The alleged mishandling of death investigations in San Joaquin County inflicted distress and extra costs on grieving families, wasted county resources and potentially impeded prosecutions — according to two forensic pathologists who quit performing autopsies for the sheriff-coroner last year.

A KQED investigation into those allegations confirmed that the coroner’s office, under Sheriff Steve Moore, released the wrong bodies to families in 2016 and 2017, and once lost track of a body in the morgue for months.

The coroner also charged hundreds of families hundreds of dollars each to transport their loved ones to the morgue — unnecessarily, the doctors say.

In other instances, sheriff’s deputies — who are also charged with coroner duties — failed to report deaths to the forensic pathologists that the county was legally required to investigate in a timely manner. The doctors said that prevented them from performing the autopsies and tests necessary to determine how and why the people died.

In San Joaquin County, as in most California counties, the elected sheriff is also the coroner and is charged with investigating sudden, suspicious or violent deaths.

Dr. Bennet Omalu (Courtesy of Dr. Bennet Omalu)

Allegations of misconduct in the San Joaquin County Sheriff’s Office surfaced last year when Dr. Bennet Omalu, the chief forensic pathologist for the county, resigned — one week after the resignation of his colleague, Dr. Susan Parson, also a forensic pathologist. Omalu, world renowned for his discovery of a deadly brain disease in professional football players, accused Moore of interfering with death investigations in order to protect law enforcement officers. Both doctors said the sheriff prevented them from completing investigations by withholding evidence and investigatory reports.

Omalu declined to comment on specific allegations, but in a recent interview he said: “We should never, ever, compromise our standards, compromise the integrity and the credibility of the system, especially in this type of work, where people have placed their trust in you to tell them the truth.”

Moore said in December that he never interfered with the findings of his forensic pathologists, who determine the cause of death, but that he has the final say on the manner of death.

“I do that based on the totality of the circumstances, up to and including the autopsy report provided by the doctor and the investigative report done by the coroner’s investigators,” Moore said.

Moore refused several subsequent requests for interviews.

Wrong Remains

The most shocking allegations against the coroner involve two cases where staff mixed up bodies in their care and released them to the wrong families.

That’s what happened to Carmen Rogers, whose husband, Marvin, 54, died of complications from heart disease in a Stockton motel on May 31, 2016.

Rogers declined to be interviewed about what happened, but she told her story in a legal complaint against the sheriff. Details of the handling of Marvin Rogers’ death were also revealed in internal sheriff-coroner records obtained by KQED.

Rogers agreed to have her husband cremated, and the coroner’s office sent his body to Zapata Funeral Home, according to a computer entry in coroner records.

The family held a funeral service for Marvin with the urn of what they thought were his ashes in the room; some of his cremated remains were also placed inside 14 necklaces given to his grandchildren, according to the complaint filed in San Joaquin County Superior Court.

Necklaces that can hold cremated remains for sale in San Joaquin County mortuary. (Julie Small/KQED)

But about a month after the funeral, Rogers received a call at work from the sheriff’s office, asking her to meet “to discuss an important matter,” according to the lawsuit.

The complaint details how sheriff’s detectives explained that the coroner’s office had mixed up her husband’s body with the body of another man with the same last name. The funeral home had cremated the other man’s body and sent Carmen Rogers his ashes. The body of her husband, Marvin, remained at the morgue.

After learning of the mistake Rogers was “distraught,” according to court records — “she had trouble sleeping, felt anxious, and missed work because she could not concentrate” and sought psychological counseling.

Carmen Rogers and her family held a second funeral, with the correct ashes, a month later.

In March 2017, they sued Sheriff Moore and the funeral home for damages, to cover the costs of the second funeral, and for emotional stress and strain. The family is currently in settlement negotiations with the county.

Who Was Cremated?

Meanwhile, Theresa Zavala, the daughter of the man who had been mistakenly cremated, had no idea where her father was.

Zavala, who lives outside Los Angeles, had not heard from her dad, John Rogers, for months and she filed a missing person’s report, according to her attorney. The San Joaquin County Sheriff’s Office contacted her in July 2017, more than a year after John Rogers’ death.

Sgt. Mike Reynolds phoned Zavala and said he wanted to meet with her in person to tell her what had happened to her father. According to coroner’s documents obtained by KQED, he traded messages with Zavala for months before agreeing to her request to mail the police report and discuss the matter over the phone.

John Rogers was discovered dead on May 2, 2016, in the back parking lot of Bay’s Bistro, a shuttered Lodi restaurant, according to the coroner’s records. A homeless advocate found John lying on a pile of clothes with his head propped up against a fence. Detectives were able to identify him by a driver’s license in his pocket, but could not locate his next of kin. An autopsy and toxicology test determined the 59-year-old had died of an overdose.

John’s body had been at the morgue for a month, when, on June 6, 2016, coroner staff mistakenly released his remains to Marvin Rogers’ family.

In case notes about his Oct. 6 call with Zavala, Sgt. Reynolds recounted, “I explained how the incident occurred, our actions upon discovering it occurred, and the steps we have taken to prevent it from happen[ing] again.”

Simran Sekhon, Zavala’s attorney, said the coroner promised to send Zavala her father’s remains — but to this day, she has not received them.

“They did not have an opportunity to have a funeral,” Sekhon said.

Zavala and her two sisters filed claims against San Joaquin County in January, in preparation for a lawsuit.

Another Mix-Up

In December 2017 the coroner’s office repeated the mistake — of releasing the wrong body — that had caused Carmen Rogers and Theresa Zavala so much distress. Deputies gave a Lodi family the body of a stranger — a man who shared their father’s last name, but who was decades younger.

The younger man, Robert Silva, 45, died on Oct 21, 2017, at Lodi Memorial Hospital from an infection in his blood.

About a month later, Richard Silva, 88, died of a heart attack at his senior living facility.

It took a week before officials in the coroner’s office realized they had given the wrong body to Richard Silva’s children.

On Dec. 11, deputies delivered Richard’s body to the family’s chosen funeral home and reclaimed the body of Robert.

A Dec. 12 computer entry states, “decedent was released in error on 12/04/07… Notification of the error has been made to next of kin.”

Richard’s son declined to comment for this story.

Authorities determined Robert was indigent and cremated his body at the Bay Area Cremation and Funeral Service in Stockton.

Learning From Mistakes

Rocky Shaw, with the California State Coroners Association, said these kind of mistakes are rare, “but we know it does happen.”

Shaw, who is the supervising deputy coroner for San Bernardino County, said his department once discharged the wrong body to a family, back in 2001.

“You know it’s the most embarrassing thing to an agency because the trust that we hope to instill in families is completely gone,” Shaw said. “I think if that happened to me, I’d think, ‘What are these boobs doing?’ ”

Shaw said San Bernardino officials purchased a new casket for the deceased person and paid all the mortuary costs. Luckily, he said, the family was forgiving and did not sue the department.

Shaw said he tells that story as part of a training course he teaches for coroner deputies in California — as an example of what can go wrong and how to prevent it.

The San Bernardino County coroner adopted new procedures and has not repeated the mistake. Two autopsy assistants and a supervisor have eyes on every release.

“We have adequate staffing.” Shaw said. “We make sure the procedures are there.”

Shaw said the fact that the San Joaquin County coroner mixed up bodies twice indicates the problem wasn’t adequately addressed.

“I mean if you have two, there’s something that they didn’t probably put into place,” Shaw said. “It could be a multitude of issues, but it’s terribly embarrassing and wrong.”

The chief medical examiner in Santa Clara County, Michelle Jorden, said her office established protocols to reduce the chance of mix-ups.

“It hasn’t happened here.” said Jorden, who added that each body in her morgue is assigned a case number that’s printed on a toe tag.

“The body will not be released until we have two people look at the toe tags and the matching paperwork,” she said.

Problems with adequately tracking bodies in the San Joaquin County morgue date as far back as 2013. That’s when a body went missing for more than six months. Sources close to the office said a technician discovered a badly decomposed body in the morgue. Meanwhile, the person’s relatives had been asking for their loved one for months — and were told the body was not there.

In recent years Omalu has recommended purchasing a Laboratory Information Management System (LIMS) for tracking bodies and specimens, a standard tool used by hospitals. He said the sheriff told him it was too expensive.

At one local mortuary in San Joaquin County, staff said that the coroner’s office has released the wrong body to them often enough that they now ask family members to view and identify each body before cremation or burial.

Sheriff Moore declined to answer questions about how bodies are tracked in the morgue.

Who Should Pay the $352 Coroner’s Fee

Another sign of mismanagement by the sheriff-coroner — according to Omalu and Parson — is that coroner’s deputies bring hundreds of bodies to the morgue each year “unnecessarily.”

In several memos documenting the issue, Omalu and Parson estimated that 40 percent of the bodies brought to the county morgue could have had death certificates signed by a treating physician, because the death was not unexpected or violent. That would spare families a $352 coroner’s transportation fee, and delays before they can cremate or bury a loved one.

Sheriff-coroner transportation fee, San Joaquin County (Julie Small/KQED)

For example, in one weekend in June 2017, Parson wrote, four out of 11 bodies brought to the morgue could have been handled by outside physicians.

“Those bodies should have never even come to the morgue,” Parson lamented in a memo. “They should have gone straight to the funeral home.”

Annual reports from the San Joaquin County Sheriff-Coroner’s Office show that in 2015, 351 bodies brought to the morgue — or 32 percent — were later referred to outside physicians to sign out. In 2016, it was 34 percent.

The total handling fees for those potentially unnecessary transports added up to more than $100,000 each year in revenue for the sheriff’s office.

Families of the people who died in San Joaquin County may not have noticed they paid a fee for coroner’s services. The cost is publicly posted on the sheriff-coroner website, but mortuary companies pay that fee directly to the sheriff and then bill the families for it.

The forensic pathologists say the extra work also taxes coroner resources and staff time, including detectives who spend hours contacting doctors to get them to sign death certificates, and autopsy technicians who move and store bodies.

“This gross inefficiency impacts everybody … and increases both tangible and intangible costs for the family and for the county,” Omalu wrote in a Sept. 10, 2017, memo.

Some Deaths Overlooked

Finally, the two forensic pathologists allege that the San Joaquin County Sheriff’s Office is not investigating some deaths that it should be.

In one case, the family of a Lodi woman who died in January fears they’ll never know the cause of death.

Tracy Espinosa described what happened to her fiance’s sister in an interview.

Tracy Espinosa of San Joaquin County (Julie Small/KQED)

Espinosa said her fiance’s sister, Julie Russell, had been cooking dinner around 7 p.m. on Jan. 22, 2018. Three hours later, she died.

The 60-year-old had a case of flu, and possibly pneumonia and heart problems. She also had a history of drug addiction and alcoholism, and her bedroom contained empty liquor bottles and prescription painkillers for her arthritis.

Russell’s son found her lying on the floor and called an ambulance and then called relatives.

Police cars and an ambulance were already at the house when Espinosa arrived that Monday night to find Russell flat on her back, eyes wide open, foaming at the mouth.

Espinosa does research for law enforcement on cold cases, so she knew the criteria for a coroner to take a case. She was surprised when the sheriff’s deputy said he wasn’t going to take Russell’s body to the morgue — even though she thought Russell was an obvious coroner’s case. The deputy told her to pick a funeral home instead.

“By Friday the coroner’s office told me they were coming to get her body and that they were going to charge me $350,” Espinosa said. “I said, ‘What are you talking about? She’s been at the funeral home for four days. Now you’re going to go get her?’ ”

The coroner conducted an autopsy, but Espinosa said she was told the results won’t be available for three to four months. Espinosa said she is supporting Sheriff Moore’s opponent in an upcoming election.

Omalu and Parson documented other cases where law enforcement officers failed to notify them of people who died under questionable circumstances.

One recent example involves the fetus of a woman who miscarried at 32 weeks, a month after her boyfriend assaulted her. According to an Aug. 25 memo titled “Gross Negligence of Possible Fetal Homicide,” Parson wrote that the woman told a funeral home employee about the assault and the funeral home relayed the information to the detective right after the baby died on July 9, yet no case had been opened on the death.

“I asked why he didn’t bring this to my or Dr. Omalu’s attention before now and he responded that he’s been busy,” she wrote.

Parson said by the time she learned of the baby’s death several weeks later, it was far too late to be able to determine whether or not it was related to the assault.

“I am deeply troubled that somewhere along the line, gross negligence occurred in the management of this case allowing a potential fetal homicide to fall through the cracks,” Parson wrote.

The doctors say these kinds of mistakes can happen when law enforcement officers are asked to perform medical duties.

Patrol Deputies Receive Minimal Training on Death Investigations

Sgt. Steve Walker, who retired from the San Joaquin Sheriff’s Office in 2012, said he did not receive enough training on death investigations in the academy for patrol officers.

“All I got was a manual with the words ‘coroner cases’ on it,” Walker said.

He said that wasn’t enough to prepare him to determine who should go to the morgue and who could go directly to a mortuary.

Sgt. Steve Walker retired from the San Joaquin Sheriff’s Office in 2012. (Courtesy of Steve Walker)

“When you’re on patrol, you’re doing patrol duties,” Walker said. “You’re handling criminal cases and maybe doing traffic — could be anything from a barking dog to a homicide.”

Walker said as a patrol deputy he would go days without handling a single coroner’s case, and then have to go to an intensive care unit where someone had died and rifle through binders of medical records full of words he did not understand just to figure out whether a physician could sign the death certificate instead of the coroner.

Moore is up for re-election this year, with a primary in June, and Walker is campaigning for his opponent, Pat Withrow.

California requires deputies to complete 80 hours of death investigation training within their first year on the job — and 32 hours every two years after that if their primary job is conducting coroner duties. Detectives in the sheriff-coroner’s office in San Joaquin County fall under this category, but deputies like Walker, who have a variety of duties, receive some initial training, followed by just a few hours of in-service training on coroner cases each year.

Sheriff Moore’s information officer, Deputy Dave Konecny, referred questions about staff training requirements to the San Joaquin County counsel.

A New System for Investigating Deaths

The county counsel and district attorney both said they are investigating the allegations made by Omalu and Parson, but two months on, neither agency has announced any findings.

The county Board of Supervisors has commissioned an analysis of coroner operations, which will include a comparison of the sheriff-coroner system with a medical examiner system — in which a forensic pathologist, rather than a law enforcement official, oversees death investigations.

“If the Board of Supervisors and residents want it,” Moore said late last year, “I would fully support separation.”

If the coroner’s functions are taken over by a medical examiner, Moore would continue in his elected role as the county sheriff and public administrator.

At a recent Board of Supervisors hearing, County Administrator Monica Nino said the study on the sheriff-coroner operations will not be ready until April.

The president of the San Joaquin Medical Society criticized “the lack of urgency” in addressing the allegations in a letter to supervisors this week.

“The stakes are high,” Dr. Grant Mellor wrote. “We are about to lose two highly respected, hardworking forensic pathologists.”

Parson’s last day is Feb 25. Omalu’s decade-long service ends March 5. But both doctors have said they would stay on if county officials could ensure their independence.

How Families in San Joaquin County Pay for Coroner Mistakes 10 February,2018Julie Small

Author

Julie Small

Julie Small reports on criminal justice and immigration for KQED News. Before joining KQED, she covered California government and politics for KPCC (Southern California Public Radio).  Julie began her 15-year career in journalism as the deputy foreign editor for public radio’s Marketplace. Julie’s 2010 series on lapses in California’s prison medical care won a regional Edward R. Murrow Award for investigative reporting and a Golden Mic Award from the RTNDA of Southern California. Julie earned a master’s degree in journalism from USC’s Annenberg School of Communication. She grew up in Los Angeles and now calls the East Bay home.  Contact:  jsmall@kqed.org

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