Grand jury report blames underfunding for problems at coroner’s office

A official of the Los Angeles County coroner's office removes the body of a Los Angeles International Charter High School student who was killed in a vehicle-vs.-pedestrian accident.

A official of the Los Angeles County coroner’s office removes the body of a Los Angeles International Charter High School student who was killed in a vehicle-vs.-pedestrian accident.

(Rick Loomis / Los Angeles Times)

A civil grand jury report released Thursday blamed problems in the Los Angeles County coroner’s office — including lengthy backlogs in autopsies and toxicology reports — on underfunding.

The Los Angeles County Civil Grand Jury concluded that the Department of the Medical Examiner-Coroner “is significantly understaffed in both coroner investigator and laboratory positions, has a sobering backlog in toxicology testing” and is likely to lose its accreditation if those issues are not addressed.

Losing accreditation could open county officials “to attacks on their credibility in criminal cases,” the grand jury wrote.

The coroner’s office has more than 400 bodies stored in its crypt on average and is “incapable of meeting, in the vast majority of its cases, the minimum acceptable standard autopsy report completion time of 90 days,” the report said. About 160 bodies are awaiting examination or autopsies, and an additional 250 need further testing or identification, or have been abandoned by relatives.


The job of the coroner’s office is to investigate violent and unusual deaths. Of the 60,000 to 80,000 deaths each year in the county, more than 20,000 on average are reported to the medical examiner’s officer, which brings 8,000 to 9,000 bodies in for closer examination.

The report also called out backlogs in the Office of Decedent Affairs — a separate county division that runs the county morgue at the L.A. County-USC Medical Center, the county crematory and the county cemetery.

Grand jury investigators found a “disturbing backlog of about 250 bodies stored in ‘temporary’ refrigerated trailers at the county morgue.” The backlog has since been eliminated, the report said.

The panel questioned whether it makes sense for the county to continue operating its own crematory for unclaimed dead, noting that only two of the five furnaces at the facility are operational and that the crematory can process only 10 bodies a week.

The report discussed a possible merger of the coroner’s office with the Office of Decedent Affairs, which is part of the Health Services Department. County officials have been considering a consolidation, and the grand jury found that “having separate offices in two departments unnecessarily separates county-provided services to the dead and for their survivors.”

But it added that a consolidation should not be considered until the coroner’s office has enough staff to meet its current requirements.

The county’s top medical examiner, Mark Fajardo, announced his departure last month after less than two years on the job. Fajardo attributed the office’s persistent backlogs to a lack of resources.

The grand jury appeared to agree with Fajardo’s assessment, saying the Board of Supervisors had given “inadequate resources” to the department, whose funding has remained flat for the last two years and is slightly reduced in the proposed budget for next year.


The report said that the number of investigators, forensic pathologists and toxicologists should be increased immediately and that salaries for the positions should be increased to make Los Angeles County competitive and aid in recruiting.

It’s not the first time the grand jury has called out short staffing at the coroner’s office. A 2010 report raised similar concerns.

Los Angeles County Supervisor Hilda Solis, who chairs the board, said in a statement that she was “deeply concerned” by the report.

Solis noted that the department is using outside labs to reduce the testing backlog, but said, “The overall backlog described in the report is simply unacceptable, and I am confident this board will address it with the utmost urgency.”


County Chief Executive Officer Sachi Hamai said last week, when the proposed budget was released, that the office had failed to provide required documents justifying its request for more staffing.

The department had requested 80 positions be added to its budget, but the proposed budget would increase the number by just two.

Hamai said at the time that positions might be added at a later stage in the budget process.

Coroner’s spokesman Ed Winter referred requests for comment on the grand jury report to the chief executive office.


David Sommers, spokesman for the chief executive office, said county officials had taken steps to help the coroner’s office recruit and retain staff. In January, the coroner’s office was authorized to increase the salary rate for forensic pathologists to a higher “manpower shortage recruitment rate,” he said, and bonuses for forensic attendants were approved during recent labor negotiations.

Staff from the chief executive and county auditor-controller offices did on-site assessments of the coroner’s operations and administration in February and March, and a five-member support team made up of staff from other departments is on site helping to run exams and hire staff and make sure recommended reforms are implemented, Sommers said.

Fajardo’s predecessor, retired longtime coroner Dr. Lakshmanan Sathyavagiswaran, has been appointed to head up the office on an interim basis until a permanent replacement is found.

Twitter: @sewella



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