More than half a year after county supervisors ordered improvements in the coroner’s office, local pathologists say they still believe San Diego’s lay coroner should be replaced by a full-scale medical examiner’s system.
County Coroner David Stark, while insisting that his office has taken several strides forward this year, conceded in an interview that he, too, believes the creation of a medical examiner’s office is inevitable.
“That’s the next logical change that’s going to be made,” Stark, 57, said.
Norman Hickey, the county’s chief administrative officer, said he was impressed by the effectiveness of the medical examiner’s office when he headed Hillsborough County, Fla. He said such a switch for the coroner’s office might be included with several other organizational changes he plans to recommend to the Board of Supervisors in the coming months.
Under a medical examiner’s system, Stark, an embalmer by trade, would be replaced by a doctor--a forensic pathologist who would sign all death certificates and have the final say on questions involving the cause of death.
The issue, debated off and on for the last decade, flared anew a year ago when local attorneys and pathologists from San Diego and around the nation said San Diego County was using a small-town system to investigate big-city deaths.
The critics said pathologists under contract to Stark’s office were paid too little for each autopsy and, thus, were forced to cut corners on the sometimes-complex death investigations so they could complete enough autopsies to earn a respectable living. These overworked doctors were further hindered by antiquated equipment, poor working conditions and outdated policies, observers said.
Stark agreed with much of the criticism. He asked for, and received, a large budget increase from the Board of Supervisors to fix the problems.
Now the debate centers on whether that boost has brought meaningful changes.
Stark says the extra money--his budget this year is 13% higher than last year’s--has helped him improve his laboratory by hiring a new toxicologist and lab assistant and buying two important pieces of equipment. A new X-ray machine arrived within the past month and is in use, and a gas chromatograph--a device for analyzing the presence of chemicals in human cells--will be available by the end of the year.
The changes have cut the backlog in the laboratory from 90 days to about 60 days, and Stark said his goal is to reduce the wait for lab results to 30 days.
In addition, Stark said his office has purchased a computer to improve tracking of cases, and a temporary expansion of refrigerated space in the morgue is under way--which will be replaced by a permanent expansion within 18 months.
In response to criticism of his office, Stark has also made several changes in the way bodies are treated when his pathologists are investigating suspicious deaths.
Until this year, bodies were stripped of their clothing and washed before being examined by a pathologist. The clothing from a homicide victim was often turned over to police investigators.
But critics argued that these practices deprived Stark’s pathologists of valuable clues that might help them piece together how a person died.
Now, Stark said, bodies are left in the condition in which they are discovered until a pathologist begins his examination and autopsy. An exception is made in rare cases when police homicide investigators must examine a wound that is hidden by the victim’s clothing.
Stark also agreed, under pressure, to have his doctors begin some investigations at the scene of the death rather than in the sterile confines of the autopsy room. So far, pathologists have visited the homicide scene in only four cases.
On Tuesday, the county announced that the coroner’s office has received a three-year accreditation from the National Assn. of Medical Examiners, certifying that the San Diego office meets the association’s standards for providing an effective system for the medical and legal investigation of deaths.
Yet the office policy that attracted the most criticism is still in place: Stark continues to hire pathologists to perform autopsies on a case-by-case basis and still pays them $100 for each examination.
The Board of Supervisors in December gave Stark the authority to hire six full-time doctors, including one to supervise the medical aspects of the office. But Stark said he has been able to recruit only two new pathologists so far, and he is reluctant to convert the staff from contract to full-time status before he has the entire crew of doctors on board.
Stark said he believes the salary the county is offering--$71,000 to $79,000 annually-- would be sufficient to attract full-time doctors were it not for some complicating factors. He said the cost of moving to San Diego and the price of housing here make it difficult to recruit, but the biggest obstacle is the prospect of passage of Proposition 61 on the state’s November ballot, which would limit the doctors’ salaries to $64,000 a year.
Stark also said he has been cautious in hiring new doctors because the pathologists will be difficult to remove if they fail to live up to expectations.
“We’ve been looking at the doctors very hard because these people will become regular county employees with all the protection of the civil service system,” Stark said.
The coroner, who has had a shortage of positive publicity lately, mentioned another reason for his caution: “You don’t want to hire someone and then have some reporter call up his hometown and find out we hired a jerk.”
Local pathologists and others who have had contact with Stark’s office said in interviews that the deficiencies noted a year ago still exist, and that Stark’s problems with recruiting may be attributed to the office’s poor reputation.
Dr. Stephen Baird, president of the San Diego Pathology Society, said he believes the improvements implemented to date have fallen short of the standards acceptable in a metropolitan area the size of San Diego.
“I haven’t seen any noticeable change,” Baird said. “I think we’ve got to move toward a medical examiner’s system.”
Dr. Paul Wolf, a colleague of Baird at UC San Diego and the Veterans Administration hospital, added: “I think if they had a forensic pathologist in charge, that would kind of dignify the place a little and there wouldn’t be as many problems recruiting.”
In one recent case, Wolf said, he was surprised at the results of an autopsy on a patient who died after a long bout with cancer. The case was sent to the coroner’s office from UC San Diego Medical Center because the patient died shortly after falling and hitting his head in an X-ray room.
The hospital’s own pathologists found cuts to the scalp, as well as bruising and damage to the brain, before they stopped their autopsy and referred the case to the coroner, as is done with all deaths that might not be from natural causes.
“The coroner’s autopsy report of course found the cancer. They did a good job on that,” Wolf said. “But they completely ignored the injury to the head. They said there was no hemorrhage in the scalp, that the brain was completely normal.
“I’m still concerned when I see these cases that the accuracy and efficiency of the medical diagnoses leave a lot to be desired.”
In another case handled by one of Stark’s newly recruited pathologists, the autopsy on an infant boy led to an investigation of the boy’s parents and the removal of a second child from the parents’ home. The autopsy, in January, concluded that the boy had been a victim of child abuse and had died from a head injury applied by blunt force.
A private pathologist hired by the boy’s parents, however, concluded that the infant died a natural death that was the result of birth defects in the brain. Confronted with the second opinion, the coroner’s office changed its conclusion and agreed that the death was from natural causes.
The investigation of the couple was dropped and the surviving child was returned to their custody. Now the parents have filed a $10-million claim against the county.
Robert Espinosa of El Centro, the couple’s attorney, said the coroner’s autopsy reports are unduly influenced by pressure from Children’s Hospital, which aggressively investigates all children’s deaths that might have been the result of abuse.
Espinosa also compared the case to one a year ago in which an Oceanside woman had been charged with murder based on a coroner’s report that concluded her son’s death was not the result of natural causes or an accident. The charges were dropped, however, when a second opinion in the case cast doubt on the quality of the coroner’s autopsy.
“Somewhere along the line, something has to be done to stop this kind of thing,” Espinosa said in an interview.
Because of the pending litigation, Stark declined to comment in detail about the case handled by Espinosa. He said only that the autopsy’s conclusions were changed after additional information came from Espinosa, from the second autopsy, and from the coroner’s office’s own review of the case.