Hospitals

Certain types of cases not listed in the State Law but which often pose problems or are difficult to evaluate, should be reported to the Coroner for a decision. These include, but are not limited to the following:

1. Persons dying within 24 hours of admission to the hospital, or not medically attended by a physician within 24-hours of the time of death, unless the attending physician has established a natural cause of death.
2. All deaths occurring in operating rooms, during therapeutic or diagnostic procedures or as a result of complications of these procedures (postoperative, e.g., wound infections) or when the patient has not regained consciousness after an anesthetic should be reported.  These are not all Coroner's cases unless the death is known or suspected as being due to misadventure during the surgery, therapy, procedure or anesthetic. These cases are often difficult to evaluate and should be referred to the Department of Medical Examiner-Coroner for a decision. The surgeon or physician with the most knowledge of the circumstances should report the death. The deaths occurring within 24 hours after surgery should also be reported.
3. All deaths in which the patient is comatose on arrival and remains so throughout his/her hospital care unless the cause of the coma has been definitely established as due to a natural disease.
4. The death of an unidentified person will be accepted as a Coroner’s case. It is acceptable for the treating physician to opine a cause of death for an unidentified person who dies from a natural disease process. After the death is reported, the Coroner will attempt to identify the decedent. All efforts to identify the decedent by hospital staff, law enforcement agencies or social service agencies should be well documented in the medical records. The cause of death opined by the private physician will be used by the Coroner for the official death certificate. Do not place the name “John/Jane Doe” on the signed death certificate.
5. All deaths involving hip fractures if the attending physician believes the fracture caused or contributed to the cause of death.  If the fracture is to appear anywhere on the death certificate, the certificate must be completed by the Department of Medical Examiner-Coroner and not by the attending physician.
6. All deaths in which an injury or an accident is the cause or a contributing cause regardless of how distant or remote in time or place the accident or injury may have occurred. This includes subdural hematomas, comas, paraplegia, quadriplegia, fractures and seizure disorders, regardless of the time interval between the injury and death.

All cases known or suspected as coming under the jurisdiction of the Medical Examiner-Coroner should be reported immediately to 323.343-0711. The family or next-of-kin of the decedent should not be approached for permission for an autopsy prior to clearance from the Coroner's office. Removal of tissue from Coroner's cases for scientific or transplant purposes MUST NOT be performed without prior approval of the Coroner, regardless of prior next-of-kin authorization.

The Medical Examiner-Coroner shall have discretion to determine the extent of inquiry to be made into any death occurring under natural circumstances and falling within the provisions of the law. If such inquiry determines that the physician of record has sufficient knowledge to reasonably state the cause of a death occurring under natural circumstances the Coroner may authorize the physician to sign the certificate of death. In all other instances, the Coroner or his appointed deputy shall personally sign the death certificate.  The decision as to whether a death is in fact a Coroner's case rests with the Coroner.  If it is determined, after appropriate evaluation, that the death is not a Coroner's case, it then becomes the responsibility of the attending physician to issue the death certificate.

According to Health and Safety Code 102825, the physician and surgeon last in attendance, or in the case of a patient in a skilled nursing or intermediate care facility at the time of death, the physician and surgeon last in attendance or a licensed physician assistant under the supervision of the physician and surgeon last in attendance, on a deceased person shall state on the certificate of death the disease or condition directly leading to death, antecedent causes, or other significant conditions contributing to death and any other medical and health section data as may be required on the certificate. He or she shall also specify the time in attendance, the time he or she last saw the deceased person alive, and the hour and day on which death occurred. This must be done within 15 hours after the death.  With increasing demand for tissue for transplantation, families consent for organ donation more often.  Many of our decedents are tissue donors (heart valves, cornea, skin, bone). It is therefore important that cases are reported in a timely manner and medical records are available at time of release or removal.

California Health and Safety Code Sections 7180 and 7181 establish two methods of pronouncing death.

1. Determine, in accordance with accepted medical standards, that there has been irreversible cessation of circulatory and respiratory functions. This does not necessarily have to be done by a physician, although in a hospital or nursing home it ordinarily would be.
2. Two physicians to determine that brain death has occurred. In this case, the official time of death is the time that the second physician confirms brain death. It is not the responsibility of the Department of Medical Examiner-Coroner to respond to a possible dead body to pronounce death. This office has no legal authority to enter into a case until the person is in fact pronounced dead, and then only in those cases defined by the statutes which give the Coroner clear jurisdiction.

Whenever possible the Coroner desires to have a complete copy of all medical records in the decedent's patient file at the time the decedent is removed from the hospital. These usually include paramedic reports, Emergency Room physician admission notes, history and physical notes, discharge summaries, pertinent operative consultation reports, progress notes, culture reports and toxicology reports. In all cases, a Hospital and Nursing Care Facility Report (Coroner's Form 18) must be completed in full prior to removal. All medical records must be available for release to the Coroner's department with the body. On the reverse side of the Form 18 is information describing types of deaths reportable to the Department of Medical Examiner-Coroner.  This form should be completed by the attending physician or the physician who pronounced the patient dead, or other appropriate officer of the hospital or nursing facility.

Clerical information may be provided by duly authorized ancillary personnel.

On the hospital report, any unusual circumstances concerning the death of the patient, such as an injury or accident which has occurred in the hospital or nursing facility, should be reported. Information of this nature is very important for conducting a proper and thorough medico-legal investigation. Suspicion or evidence of toxic poisoning shall also be reported. Our laboratory will conduct the appropriate toxicological analysis. In some cases, the Coroner may request blood or other samples from the hospital laboratory.

Please report the death to the Medical Examiner-Coroner's office as soon as possible. Should there be any questions regarding any death that is within the Medical Examiner-Coroner's jurisdiction, have the attending physician contact this office at 323.343.0711.

Deaths that involve gunshot wounds, stab wounds, suspected homicides or vehicular collisions, should, as a matter of hospital policy, be reported first to the law enforcement agency having jurisdiction. That agency will then be responsible for reporting the death to the Coroner. Hospital staff should notify the law enforcement agency having jurisdiction over the location where the injury occurred. This is necessary to ensure that investigations involving criminal activity are properly coordinated and that the most factual information is given to the Coroner.

When reporting the case, please state the location of the remains, (i.e., in emergency room, on ward, in morgue, unsecured storage room, etc.). Also tell the Coroner representative if the body is or will be under refrigeration up until our arrival. This will assist us in making the removal. It is of the utmost importance that information be provided as to whether there is any blood, urine or other laboratory specimens available at your facility.  This is especially important in suspected drug overdoses and in cases hospitalized over 24 hours. These specimens should not be destroyed. Rather, they should be properly preserved for release to the Coroner's representative along with the medical records when the remains are removed.

In deaths known or suspected as coming under the jurisdiction of the Medical Examiner-Coroner, all diagnostic or therapeutic apparatus on or in the body at the time of death should not be disturbed or removed from the body without the consent of the Coroner. Tubes and IV’s may be cut and clamped to prevent drainage.

1. Remains shall be refrigerated as soon as possible. If no refrigeration is available, notify the Medical Examiner-Coroner.
2. Do not clean the body or clothing after death.
3. All clothing of the deceased should remain with the body.
4. Clothing on homicide or suspected homicide victims shall not be disposed of, or destroyed. It shall be released to the Coroner or with the Coroner's consent, it may be released to the investigating police agency.
5. The body should not be disturbed in any fashion, including photography, fingerprinting or evidence collection without prior permission of the Coroner.
6. Casts, splints, bandages, etc., that are on the person at death, shall be left intact. Paramedic backboards should be removed prior to transport to the Coroner.
7. IV needles, tracheal tubes, airways, drainage tubes and any other resuscitation implements on the person at death shall remain intact on the body. Therapeutic paraphernalia will be returned to the hospital upon request.
8. If possible, admitting blood (including blood bank specimen), urine and other specimens should be saved on all patients who are classified in critical condition if their death would result in Coroner jurisdiction.
9. The placenta or the pathology report of the placenta should be submitted with the body in cases of stillbirth, fetal demise, and perinatal death.
10. Additionally, the toxicology screen results on urine and blood and the culture results on
11. CSF/Blood/Urine/Sputum should be included. It is very important that the date and time of collection of these specimens be recorded on the specimen container.
12. If specimens have been sent for serology/toxicology/viral/bacterial culture from emergency room, do not discard; do not cancel the order since patient expired. It could help the medical examiner with cause of death. If these tests are not conducted due to cost, save the specimens for Medical Examiner-Coroner.
13. If the family wishes to view the body before removal this is permissible provided the body is not cleaned or otherwise disturbed. Touching of the body is not permitted. In cases where there is potential criminal investigation, viewing should be strongly discouraged. Families should be advised that the opportunity for viewing would be at their funeral home. Families should not be told that the Coroner allows viewing. There are no facilities for viewing of decedents at the Forensic Science Center.
14. Identification of decedents is the responsibility of the Coroner. Several different methods are used. There is generally no need for next of kin or other family members to come to the Forensic Science Center for the purpose of identifying a decedent. If such assistance is required, the next of kin or other person having knowledge of the decedent will be contacted and asked to view a photograph of the decedent or produce other records.
15. Family members should be advised to contact a funeral service provider of their choice and make whatever arrangements they would like regarding the disposition of the decedent. The funeral service provider will coordinate the release of the remains and other issues on behalf of the next of kin. The Department of Medical Examiner-Coroner is neither a mortuary nor a funeral service provider. NOTE:  The Department of Health Services operates the Los Angeles County Morgue and will handle certain cases as indigent; however, proof of indigence is required. Contact the County Morgue at 323.226.7161 for more information.
16. If the family has not been notified of the death by the time the Coroner's representative arrives to remove the body, the representative should be made aware of this so that notification efforts can be initiated and/or coordinated.
17. In some instances, the death of an individual may become a Coroner’s case after or during an autopsy at a hospital. In these instances, we will require the following at the time of removal, or as soon as possible thereafter:
    1. The autopsy report describing procedures completed before the case fell under Coroner jurisdiction also include clearance number if issued prior to autopsy.
    2. All dissected organs and tissue samples collected must accompany the body;
    3. Blood sample collected during autopsy to be available for pick up when the remains are removed from the facility (blood collected should be preserved in sodium fluoride 2 gm/100 cc blood).
    4. Any blood samples collected prior to death including samples collected for the blood bank while decedent was in hospital or emergency room;
    5. Discharge summary or summary of clinical events prior to death (entire medical chart is preferable);
    6. County of Los Angeles Department of Coroner Form #18 - Death Report, duly completed and signed;
    7. If all or some of the above items will not be ready at the time of removal, please provide the name and contact number of the person who will provide these items to our staff at a later date.

In all Coroner's cases that are DOA or that are not admitted, the following procedure must be followed:

1. The next-of-kin should be contacted, if not present at the hospital. Documentation of notification should be made. Personal effects are not to be released to anyone without the consent of the Coroner. If the next of kin are unavailable, the property should be withheld and given to the Coroner representative. Should the next-of-kin leave prior to Coroner's arrival, obtain a telephone number where they can be reached.
2. After the decedent is pronounced dead, the decedent and his/her clothing shall not be disturbed in any manner, and the remains shall not be searched by anyone, nor shall the body be used for post-mortem training or practice. The body, the clothing and all personal property are under the jurisdiction of the Coroner and permission of the Coroner is required before any post-mortem handling. This prohibition applies to law enforcement agencies as well. Exception: Traffic accident victims may be searched for a "Donor Card" by law enforcement personnel. If a donor card is found, that information shall be communicated to the Coroner immediately. Should it be necessary for investigating agencies to search the remains for any other reason, they must request permission to search the remains from the Coroner Watch Commander on duty at 323.343.0714.
3. Decedents may be removed from the emergency room after the death is reported, and placed in a secured or locked room or refrigerated morgue or crypt. This is especially true if personal property remains on the decedent. If the hospital or other facility has no refrigerated storage area for the decedent, this information needs to be communicated to the Department of Coroner as part of the initial death report.
4. The Coroner's representative will make a thorough search for property, in the presence of witnesses from your facility, who will be given a copy of the official receipt for all property found on the decedent. Your cooperation with our representative will be appreciated, and will contribute to a proper and legal death investigation.

Not all Coroner cases are autopsied. Those that are not may still be autopsied by the family's private pathologist after the Coroner releases the remains to a mortuary or declines jurisdiction in the death. In any case, the private pathologist should secure a valid autopsy consent from the legal next of kin in writing before performing any post-mortem examination.
UNDER NO CIRCUMSTANCES SHOULD PHYSICIANS OR HOSPITAL STAFF IMPLY TO FAMILIES THAT REFUSAL TO GRANT THE HOSPITAL PERMISSION TO AUTOPSY WILL AUTOMATICALLY BRING THE DEATH WITHIN THE JURISDICTION OF THE DEPARTMENT OF MEDICAL EXAMINER-CORONER. CONVERSELY, NO FAMILY SHOULD BE TOLD THAT THE CORONER WOULD, IN FACT, BE PERFORMING AN AUTOPSY ON A PARTICULAR DECEDENT.
Under California Government Code Section 27491.43 (b), only the decedent can execute a certificate of religious belief against the performance of an autopsy procedure. This must be done prior to death. The next of kin has no standing to decline an autopsy in lieu of this certificate.
The legal next of kin may execute a Objection to Autopsy, Form #49, however under certain conditions, an autopsy may be required. If the legal next of kin wish to attempt to block a Coroner’s autopsy, the Coroner will allow 48 hours in which the legal next of kin may pursue a court order blocking the autopsy. If, after 48 hours, a court order is not secured, the autopsy will proceed. If a court order should issue, the Coroner will then certify the death by other means, in accordance with departmental procedures. Blocking an autopsy may have both criminal and civil legal ramifications and may affect payment on insurance claims.

The decision as to whether an autopsy is to be performed is made by a Senior Deputy Medical Examiner, in accordance with departmental policies.

Attending physicians may be allowed to observe an autopsy on their cases. Physicians should notify Investigations at 323.343.0714, if they would like to be called, or contact the Medical Division at 323.343.0520 during business hours to make your request known. The assigned Deputy Medical Examiner will inform them one (1) hour prior to autopsy. Please be aware that there are strict protective apparel policies required to maintain the health and safety of all visitors to the security floor, to include being properly fit-tested with an N-95 Hepa-Filter Respirator.

Autopsy reports are made available upon request to the hospital administration by calling 323.343.0512. Attending physicians can make an autopsy request to the family concerned with the understanding that such a request may be acted upon privately only if:

• The death of the deceased does not fall under the jurisdiction of the Coroner; or
• The case did fall under the jurisdiction of the Department of Medical Examiner-Coroner, however, an autopsy was deemed unnecessary and therefore, not performed.

If, during a family consented hospital autopsy, there are findings, which make the decedent a Coroner’s case, the hospital pathologist must provide the Department of Medical Examiner-Coroner a report on his/her dissection. The family should be referred to the Department of Medical Examiner-Coroner for further information.

Paid Autopsies

Under the California Government Code section 27520, upon request of the legal next of kin of a decedent, the Coroner shall perform an autopsy on a decedent. However, the Coroner is entitled to recover costs for the autopsy, which are to be borne by the requesting party. The costs of a paid autopsy do not include exhumation costs (if applicable). Payment of fees must be made before any services are performed. Paid autopsies are coordinated through the Investigations Division at 323.343.0714. All paid autopsies require a signed death certificate by the treating physician. If there is no death certificate, case must be discussed with a Deputy Medical Examiner or Supervising Investigator.

Not only is timely reporting necessary for reasons discussed previously, it is also paramount for effective organ and tissue recovery procedures. The donation and recovery process cannot begin until the Coroner has been properly notified of the death and approves any and all proposed transplant related procedures.

Hospital staffs are encouraged to consider a Coroner case as a potential donor. Once a death is reported to the Department of Medical Examiner-Coroner, the donation and recovery process can begin. Please understand that it is the hospital's responsibility to report a death or in some cases, contact the responsible law enforcement agency so that they may report the death. The responsibility for reporting a death should not be deferred to an organ procurement organization or tissue bank. The Coroner is supportive of organ and tissue donation and is an active participant in this life saving and life improving mission. As long as it does not interfere with injury interpretation, cause of death interpretation, and evidence collection.

The legal next of kin of a decedent are the most important participants in any organ or tissue donation process. The consent of the Coroner is only half of the equation. The legal next of kin must also approve any organ or tissue donation. The Coroner cannot approve any donation without the consent of the legal next of kin. If the decedent’s death is under the jurisdiction of the Coroner, the legal next of cannot authorize organ or tissue donation without the consent of the Coroner. On unidentified Coroner cases, the Department of Coroner does not have the authority to allow organ procurement thus requests on "Doe" cases will be denied.

The Medical Examiner-Coroner is ultimately responsible for determining mode and cause of death. The decision to authorize organ or tissue harvesting rests with the Coroner, not a law enforcement agency. While the concerns of a law enforcement agency will be taken into consideration, the Coroner will consider all facts available and make a decision based on our ability to fulfill State mandated functions. It is for this reason that the Coroner requires deaths to be reported by those having firsthand knowledge of the circumstances surrounding a death.

More often than not, it is the investigating agency that has that information.

Please ensure that the Hospital and Nursing Care Facility Report (Form #18} is complete regarding the organ and tissue donation information. Also, an admission blood sample is needed, as pre-procurement perfusion factors affect toxicological analysis.

Currently under a contractual agreement with the County of Los Angeles Department of Medical Examiner-Coroner, an approved contractor will review all cases for their donation suitability. Some restrictions to recovery of organs and tissues may be imposed so as not to compromise vital forensic evaluation and evidence collection. For example, a victim of a gunshot wound with trauma to the face would probably not be a candidate for ocular donation.

However, other tissues and possibly organs could be recovered.

Finally, tissue and organ donation should not delay funeral arrangements, prevent viewing of the decedent, or disrupt normal hospital death procedures as long as these guidelines are followed.