DEPARTMENT of Coroner REPORT

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DEPARTMENT of coroner REPORT /

FORENSIC MEDICINE BUREAU

The Forensic Medicine Bureau’s full-time permanent staff consists of board-certified forensic pathologists who are responsible for the professional medical investigation and determination of the cause and mode of each death handled by the department. Our physicians are experts in the evaluation of sudden or unexpected natural deaths and unnatural deaths such as deaths from firearms, sharp and blunt force trauma, etc. Physicians are frequently called to court to testify on cause of death and their medical findings and interpretations, particularly in homicide cases. In addition, the division has consultants in forensic neuropathology, archeology, odontology, anthropology, anesthesiology, pediatrics, surgery, ophthalmologic pathology, pulmonary pathology, pediatric forensic pathology, cardiac pathology, emergency room medicine, psychiatry, psychology and radiology to assist the deputy medical examiners in evaluating their cases.

FORENSIC SCIENCELABORATORIES BUREAU

The Forensic Science Laboratories Bureau is responsible for the identification, collection, preservation, and analysis of physical and medical evidence associated with Coroner’s cases. Its mission is to conduct a comprehensive scientific investigation into the cause and manner of any death within the Coroner’s jurisdiction through the chemical and instrumental analysis of physical and medical evidence.

The Forensic Science Laboratory is fully accredited by the prestigious American Society of Crime Laboratory Directors, and our Forensic Blood Alcohol testing program is licensed by the State of California.

HISTOLOGY LABORATORY

The histology laboratory facilitates the preparation of gross tissue specimens for microscopic examination by the medical staff. This includes hematoxylin and eosin stains, special stains, and immunohistochemical stains. Through the microscopic examination of tissue, our forensic pathologists can determine the age and degree of injury, diagnose disease including cancers, evaluate cellular variation in tissue, and identify the presence of bacteria, medical disorders, and toxins such as asbestos.

TOXICOLOGY LABORATORY

The toxicology lab uses state of the art equipment and methods to conduct chemical and instrumental analyses on post-mortem specimens to determine the extent that drugs may have contributed to the cause and manner of death. The laboratory’s experienced forensic toxicologists offer expert drug interpretation, which assists the medical examiners in answering questions like what drug was taken? How much and when was the drug taken? Did the drug contribute to the cause and/or manner of death? Was the drug use consistent with therapeutic administration, or was it an abuse? If the death is due to a drug overdose, was it intentional or accidental?

SCANNING ELECTRONMICROSCOPY LABORATORY

The Scanning Electron Microscopy (SEM) laboratory conducts gunshot residue (GSR) analyses and tool mark evaluations. Using a scanning electron microscope equipped with an energy dispersive x-ray detector, GSR analysis is used to determine whether an individual may have fired a weapon. This laboratory also performs GSR analyses for many law enforcement agencies throughout California.

Tool mark analysis involves the evaluation of trauma to biological material, especially bone and cartilage, as to the type of instrument that might have produced the trauma. This not only helps our pathologists understand the circumstances of a death, but also aids the law enforcement agency in their criminal investigation.

OPERATIONS BUREAU

This bureau is responsible for the 24-hour day, 7-day week operations of many direct services provided by the department. The Operations Bureau oversees Investigations, Forensic Photography and Support, and the Forensic Services Division. In addition, the bureau is responsible for disaster and community services, fleet management, public information and other ancillary programs such as regional offices and the Youthful Drunk Driver Visitation Program (YDDVP).

Coroner Investigators are also responsible for testimony in court and deposition on Coroner cases along with preparation of investigative reports for use in the determination of cause and manner of death.

Under state law, all Coroner Investigators are sworn peace officers. The Coroner Investigator must meet the same stringent hiring standards as any other California law enforcement agency. The Department of Coroner is a California Peace Officer Standards and Training (POST) `1 0

The department participates in a state-mandated program to examine dental records of known missing persons to aid in the identification of John and Jane Does and in a state-mandated program to investigate certain nursing home deaths to determine whether a death may be certified as natural by a private physician or handled as a Coroner’s case.

YOUTHFUL DRUNK DRIVER VISITATION PROGRAM (YDDVP)

The Department of Coroner has presented the YDDVP program since 1989 as an alternative sentence option that can be considered by a judicial officer. The program is designed to present to the participants the consequences of certain behavior in a manner that has an impact and is also educational. The program is currently offered up to 12 times per month and includes classes presented in Spanish.

ADMINISTRATIVE SERVICES BUREAU

The Administrative Services Bureau is responsible for all departmental financial operations, departmental budget preparation, fiscal reports, personnel, payroll, litigation, procurement, accounting, revenue collection, marketing, volunteer services, affirmative action, contracts and grants, internal control certification, workfare program, facilities management, information technology, and other related functions.

PUBLIC SERVICES DIVISION

This division is responsible for Coroner case file management, revenue collection (document sales, decedent billing, etc.), and interaction with the public both telephonically and at the front lobby reception area. In addition to providing information and copies of autopsy reports, Public Services staff offers many services to the public. These services include preparation of “Proof of Death” letters to verify that a death is being investigated by the Coroner and “Port of Entry” letters to confirm that a decedent had no communicable disease, necessary for the decedent’s admission into a foreign country after death.

California GovernmentCode, Section 27491

It shall be the duty of the Coroner to inquire into and determine the circumstances, manner, and cause of all violent, sudden, or unusual deaths; unattended deaths; deaths where thedeceased has not been attended by either a physician or a registerednurse, who is a member of a hospice care interdisciplinary team, asdefined by subdivision (e) of Section 1746 of the Health and SafetyCode in the 20 days before death; deaths related to or following known or suspected self-induced or criminal abortion; known or suspected homicide, suicide, or accidental poisoning; deaths known or suspected as resulting in whole or in part from or related to accident or injury either old or recent; deaths due to drowning, fire, hanging, gunshot, stabbing, cutting, exposure, starvation, acute alcoholism, drug addiction, strangulation, aspiration, or where the suspected cause of death is sudden infant death syndrome; death in whole or in part occasioned by criminal means; deaths associated with a known or alleged rape or crime against nature; deaths in prison or while under sentence; deaths known or suspected as due to contagious disease and constituting a public hazard; deaths from occupational diseases or occupational hazards; deaths of patients in state mental hospitals serving the mentally disabled and operated by the State Department of Mental Health; deaths of patients in state hospitals serving the developmentally disabled and operated by the State Department of Developmental Services; deaths under such circumstances as to afford a reasonable ground to suspect that the death was caused by the criminal act of another; and any deaths reported by physicians or other persons having knowledge of death for inquiry by coroner.

STATISTICAL SUMMARY

In calendar year 2011, after a review of the cases based on the ICAN-established criteria, of the total child deaths reported, 238 were referred to the Inter-Agency Council on Child Abuse and Neglect for tracking and follow-up. In calendar 2010, the total child deaths referred to the Inter-Agency Council on Child Abuse and Neglect for tracking and follow-up was 255, a decrease of 17 cases.

The Coroner refers to ICAN all non-natural deaths where the decedent was less than 18 years of age. If the mode of death is homicide, only those cases where the death is caused by a parent, caregiver, or other family member are referred to ICAN.

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DEPARTMENT of coroner REPORT /

DEPARTMENT OF CORONER
Selected Findings
By Cause of Death / 2010 / 2011 / Difference
Abandoned newborn / 2 / 0 / -2
Children run over in driveway accident / 5 / 3 / -2
Bathtub drowning / 3 / 2 / -1
Falling television sets / 3 / 4 / 1
Traffic Accident age less than equal 5 years old / 2 / 1 / -1
Not properly secured in the vehicle / 1 / 0 / -1
Properly secured in the vehicle / 1 / 1 / 0
Swimming pool drowning, age less than 5 years old / 8 / 5 / -3
Figure 1
2011 DEATH STATISTICS
Case Comparison by Mode of Death & Gender (Total ICAN cases: 238)
By Mode of Death / 2011 Total Cases / 2011 % of Total / 2010 Total Cases / 2010 % of Total / Total Difference
Accident / 88 / 37% / 86 / 33.7% / 2
Homicide / 23 / 9.7% / 25 / 9.8% / -2
Suicide / 19 / 8% / 16 / 6.3% / 3
Undetermined / 108 / 45.3% / 128 / 50.2% / -20
TOTAL / 238 / 100% / 255 / 100.0% / -17
By Gender / 2011 Total Cases / 2011 % of Total / 2010 Total Cases / 2010 % of Total / Total Different
Female / 99 / 41.6% / 101 / 39.6% / -2
Male / 139 / 58.4% / 153 / 60.0% / -14
Undetermined / 0 / 0.0% / 1 / 0.4% / -1
TOTAL / 238 / 100% / 255 / 100.0% / -17
Figure 2
2011 DEATH STATISTICS
Case Comparison by Mode of Ethnicity & Age (Total ICAN Cases: 238)
By Ethnicity / Total Cases / % of Total
Armenian / 1 / 0.4%
Asian / 6 / 12.5%
Black / 48 / 20.2%
Caucasian / 50 / 21.0%
Chinese / 2 / 0.8%
Filipino / 2 / 0.8%
Hispanic/latin american / 112 / 47.1%
Japanese / 1 / 0.4%
Korean / 2 / 0.8%
Pacific Islander / 1 / 0.4%
Samoan / 3 / 1.3%
Cambodian / 1 / 0.4%
TOTAL / 238 / 100.0%
By Age / Total Cases / % of Total
Stillborn / 27 / 11.3%
1 day – 30 days / 15 / 6.3%
1 – 5 months / 55 / 23.1%
6 months – 1 year / 48 / 20.2%
2 years / 12 / 5.0%
3 / 8 / 3.4%
4 / 1 / 0.4%
5 / 3 / 1.3%
6 / 5 / 2.1%
7 / 3 / 1.3%
8 / 1 / 0.4%
9 / 2 / 0.8%
10 / 0 / 0.0%
11 / 1 / 0.4%
12 / 3 / 1.3%
13 / 5 / 2.1%
14 / 13 / 5.5%
15 / 7 / 2.9%
16 / 11 / 4.6%
17 / 18 / 7.6%
TOTAL / 238 / 100.0%
Figure 3
2011MODE OF DEATH: ACCIDENTS
by Gender, by Ethnicity, & by Age (Total ICAN Cases: 88)
Accidents by Gender / Total Cases / % of Total
Female / 39 / 44.3%
Male / 49 / 55.7%
TOTAL / 88 / 100.0%
Accidents by Ethnicity / Total Cases / % of Total
Armenian / 1 / 1.1%
Asian / 3 / 3.4%
Black / 15 / 17.0%
Caucasian / 17 / 19.3%
Chinese / 1 / 1.1%
Filipino / 1 / 1.1%
Hispanic/Latin American / 47 / 53.4%
Unknown / 3 / 3.4%
TOTAL / 88 / 100.0%
Accidents by Age / Total Cases / % of Total
Stillborn / 16 / 18.2%
1 day – 30 days / 1 / 1.1%
1 month – 5 months / 2 / 2.3%
6 months – 1 year / 11 / 12.5%
2 yrs / 8 / 9.1%
3 yrs / 5 / 5.7%
4 yrs / 1 / 1.1%
5 yrs / 2 / 2.3%
6 yrs / 3 / 3.4%
7 yrs / 2 / 2.3%
8 yrs / 1 / 1.1%
9 yrs / 2 / 2.3%
10 yrs / 0 / 0.0%
11 yrs / 1 / 1.1%
12 yrs / 2 / 2.3%
13 yrs / 3 / 3.4%
14 yrs / 8 / 9.1%
15 yrs / 3 / 3.4%
16 yrs / 6 / 6.8%
17 yrs / 11 / 12.5%
TOTAL / 88 / 100.0%
Figure 4
2011MODE OF DEATH: ACCIDENTS
by Cause of Death (Total ICAN Cases: 88)
Accidents By Cause of Death / Total Cases / % of Total
Traffic accidents / 44 / 50.0%
Falls / 3 / 3.4%
Struck by falling object / 5 / 5.7%
Fall onto glass table / 1 / 1.1%
Drowning / 6 / 6.8%
Wedged between bed and furniture / 2 / 2.3%
Choking / 4 / 4.5%
House fire / 2 / 2.3%
Environmental hypothermia / 1 / 1.1%
Maternal drug use / 11 / 12.5%
Overdose / 5 / 5.7%
Therapeutic misadventure / 4 / 4.5%
Total / 88 / 100.0%
Figure 5
2011MODE OF DEATH: HOMICIDE
by Gender, by Ethnicity, & by Age (Total ICAN Cases: 23)
Homicides by Gender / Total Cases / % of Total
Female / 8 / 34.8%
Male / 15 / 65.2%
TOTAL / 23 / 100%
Homicides by Ethnicity / Total Cases / % of Total
Black / 4 / 17.4%
Caucasian / 3 / 13.0%
Hispanic/Latin American / 15 / 65.2%
Unknown / 1 / 4.3%
TOTAL / 23 / 100.0%
Homicides by Age / Total Cases / % of Total
1 month – 5 months / 7 / 30.4%
6 months – 1 year / 10 / 43.5%
2 yrs / 3 / 13.0%
3 yrs / 1 / 4.3%
6 yrs / 2 / 8.7%
TOTAL / 23 / 100.00%
Figure 6
2011MODE OF DEATH: HOMICIDE
by Gender, by Ethnicity, & by Age (Total ICAN Cases: 23)
Homicides By Cause of Death / Total Cases / % of Total
Suffocation / 1 / 4.3%
Gunshot wound / 2 / 8.7%
Stabbing / 1 / 4.3%
Blunt force trauma / 18 / 78.3%
Malnutrition and dehydration / 1 / 4.3%
TOTAL / 23 / 100.0%
Figure 7
2011MODE OF DEATH: SUICIDE
by Gender, by Ethnicity, & by Age (Total ICAN Cases: 19)
Suicides by Gender / Total Cases / % of Total
Female / 8 / 42.1%
Male / 11 / 57.9%
TOTAL / 19 / 100.0%
Suicides by Ethnicity / Total Cases / % of Total
Black / 2 / 10.5%
Caucasian / 6 / 31.6%
Hispanic/Latin American / 10 / 52.6%
Filipino / 1 / 5.3%
TOTAL / 19 / 100.0%
Suicides by Age / Total Cases / % of Total
12 yrs / 1 / 5.3%
13 yrs / 2 / 10.5%
14 yrs / 3 / 15.8%
15 yrs / 2 / 10.5%
16 yrs / 5 / 26.3%
17 yrs / 6 / 31.6%
TOTAL / 19 / 100.0%
By Cause of Death / Total Cases / % of Total
Overdose / 1 / 5.3%
Hanging / 9 / 47.4%
Gunshot wound / 4 / 21.1%
Jump from high place / 2 / 68.8%
Jump in front of vehicle / 2 / 10.5%
Intentional crash of vehicle / 1 / 10.5%
TOTAL / 19 / 100.0%
Figure 8
MODE OF DEATH: UNDETERMINED
By Cause of DeathTotal Undetermined Cases: 108
Undetermined by Gender / Total Cases / % of Total
Female / 44 / 40.7%
Male / 64 / 59.3%
TOTAL / 108 / 100.0%
Undetermined by Ethnicity / Total Cases / % of Total
Asian / 3 / 2.8%
Black / 27 / 25.0%
Caucasian / 24 / 22.24%
Cambodian / 1 / 0.9%
Chinese / 1 / 0.9%
Hispanic/Latin American / 40 / 37.0%
Japanese / 1 / 0.9%
Pacific Islander / 1 / 0.9%
Korean / 2 / 1.8%
Samoan / 3 / 2.8%
Unknown / 5 / 4.6%
TOTAL / 108 / 100.0%
Undetermined by Age / Total Cases / % of Total
Stillborn / 11 / 10.3%
1-30 days / 14 / 13.0%
1-5 months / 46 / 42.7%
6 mos - 1 yr / 27 / 25.0%
2 yrs / 1 / 0.9%
3 yrs / 2 / 1.8%
5 yrs / 1 / 0.9%
7 yrs / 1 / 0.9%
14 yrs / 2 / 1.8%
15 yrs / 2 / 1.8%
17 yrs / 1 / 0.9%
TOTAL / 108 / 100.0%
Figure 9
MODE OF DEATH: UNDETERMINED
By Cause of Death (Total cases108)
Undetermined By Cause of Death / Total Cases / % of Total
Sudden unexpected infant death (SUDS) / 15 / 14.0%
SUDS with co-sleeping / 34 / 31.5%
SUDS with unsafe sleep surface / 13 / 12.0%
SUDS with co-sleeping and unsafe sleep surface / 2 / 1.8%
SUIDS with co-existing natural disease / 13 / 12.0%
Intrauterine fetal demise / 7 / 6.5%
Drowning / 3 / 2.8%
Drug exposure / 6 / 5.6%
House fire / 1 / 0.9%
Unexplained blunt trauma / 2 / 1.8%
Failure to treat asthma / 2 / 1.8%
Unknown / 10 / 9.3%
TOTAL / 108 / 100.0%
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DEPARTMENT of coroner REPORT /

GLOSSARY OF TERMS

Accident / Death due to an unforeseen injury, or, in children, a lapse in the usual protection.
Autopsy / Post mortem (after death) examination of a body including the internal organs and structures, including dissection to determine cause of death or the nature of the pathologic change.
Death / For legal and medical purposes: a person is dead who has sustained either:
(a) Irreversible cessation of circulatory and respiratory functions, or
(b) Irreversible cessation of all functions of the entire brain
Decedent / A person who is dead.
Homicide / Death at the hands of another. The legal system rather than the Coroner determines whether a homicide is legal, justified, intentional, or malicious. In children and the elderly, neglect (failure to protect) is classified as homicide.
Mode / Classification of death based on the conditions that cause death and the circumstances under which the conditions occur. The Coroner classifies all deaths using one of the following five modes: accident, homicide, natural, Suicide, or undetermined.
Natural / Death due solely to disease and/or the aging process.
Suicide / The intentional taking of one’s own life.
Undetermined / Cases in which the Coroner is unable to assign a specific manner of death (natural, accident, suicide, homicide).
These cases often involve either insufficient information or conflicting information that affects the Coroner’s ability to make a final determination. The Coroner may designate a death as undetermined as a signal to law enforcement that the case warrants a more in-depth investigation to try to answer some of the questions surrounding the death.The Coroner also modes a death as undetermined when the autopsy findings do not establish any cause of death and one of the following is present:

1. Unsafe sleep surface

1. Co-sleeping with adult
2. Absent or inadequate scene investigation
3. Non-prescribed sedative drugs detected
4. Injuries present
5. Poor nutrition/abnormal development
6. Prior unexplained sibling death
7. History of domestic violence
8. Definite blood in the nose or airway

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