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Autopsy Doctor Resigns, Says San Joaquin Sheriff Overrode Death Findings to Protect Law Enforcement

San Joaquin County Sheriff-Coroner’s Office is pictured in this undated photo.

Credit: Julie Small/KQED

Above: San Joaquin County Sheriff-Coroner’s Office is pictured in this undated photo.

Update, 11:00 am. Tuesday: San Joaquin County’s Chief Forensic Pathologist resigned Tuesday, one day after the release of his memos blasting Sheriff-Coroner Steve Moore for interfering with death investigations to protect law enforcement officers.

In his resignation letter Tuesday, Dr. Bennet Omalu wrote that Moore is thwarting his efforts raise the standards of death investigations and overriding his authority as a physician:

Sheriff Steve Moore has always made calculated attempts to control me as a physician and influence my professional judgement. I first experienced this with Sheriff Steve Moore in 2007 when he prevented me from attending crime scenes, which detectives from police departments of other cities may have wanted me to attend, or scenes I wanted to attend, especially on complicated and/or unusual cases. The standards of practice of pathology require forensic pathologists to attend all types of scenes. I wanted to leave then but I believed this interference would stop the longer I stayed in the office and exhibited the highest and exemplary standards of practice. Unfortunately, it did not stop.


— Dr. Bennet Omalu, San Joaquin County Chief Forensic Pathologist

Omalu received national recognition for his research on a brain disease affecting football players who suffer repeated concussions. He became San Joaquin County’s chief forensic pathologist in 2007.

But, Omalu wrote, the sheriff’s interference in death investigations has “gotten worse,” over the last two years.

KQED could not immediately reach Moore for reaction to Omalu’s resignation, but in a telephone interview Monday, he denied allegations that he had meddled in forensic autopsy investigations.

In his four-page resignation letter Omalu expresses regret in resigning his post and professes his ongoing commitment to San Joaquin County.

“I fell in love with it,” Omalu wrote, “and gave my utmost best to elevate the standards and quality of practice of forensic pathology and death investigation in the County, which had fallen apart. Today, we have collectively done a wonderful job in turning the trajectory of the Coroner’s Office and providing the best standards of autopsy, pathology and medico-legal services to the good people of the County.”

Omalu wrote that he had planned to continue to serve the people of this County until his retirement, but decided to resign his employment in order to avoid the risk that he could lose his medical license for “aiding and abetting” the sheriff’s actions.

Original Story:

Two San Joaquin County forensic pathologists have accused the sheriff of meddling in death investigations in order to protect officers of the law. Documents released Monday by a pathologist who announced her resignation last week raise serious questions about the integrity of investigations of people who died in the custody of law enforcement officers who used Tasers or other types of force.

Dr. Susan Parson, who performs autopsies for the county, accused Sheriff-Coroner Steve Moore of interfering with her work, and sent copies of emails, notes and other correspondence to the district attorney and the Board of Supervisors documenting her claims.

The documents, obtained by KQED, also include correspondence and memos written by the county’s chief forensic pathologist, Dr. Bennet Omalu.

The Nigerian-born neuropathologist rose to national prominence in 2005 after he published his discovery of a degenerative brain disease in football players he named chronic traumatic encephalopathy or CTE. His discovery was documented in the 2015 film “Concussion,” starring Will Smith.

San Joaquin County hired Omalu in 2007 to raise the standards of death investigations. But in a memo Omalu wrote on Aug. 22, 2017, he indicated it was a losing prospect.

“I have always believed that the longer I spent in the office, the better the office would become,” Omalu wrote. “I was wrong.”

In March 2017, Omalu and Parson began documenting incidents they believe show wrongdoing by Sheriff Moore. The two doctors allege the sheriff labeled certain deaths as “accidents” rather than “homicides” to shield from prosecution law enforcement officers who were involved.

In the Aug. 22, 2017, memo, one of several he drafted over the past nine months to document his concerns, Omalu wrote, “The Sheriff does whatever he feels like doing as the coroner, in total disregard of bioethics, standards of practice of medicine and the generally accepted principles of medicine.”

The forensic pathologists raised other concerns, including months-long delays in getting written reports from sheriff’s investigators that the pathologists needed to complete their cases. And, in several instances, they say they discovered that a sheriff’s deputy who oversees coroner operations ordered technicians to cut the hands off bodies, without the knowledge, consent or supervision of the physicians.

Sheriff Calls Allegations False

In a telephone interview with KQED Monday, Sheriff Moore denied allegations that he had meddled in forensic autopsy investigations.

“That is untrue,” Moore said. “As coroner I have not interfered. I’ve never changed any cause of death.”

Determining cause of death — what killed a person — is the purview of the forensic pathologist, he said, but he has the final say on determining the manner: whether a person’s death is an accident, a homicide, a suicide, a result of natural causes or undetermined.

‘As coroner I have not interfered. I have never changed any cause of death.’

— Steve Moore, San Joaquin County Sheriff-Coroner

“I’m charged with the responsibility to establish the manner of death and I do that based on the totality of the circumstances, up to and including the autopsy report provided by the doctor and the investigative report done by the coroner’s investigators.”

Moore said that if he has questions about the autopsy report he’ll discuss them with the doctors, but he’s not required to explain his decision to them.

As to surgically removing hands from corpses, Moore said it’s true that when a body is too decomposed for his office to identify, coroner’s staffers send the hands to a special crime lab at the California Department of Justice for identification.

“I would much rather make sure that the decedent I identify is that person, versus make an error and say it’s somebody else,” he said.

An Aug. 20, 2017, memo to Sgt. Mike Reynolds indicates that the doctors expressed concerns to the sheriff through the proper chain of command. The physicians wrote that they felt “extremely intimidated, harassed, threatened and controlled by some of the practices, cultures and traditions of the Sheriff’s office.”

The doctors’ most serious accusation by far is that the sheriff interfered in cases where law enforcement was involved in a person’s death.

Evidence of a Homicide Withheld

Omalu cited the case of Daniel Humphreys, a father of two who died on a Stockton freeway median in 2008 after crashing his motorcycle as he fled arrest.

In a deposition for a lawsuit brought by Humphreys’ family, Omalu said he was told by investigators that a California Highway Patrol officer had used a Taser on Humphreys once or twice. But when Omalu asked to see a computer record that the weapon automatically generates when fired, he was told there was no report to see. In his autopsy report, Omalu attributed Humphreys’ death to a head injury from the accident.

Two years later, a deputy district attorney shared the Taser report with Omalu. It showed that the CHP officer in fact fired the Taser at Humphreys 31 times. A source close to the sheriff’s office said that the sheriff had access to the Taser report since the day after Humphreys’ death.

“Information was withheld from me, allegedly to mislead me from determining the case to be a homicide,” Omalu wrote in a memo attached to a Oct. 1, 2017 letter to Dr. Sheela Kapre, the medical director of San Joaquin General Hospital.

Omalu subsequently amended his autopsy report to indicate that the death was a homicide by electrocution.

“The sheriff was using his political office as the coroner to protect police officers whenever someone died while in custody or during arrest,” Omalu wrote in an earlier memo documenting the case. “I had thought that this was initially an anomaly, but now, especially beginning in 2016, it has become routine practice.”

Omalu said the sheriff asked him to change the manner of death on an internal worksheet that accompanies each autopsy report — in several cases where people died after law enforcement officers used Tasers, chokeholds or other types of force.

In 2016, Omalu’s notes indicate, this occurred in all three cases of people who died during arrest in San Joaquin County that year.

One case involved Abelino Cordova-Cuevas, 28, who died in a March 7, 2016, confrontation with Stockton police.

Police told the Stockton Record that officers used a stun gun to subdue Cordova-Cuevas. An attorney representing the family alleged the officers used an illegal chokehold.

Omalu found that the man had died from asphyxiation and blunt force trauma and that his death was a homicide. But the sheriff certified the manner of death an accident.

The family sued the city of Stockton and its police department for civil rights violations. The case was removed to the U.S. District Court for the Eastern District of California, in Sacramento, and is scheduled to be heard in 2019.

In another case, Filiberto Valencia, 26, died after Stockton police officers beat him, sat on him and stunned him with a Taser, according to the Valencia family’s attorney, Walter Walker, who reviewed interviews with the officers involved. The confrontation occurred Jan. 19, 2016, after Valencia suffered a schizophrenic episode and broke into a group home and boarded himself into a bathroom with a girl and three women.

In his Aug. 22, 2017, memo, Omalu asserted that the sheriff “told me that he wanted to make it an accident since officers were involved.”

In the end, the sheriff categorized it as a homicide — but, according to Omalu, only after learning that Valencia had also been beaten by civilians.

Omalu wrote that the sheriff wanted that included in the autopsy report to clear the police. “He said that I should amend my report and state that he died from the civilians and not the police.”

The Valencia family is suing the city of Stockton and Stockton police for federal civil rights violations.

According to Walker, the family’s attorney, officers beat Valencia after they gained access to the bathroom where he had barricaded himself. One admitted to hitting him over the head with a gun, while another officer struck him repeatedly with a baton, Walker said.

‘This is simply daylight corruption and nothing else. … He is using his office and powers to protect police officers.’ “We have pictures of blood all around the bathroom,” Walker said in an interview with KQED. “Quite clearly he had been beaten to death. And this is evidenced by the coroner’s and autopsy reports.”

— Dr. Bennet Omalu, San Joaquin County Chief Forensic Pathologist

Walker added that he had to subpoena the sheriff four times to get those reports.

As recently as Aug. 21, 2017, Omalu documented, the sheriff wanted to change the manner of death of a case that had been closed in 2016.

The autopsy of Samuel Augustine Jr. concluded that he died June 7, 2016, of a traumatic brain injury and a spinal cord injury during arrest by Stockton police — and that the manner of death was homicide. Omalu wrote that the sheriff told him that his findings were wrong and should be changed.

“This is simply daylight corruption and nothing else,” Omalu wrote in a memo dated the day after he alleges the sheriff approached him. “He is using his office and powers to protect police officers.”

Omalu came to the conclusion that Sheriff Moore “seems to believe that every officer-involved death should be ruled an accident because the police did not mean to kill anyone.”

The National Association of Medical Examiners defines homicide as “death at the hands of another.” In the field of forensic pathology the term does not ascribe motive or guilt.

The sheriff also certified the 2008 death of Daniel Humphreys as an accident — even after evidence showed that the arresting officer had discharged an electrical shock at Humphreys repeatedly.

Omalu blames that outcome in part on the county’s reliance on the sheriff-coroner system, in which death investigations are conducted under the purview of a law enforcement agency.

California’s Sheriff-Coroners Have Last Word on Deaths

In 50 of 58 California counties, the elected sheriff also serves as coroner and oversees the medical investigations of sudden, suspicious or violent deaths, and all in-custody deaths. A forensic pathologist who works for the sheriff conducts a physical exam or autopsy to determine the cause of a death. The pathologist can also suggest the manner by which the person died. But the sheriff-coroner ultimately decides and certifies the manner of death.

In California’s remaining eight counties, including San Francisco, Santa Clara and San Diego, the medical examiner is independent of the sheriff or any law enforcement agency.

Randy Hanzlick, a retired forensic pathologist in Atlanta, Georgia, has studied the sheriff-coroner system, and finds problems with the arrangement.

“I think the downside basically is either a perceived or real conflict in the goals of the two entities,” said Hanzlick. He said the inherent conflict of interest becomes most problematic in cases where law enforcement officers are involved in a person’s death.

Hanzlick said it’s not uncommon for sheriff-coroners to weigh an officer’s intent when deciding whether to certify a death as an accident or a homicide.

“Did they intend to use the device? Well, probably so. Did they intend to cause the death? Well, maybe not. But did the person die as a result of the action of the officer using the device?” Hanzlick asked. “That’s where you get into the argument.”

The position of the National Association of Medical Examiners is that the objectivity of forensic pathologists depends on their freedom from political influence and the threat of litigation. A 2011 survey of the group’s members found that 43 percent of those who worked in a coroner system reported that the coroner had changed the cause on a death certificate in a way that conflicted with the autopsy findings.

New Law on Autopsies Untested

Last year California lawmakers increased the independence of the forensic pathologists working for a sheriff-coroner by defining autopsies as a medical procedure that may be performed only by a licensed physician and surgeon.

A key provision of Sen. Richard Pan’s bill, SB 1189, would have given forensic pathologists the authority to determine both cause and manner of death. However, it was opposed by the California State Sheriffs’ Association and the California State Coroners Association, and taken out. The final version of the bill, which took effect Jan. 1, 2017, upheld the sheriff-coroner’s authority to decide the manner in which people died, but added a requirement to do so “in consultation with” the forensic pathologist who performs the autopsy.

The new law also requires law enforcement officials to provide any evidence or reports the forensic pathologist requests before the autopsy report is complete.

In what could become the first test of the new law, Drs. Omalu and Parson allege that Sheriff Moore violated the law’s provisions multiple times this year.

Delayed, Incomplete, Investigatory Reports

Dr. Parson raised another serious allegation in a Nov. 2, 2017, email to sheriff’s Sgt. Reynolds. She listed 16 cases that were pending for months because deputies had not provided the investigatory reports she needed to complete autopsy reports.

In a memo documenting this accusation, Parson explained, “It is standard practice to have access to the related investigating agency report, which details how the body was found, what the investigation reveals at that moment in terms of how and when the victim was injured, the weapon used, what evidence was found at the crime scene.”

She wrote that the information is necessary to be able to determine what tests to run, what evidence to collect, “and ultimately what the cause of death is.”

Hanzlick, who is a professor at Emory University’s medical school, concurs.

“You have to have that information to guide how you approach the case and how much effort you’re going to spend in one area of the case as opposed to another,” he said.

Removal Of Hands

Both doctors also documented five instances in which the sheriff ordered technicians to cut the hands off bodies for fingerprinting to identify the remains. In the Oct. 1, 2017, correspondence to Dr. Kapre, the county hospital medical director, Parson and Omalu called it “a form of body mutilation which we should not be doing.” They added that such a procedure is not a standard autopsy protocol and should be performed only in special cases.

Omalu wrote in his memo to Dr. Kapre that Sgt. Reynolds had ordered the hands cut off “without consulting me.” He said he learned about it from a deputy coroner. In a separate memo, Omalu wrote that he advised the morgue technicians that they should refuse to do it. He said when Sgt. Reynolds later ordered him to do the procedure, he refused and he was reprimanded by the sheriff.

Forensic pathology experts consulted for this story said the decision to cut off the hands for fingerprinting fell outside the established practice of medicine. They felt that, at a minimum, the pathologist should have been consulted.

The San Joaquin District Attorney said Monday in a statement posted on Facebook that the office is aware of the allegations.

“This office is in the process of gathering information concerning homicide cases, including deaths relating to law enforcement officer involvement,” the statement said, adding that the district attorney’s office conducts independent investigations and does not rely on coroner’s reports alone.

Last week Sheriff Moore told KCRA, a Sacramento television station, that he welcomes an investigation because he has nothing to hide. He is up for re-election in 2018.

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