California Forum

He took on the NFL. Now he’s after California’s ‘primitive’ sheriff-coroner system

Bennet Omalu talks about forensic science and problems with the sheriff-coroner system

Bennet Omalu, a pathologist and former chief medical examiner in San Joaquin County, speaks about the problems surrounding Sheriff Steve Moore, who doubles as coroner.
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Bennet Omalu, a pathologist and former chief medical examiner in San Joaquin County, speaks about the problems surrounding Sheriff Steve Moore, who doubles as coroner.

It has been months since the nationally renowned Dr. Bennet Omalu abruptly quit his job as chief medical examiner of San Joaquin County, sending shock waves through California’s close-knit community of forensic pathologists.

A brilliant practitioner with a stellar reputation for his work identifying a pattern of brain disease among NFL players, Omalu probably could work anywhere in the country. Californians should be thankful that he has opted, so far, to stay here.

As his second act, he is lending his star power to long-overdue reform of California’s antiquated sheriff-coroner system, a conflict-prone setup that essentially puts local politicians in charge of suspicious death investigations, including deaths in custody.

There is no excuse for such a system in a state with the size, sophistication and socioeconomic fault lines of California. But most California counties, particularly in rural parts of the state, have some variation, instituted generations ago to save money and propped up since then by the interests that benefit from it.

Enter Omalu. Given the clout of the California State Sheriffs’ Association, which has fought for the status quo, it is clear that the lawmakers pushing for change – Sen. Richard Pan, D-Sacramento, and Sen. Cathleen Galgiani, D-Stockton – will need all the help they can get.

Galgiani and Pan, a physician, recently introduced Senate Bill 1303, which would force counties with more than 500,000 people to establish independent medical examiner’s offices, run by credentialed physicians who would report to county executives.

California is one of only three states – and the most populous, by far – to let a single official serve as both sheriff and coroner of a county. It’s a concept that literally dates to the Middle Ages, when the primary duty of a coroner was to merely confirm that someone had died so taxes could be collected on the estate.

Twenty-two states and the District of Columbia have switched to systems in which medical professionals do death investigations, understanding that having law enforcement oversee, say, the autopsies of police abuse victims invites abuse and creates an inherent conflict of interest. But California has held out; only six counties here, including Sacramento, have independent medical examiners certified by the National Association of Medical Examiners.

If passed, SB 1303 would affect six counties: San Joaquin, Stanislaus, Contra Costa, Riverside, Kern and Sonoma. Four others – Fresno, Alameda, Orange and San Mateo – would be exempt because they are charter counties and the Legislature lacks the authority to force them to change. They should voluntarily do so, as should counties below the population threshold.

For Omalu, who spent years toiling under a micromanaging sheriff-coroner of questionable competence, changing this “primitive” system is personal.

In December, he resigned from San Joaquin County, turning over months of memos describing how Sheriff-Coroner Steve Moore, who has no medical training, repeatedly interfered in death investigations by tampering with forensic evidence, changing medical reports and undermining research. In one of his more eyebrow-raising accusations, Omalu said Moore ordered the hands be cut off of five corpses and sent to a lab, though that was not necessary to determine the identities of the dead.

“He said he is the chief and I should get out,” Omalu told members of The Sacramento Bee editorial board.

Moore denies the pathologist’s claims and is running for re-election. At least he has a challenger; most incumbent sheriff-coroners are safe in their seats, once elected, and several in the June primary are running unopposed.

Proponents of the system insist that separating the two functions is too expensive. In very small counties, this may be the case.

But there are intangible costs in perpetuating the system that far outweigh the budgetary issues. How to quantify the cost to public trust, for example?

Omalu said Moore asked him to change his findings from “homicide” to “accident” in three cases of people killed by law enforcement officers. In Santa Clara County, the outcry was so great in 2015 after three jail deputies beat a mentally ill inmate to death that an independent medical examiner’s office had to be created. Is that ultimately what San Joaquin County will need?

There’s also the cost to California’s reputation. Word has gotten out among forensic pathologists about how the sheriff-coroners in this state operate, and it’s costing us talent. Pathologists are such short supply in the Central Valley, for example, that smaller counties, such as Tuolumne, are working with larger counties to outsource their autopsies.

That’s as expensive as it is inefficient. Other counties have inked contracts with private providers of pathology services, some of which are less than reputable. Not to mention the survivors whose questions about their loved ones’ deaths never really get answered, or the medical research that goes by the wayside.

Omalu points out that we might not know how West Nile Virus affects human brains had a forensic pathologist not noticed the pattern. In San Joaquin County, he said, the sheriff-coroner often overruled additional tests that might have yielded important science.

“If had done my first autopsy in California, there’s no way I could have discovered CTE,” Omalu said of the degenerative brain disease chronic traumatic encephalopathy.

State lawmakers should pass SB 1303, get rid of this archaic system and bring this critical aspect of law enforcement into the 21st century.

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