"https://ww2.kqed.org/news/wp-content/uploads/sites/10/2018/06/PatWithrow-800x550.jpg\" alt=\"San Joaquin County Sheriff-Elect Pat Withrow (second from left) and supporters celebrate the June 5 primary results.\" width=\"800\" height=\"550\" srcset=\"https://ww2.kqed.org/app/uploads/sites/10/2018/06/PatWithrow-800x550.jpg 800w, https://ww2.kqed.org/app/uploads/sites/10/2018/06/PatWithrow-160x110.jpg 160w, https://ww2.kqed.org/app/uploads/sites/10/2018/06/PatWithrow-1020x701.jpg 1020w, https://ww2.kqed.org/app/uploads/sites/10/2018/06/PatWithrow-1200x825.jpg 1200w, https://ww2.kqed.org/app/uploads/sites/10/2018/06/PatWithrow.jpg 1920w, https://ww2.kqed.org/app/uploads/sites/10/2018/06/PatWithrow-1180x811.jpg 1180w, https://ww2.kqed.org/app/uploads/sites/10/2018/06/PatWithrow-960x660.jpg 960w, https://ww2.kqed.org/app/uploads/sites/10/2018/06/PatWithrow-240x165.jpg 240w, https://ww2.kqed.org/app/uploads/sites/10/2018/06/PatWithrow-375x258.jpg 375w, https://ww2.kqed.org/app/uploads/sites/10/2018/06/PatWithrow-520x358.jpg 520w\" sizes=\"(max-width: 800px) 100vw, 800px\">\u003cfigcaption class=\"wp-caption-text\">San Joaquin County Sheriff-Elect Pat Withrow (second from left) and supporters celebrate the June 5 primary results. \u003ccite>(Courtesy Tracy Spencer)\u003c/cite>\u003c/figcaption>\u003c/figure>\n\u003cp>Withrow, who served as the deputy sheriff of San Joaquin County for nearly three decades, quit to run against Moore in 2014. Moore beat Withrow that year, drawing on strong support from county ranchers and farmers.\u003c/p>\n\u003cp>Despite the allegations against him, Moore became president of the influential \u003ca href=\"https://www.calsheriffs.org/about-us/board-of-directors/presidents-message.html\" target=\"_blank\" rel=\"noopener\">California State Sheriffs' Association\u003c/a> in April, a title he will have to forfeit when Withrow takes office next year.\u003c/p>\n\u003cp>\u003c/p>\n\u003cp>As of 2 a.m. Wednesday, Withrow had won 58 percent of the vote, with Moore taking 41 percent.\u003c/p>\n\n\u003c/div>\u003c/p>",
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"disqusTitle": "Coroner Training Seeks to Raise Standards for California Death Investigations",
"title": "Coroner Training Seeks to Raise Standards for California Death Investigations",
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"content": "\u003cp>Every year, hundreds of death investigators from across California travel to a unique training facility in Santa Ana to sharpen their skills and deepen their knowledge of the critical job.\u003c/p>\n\u003cp>The people responsible for investigating sudden, suspicious or violent deaths in a county take photos of the body, collect evidence, interview witnesses and prepare a report of their findings that ultimately contributes to a decision on how and why someone died, and what goes on a person's death certificate.\u003c/p>\n\u003cp>Decades ago the \u003ca href=\"https://www.coroners.org/\" target=\"_blank\" rel=\"noopener\">California State Coroners Association\u003c/a> and the Orange County Sheriff's Department recognized the need to standardize training for the job. In 1989 they began offering courses, often out of hotel ballrooms. But that limited what they could do. Years later they secured $15 million to build the \u003ca href=\"http://www.ocsd.org/divisions/fieldops/coroner/cctc\" target=\"_blank\" rel=\"noopener\">California Coroner Training Center\u003c/a>. The doors opened in 2004, and so did the opportunity to provide hands-on courses.\u003c/p>\n\u003ch3>'There's No Real Dead People in Here'\u003c/h3>\n\u003cp>\"What we did is we built just one big wide open room,\" said Assistant Chief Deputy Coroner for Orange County Bruce Lyle on a recent tour. \"There's a drain in the floor in case we needed blood or fluids -- fake fluids -- to mock it.\"\u003c/p>\n\u003cp>Lyle, who teaches some of the courses, quickly added, \"There's no real dead people in here.\"\u003c/p>\n\u003cp>[ad fullwidth]\u003c/p>\n\u003cp>Contained inside the room is a set of a two-bedroom apartment built out of plywood. From the outside it doesn't look like much, but inside the place is decorated and furnished with furniture, props and eerily realistic latex dummies.\u003c/p>\n\u003cp>\"He's not a very clean person,\" Lyle said of one dummy. \"He's kind of grubby. He's got a 5 o'clock shadow. You can feel it on his face.\"\u003c/p>\n\u003cp>The dummy's name, Emmanuel Quin -- or \"Manny\" Quin for short -- provides comic relief to the otherwise grim task of identifying the decedent and determining how long ago he died.\u003c/p>\n\u003cp>\"There are certain changes in the body\" Lyle explained, \"and one of them is the decomposition.\"\u003c/p>\n\u003cp>The dummy was commissioned by Burbank's \u003ca href=\"https://www.burmanfoam.com/\" target=\"_blank\" rel=\"noopener\">Burman Studio\u003c/a> to exhibit signs of decomposition, including discoloration of the skin.\u003c/p>\n\u003cp>The trainers load the set with other clues, including cigarette butts, an empty bottle of tequila, a dated prescription for pills, and a dried-out slice of pizza in a box on the floor.\u003c/p>\n\u003cp>Lyle said the barrage of stimuli simulates what investigators typically encounter at the scene of someone's death.\u003c/p>\n\u003cp>\"We have to sort of teach people to cut through all that business and get to the important stuff,\" Lyle says.\u003c/p>\n\u003cfigure id=\"attachment_11671398\" class=\"wp-caption aligncenter\" style=\"max-width: 800px\">\u003cimg class=\"size-medium wp-image-11671398\" src=\"https://ww2.kqed.org/news/wp-content/uploads/sites/10/2018/05/CoronerTrainingBldg-800x488.jpg\" alt=\"The California Coroner's Training Facility in Orange County.\" width=\"800\" height=\"488\" srcset=\"https://ww2.kqed.org/app/uploads/sites/10/2018/05/CoronerTrainingBldg-800x488.jpg 800w, https://ww2.kqed.org/app/uploads/sites/10/2018/05/CoronerTrainingBldg-160x98.jpg 160w, https://ww2.kqed.org/app/uploads/sites/10/2018/05/CoronerTrainingBldg-240x146.jpg 240w, https://ww2.kqed.org/app/uploads/sites/10/2018/05/CoronerTrainingBldg-375x229.jpg 375w, https://ww2.kqed.org/app/uploads/sites/10/2018/05/CoronerTrainingBldg-520x317.jpg 520w, https://ww2.kqed.org/app/uploads/sites/10/2018/05/CoronerTrainingBldg.jpg 867w\" sizes=\"(max-width: 800px) 100vw, 800px\">\u003cfigcaption class=\"wp-caption-text\">The California Coroner Training Center in Orange County trains coroners from across California. \u003ccite>(Courtesy Orange County Sheriff's Dept.)\u003c/cite>\u003c/figcaption>\u003c/figure>\n\u003cp>When trainings are in session, actors play bereaved relatives or roommates with information the investigator has to elicit.\u003c/p>\n\u003cp>\"The last thing I want to do is have somebody come in and just look at the body and think that that's the extent of their investigation,\" Lyle says.\u003c/p>\n\u003cp>Most of the death investigators that come for the training work for one of 41 counties in California where the sheriff and coroner’s office are one.\u003c/p>\n\u003cp>Lyle, who is also incoming president of the California State Coroners Association, says the philosophy for the training is to get attendees to apply their experience investigating crimes to death investigations.\u003c/p>\n\u003cp>According to the Orange County Sheriff's Department website, \"The ultimate vision of the Training Center’s leadership is to 'raise the bar' in the coroner profession by improving the caliber of investigations conducted throughout the state.\"\u003c/p>\n\u003ch3>Varying Levels of Expertise\u003c/h3>\n\u003cp>The level of expertise in death investigations varies widely from county to county.\u003c/p>\n\u003cp>Some of the larger sheriff's departments in Orange County and San Bernardino County created a separate coroner's division and assigned dedicated deputies to investigate deaths, which allowed them to develop expertise over years, even decades.\u003c/p>\n\u003caside class=\"alignright\">\n\u003ch3>\u003ca href=\"https://www.kqed.org/news/11648821/how-families-in-san-joaquin-county-pay-for-coroner-mistakes\">How Families Pay for San Joaquin Coroner Mistakes\u003c/a>\u003c/h3>\n\u003cfigure>\u003ca href=\"https://www.kqed.org/news/11648821/how-families-in-san-joaquin-county-pay-for-coroner-mistakes\">\u003cimg src=\"https://ww2.kqed.org/news/wp-content/uploads/sites/10/2018/02/RS29311_alt_681-1180x1573.jpg\" alt=\"\">\u003c/a>\u003c/figure>\n\u003c/aside>\n\u003cp>Smaller counties such as San Joaquin County dedicated a handful of deputies for coroner's work who typically investigate more complex death scenes such as a homicide -- but often patrol deputies who received minimal training in death investigations respond to the scene of a death.\u003c/p>\n\u003cp>The Orange County Sheriff-Coroner's Office is working with the California State Coroners Association to establish an accreditation program for death investigators.\u003c/p>\n\u003ch3>Some Counties Could Be Required to End Sheriff's Role as Coroner\u003c/h3>\n\u003cp>Some of those offices could change under \u003ca href=\"https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=201720180SB1303\" target=\"_blank\" rel=\"noopener\">state Senate Bill 1303\u003c/a>. The bill would force several large counties to create a completely separate medical examiner’s office for death investigations -- with a physician in charge.\u003c/p>\n\u003cp>The measure was introduced by Sen. Richard Pan in response to a scandal in Joaquin County that erupted last year.\u003c/p>\n\u003cp>Two forensic pathologists who worked for Sheriff-Coroner Steve Moore \u003ca href=\"https://www.kqed.org/news/11633330/autopsy-doctor-quits-alleges-sheriff-interfered-in-death-probes\" target=\"_blank\" rel=\"noopener\">accused him of pressuring them\u003c/a> to change their autopsy findings in deaths involving law enforcement officers. Moore denied the allegations.\u003c/p>\n\u003cp>The doctors also faulted the inexperience among deputies responding to coroner calls for driving up costs and \u003ca href=\"https://www.kqed.org/news/11648821/how-families-in-san-joaquin-county-pay-for-coroner-mistakes\" target=\"_blank\" rel=\"noopener\">creating backlogs and delays\u003c/a>.\u003c/p>\n\u003cp>\u003c/p>\n\u003cp>If passed, SB 1303 would not interfere with the plans to expand coroner training at the facility in Orange County.\u003c/p>\n\n",
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"content": "\u003cdiv class=\"post-body\">\u003cp>\u003cp>Every year, hundreds of death investigators from across California travel to a unique training facility in Santa Ana to sharpen their skills and deepen their knowledge of the critical job.\u003c/p>\n\u003cp>The people responsible for investigating sudden, suspicious or violent deaths in a county take photos of the body, collect evidence, interview witnesses and prepare a report of their findings that ultimately contributes to a decision on how and why someone died, and what goes on a person's death certificate.\u003c/p>\n\u003cp>Decades ago the \u003ca href=\"https://www.coroners.org/\" target=\"_blank\" rel=\"noopener\">California State Coroners Association\u003c/a> and the Orange County Sheriff's Department recognized the need to standardize training for the job. In 1989 they began offering courses, often out of hotel ballrooms. But that limited what they could do. Years later they secured $15 million to build the \u003ca href=\"http://www.ocsd.org/divisions/fieldops/coroner/cctc\" target=\"_blank\" rel=\"noopener\">California Coroner Training Center\u003c/a>. The doors opened in 2004, and so did the opportunity to provide hands-on courses.\u003c/p>\n\u003ch3>'There's No Real Dead People in Here'\u003c/h3>\n\u003cp>\"What we did is we built just one big wide open room,\" said Assistant Chief Deputy Coroner for Orange County Bruce Lyle on a recent tour. \"There's a drain in the floor in case we needed blood or fluids -- fake fluids -- to mock it.\"\u003c/p>\n\u003cp>Lyle, who teaches some of the courses, quickly added, \"There's no real dead people in here.\"\u003c/p>\n\u003cp>\u003c/p>\u003c/div>",
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"content": "\u003cdiv class=\"post-body\">\u003cp>\u003c/p>\n\u003cp>Contained inside the room is a set of a two-bedroom apartment built out of plywood. From the outside it doesn't look like much, but inside the place is decorated and furnished with furniture, props and eerily realistic latex dummies.\u003c/p>\n\u003cp>\"He's not a very clean person,\" Lyle said of one dummy. \"He's kind of grubby. He's got a 5 o'clock shadow. You can feel it on his face.\"\u003c/p>\n\u003cp>The dummy's name, Emmanuel Quin -- or \"Manny\" Quin for short -- provides comic relief to the otherwise grim task of identifying the decedent and determining how long ago he died.\u003c/p>\n\u003cp>\"There are certain changes in the body\" Lyle explained, \"and one of them is the decomposition.\"\u003c/p>\n\u003cp>The dummy was commissioned by Burbank's \u003ca href=\"https://www.burmanfoam.com/\" target=\"_blank\" rel=\"noopener\">Burman Studio\u003c/a> to exhibit signs of decomposition, including discoloration of the skin.\u003c/p>\n\u003cp>The trainers load the set with other clues, including cigarette butts, an empty bottle of tequila, a dated prescription for pills, and a dried-out slice of pizza in a box on the floor.\u003c/p>\n\u003cp>Lyle said the barrage of stimuli simulates what investigators typically encounter at the scene of someone's death.\u003c/p>\n\u003cp>\"We have to sort of teach people to cut through all that business and get to the important stuff,\" Lyle says.\u003c/p>\n\u003cfigure id=\"attachment_11671398\" class=\"wp-caption aligncenter\" style=\"max-width: 800px\">\u003cimg class=\"size-medium wp-image-11671398\" src=\"https://ww2.kqed.org/news/wp-content/uploads/sites/10/2018/05/CoronerTrainingBldg-800x488.jpg\" alt=\"The California Coroner's Training Facility in Orange County.\" width=\"800\" height=\"488\" srcset=\"https://ww2.kqed.org/app/uploads/sites/10/2018/05/CoronerTrainingBldg-800x488.jpg 800w, https://ww2.kqed.org/app/uploads/sites/10/2018/05/CoronerTrainingBldg-160x98.jpg 160w, https://ww2.kqed.org/app/uploads/sites/10/2018/05/CoronerTrainingBldg-240x146.jpg 240w, https://ww2.kqed.org/app/uploads/sites/10/2018/05/CoronerTrainingBldg-375x229.jpg 375w, https://ww2.kqed.org/app/uploads/sites/10/2018/05/CoronerTrainingBldg-520x317.jpg 520w, https://ww2.kqed.org/app/uploads/sites/10/2018/05/CoronerTrainingBldg.jpg 867w\" sizes=\"(max-width: 800px) 100vw, 800px\">\u003cfigcaption class=\"wp-caption-text\">The California Coroner Training Center in Orange County trains coroners from across California. \u003ccite>(Courtesy Orange County Sheriff's Dept.)\u003c/cite>\u003c/figcaption>\u003c/figure>\n\u003cp>When trainings are in session, actors play bereaved relatives or roommates with information the investigator has to elicit.\u003c/p>\n\u003cp>\"The last thing I want to do is have somebody come in and just look at the body and think that that's the extent of their investigation,\" Lyle says.\u003c/p>\n\u003cp>Most of the death investigators that come for the training work for one of 41 counties in California where the sheriff and coroner’s office are one.\u003c/p>\n\u003cp>Lyle, who is also incoming president of the California State Coroners Association, says the philosophy for the training is to get attendees to apply their experience investigating crimes to death investigations.\u003c/p>\n\u003cp>According to the Orange County Sheriff's Department website, \"The ultimate vision of the Training Center’s leadership is to 'raise the bar' in the coroner profession by improving the caliber of investigations conducted throughout the state.\"\u003c/p>\n\u003ch3>Varying Levels of Expertise\u003c/h3>\n\u003cp>The level of expertise in death investigations varies widely from county to county.\u003c/p>\n\u003cp>Some of the larger sheriff's departments in Orange County and San Bernardino County created a separate coroner's division and assigned dedicated deputies to investigate deaths, which allowed them to develop expertise over years, even decades.\u003c/p>\n\u003caside class=\"alignright\">\n\u003ch3>\u003ca href=\"https://www.kqed.org/news/11648821/how-families-in-san-joaquin-county-pay-for-coroner-mistakes\">How Families Pay for San Joaquin Coroner Mistakes\u003c/a>\u003c/h3>\n\u003cfigure>\u003ca href=\"https://www.kqed.org/news/11648821/how-families-in-san-joaquin-county-pay-for-coroner-mistakes\">\u003cimg src=\"https://ww2.kqed.org/news/wp-content/uploads/sites/10/2018/02/RS29311_alt_681-1180x1573.jpg\" alt=\"\">\u003c/a>\u003c/figure>\n\u003c/aside>\n\u003cp>Smaller counties such as San Joaquin County dedicated a handful of deputies for coroner's work who typically investigate more complex death scenes such as a homicide -- but often patrol deputies who received minimal training in death investigations respond to the scene of a death.\u003c/p>\n\u003cp>The Orange County Sheriff-Coroner's Office is working with the California State Coroners Association to establish an accreditation program for death investigators.\u003c/p>\n\u003ch3>Some Counties Could Be Required to End Sheriff's Role as Coroner\u003c/h3>\n\u003cp>Some of those offices could change under \u003ca href=\"https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=201720180SB1303\" target=\"_blank\" rel=\"noopener\">state Senate Bill 1303\u003c/a>. The bill would force several large counties to create a completely separate medical examiner’s office for death investigations -- with a physician in charge.\u003c/p>\n\u003cp>The measure was introduced by Sen. Richard Pan in response to a scandal in Joaquin County that erupted last year.\u003c/p>\n\u003cp>Two forensic pathologists who worked for Sheriff-Coroner Steve Moore \u003ca href=\"https://www.kqed.org/news/11633330/autopsy-doctor-quits-alleges-sheriff-interfered-in-death-probes\" target=\"_blank\" rel=\"noopener\">accused him of pressuring them\u003c/a> to change their autopsy findings in deaths involving law enforcement officers. Moore denied the allegations.\u003c/p>\n\u003cp>The doctors also faulted the inexperience among deputies responding to coroner calls for driving up costs and \u003ca href=\"https://www.kqed.org/news/11648821/how-families-in-san-joaquin-county-pay-for-coroner-mistakes\" target=\"_blank\" rel=\"noopener\">creating backlogs and delays\u003c/a>.\u003c/p>\n\u003cp>\u003c/p>\n\u003cp>If passed, SB 1303 would not interfere with the plans to expand coroner training at the facility in Orange County.\u003c/p>\n\n\u003c/div>\u003c/p>",
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"disqusTitle": "Reports of Sheriff's Interference in Death Investigations Spur Change in Santa Clara County",
"title": "Reports of Sheriff's Interference in Death Investigations Spur Change in Santa Clara County",
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"content": "\u003cp>Every time the phone rings in Rosa Vega's office, it means someone in Santa Clara County has died.\u003c/p>\n\u003cp>\"People are calling from agencies, mortuaries and the field with deaths to report,\" the chief investigator for the medical examiner said earlier this year during a tour of the county morgue.\u003c/p>\n\u003cp>Vega is the first point of contact for the office that handles about 5,000 calls a year -- or roughly half of all deaths in Santa Clara County. Of those, the medical examiner investigates an average of 1,500 cases per year.\u003c/p>\n\u003caside class=\"alignright\">\u003ca href=\"https://www.kqed.org/news/11285099/inmates-brutal-beating-death-spurs-scrutiny-and-reform-in-santa-clara-county-jails\">Inmate's Brutal Beating Death Spurs Scrutiny and Reform in Santa Clara County Jails\u003c/a>\u003c/aside>\n\u003cp>With the establishment of an independent medical examiner's system in Santa Clara County last year, those investigations are now free from influence of the county sheriff. State \u003ca href=\"https://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=201520160SB1189\" target=\"_blank\" rel=\"noopener\">legislation\u003c/a> currently in the Senate Appropriations Committee would require other large counties throughout California to establish similar systems.\u003c/p>\n\u003cp>Vega and her team of civilian investigators make the initial assessment about which cases warrant a closer look, based on the circumstance of the death.\u003c/p>\n\u003cp>[ad fullwidth]\u003c/p>\n\u003cp>“Were they hospitalized for any recent injuries or trauma?” Vega asks callers. “Is there any acute drugs or alcohol associated with the death, and is there any suspicions of foul play, choking, abuse, suicide or homicide?”\u003c/p>\n\u003cfigure id=\"attachment_11669736\" class=\"wp-caption alignright\" style=\"max-width: 1920px\">\u003cimg class=\"size-full wp-image-11669736\" src=\"https://ww2.kqed.org/news/wp-content/uploads/sites/10/2018/05/RS31077_IMG_6343-qut.jpg\" alt=\"\" width=\"1920\" height=\"1440\" srcset=\"https://ww2.kqed.org/app/uploads/sites/10/2018/05/RS31077_IMG_6343-qut.jpg 1920w, https://ww2.kqed.org/app/uploads/sites/10/2018/05/RS31077_IMG_6343-qut-160x120.jpg 160w, https://ww2.kqed.org/app/uploads/sites/10/2018/05/RS31077_IMG_6343-qut-800x600.jpg 800w, https://ww2.kqed.org/app/uploads/sites/10/2018/05/RS31077_IMG_6343-qut-1020x765.jpg 1020w, https://ww2.kqed.org/app/uploads/sites/10/2018/05/RS31077_IMG_6343-qut-1200x900.jpg 1200w, https://ww2.kqed.org/app/uploads/sites/10/2018/05/RS31077_IMG_6343-qut-1180x885.jpg 1180w, https://ww2.kqed.org/app/uploads/sites/10/2018/05/RS31077_IMG_6343-qut-960x720.jpg 960w, https://ww2.kqed.org/app/uploads/sites/10/2018/05/RS31077_IMG_6343-qut-240x180.jpg 240w, https://ww2.kqed.org/app/uploads/sites/10/2018/05/RS31077_IMG_6343-qut-375x281.jpg 375w, https://ww2.kqed.org/app/uploads/sites/10/2018/05/RS31077_IMG_6343-qut-520x390.jpg 520w\" sizes=\"(max-width: 1920px) 100vw, 1920px\">\u003cfigcaption class=\"wp-caption-text\">Rosa Vega became chief investigator for the medical examiner in 2017, after county officials ended the sheriff's oversight of death investigations. \u003ccite>(Julie Small/KQED)\u003c/cite>\u003c/figcaption>\u003c/figure>\n\u003cp>Depending on the answers, Vega may bring the body to the morgue for a medical examiner to investigate further.\u003c/p>\n\u003cp>\u003cstrong>Questions Of Bias, Interference Drove Change\u003c/strong>\u003c/p>\n\u003cp>Until 2017, Sheriff Laurie Smith and her staff exercised administrative control over Vega and the medical examiners that investigated sudden, suspicious or violent deaths, including all deaths that occurred in county jails run by the sheriff.\u003c/p>\n\u003cp>Every California county has an agency responsible for investigating those kinds of deaths, and most are under a sheriff. That's the sheriff-coroner's system.\u003c/p>\n\u003cp>Officials began to question that arrangement after a medical examiner accused Smith of having impeded death investigations in certain cases.\u003c/p>\n\u003cp>Dr. Michelle Jorden testified at a budget hearing in 2016 that the sheriff had withheld evidence from physicians and tried to intimidate them into signing an agreement not to speak to the press.\u003c/p>\n\u003cfigure id=\"attachment_11669733\" class=\"wp-caption alignleft\" style=\"max-width: 1920px\">\u003cimg class=\"size-full wp-image-11669733\" src=\"https://ww2.kqed.org/news/wp-content/uploads/sites/10/2018/05/RS29013_IMG_6260-qut.jpg\" alt=\"\" width=\"1920\" height=\"1440\" srcset=\"https://ww2.kqed.org/app/uploads/sites/10/2018/05/RS29013_IMG_6260-qut.jpg 1920w, https://ww2.kqed.org/app/uploads/sites/10/2018/05/RS29013_IMG_6260-qut-160x120.jpg 160w, https://ww2.kqed.org/app/uploads/sites/10/2018/05/RS29013_IMG_6260-qut-800x600.jpg 800w, https://ww2.kqed.org/app/uploads/sites/10/2018/05/RS29013_IMG_6260-qut-1020x765.jpg 1020w, https://ww2.kqed.org/app/uploads/sites/10/2018/05/RS29013_IMG_6260-qut-1200x900.jpg 1200w, https://ww2.kqed.org/app/uploads/sites/10/2018/05/RS29013_IMG_6260-qut-1180x885.jpg 1180w, https://ww2.kqed.org/app/uploads/sites/10/2018/05/RS29013_IMG_6260-qut-960x720.jpg 960w, https://ww2.kqed.org/app/uploads/sites/10/2018/05/RS29013_IMG_6260-qut-240x180.jpg 240w, https://ww2.kqed.org/app/uploads/sites/10/2018/05/RS29013_IMG_6260-qut-375x281.jpg 375w, https://ww2.kqed.org/app/uploads/sites/10/2018/05/RS29013_IMG_6260-qut-520x390.jpg 520w\" sizes=\"(max-width: 1920px) 100vw, 1920px\">\u003cfigcaption class=\"wp-caption-text\">Santa Clara Medical Examiner Michelle Jorden \u003ccite>(Julie Small/KQED)\u003c/cite>\u003c/figcaption>\u003c/figure>\n\u003cp>“In certain cases the sheriff's office has impeded the examiners from receiving evidence necessary for the determination of cause and manner of death,” Jorden told supervisors.\u003c/p>\n\u003cp>She also faulted the sheriff’s “poor management” of the office and a “general lack of support for the doctors and staff.\"\u003c/p>\n\u003cp>Jorden urged supervisors to end the sheriff’s control over death investigations \"to have full independent control of our office and operate the office to the highest, highest standards possible without the potential for perceived law enforcement influence.\"\u003c/p>\n\u003cp>Smith said she hadn't done anything improper, but in the wake of the 2015 beating \u003ca href=\"https://www.kqed.org/news/10912163/two-mentally-ill-inmates-died-in-one-month-what-can-we-learn\" target=\"_blank\" rel=\"noopener\">death\u003c/a> of a mentally ill inmate, Jorden’s testimony took on more weight.\u003c/p>\n\u003cp>On Aug. 26, 2015, inmate Michael Tyree collapsed in his cell at the county's Main Jail. The medical examiner determined he was beaten so hard that his spleen ruptured and he died. Three correctional sheriff's deputies were arrested and eventually convicted of second-degree murder. They were each \u003ca href=\"https://www.kqed.org/news/11640126/jail-deputies-face-15-years-to-life-for-fatal-beating-of-mentally-ill-inmate\" target=\"_blank\" rel=\"noopener\">sentenced\u003c/a> to a 15-year-to-life prison term.\u003c/p>\n\u003cp>The county severed the sheriff's oversight of the medical examiners, at a cost of $846,000 a year to run a separate office, according to Deputy County Executive Martha Wapenski. The cost was offset somewhat by the reassignment of three sheriff administrators.\u003c/p>\n\u003cp>Paula Canny, an attorney who won a $3.6 million settlement for Tyree's family, supports the decision to spend more to ensure death investigations are free from pressure.\u003c/p>\n\u003cp>“There's a fundamental inherent conflict of interest -- especially as it relates to jail deaths” Canny said, “because who's in charge of a jail? The sheriff!”\u003c/p>\n\u003cfigure id=\"attachment_10912297\" class=\"wp-caption alignright\" style=\"max-width: 160px\">\u003cimg class=\"size-thumbnail wp-image-10912297\" src=\"https://ww2.kqed.org/news/wp-content/uploads/sites/10/2016/03/Michael-Head-Shot-Pic-400x500.jpg\" alt=\"A photo of Michael Tyree several years before his death.\" width=\"160\" height=\"200\">\u003cfigcaption class=\"wp-caption-text\">A photo of Michael Tyree several years before his death. \u003ccite>(Courtesy the Tyree family)\u003c/cite>\u003c/figcaption>\u003c/figure>\n\u003cp>While Sheriff Smith received some credit for swiftly arresting members of her staff, a blue-ribbon panel faulted her for lax oversight of correctional deputies that had allowed a culture of \u003ca href=\"https://www.kqed.org/news/10875665/santa-clara-county-jail-report-finds-widespread-complaints-of-inmate-abuse\" target=\"_blank\" rel=\"noopener\">abuse\u003c/a> to flourish in the jails.\u003c/p>\n\u003cp>\u003cstrong>Chief Medical Examiner’s Gold Standard\u003c/strong>\u003c/p>\n\u003cp>Jorden became chief medical examiner last year, administering the office, overseeing death investigations and conducting some of the autopsies herself.\u003c/p>\n\u003cp>\"Because my patients are deceased, they can't tell me what happened to them,\" Jorden said. \"And that's where the importance of the job comes in.\"\u003c/p>\n\u003cp>Sometimes an external examination of a body clearly provides the answers to how and why someone died, but in other cases an autopsy is required.\u003c/p>\n\u003cp>Jorden said autopsy findings can and do change the picture.\u003c/p>\n\u003cp>\"There are some cases that appear that the person had died from natural causes, but it turns out to be homicide,\" she said. \"And that's important. We're bringing closure to that deceased individual, their family. But we're also now allowing that case to undergo further investigation by law enforcement. So other people in the community aren't hurt.\"\u003c/p>\n\u003cp>Under Jorden’s leadership the medical examiner’s office has added four positions to replace sheriff administrators. She’s developing a residency program in forensic pathology, and training staff to handle a potential disaster that could result in mass casualties, something she said the sheriff refused to fund.\u003c/p>\n\u003cp>But most importantly Jorden said the independence of the medical examiner's office means that Santa Clara County residents are getting the gold standard in death investigation.\u003c/p>\n\u003cp>“Now here we have a civilian investigator conducting the investigation completely separate from any type of influence,” she said.\u003c/p>\n\u003cp>Those findings are then given to the medical examiner, who will interpret them.\u003c/p>\n\u003cp>\u003c/p>\n\u003cp>\"That's the gold standard because you have someone able to understand those findings and then take into consideration the circumstances surrounding the death,” Jorden said.\u003c/p>\n\n",
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"content": "\u003cdiv class=\"post-body\">\u003cp>\u003cp>Every time the phone rings in Rosa Vega's office, it means someone in Santa Clara County has died.\u003c/p>\n\u003cp>\"People are calling from agencies, mortuaries and the field with deaths to report,\" the chief investigator for the medical examiner said earlier this year during a tour of the county morgue.\u003c/p>\n\u003cp>Vega is the first point of contact for the office that handles about 5,000 calls a year -- or roughly half of all deaths in Santa Clara County. Of those, the medical examiner investigates an average of 1,500 cases per year.\u003c/p>\n\u003caside class=\"alignright\">\u003ca href=\"https://www.kqed.org/news/11285099/inmates-brutal-beating-death-spurs-scrutiny-and-reform-in-santa-clara-county-jails\">Inmate's Brutal Beating Death Spurs Scrutiny and Reform in Santa Clara County Jails\u003c/a>\u003c/aside>\n\u003cp>With the establishment of an independent medical examiner's system in Santa Clara County last year, those investigations are now free from influence of the county sheriff. State \u003ca href=\"https://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=201520160SB1189\" target=\"_blank\" rel=\"noopener\">legislation\u003c/a> currently in the Senate Appropriations Committee would require other large counties throughout California to establish similar systems.\u003c/p>\n\u003cp>Vega and her team of civilian investigators make the initial assessment about which cases warrant a closer look, based on the circumstance of the death.\u003c/p>\n\u003cp>\u003c/p>\u003c/div>",
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"content": "\u003cdiv class=\"post-body\">\u003cp>\u003c/p>\n\u003cp>“Were they hospitalized for any recent injuries or trauma?” Vega asks callers. “Is there any acute drugs or alcohol associated with the death, and is there any suspicions of foul play, choking, abuse, suicide or homicide?”\u003c/p>\n\u003cfigure id=\"attachment_11669736\" class=\"wp-caption alignright\" style=\"max-width: 1920px\">\u003cimg class=\"size-full wp-image-11669736\" src=\"https://ww2.kqed.org/news/wp-content/uploads/sites/10/2018/05/RS31077_IMG_6343-qut.jpg\" alt=\"\" width=\"1920\" height=\"1440\" srcset=\"https://ww2.kqed.org/app/uploads/sites/10/2018/05/RS31077_IMG_6343-qut.jpg 1920w, https://ww2.kqed.org/app/uploads/sites/10/2018/05/RS31077_IMG_6343-qut-160x120.jpg 160w, https://ww2.kqed.org/app/uploads/sites/10/2018/05/RS31077_IMG_6343-qut-800x600.jpg 800w, https://ww2.kqed.org/app/uploads/sites/10/2018/05/RS31077_IMG_6343-qut-1020x765.jpg 1020w, https://ww2.kqed.org/app/uploads/sites/10/2018/05/RS31077_IMG_6343-qut-1200x900.jpg 1200w, https://ww2.kqed.org/app/uploads/sites/10/2018/05/RS31077_IMG_6343-qut-1180x885.jpg 1180w, https://ww2.kqed.org/app/uploads/sites/10/2018/05/RS31077_IMG_6343-qut-960x720.jpg 960w, https://ww2.kqed.org/app/uploads/sites/10/2018/05/RS31077_IMG_6343-qut-240x180.jpg 240w, https://ww2.kqed.org/app/uploads/sites/10/2018/05/RS31077_IMG_6343-qut-375x281.jpg 375w, https://ww2.kqed.org/app/uploads/sites/10/2018/05/RS31077_IMG_6343-qut-520x390.jpg 520w\" sizes=\"(max-width: 1920px) 100vw, 1920px\">\u003cfigcaption class=\"wp-caption-text\">Rosa Vega became chief investigator for the medical examiner in 2017, after county officials ended the sheriff's oversight of death investigations. \u003ccite>(Julie Small/KQED)\u003c/cite>\u003c/figcaption>\u003c/figure>\n\u003cp>Depending on the answers, Vega may bring the body to the morgue for a medical examiner to investigate further.\u003c/p>\n\u003cp>\u003cstrong>Questions Of Bias, Interference Drove Change\u003c/strong>\u003c/p>\n\u003cp>Until 2017, Sheriff Laurie Smith and her staff exercised administrative control over Vega and the medical examiners that investigated sudden, suspicious or violent deaths, including all deaths that occurred in county jails run by the sheriff.\u003c/p>\n\u003cp>Every California county has an agency responsible for investigating those kinds of deaths, and most are under a sheriff. That's the sheriff-coroner's system.\u003c/p>\n\u003cp>Officials began to question that arrangement after a medical examiner accused Smith of having impeded death investigations in certain cases.\u003c/p>\n\u003cp>Dr. Michelle Jorden testified at a budget hearing in 2016 that the sheriff had withheld evidence from physicians and tried to intimidate them into signing an agreement not to speak to the press.\u003c/p>\n\u003cfigure id=\"attachment_11669733\" class=\"wp-caption alignleft\" style=\"max-width: 1920px\">\u003cimg class=\"size-full wp-image-11669733\" src=\"https://ww2.kqed.org/news/wp-content/uploads/sites/10/2018/05/RS29013_IMG_6260-qut.jpg\" alt=\"\" width=\"1920\" height=\"1440\" srcset=\"https://ww2.kqed.org/app/uploads/sites/10/2018/05/RS29013_IMG_6260-qut.jpg 1920w, https://ww2.kqed.org/app/uploads/sites/10/2018/05/RS29013_IMG_6260-qut-160x120.jpg 160w, https://ww2.kqed.org/app/uploads/sites/10/2018/05/RS29013_IMG_6260-qut-800x600.jpg 800w, https://ww2.kqed.org/app/uploads/sites/10/2018/05/RS29013_IMG_6260-qut-1020x765.jpg 1020w, https://ww2.kqed.org/app/uploads/sites/10/2018/05/RS29013_IMG_6260-qut-1200x900.jpg 1200w, https://ww2.kqed.org/app/uploads/sites/10/2018/05/RS29013_IMG_6260-qut-1180x885.jpg 1180w, https://ww2.kqed.org/app/uploads/sites/10/2018/05/RS29013_IMG_6260-qut-960x720.jpg 960w, https://ww2.kqed.org/app/uploads/sites/10/2018/05/RS29013_IMG_6260-qut-240x180.jpg 240w, https://ww2.kqed.org/app/uploads/sites/10/2018/05/RS29013_IMG_6260-qut-375x281.jpg 375w, https://ww2.kqed.org/app/uploads/sites/10/2018/05/RS29013_IMG_6260-qut-520x390.jpg 520w\" sizes=\"(max-width: 1920px) 100vw, 1920px\">\u003cfigcaption class=\"wp-caption-text\">Santa Clara Medical Examiner Michelle Jorden \u003ccite>(Julie Small/KQED)\u003c/cite>\u003c/figcaption>\u003c/figure>\n\u003cp>“In certain cases the sheriff's office has impeded the examiners from receiving evidence necessary for the determination of cause and manner of death,” Jorden told supervisors.\u003c/p>\n\u003cp>She also faulted the sheriff’s “poor management” of the office and a “general lack of support for the doctors and staff.\"\u003c/p>\n\u003cp>Jorden urged supervisors to end the sheriff’s control over death investigations \"to have full independent control of our office and operate the office to the highest, highest standards possible without the potential for perceived law enforcement influence.\"\u003c/p>\n\u003cp>Smith said she hadn't done anything improper, but in the wake of the 2015 beating \u003ca href=\"https://www.kqed.org/news/10912163/two-mentally-ill-inmates-died-in-one-month-what-can-we-learn\" target=\"_blank\" rel=\"noopener\">death\u003c/a> of a mentally ill inmate, Jorden’s testimony took on more weight.\u003c/p>\n\u003cp>On Aug. 26, 2015, inmate Michael Tyree collapsed in his cell at the county's Main Jail. The medical examiner determined he was beaten so hard that his spleen ruptured and he died. Three correctional sheriff's deputies were arrested and eventually convicted of second-degree murder. They were each \u003ca href=\"https://www.kqed.org/news/11640126/jail-deputies-face-15-years-to-life-for-fatal-beating-of-mentally-ill-inmate\" target=\"_blank\" rel=\"noopener\">sentenced\u003c/a> to a 15-year-to-life prison term.\u003c/p>\n\u003cp>The county severed the sheriff's oversight of the medical examiners, at a cost of $846,000 a year to run a separate office, according to Deputy County Executive Martha Wapenski. The cost was offset somewhat by the reassignment of three sheriff administrators.\u003c/p>\n\u003cp>Paula Canny, an attorney who won a $3.6 million settlement for Tyree's family, supports the decision to spend more to ensure death investigations are free from pressure.\u003c/p>\n\u003cp>“There's a fundamental inherent conflict of interest -- especially as it relates to jail deaths” Canny said, “because who's in charge of a jail? The sheriff!”\u003c/p>\n\u003cfigure id=\"attachment_10912297\" class=\"wp-caption alignright\" style=\"max-width: 160px\">\u003cimg class=\"size-thumbnail wp-image-10912297\" src=\"https://ww2.kqed.org/news/wp-content/uploads/sites/10/2016/03/Michael-Head-Shot-Pic-400x500.jpg\" alt=\"A photo of Michael Tyree several years before his death.\" width=\"160\" height=\"200\">\u003cfigcaption class=\"wp-caption-text\">A photo of Michael Tyree several years before his death. \u003ccite>(Courtesy the Tyree family)\u003c/cite>\u003c/figcaption>\u003c/figure>\n\u003cp>While Sheriff Smith received some credit for swiftly arresting members of her staff, a blue-ribbon panel faulted her for lax oversight of correctional deputies that had allowed a culture of \u003ca href=\"https://www.kqed.org/news/10875665/santa-clara-county-jail-report-finds-widespread-complaints-of-inmate-abuse\" target=\"_blank\" rel=\"noopener\">abuse\u003c/a> to flourish in the jails.\u003c/p>\n\u003cp>\u003cstrong>Chief Medical Examiner’s Gold Standard\u003c/strong>\u003c/p>\n\u003cp>Jorden became chief medical examiner last year, administering the office, overseeing death investigations and conducting some of the autopsies herself.\u003c/p>\n\u003cp>\"Because my patients are deceased, they can't tell me what happened to them,\" Jorden said. \"And that's where the importance of the job comes in.\"\u003c/p>\n\u003cp>Sometimes an external examination of a body clearly provides the answers to how and why someone died, but in other cases an autopsy is required.\u003c/p>\n\u003cp>Jorden said autopsy findings can and do change the picture.\u003c/p>\n\u003cp>\"There are some cases that appear that the person had died from natural causes, but it turns out to be homicide,\" she said. \"And that's important. We're bringing closure to that deceased individual, their family. But we're also now allowing that case to undergo further investigation by law enforcement. So other people in the community aren't hurt.\"\u003c/p>\n\u003cp>Under Jorden’s leadership the medical examiner’s office has added four positions to replace sheriff administrators. She’s developing a residency program in forensic pathology, and training staff to handle a potential disaster that could result in mass casualties, something she said the sheriff refused to fund.\u003c/p>\n\u003cp>But most importantly Jorden said the independence of the medical examiner's office means that Santa Clara County residents are getting the gold standard in death investigation.\u003c/p>\n\u003cp>“Now here we have a civilian investigator conducting the investigation completely separate from any type of influence,” she said.\u003c/p>\n\u003cp>Those findings are then given to the medical examiner, who will interpret them.\u003c/p>\n\u003cp>\u003c/p>\n\u003cp>\"That's the gold standard because you have someone able to understand those findings and then take into consideration the circumstances surrounding the death,” Jorden said.\u003c/p>\n\n\u003c/div>\u003c/p>",
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"disqusTitle": "Stephon Clark Autopsy Controversy: As Coroner Points to Errors, Private Doctor Defends His Findings",
"title": "Stephon Clark Autopsy Controversy: As Coroner Points to Errors, Private Doctor Defends His Findings",
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"content": "\u003cp>The forensic pathologist who performed a private autopsy on \u003ca href=\"https://www.kqed.org/news/tag/stephon-clark/\" target=\"_blank\" rel=\"noopener\">Stephon Clark\u003c/a> said in a statement late Wednesday that he stands \"firmly in defense\" of his findings in the high-profile Sacramento police shooting case.\u003c/p>\n\u003cp>The statement from Dr. Bennet Omalu come after an official report released by the Sacramento County coroner declared that Omalu's autopsy contained \"erroneous information.\"\u003c/p>\n\u003cp>Omalu \u003ca href=\"https://www.kqed.org/news/11658808/independent-autopsy-finds-police-shot-stephon-clark-in-the-back\" target=\"_blank\" rel=\"noopener\">announced his original findings\u003c/a> at a March 30 press conference with attorneys for Clark's family but has not made public a complete report on the private autopsy he performed. In his report, Omalu said the unarmed Clark was shot 8 times, primarily in the back.\u003c/p>\n\u003cp>Clark died the evening of March 18, after two Sacramento police officers fired 20 rounds at him seconds after confronting him in his grandparents' back yard.\u003c/p>\n\u003cp>The officers say they were responding to 911 calls regarding a suspect breaking into cars in the south Sacramento neighborhood, and a sheriff's helicopter reported that Clark broke a window on a neighbor's house before he was recorded jumping a fence.\u003c/p>\n\u003cp>[ad fullwidth]\u003c/p>\n\u003cp>https://www.youtube.com/watch?v=4ICLcwf7YsY&feature=youtu.be\u003c/p>\n\u003cp>The officers arrived about 30 seconds later. One of the officers was recorded on body camera video shouting, \"Show me your hands -- gun!\" then repeating it before shouting \"Gun, gun, gun!\" a second before both officers started firing.\u003c/p>\n\u003cp>A cellphone was discovered near Clark's body.\u003c/p>\n\u003cp>The Sacramento County coroner's report \u003ca href=\"https://www.kqed.org/news/11665949/dueling-autopsies-stir-controversy-over-sacramento-police-shooting-of-stephon-clark\" target=\"_blank\" rel=\"noopener\">made public on Tuesday\u003c/a> was prefaced by a letter that said Omalu's private autopsy was reviewed by three additional forensic pathologists in the office, plus former Sacramento County forensic pathologist Gregory Reiber, \"in an effort to ensure we got the facts correct.\"\u003c/p>\n\u003cp>The \u003ca href=\"http://www.cityofsacramento.org/-/media/Corporate/Files/Police/Transparency/Officer-Involved-Shootings/Coroner-Report-2018_0427.pdf?la=en\" target=\"_blank\" rel=\"noopener\">coroner's report\u003c/a> found seven gunshot wounds on Clark's body, and Reiber wrote in his \u003ca href=\"http://www.cityofsacramento.org/-/media/Corporate/Files/Police/Transparency/Officer-Involved-Shootings/Reiber-Review-2018_0422-V2.pdf?la=en\" target=\"_blank\" rel=\"noopener\">review\u003c/a> that Omalu mistook an exit wound on the left side of Clark's chest for an eighth entry wound.\u003c/p>\n\u003cp>\"This is a significant error, as it leads to incorrect conclusions regarding the relative positions of the victim and the shooters during the event,\" Reiber wrote.\u003c/p>\n\u003cp>While Omalu said Clark wasn't facing the police when they shot him, Reiber concluded that the body camera and helicopter videos show \"there was an initial face-on confrontation,\" and that Clark was moving toward the officers when they began to fire.\u003c/p>\n\u003cp>Reiber's analysis also challenged Omalu's conclusion that Clark had been shot primarily from behind. He argued that three of six wounds Omalu had described as being in the back were actually on Clark's right side.\u003c/p>\n\u003cp>Omalu's statement dismissed Reiber's statement as \"inaccurate.\"\u003c/p>\n\u003cp>In a \u003ca href=\"https://docs.google.com/document/d/10tisgumYJ7lbGNLSxVnlMtc0SZcq2Ofy3fp65pSQXHo/edit?usp=sharing\" target=\"_blank\" rel=\"noopener\">joint statement\u003c/a>, three civil attorneys representing Clark's family defended Omalu's credibility and criticized Reiber's past association with the Sacramento County coroner.\u003c/p>\n\u003cp>\"It is outrageous, but not surprising, that authorities would attempt to defend the indefensible,\" the statement by attorneys Ben Crump, Brian Panish and Dale Galipo says. \"Stephon Clark was shot in the back, multiple times, while armed with nothing more than a cellphone, posing no real threat to police.\"\u003c/p>\n\u003cp>The statement says Reiber \"was employed by the County of Sacramento and has been historically pro-law enforcement.\"\u003c/p>\n\u003cp>The attorneys point to Reiber's recent testimony to the state Senate Public Safety Committee in opposition to \u003ca href=\"https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=201720180SB1303\" target=\"_blank\" rel=\"noopener\">legislation\u003c/a> that would require large California counties to use a medical examiner system, independent of county sheriff's departments, to investigate suspicious deaths. Most California counties use a sheriff-coroner system, where the sheriff makes the ultimate determination of manner of death.\u003c/p>\n\u003cp>The sheriff-coroner system has faced recent criticism, driven in part by Omalu, who \u003ca href=\"https://www.kqed.org/news/11634689/autopsy-doctors-sheriff-overrode-death-findings-to-protect-law-enforcement\" target=\"_blank\" rel=\"noopener\">resigned\u003c/a> as San Joaquin County's chief forensic pathologist in December, alleging interference from Sheriff Steve Moore in cases involving deaths at the hands of law enforcement. Omalu also testified in support of the bill mandating a medical examiner system for large California counties.\u003c/p>\n\u003cp>Omalu said in \u003ca href=\"https://drive.google.com/file/d/1b1SQNtL2hzOsFFaU3P8F81xBmrLSCeqE/view\" target=\"_blank\" rel=\"noopener\">his statement\u003c/a> that the initial autopsy on Clark -- performed by Sacramento County forensic pathologist Keng-Chin Su -- neglected both basic and advanced procedures that could provide insight into Clark's death.\u003c/p>\n\u003cp>\"To my utter dismay, I observed that none of the gunshot wounds had been previously excised for histologic evaluation,\" Omalu wrote, referring to a microscopic examination of the tissue around the gunshot wounds. He wrote that his examination of \"the wound in question\" on back of Clark's left side \"demonstrated a gunshot wound of entrance.\"\u003c/p>\n\u003cp>Omalu wrote that he also removed the spinal cord and documented significant injuries not identified in the coroner's report.\u003c/p>\n\u003cp>\"At this time, none of the pathologists who have signed the autopsy report and claimed that I was wrong have examined the spinal cord, either grossly or microscopically,\" Omalu wrote.\u003c/p>\n\u003cp>Finally, Omalu and the attorneys released a black-and-white \u003ca href=\"https://drive.google.com/file/d/1VYcqQeC4oYjFljbgLJTc0P9kEfTug2aF/view\" target=\"_blank\" rel=\"noopener\">photograph\u003c/a> of the upper right, back of Clark's body, which shows six gunshot wounds.\u003c/p>\n\u003cp>\u003c/p>\n\u003cp>\"Experts may have different opinions, but a picture is a picture,\" Omalu wrote. \"A picture does not have an opinion.\"\u003c/p>\n\n",
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"content": "\u003cdiv class=\"post-body\">\u003cp>\u003cp>The forensic pathologist who performed a private autopsy on \u003ca href=\"https://www.kqed.org/news/tag/stephon-clark/\" target=\"_blank\" rel=\"noopener\">Stephon Clark\u003c/a> said in a statement late Wednesday that he stands \"firmly in defense\" of his findings in the high-profile Sacramento police shooting case.\u003c/p>\n\u003cp>The statement from Dr. Bennet Omalu come after an official report released by the Sacramento County coroner declared that Omalu's autopsy contained \"erroneous information.\"\u003c/p>\n\u003cp>Omalu \u003ca href=\"https://www.kqed.org/news/11658808/independent-autopsy-finds-police-shot-stephon-clark-in-the-back\" target=\"_blank\" rel=\"noopener\">announced his original findings\u003c/a> at a March 30 press conference with attorneys for Clark's family but has not made public a complete report on the private autopsy he performed. In his report, Omalu said the unarmed Clark was shot 8 times, primarily in the back.\u003c/p>\n\u003cp>Clark died the evening of March 18, after two Sacramento police officers fired 20 rounds at him seconds after confronting him in his grandparents' back yard.\u003c/p>\n\u003cp>The officers say they were responding to 911 calls regarding a suspect breaking into cars in the south Sacramento neighborhood, and a sheriff's helicopter reported that Clark broke a window on a neighbor's house before he was recorded jumping a fence.\u003c/p>\n\u003cp>\u003c/p>\u003c/div>",
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"content": "\u003cdiv class=\"post-body\">\u003cp>\u003c/p>\u003c/p>\u003cp>\u003cspan class='utils-parseShortcode-shortcodes-__youtubeShortcode__embedYoutube'>\n \u003cspan class='utils-parseShortcode-shortcodes-__youtubeShortcode__embedYoutubeInside'>\n \u003ciframe\n loading='lazy'\n class='utils-parseShortcode-shortcodes-__youtubeShortcode__youtubePlayer'\n type='text/html'\n src='//www.youtube.com/embed/4ICLcwf7YsY'\n title='//www.youtube.com/embed/4ICLcwf7YsY'\n allowfullscreen='true'\n style='border:0;'>\u003c/iframe>\n \u003c/span>\n \u003c/span>\u003c/p>\u003cp>\u003cp>The officers arrived about 30 seconds later. One of the officers was recorded on body camera video shouting, \"Show me your hands -- gun!\" then repeating it before shouting \"Gun, gun, gun!\" a second before both officers started firing.\u003c/p>\n\u003cp>A cellphone was discovered near Clark's body.\u003c/p>\n\u003cp>The Sacramento County coroner's report \u003ca href=\"https://www.kqed.org/news/11665949/dueling-autopsies-stir-controversy-over-sacramento-police-shooting-of-stephon-clark\" target=\"_blank\" rel=\"noopener\">made public on Tuesday\u003c/a> was prefaced by a letter that said Omalu's private autopsy was reviewed by three additional forensic pathologists in the office, plus former Sacramento County forensic pathologist Gregory Reiber, \"in an effort to ensure we got the facts correct.\"\u003c/p>\n\u003cp>The \u003ca href=\"http://www.cityofsacramento.org/-/media/Corporate/Files/Police/Transparency/Officer-Involved-Shootings/Coroner-Report-2018_0427.pdf?la=en\" target=\"_blank\" rel=\"noopener\">coroner's report\u003c/a> found seven gunshot wounds on Clark's body, and Reiber wrote in his \u003ca href=\"http://www.cityofsacramento.org/-/media/Corporate/Files/Police/Transparency/Officer-Involved-Shootings/Reiber-Review-2018_0422-V2.pdf?la=en\" target=\"_blank\" rel=\"noopener\">review\u003c/a> that Omalu mistook an exit wound on the left side of Clark's chest for an eighth entry wound.\u003c/p>\n\u003cp>\"This is a significant error, as it leads to incorrect conclusions regarding the relative positions of the victim and the shooters during the event,\" Reiber wrote.\u003c/p>\n\u003cp>While Omalu said Clark wasn't facing the police when they shot him, Reiber concluded that the body camera and helicopter videos show \"there was an initial face-on confrontation,\" and that Clark was moving toward the officers when they began to fire.\u003c/p>\n\u003cp>Reiber's analysis also challenged Omalu's conclusion that Clark had been shot primarily from behind. He argued that three of six wounds Omalu had described as being in the back were actually on Clark's right side.\u003c/p>\n\u003cp>Omalu's statement dismissed Reiber's statement as \"inaccurate.\"\u003c/p>\n\u003cp>In a \u003ca href=\"https://docs.google.com/document/d/10tisgumYJ7lbGNLSxVnlMtc0SZcq2Ofy3fp65pSQXHo/edit?usp=sharing\" target=\"_blank\" rel=\"noopener\">joint statement\u003c/a>, three civil attorneys representing Clark's family defended Omalu's credibility and criticized Reiber's past association with the Sacramento County coroner.\u003c/p>\n\u003cp>\"It is outrageous, but not surprising, that authorities would attempt to defend the indefensible,\" the statement by attorneys Ben Crump, Brian Panish and Dale Galipo says. \"Stephon Clark was shot in the back, multiple times, while armed with nothing more than a cellphone, posing no real threat to police.\"\u003c/p>\n\u003cp>The statement says Reiber \"was employed by the County of Sacramento and has been historically pro-law enforcement.\"\u003c/p>\n\u003cp>The attorneys point to Reiber's recent testimony to the state Senate Public Safety Committee in opposition to \u003ca href=\"https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=201720180SB1303\" target=\"_blank\" rel=\"noopener\">legislation\u003c/a> that would require large California counties to use a medical examiner system, independent of county sheriff's departments, to investigate suspicious deaths. Most California counties use a sheriff-coroner system, where the sheriff makes the ultimate determination of manner of death.\u003c/p>\n\u003cp>The sheriff-coroner system has faced recent criticism, driven in part by Omalu, who \u003ca href=\"https://www.kqed.org/news/11634689/autopsy-doctors-sheriff-overrode-death-findings-to-protect-law-enforcement\" target=\"_blank\" rel=\"noopener\">resigned\u003c/a> as San Joaquin County's chief forensic pathologist in December, alleging interference from Sheriff Steve Moore in cases involving deaths at the hands of law enforcement. Omalu also testified in support of the bill mandating a medical examiner system for large California counties.\u003c/p>\n\u003cp>Omalu said in \u003ca href=\"https://drive.google.com/file/d/1b1SQNtL2hzOsFFaU3P8F81xBmrLSCeqE/view\" target=\"_blank\" rel=\"noopener\">his statement\u003c/a> that the initial autopsy on Clark -- performed by Sacramento County forensic pathologist Keng-Chin Su -- neglected both basic and advanced procedures that could provide insight into Clark's death.\u003c/p>\n\u003cp>\"To my utter dismay, I observed that none of the gunshot wounds had been previously excised for histologic evaluation,\" Omalu wrote, referring to a microscopic examination of the tissue around the gunshot wounds. He wrote that his examination of \"the wound in question\" on back of Clark's left side \"demonstrated a gunshot wound of entrance.\"\u003c/p>\n\u003cp>Omalu wrote that he also removed the spinal cord and documented significant injuries not identified in the coroner's report.\u003c/p>\n\u003cp>\"At this time, none of the pathologists who have signed the autopsy report and claimed that I was wrong have examined the spinal cord, either grossly or microscopically,\" Omalu wrote.\u003c/p>\n\u003cp>Finally, Omalu and the attorneys released a black-and-white \u003ca href=\"https://drive.google.com/file/d/1VYcqQeC4oYjFljbgLJTc0P9kEfTug2aF/view\" target=\"_blank\" rel=\"noopener\">photograph\u003c/a> of the upper right, back of Clark's body, which shows six gunshot wounds.\u003c/p>\n\u003cp>\u003c/p>\n\u003cp>\"Experts may have different opinions, but a picture is a picture,\" Omalu wrote. \"A picture does not have an opinion.\"\u003c/p>\n\n\u003c/div>\u003c/p>",
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"disqusTitle": "San Joaquin County Sheriff Stripped of Role in Death Investigations",
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"content": "\u003cp>San Joaquin County supervisors voted unanimously Tuesday to adopt a new model for investigating deaths in the wake of allegations that the coroner, who is also the elected sheriff, used his political office to shield officers who killed civilians.\u003c/p>\n\u003cp>The 5-0 vote eliminated the office of the coroner, currently run by the Sheriff Steve Moore, and replaced it with a medical examiner’s office run by a board-certified forensic pathologist.\u003c/p>\n\u003cp>“I will support whatever you determine is best, because I want what is best for San Joaquin County,\" Moore told supervisors before the vote. \"I have always endeavored to do that in everything I’ve done while I have been sheriff-coroner.”\u003c/p>\n\u003cp>Moore came under heavy scrutiny last year after pathologist Dr. Bennet Omalu quit along with colleague Dr. Susan Parson. Omalu, renowned for his discovery of a concussion-related disease in football players, accused the sheriff of thwarting death investigations by withholding evidence and pressuring them to change their findings.\u003c/p>\n\u003cp>Moore has repeatedly denied the allegations.\u003c/p>\n\u003cp>[ad fullwidth]\u003c/p>\n\u003cp>In San Joaquin County and most other California counties a forensic pathologist determines the cause of all sudden, suspicious or violent deaths. Then the elected sheriff-coroner decides whether it was an accident, homicide, suicide, natural or undetermined manner of death.\u003c/p>\n\u003cp>A KQED \u003ca href=\"https://www.kqed.org/news/11633330/autopsy-doctor-quits-alleges-sheriff-interfered-in-death-probes\" target=\"_blank\" rel=\"noopener\">investigation\u003c/a> found at least two cases involving civilians killed by law enforcement officers where the sheriff ignored the forensic pathologists' opinions that the deaths should be classified as homicides and instead certified them as accidents.\u003c/p>\n\u003cp>An independent \u003ca href=\"https://www.kqed.org/news/11663351/san-joaquin-county-should-install-independent-medical-examiner-audit-finds\" target=\"_blank\" rel=\"noopener\">audit \u003c/a>of the department released last week found “several” in-custody deaths in 2016 with similar discrepancies. At Tuesday’s board meeting, the author, \u003ca href=\"https://ocme.dc.gov/page/executive-staff-ocme\" target=\"_blank\" rel=\"noopener\">Dr. Roger Mitchell,\u003c/a> told the board that a medical examiner is needed in San Joaquin County.\u003c/p>\n\u003cp>He told county supervisors they need to bring in someone with experience to hire and train the investigators for that department.\u003c/p>\n\u003cp>Mitchell, who is the chief medical examiner in Washington, D.C., made a number of recommendations to address deficiencies in how the county investigates deaths. For example, he suggested the county end the practice of sending patrol deputies with virtually no training to handle coroner cases where they may have to observe details at death scenes and collect evidence.\u003c/p>\n\u003cp>KQED previously reported that a lack of training for coroner deputies may have contributed to costly \u003ca href=\"https://www.kqed.org/news/11648821/how-families-in-san-joaquin-county-pay-for-coroner-mistakes\" target=\"_blank\" rel=\"noopener\">mistakes\u003c/a>.\u003c/p>\n\u003cp>Moore told supervisors that the audit also shows “everyone is doing the best they possibly can ... there is no negligence or malice of thought in anything that was done.”\u003c/p>\n\u003cp>\u003c/p>\n\u003cp>County officials still need to work out the details for how to establish the new medical examiner system, which relies on physicians and civilian investigators, and how much it will cost. So far there is no timeline, but Mitchell estimated it could take at least a year.\u003c/p>\n\n",
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"excerpt": "San Joaquin County officials vote to eliminated the coroner's office in the wake of allegations that the sheriff overseeing death investigations overrode the autopsy findings of forensic pathologists in cases where an officer of the law killed a civilian.",
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"content": "\u003cdiv class=\"post-body\">\u003cp>\u003cp>San Joaquin County supervisors voted unanimously Tuesday to adopt a new model for investigating deaths in the wake of allegations that the coroner, who is also the elected sheriff, used his political office to shield officers who killed civilians.\u003c/p>\n\u003cp>The 5-0 vote eliminated the office of the coroner, currently run by the Sheriff Steve Moore, and replaced it with a medical examiner’s office run by a board-certified forensic pathologist.\u003c/p>\n\u003cp>“I will support whatever you determine is best, because I want what is best for San Joaquin County,\" Moore told supervisors before the vote. \"I have always endeavored to do that in everything I’ve done while I have been sheriff-coroner.”\u003c/p>\n\u003cp>Moore came under heavy scrutiny last year after pathologist Dr. Bennet Omalu quit along with colleague Dr. Susan Parson. Omalu, renowned for his discovery of a concussion-related disease in football players, accused the sheriff of thwarting death investigations by withholding evidence and pressuring them to change their findings.\u003c/p>\n\u003cp>Moore has repeatedly denied the allegations.\u003c/p>\n\u003cp>\u003c/p>\u003c/div>",
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"content": "\u003cdiv class=\"post-body\">\u003cp>\u003c/p>\n\u003cp>In San Joaquin County and most other California counties a forensic pathologist determines the cause of all sudden, suspicious or violent deaths. Then the elected sheriff-coroner decides whether it was an accident, homicide, suicide, natural or undetermined manner of death.\u003c/p>\n\u003cp>A KQED \u003ca href=\"https://www.kqed.org/news/11633330/autopsy-doctor-quits-alleges-sheriff-interfered-in-death-probes\" target=\"_blank\" rel=\"noopener\">investigation\u003c/a> found at least two cases involving civilians killed by law enforcement officers where the sheriff ignored the forensic pathologists' opinions that the deaths should be classified as homicides and instead certified them as accidents.\u003c/p>\n\u003cp>An independent \u003ca href=\"https://www.kqed.org/news/11663351/san-joaquin-county-should-install-independent-medical-examiner-audit-finds\" target=\"_blank\" rel=\"noopener\">audit \u003c/a>of the department released last week found “several” in-custody deaths in 2016 with similar discrepancies. At Tuesday’s board meeting, the author, \u003ca href=\"https://ocme.dc.gov/page/executive-staff-ocme\" target=\"_blank\" rel=\"noopener\">Dr. Roger Mitchell,\u003c/a> told the board that a medical examiner is needed in San Joaquin County.\u003c/p>\n\u003cp>He told county supervisors they need to bring in someone with experience to hire and train the investigators for that department.\u003c/p>\n\u003cp>Mitchell, who is the chief medical examiner in Washington, D.C., made a number of recommendations to address deficiencies in how the county investigates deaths. For example, he suggested the county end the practice of sending patrol deputies with virtually no training to handle coroner cases where they may have to observe details at death scenes and collect evidence.\u003c/p>\n\u003cp>KQED previously reported that a lack of training for coroner deputies may have contributed to costly \u003ca href=\"https://www.kqed.org/news/11648821/how-families-in-san-joaquin-county-pay-for-coroner-mistakes\" target=\"_blank\" rel=\"noopener\">mistakes\u003c/a>.\u003c/p>\n\u003cp>Moore told supervisors that the audit also shows “everyone is doing the best they possibly can ... there is no negligence or malice of thought in anything that was done.”\u003c/p>\n\u003cp>\u003c/p>\n\u003cp>County officials still need to work out the details for how to establish the new medical examiner system, which relies on physicians and civilian investigators, and how much it will cost. So far there is no timeline, but Mitchell estimated it could take at least a year.\u003c/p>\n\n\u003c/div>\u003c/p>",
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"disqusTitle": "Reversal on Death Ruling for Man Killed by Police Raises Doubts in San Joaquin County",
"title": "Reversal on Death Ruling for Man Killed by Police Raises Doubts in San Joaquin County",
"headTitle": "The California Report | KQED News",
"content": "\u003cp>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.\u003c/p>\n\u003cp>Last month, a full two years later, the discrepancy was \u003ca href=\"https://www.kqed.org/news/11634689/autopsy-doctors-sheriff-overrode-death-findings-to-protect-law-enforcement\" target=\"_blank\" rel=\"noopener\">exposed\u003c/a>, and the sheriff reclassified the death of Abelino Cordova-Cuevas as a homicide.\u003c/p>\n\u003cp>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.\u003c/p>\n\u003cp>“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.”\u003c/p>\n\u003cp>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.\u003c/p>\n\u003cp>[ad fullwidth]\u003c/p>\n\u003cp>The lawyer discovered the omission during a deposition of Omalu, who noted that the cover sheet was missing from his autopsy report.\u003c/p>\n\u003cfigure id=\"attachment_11664418\" class=\"wp-caption alignright\" style=\"max-width: 1363px\">\u003cimg class=\"wp-image-11664418 size-full\" src=\"https://ww2.kqed.org/news/wp-content/uploads/sites/10/2018/04/Cordova-Cuevas-Pending-Cause-sheet.jpg\" alt=\"\" width=\"1363\" height=\"1755\" srcset=\"https://ww2.kqed.org/app/uploads/sites/10/2018/04/Cordova-Cuevas-Pending-Cause-sheet.jpg 1363w, https://ww2.kqed.org/app/uploads/sites/10/2018/04/Cordova-Cuevas-Pending-Cause-sheet-160x206.jpg 160w, https://ww2.kqed.org/app/uploads/sites/10/2018/04/Cordova-Cuevas-Pending-Cause-sheet-800x1030.jpg 800w, https://ww2.kqed.org/app/uploads/sites/10/2018/04/Cordova-Cuevas-Pending-Cause-sheet-1020x1313.jpg 1020w, https://ww2.kqed.org/app/uploads/sites/10/2018/04/Cordova-Cuevas-Pending-Cause-sheet-932x1200.jpg 932w, https://ww2.kqed.org/app/uploads/sites/10/2018/04/Cordova-Cuevas-Pending-Cause-sheet-1180x1519.jpg 1180w, https://ww2.kqed.org/app/uploads/sites/10/2018/04/Cordova-Cuevas-Pending-Cause-sheet-960x1236.jpg 960w, https://ww2.kqed.org/app/uploads/sites/10/2018/04/Cordova-Cuevas-Pending-Cause-sheet-240x309.jpg 240w, https://ww2.kqed.org/app/uploads/sites/10/2018/04/Cordova-Cuevas-Pending-Cause-sheet-375x483.jpg 375w, https://ww2.kqed.org/app/uploads/sites/10/2018/04/Cordova-Cuevas-Pending-Cause-sheet-520x670.jpg 520w\" sizes=\"(max-width: 1363px) 100vw, 1363px\">\u003cfigcaption class=\"wp-caption-text\">Abelino Cordova-Cuevas autopsy cover sheet. \u003ccite>(San Joaquin County Sheriff-Coroner's Office)\u003c/cite>\u003c/figcaption>\u003c/figure>\n\u003cp>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.\u003c/p>\n\u003cp>Going forward, all officer-involved deaths would require a coroner’s \u003ca href=\"https://www.kqed.org/news/11658317/san-joaquin-sheriff-coroner-opens-some-death-investigations-to-public\" target=\"_blank\" rel=\"noopener\">inquest\u003c/a> 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.\u003c/p>\n\u003cp>“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.\u003c/p>\n\u003cp>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.”\u003c/p>\n\u003cp>\u003cstrong>Deadly Traffic Stop\u003c/strong>\u003c/p>\n\u003cp>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.\u003c/p>\n\u003cp>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.\u003c/p>\n\u003cp>Security camera \u003ca href=\"https://www.youtube.com/watch?v=dJNSeeCkAfc\" target=\"_blank\" rel=\"noopener\">footage\u003c/a> 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.\u003c/p>\n\u003cp>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.\u003c/p>\n\u003cp>When Cordova-Cuevas became unresponsive, officers called for medics and tried to resuscitate him. He was taken to a local hospital and pronounced dead.\u003c/p>\n\u003cp>\u003cstrong>Coroner Overrode Doctor’s Opinion on Homicide \u003c/strong>\u003c/p>\n\u003cp>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.\u003c/p>\n\u003cfigure id=\"attachment_11648872\" class=\"wp-caption alignright\" style=\"max-width: 1920px\">\u003cimg src=\"https://ww2.kqed.org/news/wp-content/uploads/sites/10/2018/02/RS29306_IMG_2022-qut.jpg\" alt=\"\" width=\"1920\" height=\"2880\" class=\"size-full wp-image-11648872\" srcset=\"https://ww2.kqed.org/app/uploads/sites/10/2018/02/RS29306_IMG_2022-qut.jpg 1920w, https://ww2.kqed.org/app/uploads/sites/10/2018/02/RS29306_IMG_2022-qut-160x240.jpg 160w, https://ww2.kqed.org/app/uploads/sites/10/2018/02/RS29306_IMG_2022-qut-800x1200.jpg 800w, https://ww2.kqed.org/app/uploads/sites/10/2018/02/RS29306_IMG_2022-qut-1020x1530.jpg 1020w, https://ww2.kqed.org/app/uploads/sites/10/2018/02/RS29306_IMG_2022-qut-1180x1770.jpg 1180w, https://ww2.kqed.org/app/uploads/sites/10/2018/02/RS29306_IMG_2022-qut-960x1440.jpg 960w, https://ww2.kqed.org/app/uploads/sites/10/2018/02/RS29306_IMG_2022-qut-240x360.jpg 240w, https://ww2.kqed.org/app/uploads/sites/10/2018/02/RS29306_IMG_2022-qut-375x563.jpg 375w, https://ww2.kqed.org/app/uploads/sites/10/2018/02/RS29306_IMG_2022-qut-520x780.jpg 520w\" sizes=\"(max-width: 1920px) 100vw, 1920px\">\u003cfigcaption class=\"wp-caption-text\">Dr. Bennet Omalu \u003ccite>(Courtesy of Dr. Bennet Omalu)\u003c/cite>\u003c/figcaption>\u003c/figure>\n\u003cp>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.\u003c/p>\n\u003cp>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.\u003c/p>\n\u003cp>“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.’”\u003c/p>\n\u003cp>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.\u003c/p>\n\u003cp>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.\u003c/p>\n\u003cp>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.\u003c/p>\n\u003cp>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.”\u003c/p>\n\u003cp>A KQED \u003ca href=\"https://www.kqed.org/news/11636262/the-officer-tased-him-31-times-the-sheriff-called-his-death-an-accident\" target=\"_blank\" rel=\"noopener\">investigation\u003c/a> 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.\u003c/p>\n\u003cp>An independent \u003ca href=\"https://www.kqed.org/news/11663351/san-joaquin-county-should-install-independent-medical-examiner-audit-finds\" target=\"_blank\" rel=\"noopener\">audit\u003c/a> 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.\u003c/p>\n\u003cp>Moore declined to be interviewed for this story, but has repeatedly denied that he interfered with his doctors’ findings.\u003c/p>\n\u003cp>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.”\u003c/p>\n\u003cp>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.”\u003c/p>\n\u003cp>Controversy over Sheriff Moore’s handling of death investigations became public when Omalu and Parson resigned last December.\u003c/p>\n\u003cp>\u003cstrong>Addendum to Homicide\u003c/strong>\u003c/p>\n\u003cp>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.\u003c/p>\n\u003cp>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.’”\u003c/p>\n\u003cp>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.\u003c/p>\n\u003cp>“They completely disregarded that,” Bentley said.\u003c/p>\n\u003cp>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.\u003c/p>\n\u003cp>[ad floatright]\u003c/p>\n\u003cp>The district attorney launched an investigation into Moore’s office last year, which is ongoing.\u003c/p>\n\n",
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"excerpt": "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.",
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"description": "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.",
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"content": "\u003cdiv class=\"post-body\">\u003cp>\u003cp>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.\u003c/p>\n\u003cp>Last month, a full two years later, the discrepancy was \u003ca href=\"https://www.kqed.org/news/11634689/autopsy-doctors-sheriff-overrode-death-findings-to-protect-law-enforcement\" target=\"_blank\" rel=\"noopener\">exposed\u003c/a>, and the sheriff reclassified the death of Abelino Cordova-Cuevas as a homicide.\u003c/p>\n\u003cp>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.\u003c/p>\n\u003cp>“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.”\u003c/p>\n\u003cp>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.\u003c/p>\n\u003cp>\u003c/p>\u003c/div>",
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"content": "\u003cdiv class=\"post-body\">\u003cp>\u003c/p>\n\u003cp>The lawyer discovered the omission during a deposition of Omalu, who noted that the cover sheet was missing from his autopsy report.\u003c/p>\n\u003cfigure id=\"attachment_11664418\" class=\"wp-caption alignright\" style=\"max-width: 1363px\">\u003cimg class=\"wp-image-11664418 size-full\" src=\"https://ww2.kqed.org/news/wp-content/uploads/sites/10/2018/04/Cordova-Cuevas-Pending-Cause-sheet.jpg\" alt=\"\" width=\"1363\" height=\"1755\" srcset=\"https://ww2.kqed.org/app/uploads/sites/10/2018/04/Cordova-Cuevas-Pending-Cause-sheet.jpg 1363w, https://ww2.kqed.org/app/uploads/sites/10/2018/04/Cordova-Cuevas-Pending-Cause-sheet-160x206.jpg 160w, https://ww2.kqed.org/app/uploads/sites/10/2018/04/Cordova-Cuevas-Pending-Cause-sheet-800x1030.jpg 800w, https://ww2.kqed.org/app/uploads/sites/10/2018/04/Cordova-Cuevas-Pending-Cause-sheet-1020x1313.jpg 1020w, https://ww2.kqed.org/app/uploads/sites/10/2018/04/Cordova-Cuevas-Pending-Cause-sheet-932x1200.jpg 932w, https://ww2.kqed.org/app/uploads/sites/10/2018/04/Cordova-Cuevas-Pending-Cause-sheet-1180x1519.jpg 1180w, https://ww2.kqed.org/app/uploads/sites/10/2018/04/Cordova-Cuevas-Pending-Cause-sheet-960x1236.jpg 960w, https://ww2.kqed.org/app/uploads/sites/10/2018/04/Cordova-Cuevas-Pending-Cause-sheet-240x309.jpg 240w, https://ww2.kqed.org/app/uploads/sites/10/2018/04/Cordova-Cuevas-Pending-Cause-sheet-375x483.jpg 375w, https://ww2.kqed.org/app/uploads/sites/10/2018/04/Cordova-Cuevas-Pending-Cause-sheet-520x670.jpg 520w\" sizes=\"(max-width: 1363px) 100vw, 1363px\">\u003cfigcaption class=\"wp-caption-text\">Abelino Cordova-Cuevas autopsy cover sheet. \u003ccite>(San Joaquin County Sheriff-Coroner's Office)\u003c/cite>\u003c/figcaption>\u003c/figure>\n\u003cp>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.\u003c/p>\n\u003cp>Going forward, all officer-involved deaths would require a coroner’s \u003ca href=\"https://www.kqed.org/news/11658317/san-joaquin-sheriff-coroner-opens-some-death-investigations-to-public\" target=\"_blank\" rel=\"noopener\">inquest\u003c/a> 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.\u003c/p>\n\u003cp>“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.\u003c/p>\n\u003cp>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.”\u003c/p>\n\u003cp>\u003cstrong>Deadly Traffic Stop\u003c/strong>\u003c/p>\n\u003cp>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.\u003c/p>\n\u003cp>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.\u003c/p>\n\u003cp>Security camera \u003ca href=\"https://www.youtube.com/watch?v=dJNSeeCkAfc\" target=\"_blank\" rel=\"noopener\">footage\u003c/a> 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.\u003c/p>\n\u003cp>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.\u003c/p>\n\u003cp>When Cordova-Cuevas became unresponsive, officers called for medics and tried to resuscitate him. He was taken to a local hospital and pronounced dead.\u003c/p>\n\u003cp>\u003cstrong>Coroner Overrode Doctor’s Opinion on Homicide \u003c/strong>\u003c/p>\n\u003cp>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.\u003c/p>\n\u003cfigure id=\"attachment_11648872\" class=\"wp-caption alignright\" style=\"max-width: 1920px\">\u003cimg src=\"https://ww2.kqed.org/news/wp-content/uploads/sites/10/2018/02/RS29306_IMG_2022-qut.jpg\" alt=\"\" width=\"1920\" height=\"2880\" class=\"size-full wp-image-11648872\" srcset=\"https://ww2.kqed.org/app/uploads/sites/10/2018/02/RS29306_IMG_2022-qut.jpg 1920w, https://ww2.kqed.org/app/uploads/sites/10/2018/02/RS29306_IMG_2022-qut-160x240.jpg 160w, https://ww2.kqed.org/app/uploads/sites/10/2018/02/RS29306_IMG_2022-qut-800x1200.jpg 800w, https://ww2.kqed.org/app/uploads/sites/10/2018/02/RS29306_IMG_2022-qut-1020x1530.jpg 1020w, https://ww2.kqed.org/app/uploads/sites/10/2018/02/RS29306_IMG_2022-qut-1180x1770.jpg 1180w, https://ww2.kqed.org/app/uploads/sites/10/2018/02/RS29306_IMG_2022-qut-960x1440.jpg 960w, https://ww2.kqed.org/app/uploads/sites/10/2018/02/RS29306_IMG_2022-qut-240x360.jpg 240w, https://ww2.kqed.org/app/uploads/sites/10/2018/02/RS29306_IMG_2022-qut-375x563.jpg 375w, https://ww2.kqed.org/app/uploads/sites/10/2018/02/RS29306_IMG_2022-qut-520x780.jpg 520w\" sizes=\"(max-width: 1920px) 100vw, 1920px\">\u003cfigcaption class=\"wp-caption-text\">Dr. Bennet Omalu \u003ccite>(Courtesy of Dr. Bennet Omalu)\u003c/cite>\u003c/figcaption>\u003c/figure>\n\u003cp>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.\u003c/p>\n\u003cp>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.\u003c/p>\n\u003cp>“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.’”\u003c/p>\n\u003cp>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.\u003c/p>\n\u003cp>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.\u003c/p>\n\u003cp>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.\u003c/p>\n\u003cp>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.”\u003c/p>\n\u003cp>A KQED \u003ca href=\"https://www.kqed.org/news/11636262/the-officer-tased-him-31-times-the-sheriff-called-his-death-an-accident\" target=\"_blank\" rel=\"noopener\">investigation\u003c/a> 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.\u003c/p>\n\u003cp>An independent \u003ca href=\"https://www.kqed.org/news/11663351/san-joaquin-county-should-install-independent-medical-examiner-audit-finds\" target=\"_blank\" rel=\"noopener\">audit\u003c/a> 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.\u003c/p>\n\u003cp>Moore declined to be interviewed for this story, but has repeatedly denied that he interfered with his doctors’ findings.\u003c/p>\n\u003cp>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.”\u003c/p>\n\u003cp>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.”\u003c/p>\n\u003cp>Controversy over Sheriff Moore’s handling of death investigations became public when Omalu and Parson resigned last December.\u003c/p>\n\u003cp>\u003cstrong>Addendum to Homicide\u003c/strong>\u003c/p>\n\u003cp>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.\u003c/p>\n\u003cp>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.’”\u003c/p>\n\u003cp>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.\u003c/p>\n\u003cp>“They completely disregarded that,” Bentley said.\u003c/p>\n\u003cp>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.\u003c/p>\n\u003cp>\u003c/p>\u003c/div>",
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"content": "\u003cdiv class=\"post-body\">\u003cp>\u003c/p>\n\u003cp>The district attorney launched an investigation into Moore’s office last year, which is ongoing.\u003c/p>\n\n\u003c/div>\u003c/p>",
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"content": "\u003cp>An audit of San Joaquin County’s sheriff-coroner operations, made public Wednesday, concluded that removing the sheriff from death investigations and instituting a medical examiner’s office run by a physician is the best way to ensure the probes remain independent from law enforcement.\u003c/p>\n\u003caside class=\"pullquote alignright\">\u003cspan style=\"font-size: x-large\">\u003cstrong>‘The office must be and appear to be independent of law enforcement particularly when investigating deaths in the custody of law enforcement or while in jail/prison.’\u003c/strong>\u003c/span>\u003ccite>San Joaquin County Coroner Review and Audit\u003c/cite>\u003c/aside>\n\u003cp>The recommendation is based in part on the conclusion that there were a number of discrepancies in the handling of cases where people died at the hands of law enforcement officers. San Joaquin County supervisors are set to consider the audit, along with options for reconstituting the office of the sheriff-coroner, at a meeting next week.\u003c/p>\n\u003cp>County officials hired Dr. Roger Mitchell, the medical examiner for Washington, D.C., to conduct the audit after two \u003ca href=\"https://www.kqed.org/news/11638866/pathologists-say-san-joaquin-sheriffs-meddling-could-have-compromised-murder-cases\" target=\"_blank\" rel=\"noopener noreferrer\">forensic pathologists accused\u003c/a> Sheriff Steve Moore of interfering in death investigations. Mitchell is scheduled to present supervisors with the findings of his audit, published in a report by RAM Consulting LLC.\u003c/p>\n\u003cp>In San Joaquin County, the coroner, who is also the elected sheriff, investigates all sudden, suspicious or violent deaths. Most California counties use that system, and just a few larger counties have an independent medical examiner. The San Joaquin County Sheriff-Coroner’s Office strives to “serve as an independent finder of fact,” according to a mission statement.\u003c/p>\n\u003cp>But the chief forensic pathologist who worked in that office accused the sheriff of manipulating findings to shield peace officers from prosecution.\u003c/p>\n\u003cp>[ad fullwidth]\u003c/p>\n\u003cp>Dr. Bennet Omalu, best known for his discovery of a concussion-related disease in football players, had served as the county’s chief forensic pathologist for a decade when he \u003ca href=\"https://www.kqed.org/news/11634689/autopsy-doctors-sheriff-overrode-death-findings-to-protect-law-enforcement\" target=\"_blank\" rel=\"noopener noreferrer\">resigned in early December\u003c/a>, citing a handful of cases in which Moore ignored his opinion that a death at the hands of law enforcement officers was a homicide.\u003c/p>\n\u003cp>KQED News has verified three cases, two in 2016 and one in 2008, in which the sheriff-coroner certified an in-custody death as an accident after Omalu found that it was a homicide.\u003c/p>\n\u003cp>Another former San Joaquin County forensic pathologist, Dr. Susan Parson, \u003ca href=\"https://www.kqed.org/news/11633330/autopsy-doctor-quits-alleges-sheriff-interfered-in-death-probes\" rel=\"noopener noreferrer\" target=\"_blank\">resigned\u003c/a> about a week before Omalu and made similar allegations about Moore interfering with her work.\u003c/p>\n\u003cp>The doctors’ resignations, and their reasons, have apparently made it hard to replace them. A recruiter was initially contacted by 20 candidates, according to a county administrator’s report, but many of them later withdrew their interest.\u003c/p>\n\u003cp>“[M]any of the candidates have declined to pursue employment with San Joaquin County due to on-line searches revealing the media presence reporting on this issue, as well as the negative reaction to the location,” the report says.\u003c/p>\n\u003caside class=\"alignright\">\n\u003ch3>The Officer Tased Him 31 Times; the Sheriff Called His Death an Accident\u003c/h3>\n\u003cfigure>\u003ca href=\"https://www.kqed.org/news/11636262/the-officer-tased-him-31-times-the-sheriff-called-his-death-an-accident\" target=\"_blank\" rel=\"noopener noreferrer\">\u003cimg decoding=\"async\" src=\"https://ww2.kqed.org/wp-content/uploads/sites/10/2017/12/IMG_6146.jpg\" alt=\"\">\u003c/a>\u003c/figure>\n\u003cp>Stockton woman says San Joaquin County sheriff swept evidence of excessive force ‘under a carpet’ in her ex-husband’s death.\u003c/p>\n\u003c/aside>\n\u003cp>Mitchell’s audit included a review of 130 investigatory and autopsy reports from 2016, or about 10 percent of the year’s coroner cases. Of the five cases where people died in custody, both in jail and during arrest, the audit found a discrepancy between the forensic pathologists’ opinion and the coroner’s opinion. which determined the ultimate certification in the manner of death.\u003c/p>\n\u003cp>“The manner of death recorded by the forensic pathologist on the data sheet was not the manner of death certified by the coroner in several of the cases reviewed,” the audit says. “In cases where there was a direct physical altercation with law enforcement, the forensic pathologist indicated the manner as homicide. The ultimate coroner manner of death was certified as accident for the aforementioned cases.”\u003c/p>\n\u003cp>Mitchell’s audit also included interviews of key staff in the coroner’s office, including the two forensic pathologists — Omalu and Parson — Sheriff Moore and the district attorney, which is conducting a separate investigation into the doctors’ allegations.\u003c/p>\n\u003cp>“The office must be and appear to be independent of law enforcement particularly when investigating deaths in the custody of law enforcement or while in jail/prison,” Mitchell wrote. “This requires a complete shift towards a Medical Examiner System.”\u003c/p>\n\u003cp>Mitchell wrote that the medical examiner system — run by a physician certified in pathology — offers the best tools to improve standards and service and to “maintain independent objectivity, and rebuild the public trust.”\u003c/p>\n\u003cp>“The organizational structure must ensure that the individuals with the most knowledge and experience in conducting medicolegal death investigations provide the ultimate management and leadership for the office,” Mitchell wrote.\u003c/p>\n\u003cp>San Joaquin County District Attorney Tori Verber Salazar, who called for the creation of an independent medical examiner’s office after the doctors’ allegations against Moore surfaced, agrees with Mitchell’s recommendation.\u003c/p>\n\u003cp>“Having a chief medical examiner, additional medical examiners and a highly skilled board-certified investigative team would address these issues and ensure those loved ones in our community who are no longer with us are receiving the best practices and procedures and the best investigation that we can provide them,” Verber Salazar said. “We owe them that.”\u003c/p>\n\u003caside class=\"alignleft\">\n\u003ch3 style=\"text-align: left\">How Families in San Joaquin County Pay for Coroner Mistakes\u003c/h3>\n\u003cfigure>\u003ca href=\"https://www.kqed.org/news/11648821/how-families-in-san-joaquin-county-pay-for-coroner-mistakes\" target=\"_blank\" rel=\"noopener noreferrer\">\u003cimg decoding=\"async\" src=\"https://ww2.kqed.org/wp-content/uploads/sites/10/2017/11/RS28170_IMG_6103-qut-1180x885.jpg\" alt=\"\">\u003c/a>\u003c/figure>\n\u003cp style=\"text-align: left\">Mixed-up bodies, unwarranted fees and failure to investigate: more allegations of incompetence in the San Joaquin County Sheriff’s Office.\u003c/p>\n\u003c/aside>\n\u003cp>She wants to set up an interim coroner for roughly a year while the medical examiner’s office is being created, but in the meantime, she said, all deputies who conduct coroner work should receive robust training and certification in death investigations.\u003c/p>\n\u003cp>Mitchell’s report found that while the five sheriff’s deputies who are responsible for death investigations for the entire county receive 80 hours in death investigation training when they start on the job, they receive little-to-no ongoing education. Patrol deputies who respond to many of the coroner calls have even less formal education in death investigations and, according to the audit, there’s no evidence that they consult physicians when the encounter complex death investigation scenes. Forensic pathologists are neither required nor encouraged to go to the scene themselves, the audit says.\u003c/p>\n\u003cp>“It’s incumbent upon us to provide the best possible services that we can, with the best trained individuals, and do so in a manner that is respectful to them and to their family,” Verber Salazar said.\u003c/p>\n\u003cp>She declined to comment on her ongoing investigation into the doctors’ allegations.\u003c/p>\n\u003cp>A separate report by San Joaquin County Counsel Mark Myles found some evidence of disruptive delays in getting medical records and detective reports, which in turn delayed the completion of autopsy reports. And he noted that none of the sheriff’s deputies handling coroner cases were certified by an independent credentialing organization, such as the American Board of Medicolegal Death Investigators.\u003c/p>\n\u003cp>Only three of the coroner deputies had received in-depth training in death investigations, the county counsel found.\u003c/p>\n\u003cp>Aside from the need for more training, Myles concluded that most of the issues the doctors raised could have been “avoided, addressed, or remedied in an atmosphere of mutual respect and effective communication.”\u003c/p>\n\u003cp>Myles said last week that he found no evidence the sheriff broke any laws or violated standards supported by the National Association of Medical Examiners.\u003c/p>\n\u003cp>“The law grants great discretion to the coroner in the exercise of their duties,” Myles said. He said national standards note “room for a difference of opinion on determination of the manner of death.”\u003c/p>\n\u003cp>Myles’ review of allegations concluded: “Counsel has not found any facts to support nefarious or callous motives ascribed to the Chief Deputy Coroner or the Coroner.”\u003c/p>\n\u003cp>The San Joaquin Board of Supervisors will hear both reports at a meeting on April 24.\u003c/p>\n\u003cp>Read the audit and county counsel’s report below:\u003c/p>\n\u003cp>[ad floatright]\u003c/p>\n\u003cp>[documentcloud url=\"https://www.documentcloud.org/documents/4442328-San-Joaquin-County-Coroner-Review-and-Audit-Report\" notes=\"true\" text=\"true\" search=\"true\" sidebar=\"true\" pdf=\"true\" responsive=\"true\" page=\"1\"]\u003c/p>\n\n",
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"excerpt": "An independent review of sheriff-coroner operations in San Joaquin County found the office is out of compliance with many national standards, and recommends making death investigations independent of the office.",
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"content": "\u003cdiv class=\"post-body\">\u003cp>\u003cp>An audit of San Joaquin County’s sheriff-coroner operations, made public Wednesday, concluded that removing the sheriff from death investigations and instituting a medical examiner’s office run by a physician is the best way to ensure the probes remain independent from law enforcement.\u003c/p>\n\u003caside class=\"pullquote alignright\">\u003cspan style=\"font-size: x-large\">\u003cstrong>‘The office must be and appear to be independent of law enforcement particularly when investigating deaths in the custody of law enforcement or while in jail/prison.’\u003c/strong>\u003c/span>\u003ccite>San Joaquin County Coroner Review and Audit\u003c/cite>\u003c/aside>\n\u003cp>The recommendation is based in part on the conclusion that there were a number of discrepancies in the handling of cases where people died at the hands of law enforcement officers. San Joaquin County supervisors are set to consider the audit, along with options for reconstituting the office of the sheriff-coroner, at a meeting next week.\u003c/p>\n\u003cp>County officials hired Dr. Roger Mitchell, the medical examiner for Washington, D.C., to conduct the audit after two \u003ca href=\"https://www.kqed.org/news/11638866/pathologists-say-san-joaquin-sheriffs-meddling-could-have-compromised-murder-cases\" target=\"_blank\" rel=\"noopener noreferrer\">forensic pathologists accused\u003c/a> Sheriff Steve Moore of interfering in death investigations. Mitchell is scheduled to present supervisors with the findings of his audit, published in a report by RAM Consulting LLC.\u003c/p>\n\u003cp>In San Joaquin County, the coroner, who is also the elected sheriff, investigates all sudden, suspicious or violent deaths. Most California counties use that system, and just a few larger counties have an independent medical examiner. The San Joaquin County Sheriff-Coroner’s Office strives to “serve as an independent finder of fact,” according to a mission statement.\u003c/p>\n\u003cp>But the chief forensic pathologist who worked in that office accused the sheriff of manipulating findings to shield peace officers from prosecution.\u003c/p>\n\u003cp>\u003c/p>\u003c/div>",
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"content": "\u003cdiv class=\"post-body\">\u003cp>\u003c/p>\n\u003cp>Dr. Bennet Omalu, best known for his discovery of a concussion-related disease in football players, had served as the county’s chief forensic pathologist for a decade when he \u003ca href=\"https://www.kqed.org/news/11634689/autopsy-doctors-sheriff-overrode-death-findings-to-protect-law-enforcement\" target=\"_blank\" rel=\"noopener noreferrer\">resigned in early December\u003c/a>, citing a handful of cases in which Moore ignored his opinion that a death at the hands of law enforcement officers was a homicide.\u003c/p>\n\u003cp>KQED News has verified three cases, two in 2016 and one in 2008, in which the sheriff-coroner certified an in-custody death as an accident after Omalu found that it was a homicide.\u003c/p>\n\u003cp>Another former San Joaquin County forensic pathologist, Dr. Susan Parson, \u003ca href=\"https://www.kqed.org/news/11633330/autopsy-doctor-quits-alleges-sheriff-interfered-in-death-probes\" rel=\"noopener noreferrer\" target=\"_blank\">resigned\u003c/a> about a week before Omalu and made similar allegations about Moore interfering with her work.\u003c/p>\n\u003cp>The doctors’ resignations, and their reasons, have apparently made it hard to replace them. A recruiter was initially contacted by 20 candidates, according to a county administrator’s report, but many of them later withdrew their interest.\u003c/p>\n\u003cp>“[M]any of the candidates have declined to pursue employment with San Joaquin County due to on-line searches revealing the media presence reporting on this issue, as well as the negative reaction to the location,” the report says.\u003c/p>\n\u003caside class=\"alignright\">\n\u003ch3>The Officer Tased Him 31 Times; the Sheriff Called His Death an Accident\u003c/h3>\n\u003cfigure>\u003ca href=\"https://www.kqed.org/news/11636262/the-officer-tased-him-31-times-the-sheriff-called-his-death-an-accident\" target=\"_blank\" rel=\"noopener noreferrer\">\u003cimg decoding=\"async\" src=\"https://ww2.kqed.org/wp-content/uploads/sites/10/2017/12/IMG_6146.jpg\" alt=\"\">\u003c/a>\u003c/figure>\n\u003cp>Stockton woman says San Joaquin County sheriff swept evidence of excessive force ‘under a carpet’ in her ex-husband’s death.\u003c/p>\n\u003c/aside>\n\u003cp>Mitchell’s audit included a review of 130 investigatory and autopsy reports from 2016, or about 10 percent of the year’s coroner cases. Of the five cases where people died in custody, both in jail and during arrest, the audit found a discrepancy between the forensic pathologists’ opinion and the coroner’s opinion. which determined the ultimate certification in the manner of death.\u003c/p>\n\u003cp>“The manner of death recorded by the forensic pathologist on the data sheet was not the manner of death certified by the coroner in several of the cases reviewed,” the audit says. “In cases where there was a direct physical altercation with law enforcement, the forensic pathologist indicated the manner as homicide. The ultimate coroner manner of death was certified as accident for the aforementioned cases.”\u003c/p>\n\u003cp>Mitchell’s audit also included interviews of key staff in the coroner’s office, including the two forensic pathologists — Omalu and Parson — Sheriff Moore and the district attorney, which is conducting a separate investigation into the doctors’ allegations.\u003c/p>\n\u003cp>“The office must be and appear to be independent of law enforcement particularly when investigating deaths in the custody of law enforcement or while in jail/prison,” Mitchell wrote. “This requires a complete shift towards a Medical Examiner System.”\u003c/p>\n\u003cp>Mitchell wrote that the medical examiner system — run by a physician certified in pathology — offers the best tools to improve standards and service and to “maintain independent objectivity, and rebuild the public trust.”\u003c/p>\n\u003cp>“The organizational structure must ensure that the individuals with the most knowledge and experience in conducting medicolegal death investigations provide the ultimate management and leadership for the office,” Mitchell wrote.\u003c/p>\n\u003cp>San Joaquin County District Attorney Tori Verber Salazar, who called for the creation of an independent medical examiner’s office after the doctors’ allegations against Moore surfaced, agrees with Mitchell’s recommendation.\u003c/p>\n\u003cp>“Having a chief medical examiner, additional medical examiners and a highly skilled board-certified investigative team would address these issues and ensure those loved ones in our community who are no longer with us are receiving the best practices and procedures and the best investigation that we can provide them,” Verber Salazar said. “We owe them that.”\u003c/p>\n\u003caside class=\"alignleft\">\n\u003ch3 style=\"text-align: left\">How Families in San Joaquin County Pay for Coroner Mistakes\u003c/h3>\n\u003cfigure>\u003ca href=\"https://www.kqed.org/news/11648821/how-families-in-san-joaquin-county-pay-for-coroner-mistakes\" target=\"_blank\" rel=\"noopener noreferrer\">\u003cimg decoding=\"async\" src=\"https://ww2.kqed.org/wp-content/uploads/sites/10/2017/11/RS28170_IMG_6103-qut-1180x885.jpg\" alt=\"\">\u003c/a>\u003c/figure>\n\u003cp style=\"text-align: left\">Mixed-up bodies, unwarranted fees and failure to investigate: more allegations of incompetence in the San Joaquin County Sheriff’s Office.\u003c/p>\n\u003c/aside>\n\u003cp>She wants to set up an interim coroner for roughly a year while the medical examiner’s office is being created, but in the meantime, she said, all deputies who conduct coroner work should receive robust training and certification in death investigations.\u003c/p>\n\u003cp>Mitchell’s report found that while the five sheriff’s deputies who are responsible for death investigations for the entire county receive 80 hours in death investigation training when they start on the job, they receive little-to-no ongoing education. Patrol deputies who respond to many of the coroner calls have even less formal education in death investigations and, according to the audit, there’s no evidence that they consult physicians when the encounter complex death investigation scenes. Forensic pathologists are neither required nor encouraged to go to the scene themselves, the audit says.\u003c/p>\n\u003cp>“It’s incumbent upon us to provide the best possible services that we can, with the best trained individuals, and do so in a manner that is respectful to them and to their family,” Verber Salazar said.\u003c/p>\n\u003cp>She declined to comment on her ongoing investigation into the doctors’ allegations.\u003c/p>\n\u003cp>A separate report by San Joaquin County Counsel Mark Myles found some evidence of disruptive delays in getting medical records and detective reports, which in turn delayed the completion of autopsy reports. And he noted that none of the sheriff’s deputies handling coroner cases were certified by an independent credentialing organization, such as the American Board of Medicolegal Death Investigators.\u003c/p>\n\u003cp>Only three of the coroner deputies had received in-depth training in death investigations, the county counsel found.\u003c/p>\n\u003cp>Aside from the need for more training, Myles concluded that most of the issues the doctors raised could have been “avoided, addressed, or remedied in an atmosphere of mutual respect and effective communication.”\u003c/p>\n\u003cp>Myles said last week that he found no evidence the sheriff broke any laws or violated standards supported by the National Association of Medical Examiners.\u003c/p>\n\u003cp>“The law grants great discretion to the coroner in the exercise of their duties,” Myles said. He said national standards note “room for a difference of opinion on determination of the manner of death.”\u003c/p>\n\u003cp>Myles’ review of allegations concluded: “Counsel has not found any facts to support nefarious or callous motives ascribed to the Chief Deputy Coroner or the Coroner.”\u003c/p>\n\u003cp>The San Joaquin Board of Supervisors will hear both reports at a meeting on April 24.\u003c/p>\n\u003cp>Read the audit and county counsel’s report below:\u003c/p>\n\u003cp>\u003c/p>\u003c/div>",
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"content": "\u003cp>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.\u003c/p>\n\u003cp>Dr. Bennet Omalu and Dr. Susan Parson \u003ca href=\"https://ww2.kqed.org/news/2017/12/04/autopsy-doctors-sheriff-overrode-death-findings-to-protect-law-enforcement/\">accused Sheriff Steve Moore\u003c/a> of pressuring them to change medical findings, especially in \u003ca href=\"https://ww2.kqed.org/news/2017/12/11/the-officer-tased-him-31-times-the-sheriff-called-his-death-an-accident/\" target=\"_blank\" rel=\"noopener\">cases involving law enforcement officers\u003c/a>.\u003c/p>\n\u003cp>“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.\u003c/p>\n\u003cp>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.”\u003c/p>\n\u003ch2>Contra Costa County Benefits from Coroner’s Inquests\u003c/h2>\n\u003cp>During the inquest hearing the coroner, a designated deputy or an independent hearing officer — typically an attorney — will select and question witnesses.\u003c/p>\n\u003cp>[ad fullwidth]\u003c/p>\n\u003cp>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.\u003c/p>\n\u003cp>“I am a fan of it,” said attorney Matthew Guichard, who has conducted \u003ca href=\"http://cclawyer.cccba.org/2015/03/coroners-inquests/\" target=\"_blank\" rel=\"noopener\">coroner’s inquests\u003c/a> 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.”\u003c/p>\n\u003cp>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.\u003c/p>\n\u003caside class=\"alignright\">\n\u003ch3>\u003ca href=\"https://www.kqed.org/news/11648821/how-families-in-san-joaquin-county-pay-for-coroner-mistakes\">How Families in San Joaquin County Pay for Coroner Mistakes\u003c/a>\u003c/h3>\n\u003cfigure>\u003ca href=\"https://www.kqed.org/news/11648821/how-families-in-san-joaquin-county-pay-for-coroner-mistakes\">\u003cimg decoding=\"async\" src=\"https://ww2.kqed.org/wp-content/uploads/sites/10/2017/11/RS28170_IMG_6103-qut-1180x885.jpg\" alt=\"\">\u003c/a>\u003c/figure>\n\u003c/aside>\n\u003cp>Guichard believes the inquests have made a difference in how the public views fatalities involving officers.\u003c/p>\n\u003cp>“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.”\u003c/p>\n\u003ch2>Some See Bias With Inquests Controlled by a Sheriff-Coroner\u003c/h2>\n\u003cp>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.\u003c/p>\n\u003cp>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.\u003c/p>\n\u003cp>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.\u003c/p>\n\u003cp>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.\u003c/p>\n\u003cp>\u003c/p>\n\u003cp>That report is due in April.\u003c/p>\n\n",
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"excerpt": "San Joaquin County will hold public inquests into all officer-involved fatalities -- but critics say that won't protect residents from law enforcement meddling in death investigations.",
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"content": "\u003cdiv class=\"post-body\">\u003cp>\u003cp>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.\u003c/p>\n\u003cp>Dr. Bennet Omalu and Dr. Susan Parson \u003ca href=\"https://ww2.kqed.org/news/2017/12/04/autopsy-doctors-sheriff-overrode-death-findings-to-protect-law-enforcement/\">accused Sheriff Steve Moore\u003c/a> of pressuring them to change medical findings, especially in \u003ca href=\"https://ww2.kqed.org/news/2017/12/11/the-officer-tased-him-31-times-the-sheriff-called-his-death-an-accident/\" target=\"_blank\" rel=\"noopener\">cases involving law enforcement officers\u003c/a>.\u003c/p>\n\u003cp>“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.\u003c/p>\n\u003cp>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.”\u003c/p>\n\u003ch2>Contra Costa County Benefits from Coroner’s Inquests\u003c/h2>\n\u003cp>During the inquest hearing the coroner, a designated deputy or an independent hearing officer — typically an attorney — will select and question witnesses.\u003c/p>\n\u003cp>\u003c/p>\u003c/div>",
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"content": "\u003cdiv class=\"post-body\">\u003cp>\u003c/p>\n\u003cp>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.\u003c/p>\n\u003cp>“I am a fan of it,” said attorney Matthew Guichard, who has conducted \u003ca href=\"http://cclawyer.cccba.org/2015/03/coroners-inquests/\" target=\"_blank\" rel=\"noopener\">coroner’s inquests\u003c/a> 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.”\u003c/p>\n\u003cp>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.\u003c/p>\n\u003caside class=\"alignright\">\n\u003ch3>\u003ca href=\"https://www.kqed.org/news/11648821/how-families-in-san-joaquin-county-pay-for-coroner-mistakes\">How Families in San Joaquin County Pay for Coroner Mistakes\u003c/a>\u003c/h3>\n\u003cfigure>\u003ca href=\"https://www.kqed.org/news/11648821/how-families-in-san-joaquin-county-pay-for-coroner-mistakes\">\u003cimg decoding=\"async\" src=\"https://ww2.kqed.org/wp-content/uploads/sites/10/2017/11/RS28170_IMG_6103-qut-1180x885.jpg\" alt=\"\">\u003c/a>\u003c/figure>\n\u003c/aside>\n\u003cp>Guichard believes the inquests have made a difference in how the public views fatalities involving officers.\u003c/p>\n\u003cp>“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.”\u003c/p>\n\u003ch2>Some See Bias With Inquests Controlled by a Sheriff-Coroner\u003c/h2>\n\u003cp>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.\u003c/p>\n\u003cp>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.\u003c/p>\n\u003cp>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.\u003c/p>\n\u003cp>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.\u003c/p>\n\u003cp>\u003c/p>\n\u003cp>That report is due in April.\u003c/p>\n\n\u003c/div>\u003c/p>",
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"info": "What kind of no sabo word is Hyphenación? For us, it’s about living within a hyphenation. Like being a third-gen Mexican-American from the Texas border now living that Bay Area Chicano life. Like Xorje! Each week we bring together a couple of hyphenated Latinos to talk all about personal life choices: family, careers, relationships, belonging … everything is on the table. ",
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"info": "The Political Mind of Jerry Brown brings listeners the wisdom of the former Governor, Mayor, and presidential candidate. Scott Shafer interviewed Brown for more than 40 hours, covering the former governor's life and half-century in the political game – and Brown has some lessons he'd like to share. ",
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"marketplace": {
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"info": "Our flagship program, helmed by Kai Ryssdal, examines what the day in money delivered, through stories, conversations, newsworthy numbers and more. Updated Monday through Friday at about 3:30 p.m. PT.",
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"mindshift": {
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"info": "The MindShift podcast explores the innovations in education that are shaping how kids learn. Hosts Ki Sung and Katrina Schwartz introduce listeners to educators, researchers, parents and students who are developing effective ways to improve how kids learn. We cover topics like how fed-up administrators are developing surprising tactics to deal with classroom disruptions; how listening to podcasts are helping kids develop reading skills; the consequences of overparenting; and why interdisciplinary learning can engage students on all ends of the traditional achievement spectrum. This podcast is part of the MindShift education site, a division of KQED News. KQED is an NPR/PBS member station based in San Francisco. You can also visit the MindShift website for episodes and supplemental blog posts or tweet us \u003ca href=\"https://twitter.com/MindShiftKQED\">@MindShiftKQED\u003c/a> or visit us at \u003ca href=\"/mindshift\">MindShift.KQED.org\u003c/a>",
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"order": 12
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"onourwatch": {
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"info": "For decades, the process for how police police themselves has been inconsistent – if not opaque. In some states, like California, these proceedings were completely hidden. After a new police transparency law unsealed scores of internal affairs files, our reporters set out to examine these cases and the shadow world of police discipline. On Our Watch brings listeners into the rooms where officers are questioned and witnesses are interrogated to find out who this system is really protecting. Is it the officers, or the public they've sworn to serve?",
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},
"perspectives": {
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"order": 14
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"info": "The economy explained. Imagine you could call up a friend and say, Meet me at the bar and tell me what's going on with the economy. Now imagine that's actually a fun evening.",
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"politicalbreakdown": {
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"title": "Political Breakdown",
"tagline": "Politics from a personal perspective",
"info": "Political Breakdown is a new series that explores the political intersection of California and the nation. Each week hosts Scott Shafer and Marisa Lagos are joined with a new special guest to unpack politics -- with personality — and offer an insider’s glimpse at how politics happens.",
"airtime": "THU 6:30pm-7pm",
"imageSrc": "https://cdn.kqed.org/wp-content/uploads/2024/04/Political-Breakdown-2024-Podcast-Tile-703x703-1.jpg",
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"order": 5
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"possible": {
"id": "possible",
"title": "Possible",
"info": "Possible is hosted by entrepreneur Reid Hoffman and writer Aria Finger. Together in Possible, Hoffman and Finger lead enlightening discussions about building a brighter collective future. The show features interviews with visionary guests like Trevor Noah, Sam Altman and Janette Sadik-Khan. Possible paints an optimistic portrait of the world we can create through science, policy, business, art and our shared humanity. It asks: What if everything goes right for once? How can we get there? Each episode also includes a short fiction story generated by advanced AI GPT-4, serving as a thought-provoking springboard to speculate how humanity could leverage technology for good.",
"airtime": "SUN 2pm",
"imageSrc": "https://cdn.kqed.org/wp-content/uploads/2024/04/Possible-Podcast-Tile-360x360-1.jpg",
"officialWebsiteLink": "https://www.possible.fm/",
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"source": "Possible"
},
"link": "/radio/program/possible",
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"spotify": "https://open.spotify.com/show/730YpdUSNlMyPQwNnyjp4k"
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},
"pri-the-world": {
"id": "pri-the-world",
"title": "PRI's The World: Latest Edition",
"info": "Each weekday, host Marco Werman and his team of producers bring you the world's most interesting stories in an hour of radio that reminds us just how small our planet really is.",
"airtime": "MON-FRI 2pm-3pm",
"imageSrc": "https://cdn.kqed.org/wp-content/uploads/2024/04/The-World-Podcast-Tile-360x360-1.jpg",
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},
"radiolab": {
"id": "radiolab",
"title": "Radiolab",
"info": "A two-time Peabody Award-winner, Radiolab is an investigation told through sounds and stories, and centered around one big idea. In the Radiolab world, information sounds like music and science and culture collide. Hosted by Jad Abumrad and Robert Krulwich, the show is designed for listeners who demand skepticism, but appreciate wonder. WNYC Studios is the producer of other leading podcasts including Freakonomics Radio, Death, Sex & Money, On the Media and many more.",
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},
"reveal": {
"id": "reveal",
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