Hands chopped off bodies; corpses left to deteriorate; doctors pressured to classify officer-involved deaths as accidents rather than homicides: San Joaquin County’s two forensic pathologists resigned in recent days over what they said was intolerable interference by Sheriff-Coroner Steve Moore.
Dr. Bennet Omalu Tuesday announced his resignation as San Joaquin County’s chief medical examiner. Last week, Omalu’s colleague Susan Parson announced her resignation. Under Moore, they said, the county has failed to adequately investigate deaths in the Central Valley.
The two pathologists have been documenting events inside the Sheriff-Coroner’s operation for months. The pair publicly released more than 100 pages of memos this week detailing their allegations, in addition to sending them to the San Joaquin County Board of Supervisors and the county district attorney in a push for a broader investigation.
“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,” Omalu wrote in a memo dated Aug. 22.
Omalu is a nationally recognized forensic pathologist best known for his work on concussion-related brain injuries sustained by many football players. He is also a volunteer associate clinical professor at the University of California, Davis. His work was turned into the 2015 film “Concussion,” starring Will Smith as Omalu.
“The sheriff is interfering with the doctors’ ability to do their job and he is trying to influence their decisions,” said Patricia Hernandez, the union representative for both Omalu and Parson, who declined to be interviewed. “I would call it rogue mismanagement.”
San Joaquin County Sheriff’s office public information officer Dave Konecny did not return a call for comment. Moore posted a statement on Facebook on Nov. 28 that said he takes “my job extremely seriously.”
“As Coroner, the law requires me to make the final determination in the manner of death of each case processed here at the Office,” Moore wrote. “I want to make it clear that at no time did I attempt to control or influence (Parson’s) professional judgment and conclusions.”
Moore has served as the county sheriff since 2007. He will be up for re-election in November 2018.
Omalu alleges the sheriff on multiple occasions asked him to change his findings on the manner of death in officer-involved cases – including three officer-involved deaths in 2016.
“Before I began my documentation in May 2017, I had observed long before this that the sheriff was using his political office as the coroner to influence the death investigation of persons who die while in custody or during arrest by the police,” Omalu wrote in the Aug. 22 memo. “I had thought that this was initially an anomaly, but now, especially beginning in 2016, it has become routine practice.”
Omalu said the first time Moore asked him to change his finding in an officer-involved case was in 2008, when Omalu wrote that “information was intentionally withheld from me by the sheriff in order to mislead me from determining the case was a homicide.”
Omalu ruled that death an accident, but revised his finding to homicide after receiving the additional information.
In 2016, Omalu said the sheriff again pressured him to change his finding in an officer-involved case, this one involving the death of Filberto Valencia, 26.
Valencia’s family told media he was a schizophrenic having a mental episode. The family called police for help, but Valencia left the home and attempted to enter other nearby houses before eventually gaining access to a residential facility. There, he barricaded himself in a bathroom with a 10-year-old girl and three women, according to the family’s attorney, Walter Walker.
Walker said a Stockton police officer hit Valencia over the head twice with the butt of a gun before repeatedly punching him. A second officer hit him with a baton, while a third officer shot him four times with a Taser, said Walker. Valencia became unresponsive and died.
Omalu found Valencia’s death was due to blunt force trauma and ruled it a homicide – a medical finding meaning death at the hands of another human. The medical ruling of homicide is different from a legal ruling, but Omalu wrote that the sheriff wanted it changed.
“The sheriff called me into his office and told me that he wanted to make it an accident since officers were involved,” wrote Omalu. “I told him that he may have died from the trauma he suffered in the first fight involving other citizens who were not police officers. ... He said that I should amend my report and state that he died from the civilians and not the police officers. I told him I could not do it, first it was unethical and wrong.”
The Valencia family has filed a federal civil rights lawsuit in the case.
Then, on Aug. 21, Omalu alleged Moore came to him again, asking him to change his finding in a case that had happened about a year earlier, in 2016. Samuel Augustine, 57, died after what media described as a “violent fight” with officers. Augustine, a sex offender, had been attempting to light a fire near a bridge and was armed with a sledgehammer and machete, though he dropped them as officers approached, according to media reports.
Omalu found Augustine had died as a result of “traumatic brain and spinal cord injury during police arrest.” Moore disputed that.
Omalu recalled that Moore told him in a meeting that “he did not see what the police did wrong in their arrest of the individual, and there was nothing in the medical records to support the autopsy findings,” he wrote. “In his mind, he seems to believe that every officer involved death should be ruled an accident because police did not mean to kill anyone.”
Parson and Omalu also allege that the sheriff’s staff ordered the hands be cut off of at least five corpses this year to be sent to a forensics lab to identify the deceased. Omalu and Parson both said that in some instances, the victims’ identity was already known and in others, police failed to attempt to identify the dead by investigative means.
“These individuals were found dead at their residences and were positively identified by either a neighbor or a family member,” Omalu wrote in a May 25 memo. “In my opinion, taking out the hands of these cases, was a form of body mutilation, which we should not be doing.”
Independent forensic pathologist Judy Melinek, who consults on legal cases from San Francisco, said removing the hands for identification was “bizarre” and confirmed it was not a standard practice.
“I have no idea why that would be medically necessary or forensically necessary,” Melinek said. “You don’t need to do this for identification purposes. You could just take fingerprints.”
Omalu also charged that staff at the coroner’s office, under the sheriff’s control, often took months to do routine paperwork and at times failed to account for the bodies in the morgue. In dozens of instances, the two pathologists said sheriff’s staff failed to provide even basic information about deceased people such as the circumstances and location where they were found, impeding the ability of the doctors to investigate.
Parson wrote that she was told she was requesting too many medical records on her patients.
Omalu and Parson said the delays meant families regularly had to wait weeks or even months to claim bodies, and that the corpses often decomposed before proper autopsies could be done – making it harder for the pathologists to determine the cause of death.
“This goes way outside and beneath the standards of practice of medicine in the State of California and across the world,” Omalu wrote. “For every patient, autopsy or case, information, medical records, police reports and other professional reports must be ready for the physician to review.”
Parson and Omalu allege the sheriff and his staff tried to intimidate and harass the pair into cooperating.
In an email from Omalu and Parson to Sgt. Mike Reynolds with the subject line “scheduling of work hours of physicians, physician independence, physician professional judgment and unbiased credibility” sent Aug. 20, Parson and Omalu objected to the sheriff’s office forcing them to surrender planning of their schedules, among other conflicts.
“As physicians we are beginning to feel extremely intimidated, harassed, threatened and controlled by some of the practices, cultures and traditions of the Sheriff’s Office,” the email said. “(They) are beginning to erode our independence as physicians and are beginning to influence our professional judgments, analyses, conclusions and opinions on each and every case we do in the office.”
Omalu will continue serving in his role through March 5, according to his letter of resignation. He plans to stop performing autopsies effective immediately to focus on 150 pending and open cases before his departure. Hernandez said both Omalu and Parson have spoken with other counties about new jobs.
Dr. Reed Mellor, a Stockton-based pediatrician and president of the San Joaquin County Medical Society, called the allegations “alarming” and urged authorities to conduct a full investigation of Moore’s actions in a statement distributed via the California Medical Association.
“Physician independence is paramount to avoid improper influence on the practice of medicine,” Mellor said in the statement. “Physicians have the unique obligation to put the patient first, and thus, they must be empowered to work independently in serving the best needs of the patient.”
The San Joaquin County District Attorney’s office issued a statement that said it was in receipt of the doctors’ allegations and “is in the process of gathering information concerning homicide cases, including deaths relating to law enforcement officer involvement.”