Outmoded San Diego Coroner’s Office Comes Under Fire

On an otherwise barren wall in a hallway of the San Diego County coroner’s office hangs a modest plaque bearing a quote from American statesman Bernard Baruch.

“Every man has a right to his opinion, but no man has a right to be wrong in his facts,” the plaque says.

County Coroner David Stark and his office have violated those words of wisdom, numerous critics charge.

Local attorneys and doctors, and medical examiners from other counties and states say San Diego County long ago outgrew its old-fashioned coroner’s office, where a layman, Stark, supervises and can overrule the medical judgments that doctors make in the cause of death in thousands of cases, from simple heart attacks to the most complicated suspected homicides.

The office’s use of outmoded techniques and obsolete equipment and the county’s reluctance to pay the going rate for autopsies forces the pathologists who work for Stark to rush through huge volumes of cases to bring up their pay, producing work that barely meets or sometimes falls short of the professional standards of forensic pathology, these critics say.

Because Stark, an embalmer by trade, is an appointed official with no medical background, he is vulnerable to pressure from police, prosecutors and hospital physicians in whose interest it may be to push forward with homicide charges, even when the facts of the case are unclear, defense attorneys complain.

Almost any defense attorney who has been in San Diego for any length of time has a horror story to tell about his or her dealings with the coroner’s office. Though many say they have cordial relationships with Stark and his pathologists, they contend that the office’s shoddy work too often forces attorneys to bring in costly expert witnesses to offer second, and usually conflicting, opinions.

Whether it be the distance between a gun and a victim’s body, the path bullets travel as they pass through the body, or the presence of bite marks on a victim’s tongue indicating a possible seizure just before death, clues from an autopsy can help decide a person’s guilt or innocence or mean the difference between a conviction on charges of murder or manslaughter. Just such clues, critics charge, have been missed or misinterpreted by the coroner and his pathologists.

“The controversy really comes down to the question of what is the most effective and independent and just system for handling the medical examination of deaths,” Elisabeth Semel, president of the Criminal Defense Lawyers’ Club, said in an interview. “My concern is whether or not the system we have is doing the best job in a professional sense.”

Semel and others believe it is time for San Diego County to switch to a medical examiner’s office, in which a specially trained forensic pathologist would lead a staff of full-time doctors, and a layman such as Stark would answer to that doctor and supervise the non-medical aspects of the office.

“San Diego being the size that it is, there is absolutely no question you need a professional type of operation,” said Dr. Werner Spitz, chief medical examiner in Wayne County, Mich., which serves the city of Detroit. “I have an idea that right now this is a hit and miss kind of thing.”

San Diego is the largest city in the nation still served by a county coroner, the only city among the nation’s 20 largest without a county medical examiner or a coroner’s office headed by a doctor. Nationwide, 18 states and the District of Columbia have medical examiner systems and 15 states have coroners. The others have both systems.

In California, four counties--San Francisco, Los Angeles, Santa Clara and Ventura--have appointed medical examiners. Fifty-one counties have elected coroners, coroner-sheriffs as in Orange County, or coroner-public administrators. Two counties have appointed coroner-public administrators and one county--San Diego--has an appointed coroner in a separate department.

Although they often use different techniques, the chief duties of a coroner or medical examiner are the same: to determine the cause and manner--accident, suicide or homicide--of death when someone dies under suspicious or unexpected circumstances. A medical examiner’s office usually has full-time pathologists, who often visit the scene of suspected homicides, a technique used rarely by the doctors who work for the San Diego County coroner on a per-case basis.

At the rate of $100 an autopsy, San Diego’s pathologists must perform nearly 700 autopsies a year to earn $70,000--a wage considered comparable to what they could get in the private sector. That means they often perform as many as five autopsies a day, a rate hospital pathologists say is too high to allow the quality that is expected in a county the size of San Diego.

Dr. Stephen Baird, president of the San Diego Pathology Society and chief of pathology at the Veterans Administration hospital in La Jolla, said the society, which called for a medical examiner’s system several years ago, may do so again after its officers discuss the issue at a meeting Thursday.

Dr. Paul Wolf, a colleague of Baird’s at the VA hospital and at UC San Diego Medical Center, each week routinely reviews hospital and coroner’s autopsies with the deceased patients’ attending physicians and surgeons. Wolf said he is often “embarrassed” at the coroner’s autopsy reports because they fail to mention obvious medical problems that led to the patient’s death.

“They are not as careful as they should be,” Wolf said. “It takes a couple of hours to do a good autopsy. You’ve got to carefully dissect each organ and look for abnormalities. That’s the role of pathologists. We are the quality control of the practice of medicine.”

Wolf said it is not uncommon for an autopsy on a patient who had kidney failure that led to cardiac arrest to report that the patient died of “cardio-respiratory failure” or “cardiac arrest,” while ignoring the underlying causes of the person’s death.

“Just a statement of cardiac arrest is a meaningless diagnosis,” Wolf said. “Everyone who dies has a cardiac arrest.”

But Stark, a thin, soft-spoken man who seems to be enjoying the debate swirling around his office, said the county coroner has no business performing what he calls an “academic autopsy.”

“A coroner’s autopsy does not meet academic standards,” he said. “The mandate for a coroner is to determine the cause of death and the manner of death. Anything beyond that is academic.”

Most of the criticism of Stark’s operation has come over its work in homicide cases, which make up only about 6% of the office’s workload of 2,500 autopsies a year. One of the harshest critics has been Dr. Hormez Guard, a forensic pathologist who worked for the county for 18 months before he was forced to quit in October because of personal and philosophical differences with Stark. Guard now works as a private consultant for defense attorneys, and since severing his ties with the county he has been an almost constant thorn in Stark’s side, in interviews and in testimony from the witness stand.

Guard contends, and interviews with medical examiners elsewhere confirm, that pathologists here are hampered in their investigations because they do not visit the scene of suspected homicides, and they rarely see bodies in the condition in which they are found.

In a March, 1984, case, for example, Guard performed the autopsy on 31-year-old Arthur Hanford, who police said had been shot to death by Mario Brucoli, his 72-year-old landlord. Brucoli contended that he had confronted Hanford over a rent dispute and had pulled a gun in self-defense after the younger man threatened him. The gun discharged in a struggle, and Hanford was killed, Brucoli said. Police homicide investigators, however, relying on the eye-witness accounts of Hanford’s family, said Brucoli shot Hanford, not in a struggle, but from several feet away, and they charged him with murder.

After studying Hanford’s wounds, Guard testified that he could not accurately judge the distance from which the shot was fired. It was then that defense attorney George Booth showed Guard a leather jacket the victim was wearing when he was shot, a jacket Guard had not seen before. The pathologist testified the next day that he could tell from the hole in the jacket that the shot was fired at very close range. Brucoli was acquitted.

“He (Guard) was the most devastating witness I’d ever seen in 12 years of defending people,” said Booth, now a Mono County prosecutor.

A similar issue arose in the ongoing trial of Herman (Rock) Kreutzer, the former candidate for county supervisor who is accused of ambushing and killing his son-in-law, James Spencer, at Kreutzer’s Big Oak Ranch in East County.

Prosecutors contend that Kreutzer shot Spencer while the victim was crouching on his knees, but Guard’s original autopsy said Spencer’s wounds indicated that the bullets traveled upward through his body, a conclusion that clashed with the prosecution’s theory that the killing was an execution. After viewing Spencer’s clothing and, he says, after being cajoled by Stark and a deputy district attorney, Guard amended his autopsy to say that the bullets could have traveled downward.

That conclusion was supported in testimony Aug. 12 by Charles Petty, the chief medical examiner of Dallas County, Texas. Petty, a nationally known forensic pathologist who heads what is considered to be one of the most sophisticated medical examiner’s offices in the country, used a special X-ray analysis to determine the path one bullet took through Spencer’s clothes. Petty said it would be difficult to make such a judgment without the kind of equipment he used.

Like Guard, several attorneys interviewed by The Times also recalled cases in which, they said, the coroner’s conclusions were either incomplete or wrong.

Louis Katz, a longtime San Diego attorney who once headed the county’s Office of Defender Services, said he complained to the county and the district attorney about the “archaic practices” in the coroner’s office as long ago as 1969.

In 1973, Katz handled a murder case in which two experts for the defense determined that the coroner’s office had accidentally mixed microscopic slides of the murder victim’s liver with those from another corpse. Katz blames the low pay for coroner’s pathologists for such mistakes.

“They (pathologists) are getting a hundred bucks,” Katz said. “They use technicians who come in and clean the body, do the incision, cut the skull open and the doctor comes in and just looks. They look at the body and dictate (their conclusions). They want to make sure that for $100 they get in and out fast.”

Coroner’s pathologists here are so rushed that they fail to collect or study all the evidence before making their findings, lawyer Milton Silverman Jr. said. Without visiting the scene of a crime or viewing the victim’s body clothed and, sometimes, bloody, the pathologists are depriving themselves of valuable clues, Silverman contends.

“The traditional way of solving puzzles is to get all the pieces and put them together,” Silverman said. “The coroner’s office doesn’t do that. They go in and look at the body and in some sort of mystical experience, they’re supposed to get vibrations from the dead person as to how he died.”

Silverman was the defense attorney in the first trial of Clifford Lee Stone, a homosexual who was charged with murder in the 1979 death of a woman he said raped him in Balboa Park before he killed her with a large rock. Stone’s murder trial ended in a hung jury after Silverman and Spitz discovered clues that had been overlooked by the coroner’s autopsy.

While the coroner’s pathologist had concluded that three wounds on the back of the victim’s head were the result of bludgeoning, Silverman saw in pictures of the death scene three small rocks close together on the ground, just where the victim’s head had fallen. Spitz showed how those rocks, rather than three separate blows from the defendant, could have caused the victim’s wounds, bolstering’s Stone’s self-defense claim. He was later convicted of manslaughter.

Attorney Stephen Feldman remembers a case in which his client, Larry Overall, contended that a man he killed had attacked him while under the influence of cocaine. But the coroner’s autopsy concluded that the victim’s body had at most a “trace” of cocaine, a finding Feldman said was meaningless for his purposes.

So Feldman called as a witness an expert from a Salt Lake City toxicology lab who performed new tests on the victim’s tissue and concluded that he had in his body a much higher level of cocaine, a finding that gave credibility to Feldman’s contention that the victim had suffered from a “cocaine rage.” Overall’s first murder trial ended in a hung jury and he later pleaded guilty to manslaughter.

In a more recent case, the coroner’s office came under fire from the black community when its original autopsy on Jeffrey Richardson, who died in police custody in October, 1983, concluded that the death was accidental, the result of a PCP-induced irregular heartbeat. A second autopsy by Dr. Robert Bucklin, then a Los Angeles County pathologist and now supervising pathologist in San Diego, found that Richardson’s trachea had not been examined.

Bucklin discovered hemorrhaging on the pharynx and innermost throat muscles, signs that pressure had been applied to Richardson’s neck, despite police reports to the contrary. The autopsy also discovered a small tumor on a vocal cord that further restricted Richardson’s breathing.

Although Stark blamed the error on a terminal brain tumor affecting the memory of the late Dr. Frank Raasch, a highly regarded pathologist who performed the first autopsy on Richardson, leaders of San Diego’s black community said the errors were evidence that the coroner’s office was protecting the police--an allegation that strikes at the heart of the integrity of any coroner or medical examiner.

Similar charges have been leveled against Stark by attorneys who believe Children’s Hospital pediatricians wield too much influence over coroner’s autopsies in cases where child abuse is suspected, pressuring the pathologists to declare a child’s death a homicide when an accident might be a more likely conclusion.

In one case, charges against a woman accused of murdering her child were dropped after a second, private autopsy performed at the request of the defense attorney concluded that the child died of chronic heart disease, not a traumatic heart injury as was alleged. In another case, a Carlsbad attorney has filed a $1-million claim against the county on behalf of a former Oceanside woman who contends that an incorrect autopsy led to her being unjustly charged with killing her 2 1/2-year-old son. Murder charges were dismissed because of insufficient evidence after a preliminary hearing, although she remains on trial for child abuse.

Although Stark’s operation has been criticized in the past by prosecutors in the district attorney’s office, that dissatisfaction seems to have faded.

“Overall, I think the coroner’s office is doing a satisfactory job,” Richard Neeley, chief deputy district attorney, said in an interview. “Of course, there have been mistakes made. That goes along with any profession or business. Mistakes are going to be made. You just try to make as few as possible.”

Stark bristles at defense attorneys’ suggestions that his office is anything but objective.

“Whether you are a coroner or a medical examiner, your mission is to be an impartial office,” he said. “Naturally, you work with the police or the sheriff’s department or the district attorney on a daily basis. But I think to suggest that we work for the police department or for law enforcement is not true.”

Stark, however, concedes that his office has problems. Although he says his pathologists have access to death scenes and clothing if they desire, Stark said he “agrees with most” of Guard’s criticism. Stark contends that the problems cited by Guard and others stem from a lack of money. Although a recent survey shows that most large California counties run coroner’s offices for about $1 per capita--about the same level as Stark’s $2-million annual budget--he contends that the survey does not provide an accurate comparison.

“We need some budget recognition,” Stark said. “We need to clearly identify to the county administration that what we do is an important function. We’ve been suffering along and now it’s beginning to show.”

Stark said his office needs new equipment--”We have modern instrumentation, but it was modern 10 or 15 years ago”--and more technicians to put a dent in the 90-day backlog for laboratory results. He said a coroner’s office should have its own photography department, rather than relying on the work of police photographers. And Stark admitted that the quality of work suffers when his pathologists perform an average of 700 autopsies a year--almost twice the national norm.

“They’re not doing any (autopsies) that don’t need to be done, but they’re not taking the time to do them as carefully as they can,” Stark said.

Stark said he is about to submit to Chief Administrative Officer Clifford Graves a proposal for changes in the office that could cost hundreds of thousands of dollars. He said he will ask that the coroner’s half-time supervising pathologist, whom Stark hired the last time there was pressure for a medical examiner, be made full-time; that two staff members be added to the lab, and that the pay for contract pathologists be raised to as much as $200 per autopsy.

Stark even said he would not argue against the implementation of a medical examiner’s system if that is the choice of the county Board of Supervisors. “I don’t have any problem with that,” he said. “It might be better.”

But he hastened to add that the success of a such a system would depend more on the chief medical examiner than on the office organization chart. Experience in other jurisdictions shows that despite its popularity among pathologists, the medical examiner’s system is not immune from allegations of wrongdoing.

Former Los Angeles County Chief Medical Examiner-Coroner Dr. Thomas Noguchi, an internationally known forensic pathologist and author of the autobiography “Coroner,” was demoted in August, 1983, after he was cited for mismanagement of his department, excessive pursuit of outside activities and making improper statements to the media about the deaths of several celebrities, including Natalie Wood and William Holden.

New York City’s chief medical examiner, Dr. Elliot Gross, took a 60-day leave from his job earlier this month after the state Health Department charged him with medical misconduct in the handling of a series of cases, including deaths of people in police custody.

And Dr. William Brady, the Oregon state medical examiner, has been suspended without pay pending an investigation into an office slush fund allegedly formed with money raised by selling autopsy reports and pituitary glands from corpses handled by the office.

Dr. Joseph Davis, chief medical examiner for Dade County, Florida, said at a recent forum that he believes a coroner can be just as effective as a medical examiner.

“If you have a competent coroner who is not a physician and who is a competent administrator, the office will run well,” Davis said. “If you have an incompetent administrative type of physician who is a medical examiner, the office will have problems.

“I know some people who have never been near a medical school who can walk into a death scene and come up with an extremely accurate appraisal of what really happened. On the other hand, I know people who have doctorate-level degrees who couldn’t find their way out of a paper bag, even if there’s a sign pointing to the opening in the bag.”

(Monday: Coroners, pathologists in conflict of interest?)