Grand jury says county needs morgue


It’s a scene familiar to any fan of film or television crime dramas: In the cold light of the city morgue, the forensic pathologist, in goggles, gloves and lab coat, investigates the cause of death. In most cases, as in fiction, such investigations take place in a purpose-built facility of chilled rooms and stainless steel gurneys that is almost sacral in its silence and sterility.

Not so in Marin County, where autopsies are routinely performed in the backs of local mortuaries—in conditions that a May 29 report of the 2011-2012 Marin County Civil Grand Jury called “unacceptable” and “inefficient,” and subject to “antiquated equipment,” “minimal” security and sanitary conditions that are “sometimes less than desirable.”

According to the report, conditions in the three funeral homes used by the county — Monte’s Chapel of the Hills, Keaton’s Mortuary and Mt. Tamalpais Mortuary—ranged from recently renovated, clean and somewhat equipped to outdated, unsafe and inadequate.

The report complained of one facility in particular that uses hand-crank autopsy tables, yellowed hoses connected to sinks, floors with no drains, and equipment dating from the 1960’s. For the purpose of performing autopsies, none of the facilities were ideal.

“It was always a nightmare,” former Marin County Coroner Ken Holmes, who served in the elected position for 14 years and as assistant county coroner for 12, said. “From about 1980 on, my mantra has always been that Marin County is living in the dark ages. We need a forensic facility that is safe and secure, to have evidence from homicide cases removed from any public view. When we have mortuary employees hanging around, that’s the public. They can tell people anything they see or hear.”

In 2011, some 115 autopsies were performed in Marin County. But all decedents from homicide cases and other suspicious deaths are transported to the Napa County morgue, a state-of-the-art, green building constructed in 2006 that boasts a stainless steel five-table autopsy room, cold storage lockers for human remains, a crime lab equipped with liquid nitrogen tanks to store crime evidence and a scanning electron microscope used to analyze ballistic evidence. Last year, five Marin cases were sent to Napa.

But according to the report, even homicide victims that are evaluated in Napa are sometimes sent to a Marin funeral home first, where lax security could make it “easy for anyone to walk off with a decedent’s personal effects” or jeopardize criminal investigations.

“I was always on edge, wondering when some smart defense attorney would find out [about the autopsy conditions and procedures] and say that anything found during the course of the autopsy needed to be thrown out because of exposure to the outside world,” Mr. Holmes said. “It never happened, but I’m surprised that it didn’t.”

Mr. Holmes, who retired in 2010 after he lost the election for the newly combined Sheriff-Coroner post to then Sheriff Robert Doyle, said there were times during his tenure when forensic pathologists refused to do autopsies in certain mortuaries until either the lighting was changed or the ventilation was updated.

“It’s horrifying, but that is what we were forced to work with because of the board of supervisors, via the county administrator,” Mr. Holmes said. “They didn’t care and they still don’t.”

In fact, this is the third grand jury report since 2001 to decry the lack of a county morgue. After the first report, which recommended that the county coroner establish a morgue “as soon as possible,” the board responded that it must first receive a financial feasibility analysis prepared by the county administrator. To date, such an analysis has still not been done, the jury stated.

In response to a second report in 2009, the board said that while a morgue had “not yet been implemented,” the county was working to establish a modern facility that would include a morgue and directly related forensic functions “in the future,” and had earmarked $1.75 million for that purpose. This year’s grand jury learned that those funds were instead used to purchase the Marin Commons building at 1600 Los Gamos Road, in San Rafael, which will house an emergency operations center and Sheriff’s headquarters, but no morgue.

“It’s a joke the way they treat the civil grand jury reports,” Mr. Holmes said.

As a temporary measure, until the county has its own morgue and autopsy suite, the report recommends Marin have all autopsies and external examinations performed at the Napa County morgue. And while a brand new forensic facility would be ideal, serious consideration should be given to setting aside funds to retrofit a space at the new Commons, the report states.

Sheriff Robert Doyle, who is now also the county’s coroner, sees things differently. “If we had an extra $2 million, plus $100,000 a year in operations costs, then maybe,” Mr. Doyle said. “But I just think these are tough economic times. If we were going to add $2 million to the budget, I still don’t think this would be a priority. In a perfect world we would have a morgue, but now we don’t have the money.”

While he admitted that conditions were not ideal, Mr. Doyle said that transporting all decedents to Napa for autopsy was “unnecessary” and “impractical.”

The report stated that while moving each operation to Napa would be more expensive—costing the county an additional $115,000 per year—the jury believed a lower price could be negotiated, and would ensure that autopsies and exams were performed in a “clean, safe, professional and dignified manner.”

Civil Grand Jury Foreperson Mike Chernock, who did not prepare the report, said the question of whether or not Marin needed its own morgue arose from complaints from the public.

“[The jury] went to Napa to observe how their operations were conducted, and in comparison [Marin] looked pretty bad,” he said. “It’s awful. Unfortunately there doesn’t seem to be the political will to make the changes happen. Our job is to keep poking [the board of supervisors].”

Mr. Chernock also pointed out that using Napa or a facility like it would also make it easier to recover tissue intended for donation—whether for life-saving measures, to restore vision or to aid burn victims.

Angela Rosati, who manages tissue services at the California Transplant Donor Network, said that while everyone involved worked hard to make the recovery of tissue happen, it “wasn’t easy” under Marin’s current practices.

Napa’s Coroner Leroy Anderson said the new facility has made a big difference, especially when it comes to collecting evidence in a controlled environment. The morgue’s full body X-ray machine has also been especially helpful in cases of unattended or other mysterious deaths, preventing unnecessary autopsies.

But at least one Marin mortuary was concerned that the report painted it in an unfairly negative light. Luke Boncore, location manager of Keaton’s, said it was easy for an outsider to find standard mortuary practice upsetting, and carelessly spreading unspecified accusations of poor conditions could damage the relationship between mortuaries and the people who entrusted them with the care of their dearly departed.

“We’ve been working with the coroner for a long time,” Mr. Boncore said, “and ultimately the relationship works very well. One of the original owners of Keaton’s was the coroner himself. The way we operate now is well within regulations. Regardless of whether we’re working with the county or not, we have deadbolts and an electronic security system. We take these measures seriously, and are owned by a larger company with considerable resources, so we’re able to make any necessary improvements.”

Mr. Boncore said Keaton’s was not among the mortuaries making upgrades, as it did not currently need any.

“It is part of our custom and policy to honor the deceased, and we take great pains to do that,” he said. He noted that the prep facility is at a distance from where families come to view and commemorate their loved ones. “We can be working and have services going on at the same time, and neither is hindered,” he said.

Board of Supervisors Vice President Judy Arnold said the sheriff’s office was working with one of the mortuaries to develop a public-private partnership to fulfill the county’s needs. “In a perfect world it would be great to have a morgue,” Ms. Arnold said. “But in this economy, the sharing of services is a good thing, and when we can have a public-private partnership—that’s even better.”

To conduct the report, the Grand Jury interviewed past and present employees of the Marin County Sheriff-Coroner’s Office and employees of the Marin County Pathologist’s office, and visited the Napa County Morgue and Marin County funeral homes where autopsies and cremations are conducted.  

The jury is the only independent watchdog investigative body in Marin County and is funded through the Superior Court. It is composed of 19 citizens, selected by Superior Court Judges, tasked with monitoring the performance of local government, and making recommendations to save taxpayers’ dollars and improve services.