Partnerships for Success Corner Medical Examiner: Preserving

Evidence and Saving LivesBreakout Session A

Presenters:Allison O’Neal, Orange County Sheriff-Coroner

Anthony Maldonado, ME / Coroner Specialist, OneLegacyModerator:

Barbara Anderson, RN, Ronald Reagan UCLA Medical Center

• Demonstrate a basic understanding of the coroner role and responsibilities in regards to the donation process• Discuss CA Coroner Law, Coroner Relationships

and Coroner Case Statistics• To be able to identify a reportable death

Objectives:

When is it necessary to report a death to the coroner?

How has the collaboration between OneLegacy and the coroner increased

donation in our community?

Questions to Run On:

Coroner/Medical Examiner: Preserving Evidence and

Saving LivesAllison O’Neal,

Supervising Deputy Coroner

Orange County Sheriff’s Department-Coroner Division

948 square miles 3 million people Sheriff-Coroner system Total Deaths per year: 18,915 Orange County Coroner investigated: 5,093 Autopsies Performed: 1,654 Of autopsy cases:

◦ Natural 84%◦ Accident 10%◦ Suicide 4%◦ Homicide 1%◦ Undetermined 1%

County of OrangeCoroner Statistics

The California Government Code 27491 states that the coroner is required to:• Investigate all unnatural deaths-COD, Manner (homicide, suicide, accident,

natural, undetermined)• Deaths where the MD is unable to state COD• When deceased saw MD >20 days prior to death

Responsibilities are all or some of these depending on case. We may not physically complete the task but need to ensure it gets done:• Positively identify the deceased• Examine the deceased to document condition of body• Determine place, date and time of death• Locate and notify the next of kin• Secure personal belongings and residence• Collect evidence related to the death• Ensure the body is moved to the appropriate facility• Communicate with the related law enforcement agency or District Attorney

Role & Responsibilities of the Coroner

The Coroner is governed by California Government Code Section 27491 and Health and Safety Code Section 102850. The law states: “…a physician and surgeon, physician assistant, funeral director, or other person shall immediately notify the Coroner when he or she has the knowledge of a death that occurred or has charge of a body in which death occurred under ANY of the following:

What is Reportable to the Coroner?

Without medical attendance Not attended by an MD in 20 days prior Attending MD unable to give opinion for COD When homicide is known or suspected When suicide is known or suspected When a criminal action is involved or suspected to

be involved in a death Self-induced or criminal abortion Related to rape or crime against nature Known or suspected injury, accident-old or recent Aspiration, starvation, exposure, drug addiction or acute

alcoholism

Reportable Information (ctd.)

Poisoning Occupation diseases Contagious diseases While in-custody of a law enforcement

agency All state hospital deaths- Fairview in OC All Sudden Infant Death Syndrome

cases During or related to surgery, following

surgery or did not wake from anesthesia

Reportable Information (ctd.)

Decline (no case # given); not reportable but brief report taken.

Reportable, Non-Autopsy case Sign Out No Autopsy (SONA) Autopsy case

For Autopsy and SONA cases there is no difference in the interaction between the deputy coroner and the OL representative.

Types of OC Coroner Cases

The death is reportable but an autopsy is not necessary. In this situation the OneLegacy coordinator or hospital staff reports the death and receives a coroner case number. OL notifies OCCO on every potential organ and tissue donor.

Examples: Natural death with marijuana or ethanol in system unrelated to the COD.Positive for a contagious disease such as Hepatitis C but died from a ruptured AAA.

Non-Autopsy cases as they relate to OneLegacy

Reportable Non-natural deaths that are acute or delayed but the COD is known, well documented and a physician can state his/her opinion on the death certificate

Examples: Inpatient MVA with multiple traumatic

injuries Tylenol overdose with suicide notes found Elderly inpatient with recent fall with SDH

Sign Out No Autopsy (SONA)

After procurement, the body is picked up by the coroner and scheduled for coroner autopsy. The coroner handles the death certificate completely-cause and manner.

The OCCO does not perform autopsies over the weekend however we pride ourselves in completing our forensic investigation quickly and releasing the deceased in an average of 48 hours.

Examples: MVA’s, homicides, non-accidental trauma, competing causes such as accident vs. suicide overdoses and undetermined cases.

Autopsy Cases

The OneLegacy coordinator notifies the OCCO after brain death notes. On DCD it is after the NOK signs consent.

OL coordinator sends available charting.

OL coordinator and OCCO in constant communication.

Brain Death and DCD Cases

Case Study:Non-Accidental Trauma

OL reported brain death of a 17 month female admitted from home with suspected non-accidental trauma. Initial story to 911 was that she fell approx.

18 inches off a chair. Child was under the care of one parent’s

significant other. Admitted in full arrest. Head CT showed

complex skull fx and additional head trauma.

Case Study

Case Study

Case Study

OneLegacy obtained consent from NOK for all organs and tissue.

OCCO requested additional studies including CT chest, abdomen, pelvis, CBC, WBC, chem panel, long bone study, ocular examination

While awaiting these results we used the time to obtain information from the handling police agency, confer with child services and conduct interviews.

Case Study

An additional challenge in this case was that the incident occurred in an out of county law enforcement jurisdiction.

Coroner approved recovery of organs. Stipulation given that transplant recovery surgeons document any trauma observed during recovery.

Case Study

Based on autopsy, microscopic tests and neuropathology and toxicology the following was documented.

Confluent areas of purple-red ecchymosis of posterior base of head and posterior right ear.

Focal purple contusions of the bilateral posterior forearms. Small faint purple contusion of the right cheek. Internal trauma: a. Occipital scalp hematoma. b. Diffuse posterior subgaleal hemorrhage. c. Complex skull fractures. d. Bilateral occipital epidural hematomas. e. Bilateral optic nerve sheath hemorrhages.

Case Study

We at the OCCO are proud to be able to save lives while still conducting thorough medico-legal death investigations.

3 Lives saved from this case alone: Local 40 y/o received en bloc kidneys Local 9 month old received liver Local 2 month old received heart

Case Study

Coroner/Medical Examiner: Preserving Evidence and Saving Lives

Anthony MaldonadoM.E./Coroner Specialist

The Donation & Transplantation SymposiumOctober 15, 2013

CA Health & Safety CodeSection 7151.15

• 7151.15. (a) A county coroner shall cooperate with procurement organizations to maximize the opportunity to recover anatomical gifts for the purpose of transplantation, therapy, research, or education.

CA Health & Safety CodeSection 7151.20 (d)

• (d) If a county coroner is considering withholding one or more organs of a potential donor for any reason, the county coroner, or his or her designee, upon request from a qualified organ procurement organization, shall be present during the procedure to remove the organs. The county coroner, or his or her designee, may request a biopsy of those organs or deny removal of the organs if necessary.

Coroner protocols established and routinely revised

Coroner may request photos,

medical diagnostic testing,

consultations, etc.

Case reviews and education for

coroner staff and OneLegacy staff

Coroner/ME Relationships

2010 Organ Coroner CasesBy Circumstance of Death

CountyAlleged

Child Abuse

Alleged Homicide

Alleged Suicide

Death by Natural Cause

Drowning/Near

Drowning

Hospital Death:

Inpatient

Motor Vehicle

AccidentNone of

the Above

Non-Motor Vehicle

Accident

Unknown/Other: See Comments

Grand Total

Kern 0 5 3 1 0 0 2 1 0 0 12

Los Angeles 0 25 14 29 1 28 12 14 1 124

Orange 0 3 1 4 0 0 3 5 3 0 19Riverside 1 1 5 5 1 5 1 3 0 22San Bernardino 5 4 5 9 0 1 2 1 6 1 34Santa Barbara 0 0 1 0 0 0 0 0 1 0 2

Ventura 0 0 2 1 0 0 0 0 3 0 6

Grand Total 6 38 31 49 2 1 40 20 30 2 219

CountyAlleged

Child Abuse

Alleged Homicide

Alleged Suicide

Deathby Natural

Cause

Drowning or Near

Drowning

HospitalDeath: ER or

Outpatient

Hospital Death:

Inpatient

Motor Vehicle

Accident

Noneof the Above

Non-Motor Vehicle

Accident

Unknown/Other:

See Comments

Grand Total

Kern 0 1 1 0 0 0 0 3 0 0 0 5

Los Angeles 8 20 13 43 0 0 0 37 16 23 0 160

Orange 0 6 9 7 1 0 0 10 1 5 0 39

Riverside 0 1 5 5 1 0 0 10 0 4 0 26San Bernardino 2 5 2 5 0 0 0 8 2 6 1 31

Santa Barbara 0 0 2 0 0 0 0 0 0 0 0 2

Ventura 0 0 3 0 0 0 0 1 1 0 0 5

(blank) 0 0 0 0 0 0 0 1 0 0 0 1

Grand Total 10 33 35 60 2 0 0 70 20 38 1 269

2011 Organ Coroner CasesBy Circumstances of Death

CountyAlleged

Child Abuse

Alleged Homicide

Alleged Suicide

Deathby Natural

Cause

HospitalDeath: ER or

Outpatient

Hospital Death:

Inpatient

Motor Vehicle

Accident

Noneof the Above

Non-Motor Vehicle

Accident

Unknown/Other:

See CommentsGrand Total

Kern 0 0 1 3 0 0 2 1 1 0 8

Los Angeles 0 33 13 32 0 0 26 10 15 0 129

Orange 2 2 3 8 0 0 9 3 12 0 39Riverside 0 3 5 12 0 0 11 1 1 0 33San Bernardino 0 4 6 15 0 0 8 3 4 0 40

Santa Barbara 0 0 0 0 0 0 1 0 0 0 1

Ventura 0 0 1 0 0 0 0 2 0 0 3

Grand Total 2 42 29 70 0 0 57 20 33 0 253

2012 Organ Coroner CasesBy Circumstances of Death

CountyAlleged

Child Abuse

Alleged Homicide

Alleged Suicide

Deathby

Natural Cause

Drowning/Near

Drowning

HospitalDeath: ER or

Outpatient

Hospital Death:

Inpatient

Motor Vehicle

Accident

Noneof the Above

Non-Motor Vehicle

Accident

Unknown/Other:

See CommentsGrand Total

Kern 0 4 1 3 0 0 0 1 0 0 0 9

Los Angeles 4 13 10 42 0 0 0 33 6 16 0 124

Orange 0 3 7 3 0 0 0 7 3 6 0 30Riverside 0 2 1 8 1 0 1 6 2 6 0 27San Bernardino 3 3 2 14 0 0 0 11 2 5 0 40

Santa Barbara 0 0 1 0 0 0 0 2 0 0 0 3

Ventura 0 1 3 1 0 0 0 1 0 1 0 7

Grand Total 7 26 25 71 1 0 1 61 13 35 0 240

2013 YTD Organ Coroner CasesBy Circumstances of Death - as of September 2013

OneLegacy Organ CasesUnder Coroner Jurisdiction

2010 2011 2012 2013 YTD0

50

100

150

200

250

300

350

400

450

0%10%20%30%40%50%60%70%80%90%100%

349

417 391

322

219269 253 240

63% 65% 65%75%

Total Organ Cases Coroner's Jurisdiction % of Total

Org

an C

ases

% o

f Tot

al

OneLegacy Tissue CasesUnder Coroner Jurisdiction

2011 2012 2013 YTD0

200400600800

100012001400160018002000

0%10%20%30%40%50%60%70%80%90%100%

1600 1644 1577

990 1050 992

62% 64% 63%

Total Tissue Cases Coroner's Jurisdiction % of Total

Tiss

ue C

ases

% o

f Tot

al

When is it necessary to report a death to the coroner?

How has the collaboration between OneLegacy and the coroner increased

donation in our community?

Questions to Run On: