Orange County Grand Jury 2004-2005
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Coroner Case Reviews:
An Examination of the Process
1. Summary
The Orange County Sheriff-Coroner periodically conducts formal hearings into facts
surrounding the deaths of all persons who die while in custody or at the hands of law
enforcement personnel. The hearings are called “Coroner Case Reviews.” They are
referred to in this report as the “review” or “reviews.”
The 2004-2005 Orange County Grand Jury examined the current review process,
concluding that it is well developed, thorough, and impartial. However, the grand jury
found the process leading up to the formal case reviews to be too long (five to seven
months). Because a case review by the sheriff-coroner is necessary before a death
certificate can be issued, the length of time involved creates both emotional and practical
burdens for the families of the deceased. The length of time between the incident and the
formal review also delays notification to the public as represented by the grand jury.
2. Introduction and Purpose of Study
This study examines the coroner’s review process. The deaths involved occurred as a
result of actions by law enforcement officers in the field—such as officer-involved
shootings—as well as deaths that occurred while the decedent was in jail or otherwise in
custody. The process applies to all police agencies in Orange County. The grand jury
serves as the public’s representative at the reviews.
The study explores the extent to which the reviews are objective and unbiased. It
discusses the resources used in preparing for the formal reviews and the efficiency of the
process. It also compares the process used in Orange County with those used in two
neighboring counties.
The study does not address:
The separate investigative process conducted by the Orange County District Attorney’s
office. This investigation determines if there is any criminal culpability on the part of
law enforcement officers involved in such incidents.
Any administrative investigations conducted separately by either the sheriff-coroner or
the local law enforcement agency involved in these types of deaths. The purpose of
these investigations would be to determine what, if any, violations of departmental
policies or procedures might have occurred and what corrective action might be
necessary.
Orange County Grand Jury 2004-2005
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3. Method of Study
During the 2004-2005 year, the jury attended six coroner’s reviews covering 23 deaths.
Tours, interviews, and reviews of regulations and procedures were conducted with
pertinent agencies and personnel. Comparisons were made with methods used in two
other counties.
State laws, county regulations, memoranda of understanding (MOUs), and agreements
between law enforcement agencies were reviewed. Each staff member who participates in
the reviews was interviewed as to his or her role, the adequacy of resources, and his or
her thoughts about the process. In addition, grand jurors attended a coroner’s review in
Riverside County, which uses a process similar to the one used in Orange County. To get
another perspective, grand jurors visited San Diego County, which uses a different
process.
4. Background
4.1 The Review Defined
The coroner case reviews are conducted solely to:
Confirm the identity of the decedent and the place, date, and time of death
Determine the medical cause of death
Determine the manner of death as one of the following:
Homicide (defined as death at the hands of another)
Suicide
Accident
Natural
Unknown
4.2 History
The elected Orange County Sheriff-Coroner is the combined office of what once were
separate county agencies. They were combined in January 1971. Statewide, 45 of the 58
counties have combined these offices under a law that allows each county to choose the
method of carrying out the coroner function.
In 1985, an MOU was adopted by the Orange County Sheriff-Coroner and the county’s
District Attorney. Essentially, it said the district attorney’s office would conduct all
investigations regarding deputy-involved or in-custody deaths under the sheriff’s
jurisdiction.
Since 1990, based on a protocol adopted by the sheriff and local police chiefs, all cities
“shall request an immediate investigation by an uninvolved agency to determine criminal
culpability, if any, of those involved.” It has become customary for the district attorney’s
office to be invited to lead these types of investigations for all city police departments
except the Huntington Beach Police Department. It has a similar agreement with the
Sheriff’s Department. The purpose of these agreements is to avoid any appearance of a
conflict of interest.
Report—Coroner Case Reviews: An Examination of the Process
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4.3 Current Review Process
Upon notification of a death in which law enforcement personnel are involved, special
investigative teams are notified and dispatched to the scene. These teams involve
investigators from the district attorney’s staff, deputy coroners, and specialists from the
county’s forensics laboratory. Members of these teams are on call 24 hours a day, seven
days a week.
An investigation of the scene is conducted. Physical evidence is collected and preserved.
Photos are taken. Diagrams are drawn. The remains of the victim or victims are
transported to the coroner’s facility in Santa Ana, where an autopsy is normally
performed within 24 hours. Toxicology tests are conducted, and x-rays taken. Interviews
of all witnesses and other appropriate parties are conducted.
The following chart shows the participants in this process, their responsibilities, and
whether they investigate at the scene or report at a later time during the overall review
process.














The results of all the factors mentioned above (i.e., evidence collected at the scene,
autopsy and laboratory findings) are presented at informal preliminary meetings among
those participating in the investigation. This allows for questions and assessments as to
whether further investigation is necessary. The entire process is lengthy and requires

Participant Responsibilities for Coroner Case Reviews
Participant Reports to: Investigates
at Scene
Formal
Review
Process Duties:
District Attorney Investigator
and
Team
District
Attorney Yes Yes
• Leads Investigation
• Coordinates activities of all participants at
the scene on sheriff’s calls
• Collects information from all participants
and prepares final report for DA
Sheriff-Coroner Forensic
Specialist
and
Team
Director
Forensic
Sciences Yes Yes
• Collects physical evidence at scene of
death
• Investigates and analyzes all physical
evidence
• Reports all information and conclusions to
DA investigator and Chief Deputy Coroner
Deputy Coroner
and
Team
Chief Deputy
Coroner Yes Yes
• Investigates physical characteristics of
decedent’s body at the scene to include
location and time of death
• Reports all information and conclusions to
DA investigator and Chief Deputy Coroner
Sheriff Coroner Toxicologist
and
Team
Director
Forensic
Sciences No Yes
• Performs toxicology studies on decedent to
determine presence of drugs
• Reports findings to DA investigator and
Chief Deputy Coroner
Forensic Pathologist*
Contract
Position No Yes
• Performs autopsy on decedent within 24
hours of death to determine medical cause
of death
• Reports results to Chief Deputy Coroner
Grand Jury chart 2005
* This contract is with an Orange County Forensic Pathology medical group. When Orange County Sheriff personnel are involved, a
forensic pathologist from outside Orange County performs this function.
Orange County Grand Jury 2004-2005
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many man-hours to complete. Detailed reports must be written, and time to conduct
laboratory tests is required. The circumstances of each case influence this length of time,
as well as the number of cases being investigated at any given time.
When the information is complete, the final results are presented at a formal Coroner
Case Review, which typically covers three to four cases and takes place from five to seven
months after each incident.

















4.4 Formal Review Sequence
A senior investigator from the district attorney’s staff summarizes a detailed time line
surrounding the death.
A senior forensics specialist presents further details, often accompanied with schematic
drawings, other illustrations, or photos.
The forensic pathologist presents a summary of the autopsy, with an accompanying
diagram, emphasizing the medical cause of death.
The senior toxicologist provides the results of testing that was done to determine types
and amounts of drugs that may have been found.
The chief deputy coroner then announces the recommended medical cause and
manner of death based on the evidence presented.

Review Process Flow Chart





















Grand Jury Chart 2005
Officer
Involved or
In-Custody
Death
Dispatch
to
Scene
Lab
Procedures
Comprehensive
Report Presented
by the office of
Chief Deputy
Coroner
Input from:
D.A. team
deputy coroner
forensic team
toxicologist
pathologist
Formal
Coroner Case
Review
D.A.
Investigative
Team
Forensics
Team
Forensic
Pathologist

Toxicologist
Investigation
at Scene under
Direction
of D.A.
Deputy
Coroner
Orange
County
Grand Jury
Report—Coroner Case Reviews: An Examination of the Process
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Questions are taken from the panel, including members of the grand jury.
The sheriff-coroner, or his designee, is then asked to accept the findings and so indicate
on the death certificate.
4.5 Procedure in Other Counties
Grand jurors visited Riverside and San Diego counties to determine how their cases are
handled.
Riverside: Riverside County also has a sheriff-coroner system and conducts coroner case
reviews in much the same manner as Orange County. The most noticeable difference is
the absence of district attorney involvement in Riverside’s coroner reviews. The Riverside
District Attorney does conduct a parallel investigation to determine responsibility and
culpability, if any, but the sheriff-coroner believes there is no requirement for district
attorney investigators to participate in the coroner reviews. Riverside generally has a lag
time of approximately three months between the incident and the review. As in Orange
County, members of the Riverside Grand Jury attend the reviews.
San Diego: The process is different in San Diego County, where the sheriff does not carry
the combined title of sheriff-coroner. Identification of the deceased, and the cause and
manner of death are determined solely by the county medical examiner. The sheriff has
no input and the decision of the medical examiner is not subject to review by the sheriff.
Any investigation as to culpability is conducted by the district attorney. This system
clearly encourages independence and reduces the potential for conflicts of interest.
However, San Diego’s system appears to require a larger organization than the system
used in Orange County. The San Diego system also inhibits the sharing of information
and the potential for economizing on resources.
4.6 Numbers of Review Cases Conducted Historically
During the past five years
(2000 through 2004), the
number of deaths requiring
Orange County coroner case
reviews has increased
considerably. The chart on
the right illustrates the
increase.
During this same period,
other deaths (non-law
enforcement involved) that
require the coroner to make
similar investigations, such as homicides, suicides, traffic accident deaths, etc., have
increased from 8,144 in 2000 to 9,481 in 2004. The number of deputy coroners has
remained static at 17 and the forensic staff has remained at ten. This results in a 16.4%
increase in the overall workload and contributes to the lag in time conducting coroner
Sheriff-Coroner Review History
Year Deaths:
Shooting Deaths:
In-Custody Total
2000 3 5 8
2001 8 6 14
2002 7 5 12
2003 11 15 26
2004 14 11 25
Total 43 42 85
Grand Jury chart 2005

Orange County Grand Jury 2004-2005
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case reviews. The cases in which law enforcement is not involved take an average of two
months to complete.
5. Observations
Interviews conducted by the grand jury revealed that the entire process is time
consuming, taking five to seven months to reach the formal review stage. This creates a
burden for the loved ones of the deceased who must wait for a death certificate. This is
important because death certificates are needed by survivors to settle a decedent’s legal
affairs. For example, death certificates are required by banks, insurance companies, the
Internal Revenue Service (IRS), Social Security, and any transactions involving changes of
ownership.
The grand jury also learned that if death certificates are signed within 60 days of a death,
official copies may be obtained from the county in a timely manner. After that, it may take
up to ten weeks to obtain a copy from the state.
The grand jury sees the formal reviews as thorough and objective in preparation and
presentation. The participants involved in the process are professionals. The illustrations
and schematic drawings of the scene are informative. Perhaps by using computer
technology, they could be even more illustrative of the circumstances surrounding the
incidents.
The participants commented to the grand jury that there is excellent communication and
cooperation among the involved agencies–welcome factors in any investigation.
Further, the appearance of any conflict of interest is dispelled by the objective
participation of the district attorney’s office in the role of lead investigator. The taxpayer
is well served by the competence of the investigators at all levels of this process and the
state-of-the-art forensics equipment available for these investigations.
The grand jury represents the public at the formal review sessions and has the power to
conduct an independent investigation of events presented at these reviews. However, the
long period of time between an incident and the formal review dilutes the potential grand
jury oversight role.
Report—Coroner Case Reviews: An Examination of the Process
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6. Findings
Under California Penal Code Sections 933 and 933.05, responses are required to all
findings. The 2004-2005 Orange County Grand Jury has arrived at the following findings:
6.1 The coroner case review is thorough, objective, and accurately determines the
information required of the sheriff-coroner as to the cause and manner of death.
6.2 The five- to seven-month time difference between the incident and the formal
hearing is too long. This delays issuance of death certificates. It also delays
notification of the public as represented by the grand jury.

Responses to Findings 6.1 and 6.2 are required from the Orange County
Sheriff-Coroner.

7. Recommendations
In accordance with California Penal Code Sections 933 and 933.05, each recommendation
will be responded to by the government entity to which it is addressed. The responses are
to be submitted to the Presiding Officer of the Superior Court. Based on the findings, the
2004-2005 Orange County Grand Jury makes the following recommendations:
7.1 The coroner case review is sound and should be continued. (See Finding 6.1.)
7.2 The sheriff-coroner should develop ways to reduce the time between the incidents
and the formal hearings (see Finding 6.2).

Responses to Recommendations 7.1 and 7.2 are required from the Orange
County Sheriff-Coroner.

8. Bibliography
1. Constitution of the State of California
2. California Government Code; 27491, 24300-24308, 27460-27472
3. California Health and Safety Code; 102850-102870
4. 1985 Memorandum of Understanding between Sheriff-Coroner and District Attorney
5. 1990 Operational and Procedural Protocol–Orange County Chiefs of Police and
Sheriff Assn.
6. Web Site: www.ocsd.org/coroner
7. Web Site: www.riversidesheriff.org/coroner
8. Web Site: www.sdcounty.ca.gov/public/safety
9. Web Site: www.sdsheriff.net/sheriff1.html
Orange County Grand Jury 2004-2005
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