Saturday, February 19, 2011

Post Mortem - the Nevada County basics

Basic background information; with minor additions Mar. 1

If you saw the joint ProPublica/CaliforniaWatch/PBS Frontline investigation Post Mortem earlier this month, on the difficulties, shortcomings and lack of oversight of death investigations in the United States, you may have wondered what the situation is like in Nevada County.

It turns out that their investigation has a local angle: Forensic Medical Group, the Northern California traveling autopsy firm that employed and then re-employed problem-plagued forensic pathologist Thomas Gill, has done autopsies for Nevada County; and some of these were done by Dr. Gill.
(Note: Dr. Gill responded to Frontline saying no problems have been reported with autopsies he's done since rejoining FMG in 2007; but this statement is contradicted by further ProPublica reporting.)

Looking into how things are done in Nevada County, what I've got so far is this:

In Nevada County, as with most California counties, cause of death is determined by the coroner, who is also the sheriff - for us, that's Keith Royal. This official need have no special qualifications for the job, since it's an elected position. The actual coroner duties are delegated to the chief deputy coroner, Paul Schmidt, Schmidt told me; and then where needed, the autopsies - which might be just an external examination, or external plus internal - are contracted out to Placer County's coroner's facilities (as are Sierra County's), where they're normally performed by Placer's board-certified forensic pathologist, Dr. Donald Henrikson. When Dr. Henrikson is unavailable - when he's "on vacation, sick or is attending training" - Forensic Medical Group's forensic pathologists cover for him.
(to forestall confusion: Forensic Medical Group and California Forensic Medical Group are two entirely different entities.)

I asked if Dr. Henrikson's cause-of-death determinations have been overruled by the coroner; both Henrikson and Schmidt said no, and Schmidt also said Sheriff Royal had not overruled him on cause of death.

There's a winnowing process, so that only a small fraction of county deaths undergo autopsies through the coroner system. Nevada County deputy coroner Schmidt explained that most deaths don't even come to the coroner's attention: "generally speaking, natural deaths occurring in a hospital or medical facility and/or under a hospice physician’s care are not coroner cases". He told me California law lays out the conditions under which the coroner must be notified (Health and Safety Code 102850), and also conditions for a coroner's case proper (California Government Code Section 27491 ), writing, "the Coroner...[must] inquire into and determine the circumstances, manner, and cause of sudden deaths where the attending doctor is unable to determine the cause of death or the death is the result of homicide, suicide, accidental or undetermined means....[and also] deaths where the decedent has not been seen by their physician within 20 days".

According to the NevCo 2005-2009 Coroner's Statistics (pdf), in 2009 the winnowing went like this: 828 deaths were reported in the county, of which a little over a third (344) were reported to the coroner. Of these, less than half (153) became actual coroner cases (a distinction I don't yet understand). Of the actual coroner cases, about a third were not autopsied. (Schmidt explains that "The only time State law requires autopsies is in cases of sudden infant death syndrome. In all other death investigations, autopsies are optional. Those cases that are not actually autopsied are subject to a review of all medical records, an external examination and toxicology or combinations thereof.") The remaining two thirds (roughly 100) were autopsied. Of these ~100 autopsies, 10 were done by Forensic Medical Group, 3 of these by Dr. Gill, according to Placer County chief deputy coroner Dennis Watt.
(I do not know which ten, or which three.)

The thrust of the Frontline investigation was that the absence of regulations on death investigators leaves room for problems - due to overwork and shortcomings in training and oversight. One improvement they suggest is accreditation - by the National Association of Medical Examiners (NAME ) or the International Association of Coroners and Medical Examiners (IACME ). "The Placer County Morgue has not accredited", Watt told me, though he notes it's hardly alone in this, saying "I believe only three counties out of 58 have requested N.A.M.E accreditation."
(Watt is a member of the California State Coroners Association. (link) )

Number of autopsies done by one pathologist
A primary concern of NAME's is overwork - that when a forensic pathologist does too many autopsies, the likelihood of error rises. "The association recommends that doctors do no more than 250 autopsies per year, and 325 at the absolute maximum." (link ). Dr. Henrikson told me he does around 378 a year, of which very few - only about 3 dozen - are external only.

Whether to autopsy
Dr. Henrikson said the decision on whether to autopsy is usually discussed and made jointly by him and the chief deputy coroner, the exceptions being cases where an anthropologist's services are more appropriate. And he said that if the decedent's physician is convinced of the cause of death & willing to sign the death certificate to that effect without an autopsy, then no autopsy is deemed necessary.

Conflict of interest
When there's a potential conflict of interest in Placer County, e.g. if a suspect dies when in custody, they bring in an independent investigator, Dr. Henrikson said.

Corrections? What have I overlooked?

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