SB 1303 (Pan & Gagliani) would replace coroners with medical examiners (Part II)

Incredible as it may seem, it is still true in February of  2018 that non-medically trained persons are allowed by law to conduct autopsies including forensic autopsies where evidence that may be used at trial is being compiled. My previous post told about a particularly egregious abuse of the system, namely, the blatant political assertion of power politics to influence the collection of data to protect persons of authority who appear to have abused their authority to cover up a homicide. Now the tide is turning, or so some hope. Here's why:

State Senators Richard Pan, MD, and Cathleen Galgiani introduced SB 1303. This bill will require that counties of 500,000 or more use bona fide medical examiners for autopsies. The reliance on elected or appointed county coroners will go to the scrap heap of history. The medical examiner will have to be a liccnsed MD.

The wording of the bill needs to be more precise  -- it should say that the Medical Examiner shall be an M.D. licensed in California. There is a reason: when California's Utilization Review (UR) Guidelines were developed, licensed physicians were required to do UR. It was not felt necessary to say licensed in California since all the patients were treated in California  -- that led to a clever tactic by medical provider networks and insurance companies that then scoured the country for doctors who they felt would be willing to deny care to injured workers and others.

It helped insurance companies to use doctors not licensed in California because those doctors could not be held accountable to the California Medical Board for wrongful denials of care. In turn these denials of care enabled insurance companies to avoid paying for medical services. To avoid this quagmire in SB 1303 the bill should be amended to state that Medical Examiners shall be Medical Doctors (MDs) licensed in California. 

In Decmber of 2016 Chief Medical Examiner Bennet Omalu, MD, and Susan Parson, MD, resigned from their jobs in forensic pathology in San Joaquin County. Their complaint was "routine interference" from the Sheriff-Coroner in death investigations. The assertion was that political power was routinely asserted to impede  investigations where law enforcement personnel were involved, for instance, when a detained person died while in custody.

Loss of confidence in government has occurred as a result -- years of ignoring wrongful use of power under cover of authority has always required watchful eyes and is not a popular job. In the medical legal world, replacing elected or appointed coroners with Medical Examiners who are California licensed MDs is overdue.  

SB 1303 is sponsored by the Union of American Physicians and Dentists (UAPD) and by the California Medical Association (CMA). 

Note: Although this blog is independent, not supported by any corporate or union entity, this writer is a member of both UAPD and CMA.  

PART ONE: FORENSIC AUTOPSY LEGISLATION, SB 1189 & SB 1303: what happens when someone dies while in administrative custody?

The first hint that something was wrong in the way forensic autopsies were handled occurred after a psychiatric technician at Patton State Hospital found a decedent with "his head and torso in the trashcan, with his legs across the top of the hamper ... a cloth bag over head and face." The psych tech "pulled (the decedent) out of the trashcan." The man was dead.

A forensic autopsy showed a "a single small petechial hemohrrage in the upper outer quadrant of the left sclerae and conjunctivae, consistent with a head down position." There was also an "acute hemorrhage of the tongue."

Subsequently certain conclusions were drawn including that the psych tech had discovered a "probable drowning" -- not exactly a daring conclusion given the evidence. Official investigation and forensic autopsy followed. The physician's official findings seemed surprisingly tentative given the evidence. The diagnosis was recorded as a "probable drowning (italics added)." It was also stated that the decedent's "manner" of death was "undetermined."  Homicide was not discussed.

In this case the actual forensic autopsy was done by a licensed M.D. Witnesses present included an investigator from Patton State Hospital, one other MD, two detectives, and a forensic specialist from the San Bernardino Police Department. Why were witnesses associated with the decedent's detention present along with a preponderance of law enforcement personnel? The answer is that homicide was a consideration and so was possible mishandling of the case by law enforcement. The forensic autopsy became contentious

As a consequence of this case Senator Pan authored SB 1189 of which one of the provisions was to prevent law enforcement involved in or responsible for the custody of a decedent from being present at a forensic autopsy where their own actions or dereliction may have contributed to the decedent's demise.

The bill stated that the cause and manner of death must be determined by a licensed physician (this issue comes up again in SB 1303). One part of the bill that raised hackles was the section allowing law enforcement personnel to be present in the autopsy suite at the discretion of the pathologist and then only upon completion of pertinent education and training. That's when the sparks started flying. In due course, the bill got amended (some assert it was watered down), but was eventually signed into law on 28 September 2016 and became effective on 1 January 2017.

So now, we ask, why do we need another bill, SB 1303 (Pan)? Stay tuned for Part II. 

References

"Probable drowning (SB 1189, Pan & Jackson)," The Weinmann Report, www.politicsofhealthcare.com, 23 May 2016

"When is Death by Drowning Described as 'Undetermined?' How SB 1189 (Pan) Could Bring Clarity, The Weinmann Report, www.politicsofhealthcare.com, 30 May 2016

"Forensic Autopsy Bill, SB 1189, Clears Senate, Moves to Assembly," The Weinmann Report, www.politicsofhealthcare.com, 2 June 2016

News & Information, Vol. 31 No. 27 Senate Bill 1189 Amends Requirements Relating to Autopsies, www.jones-mayer.com/news/2017/01/03 

FORENSIC AUTOPSY BILL, SB 1189, CLEARS SENATE, MOVES TO ASSEMBLY

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.