Partnerships for Success Corner Medical Examiner: Preserving Evidence and Saving Lives

1. Partnerships for Success Corner Medical Examiner: Preserving Evidence and Saving Lives Breakout Session A Presenters: Allison O’Neal, Orange County Sheriff-Coroner Anthony Maldonado, ME / Coroner Specialist, OneLegacy Moderator: Barbara Anderson, RN, Ronald Reagan UCLA Medical Center

2. Objectives: • 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

3. Questions to Run On: 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?

4. Coroner/Medical Examiner: Preserving Evidence and Saving Lives Allison O’Neal, Supervising Deputy Coroner Orange County Sheriff’s Department-Coroner Division

5. County of OrangeCoroner Statistics • 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%

6. Role & Responsibilities of the Coroner 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

7. What is Reportable to 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:

8. Reportable Information (ctd.) • 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

9. 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

10. Types of OC Coroner Cases • 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.

11. Non-Autopsy cases as they relate to OneLegacy • 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.

12. Sign Out No Autopsy (SONA) 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

13. Autopsy Cases • 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.

14. Brain Death and DCD 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.

15. Case Study:Non-Accidental Trauma

16. Case Study OL reported brain death of a 17 month femaleadmitted 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.

17. Case Study

18. Case Study

19. 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.

20. 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.

21. 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.

22. 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

23. Coroner/Medical Examiner: Preserving Evidence and Saving Lives Anthony Maldonado M.E./Coroner Specialist The Donation & Transplantation Symposium October 15, 2013

24. 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.

25. 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.

26. Coroner/ME Relationships

27. 2010 Organ Coroner Cases By Circumstance of Death

28. 2011 Organ Coroner Cases By Circumstances of Death

29. 2012 Organ Coroner Cases By Circumstances of Death

30. 2013 YTD Organ Coroner Cases By Circumstances of Death - as of September 2013

31. OneLegacy Organ CasesUnder Coroner Jurisdiction

32. OneLegacy Tissue CasesUnder Coroner Jurisdiction

33. Questions to Run On: 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?