Coroner’s Office Is Snowed Under : Audit: The workload has led to a breakdown in controls, report says. It makes 155 recommendations on how to fix things.

The growing number of homicides in Los Angeles County is overwhelming the coroner’s office, leading to a breakdown in controls, sanitary standards and protection of personal property, according to an audit released Monday.

The 319-page report, which took a year to complete, makes 155 recommendations on how to improve the department’s efficiency and working conditions and how to save $500,000.

“Overall, the (coroner’s office) is fulfilling its legal responsibilities, but not without difficulty,” the report concluded.

County Auditor Mark Bloodgood said in a letter to supervisors that the audit did not identify any cases where the cause of death was inaccurate.

However, he said, “ . . . The risk of inaccurate determinations of cause of death will increase” due to physician shortages and increasing homicide cases.

In a letter to the auditors, Chief Medical Examiner-Coroner Ronald N. Kornblum said that he accepted all but 15 of the 155 recommendations to improve the department. Kornblum, reached Monday night at his Pasadena home, defended his department’s performance in the face of a tight budget.

“When you compare it (the office) to what it was like when I took over, I think it is pretty good, but not nearly as good as I would like it,” he said.

The Los Angeles County coroner’s office, with 200 employees and a $14-million budget, is responsible for investigating the cause of suspicious or violent deaths. The office conducts autopsies on about 9,000 bodies annually at its facility near County-USC Medical Center.

The audit found:

* Evidence that improper storage of bodies was contributing to unsanitary conditions. In one case, employees entering a room where cadavers were stored for long periods were forced to don “military-style gas masks” because of the foul odor, the audit says.

“An excessive number of bodies” were stored on portable tables, instead of in refrigerated crypts, the audit said.

Kornblum acknowledged that the crypt where bodies are stored is a “bad area. There are far too many bodies in there, and some of them stay there for quite some time.”

* “Bodies suitable for embalming are often not embalmed for several weeks,” contributing to unsanitary conditions and increasing the health risks to workers. In one case, a body decomposed because it was misplaced and embalming was delayed for several weeks, auditors said.

* “. . . Routine and major cleaning of the crypts (where bodies are stored) does not occur on a regular basis, creating unhealthful working conditions for employees.” The audit said “significant amounts” of dead insect larvae were found on the floor when one of the crypts was cleaned.

* Staff needs better training in identification of bodies. Auditors cited a case where “the identification of a decomposed cadaver was questioned because the weight of the body autopsied was recorded as being 40 pounds greater and the height five inches higher” than the height and weight mentioned on the dead person’s medical records.

These examples and others led the auditors to conclude, “Adequate controls have not been developed to ensure that bodies are properly maintained while in the custody of the department. Procedures which have been established for body storage and infection control routinely are not followed by employees, nor enforced by management.”

It was the first audit of the coroner’s office since 1982, when Dr. Thomas Noguchi was demoted from the post of chief county medical examiner for mismanagement.

J. Tyler McCauley, chief of the county’s audit division, said the $180,000 audit was ordered after a series of allegations were leveled against the coroner’s office, including some that are now the subject of a criminal investigation by the district attorney.

Among the practices still being investigated by the district attorney’s major fraud unit are reports that funeral homes doubled-billed the county and federal government for the cremation of indigents, confirmed Mike Botula, a spokesman for the district attorney.

McCauley said the audit was not intended to be an investigation of specific instances of alleged wrongdoing, but a management audit of general practices and conditions in the department.

The audit, conducted by the private firm of Harvey M. Rose Accountancy Corp., concluded that many of the problems stem from factors outside the department’s control, such as a nationwide shortage of pathologists and the increasing number of homicides requiring autopsies.

Homicide cases in 1989 jumped to 2,091 from 1,892 murders the year before.

The Los Angeles County coroner’s office, one of the busiest in the nation, last year handled 18,019 investigations while its 15 doctors performed 5,804 autopsies.

Auditors also concluded that since the coroner disbanded his short-lived internal investigations unit, “the department has been operating without an effective means of monitoring and preventing illegal and improper activities by staff.”

“As presently structured, department management is sending the message to staff that the investigation of illegal activities and improper conduct are not a high priority matter,” the report said.

Kornblum took over a coroner’s office in 1982 beset with controversy in the wake of the demotion of Noguchi, who was accused of poor management, loose evidence controls and letting his private counseling work interfere with his job performance.

After a series of court battles, Noguchi, the flamboyant “Coroner to the Stars,” failed to get his old job back and is currently a pathologist at County-USC Medical Center.

Noguchi had hired Kornblum in 1980 as the coroner’s chief of forensic medicine. Kornblum, a Chicago native, had been the Ventura County coroner, where police officials described him as an excellent pathologist, an evaluation currently supported by his peers.

By his own admission, however, Kornblum does not enjoy the job of day-to-day management of the cororner’s office.

“I’m a scientific person,” he said in a 1989 interview with The Times.

Regarding his administrative abilities, he said: “I’ve never had any formal training. If I have an Achille’s heel, that where it is.”

Kornblum said that when he became coroner, one of his immediate goals was to instill more “professionalism” in his staff and to carry out the duties of the office in a low-key manner in dramatic contrast to the razzle-dazzle style of his predecessor.

For example, Kornblum disdains the media spotlight, particularly news conferences, whereas Noguchi was known for his colorful sessions with reporters whenever a celebrity’s death came under his office’s investigation.

“We’re physicians,” Kornblum told a reporter. “We have an important job to do and we should do that with professionalism and with dignity and not make a big show out of it.” Times staff writer Ronald L. Soble contributed to this article.