Thursday, June 2, 2016


SB 1189 by Senators Pan and Hannah-Beth Jackson passed the state senate on 2 June 2016. This bill was the subject of two previous stories in The Weinmann Report, 5/23/16 and 5/30/16. We told how an unusual death was discovered at Patton State Hospital where the decedent was found with his head shoved into a barrel, immersed in 13 inches of water, and how the decedent "had a cloth bag over his head and face." The manner of death appeared suspicious and unlikely a suicide. The examining pathologist said that the cause of death was probably drowning but that the "manner" of death was "undetermined." No specific mention was made that the death may have been at the hands of another. Homicide as a possibility wasn't mentioned.

The forensic autopsy to determine actual pathology and cause of death was done by a licensed M.D. The report stated the details of gross and laboratory examination. Toxicology screen was negative.
Witnesses in attendance included one other M.D., the investigator from Patton, two detectives, and the forensic specialist from the San Bernardino Police Department.

SB 1189 was amended twice,  lessening the authority of the examining pathologist, each time seeming to allow police attendance at a forensic autopsy even though the decedent in this case died while he was in their overall custody. Efforts were made in the original state legislation to ensure that forensic autopsies would be done by licensed physicians (that should read California licenses when the death occurs in California). Efforts were also made to ensure that law enforcement could be present at the discretion of the pathologist but not if the law enforcement entity was in charge of the decedent's well being during life. These issues became debating points as the bill moved through the State Senate.

SB 1189 now goes to the Assembly. It currently states that only licensed physicians may do autopsies. We suggest that "licensed in California" be plainly stated to avoid the debacle still encountered in Utilization Review where non-California licensed physicians who have not interviewed or examined a patient may overrule and deny care to patients who've been prescribed care by licensed California physicians.

In addition to the suspicious case described in this report and our two previous reports, there is another case that deserves mention. In Ventura County last year partial autopsies were done by assistants. The doctor who was Chief Medical Examiner at the time was on vacation. He rendered his decision on cause of death upon return from vacation. These two cases explain three sections of currently proposed legislation in SB 1189 and why those sections should be kept strong,

First: the cause of death and the manner of death should be determined by physicians licensed in California if the death occurred in California; 

Second: law enforcement personnel should be allowed entrance into the autopsy suite at the discretion of the pathologist when said law enforcement has completed specified required training and education related to pathology and autopsy protocol;

Third: law enforcement who were involved or responsible for the custody of a decedent who died in their care may not be present.

This writer recommends an aye vote for SB 1189 if these provisions are kept intact.