Supervisors Order Full Evaluation of County Coroner’s Office

Acknowledging widespread public criticism of the coroner’s office, San Diego County supervisors on Tuesday ordered Chief Administrative Officer Clifford Graves to conduct a full-scale study of the department and propose ways that some of its more serious problems could be solved.

Among the questions the board wants answered is whether the county should convert the coroner’s office to a medical examiner’s system. Under such a system, a specially trained forensic pathologist heads a staff of full-time doctors, and a layman answerable to the pathologist supervises the non-medical aspects of the office.

But even if a medical examiner is not the solution, supervisors said, they want to know what can be done to restore the office’s credibility in the eyes of many of the county’s medical and legal professionals. Some have complained in recent months that Coroner David Stark’s overworked staff uses outmoded techniques and equipment and often produces shoddy autopsies that fail to fully or accurately explain the cause of death.

Supervisor Susan Golding told Graves she was not satisfied with a 14-page report on the coroner’s office he submitted Tuesday. Graves’ report concluded that the county need not convert to a medical examiner’s system to ensure good work.

“I am not convinced that we must go to a medical examiner system, but I’m not convinced we don’t need to, either,” Golding said. “I think we need a lot more work and a lot more information.”

Golding said her conversations with those in frequent contact with the coroner’s office have convinced her that the operation has serious problems.

She questioned the office’s limited use of medical techniques in the field, where deputy coroners, not doctors, visit death scenes. Unlike many medical examiner’s offices, the coroner’s policy does not call for taking body temperature to help determine the time of death.

Golding said she has also been told that the $100 per autopsy the county pays its contract pathologists is too low, forcing them to handle a high number of cases to bring up their pay. She also said there was insufficient control over the quality of the pathologists’ work and that the office’s lab was deficient.

In a brief hearing, the coroner’s office was assailed by two defense attorneys and a doctor who is head of the county pathology society.

Attorney Milton Silverman Jr. called the current system “completely laughable and totally inadequate.”

“The fact is all the modern jurisdictions nationwide that are top-notch have a medical examiner’s system,” Silverman said.

Dr. Stephen Baird, directory of pathology at the Veterans Administration Hospital in La Jolla, told the board he would submit “as many examples as you want” of what he considers poor-quality autopsy reports produced by the coroner’s office.

“We would recommend a thorough examination of the structure of the coroner’s office and personnel, with primary consideration being the quality of the reports that come out,” Baird said.

Stark, an embalmer by trade who has been with the coroner’s office for 23 years and has been coroner since 1978, said he welcomed the increased scrutiny of his operation. But he said recent changes in the organization of his office should be enough to solve most of the problems cited by his critics. The others, he said, could be remedied by adding $300,000 to his annual budget of $2 million.

Stark said the coroner’s office was “emasculated” when voters decided to make it an appointed position in the early 1960s. He said the move deprived the office of its power to pressure supervisors for a larger budget. Since Proposition 13 was passed in 1978, the coroner’s budget has not kept up with the growth in the county’s population and advances in technology, Stark said.

“They (the supervisors) have got to take the coroner’s office more seriously,” Stark said after the meeting. “When an airplane falls out of the sky or some guy goes berserk in a restaurant they pay attention, but not on a day-to-day basis. You hear very little about the coroner’s office until there’s a problem.”

Stark said he has no intention of leaving his post before his scheduled retirement date, which is about four years away.

“It’s very tempting now to say the hell with it and throw in the towel,” he said. “But I have too many years invested in it. When I leave, the office will be in as good a shape or better than it was when I came.”