Consultant: San Joaquin County should split sheriff’s, coroner’s offices

A consultant has recommended separating the duties of sheriff and coroner in San Joaquin County and establishing a separate, independent medical examiner’s office operated by a physician and not the sheriff.

“The Medical Examiner System gives the County the best opportunity and tools required to establish the necessary standards for an improved level of service, maintain independent objectivity, and rebuild the public trust,” RAM Consulting said in its report.

The report is one of two delivered to county supervisors following allegations by Dr. Bennet Omalu and Dr. Susan Parson that Sheriff-Coroner Steve Moore interfered with their work and wrongly changed their conclusions.

Moore denies any illegal misconduct and neither report detailed any illegal findings. Both, however, find fault with Moore’s management style, while not absolving the pathologists.

“The organizational structure must ensure that the individuals with the most knowledge and experience in conducting medico-legal death investigations provide the ultimate management and leadership for the office,” said the 28-page RAM report.

It added, “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.”

In the second report, the Office of the County Counsel determined that most of the allegations made by Omalu and Parsons were misguided or impossible to substantiate.

“Counsel has not found any facts to support nefarious or callous motives ascribed to the Chief Deputy Coroner or the Coroner,” wrote attorney J. Mark Myles.

In a medical examiner system, the board appoints a licensed pathologist as chief medical examiner. Medical personnel determine both cause and manner of death. They write the autopsy report.

Until recently, Moore as sheriff-coroner could overrule the pathologists and change the manner of death.

His authority has proved controversial. Moore changed Omalu’s findings of a person’s death during arrest by police from homicide to accidental.

County Counsel affirmed a sheriff’s legal right to change the manner of an arrest-related death if it is determined that, for instance, police used an intermediate and not excessive use of force without intent to kill a suspect, the reports say.

“In the cases that were cited that’s exactly what happened,” said Moore. “I made in one case it an accident versus a homicide. It (the death) was inadvertent.”

In response to criticism, Moore instituted an interim system of coroner’s inquests. The new system reduces his role.

The inquest system will remains until leaders decide on changes.

RAM and County Counsel did find one legal lapse by Moore: He failed to consult with the pathologists over a decedent’s manner of death, his duty under law.

“If the Coroner reaches a conclusion that is different from the conclusion reached by the physician, the Coroner and the physician should deliberate together regarding the determination of the manner of death so that each understands the other’s perspective,” the RAM report said.

The law does not require them to agree, the report adds.

Moore disputed the reports’ findings. “I met with Dr. Omalu in those cases, asked for his opinion,” Moore said.

The most lurid allegation is that Moore or his subordinate “on a whim” ordered the unnecessary and allegedly illegal amputation of hands or fingers off the body of unidentified corpses. This was done so the appendages could be sent to a Sacramento lab to identify the deceased.

County Counsel affirmed the sheriff ’s authority to do this, adding that this procedure is used only “when the body is in an advanced state of decomposition so that visual identification is not possible and the office is unable to obtain fingerprints through conventional methods.”

Pat Withrow, running to replace Moore as sheriff, said he “couldn’t agree more” with the recommendation to switch to a medical examiner system.

“We have already proven that the system as it stands now cannot be trusted anymore, through either conscious or unconscious bias on the part of the sheriff,” Withrow said. “For the good of the public we need to separate the two.”

Dr. Omalu declined comment, saying he had not read the full report. Omalu previously expressed support for separating sheriff and coroner duties.

Dr. Parson did not return a call for comment.

While vindicating Moore on the legal front, both reports found plenty of inefficiencies in the Coroner’s Office.

“Aside from the lack of formal training in death investigation for the patrol deputies conducting death investigations, I believe that the majority of the remaining allegations could have been avoided, addressed, or remedied in an atmosphere of mutual respect and effective communications,” Myles said in the County Counsel report. “If the forensic physicians would have engaged with the Chief Deputy Coroner or Coroner as problems were encountered, much of these complaints could have been resolved,” he concluded.

Moore said he would heed the reports’ recommendations, even if the system is changed.

“I will take responsibility for those shortfalls that are my responsibility,” he said. “I will do that in spades. If you give me the opportunity, we’re going to fix things.”