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Santa Barbara County Grand Jury report finds conflict of interest regarding in-custody death investigations Monday


SANTA BARBARA COUNTY, Calif. – A 2024 Santa Barbara Grand Jury report released Monday identified an inherent risk of a conflict of interest regarding in-custody death investigations in the county.

While the Grand Jury did not find specific cases of abuse, the report did find, "a real or perceived conflict of interest in investigating and conducting pathological exams related to deaths in custody that can be avoided or mitigated by having a separate Medical Examiner's office...or outsourcing those specific cases to an independent agency".

Santa Barbara County is one of 47 other counties in California that have a Sheriff and Coroner within the same organization detail the Grand Jury report.

To evaluate the impact of a Sheriff/Coroner system, the Grand Jury decided to compare Santa Barbara County to two of its neighboring counties, San Luis Obispo and Ventura explain the report.

San Luis Obispo County has a Sheriff/Coroner system similar to Santa Barbara County with one notable difference, pathology work is outsourced to a San Diego-based company, NAAG Forensic.

Ventura County has had a Medical Examiner's Department independent of the Ventura County Sheriff's Office that employs certified pathologists and forensic investigators since 1984.

In Santa Barbara County, the Coroner Bureau is under the authority of the Sheriff/Coroner and is managed by a Sergeant with a staff of four Sheriff's detectives alongside a Forensic Pathologist, Pathology technicians, and Adminsitrative Support detail the report.

According to the Grand Jury report, the Santa Barbara resident who submitted the Request for Investigation, a representative from the Ventura County Medical Examiner's Office, and members of the Sheriff's Offices in Santa Barbara and San Luis Obispo counties were all interviewed as part of the report's investigation.

The California Department of Justice posts the total number of Deaths in Custody statewide online.

A breakdown of those deaths is detailed in the chart below from the Grand Jury report which only list deaths up to December of 2023, the time of the request from the Grand Jury.

The Grand Jury report found that every single one of those deaths resulted in an autopsy, including those in Santa Barbara County.

The process for autopsy approval in Santa Barbara County currently requires a decision by a member of the Coroner's Detective Staff in conjunction with the pathologist as opposed to a decision solely up to the discretion of a pathologist or medical staff, like the two other counties cited in the report.

This system can lead to the Santa Barbara County Sheriff's Office as the single source of information as this article about an in-custody death at a Santa Barbara County jail from September of last year demonstrates.

The Grand Jury found that "a potential perceived conflict of interest for the Sheriff/Coroner to perform investigations and autopsies" regarding in-custody deaths existed and noted that their investigation was unable to find a single instance where the Coroner's staff had requested an independent investigative or medical examination from an external organization.

In comparison, Ventura County's Medical Examiner makes its own determinations from a department separate from the county's Sheriff's Office and while San Luis Obispo County's investigative team remains under the direction of the Sheriff, medical decisions associated with in-custody deaths are made by the forensic pathologist explain the report.

The Grand Jury report also investigated the certification process for Santa Barbara County Sheriff's Office pathologist certification process.

Both Ventura and San Luis Obispo counties require their pathologists be certified per the American Board of Medicolegal Death Investigators standards and that their facilities and equipment meet standards set by the National Association of Medical Examiners.

The U.S. Department of Justice recommends the above certifications, but they are not mandatory.

The Grand Jury found that neither the medical staff nor the Santa Barbara County Coroner's Bureau facilities are certified to these standards and that both the Pathology Technicians are retired law enforcement officers.

While both of those technicians have the required training to perform their current duties, there is no succession plan to fill those positions when needed note the report.

As a result of the investigation, the Grand Jury report makes the following recommendations:

  • The Sheriff/Coroner's office shall request another Santa Barbara County agency to conduct either a parallel or independent investigation for all in-custody deaths starting immediately or all in-custody pathology investigations shall be conducted by an independent medical examination team which should be implemented no later than the end of December of this year
  • The Sheriff/Coroner shall develop and implement a succession plan for pathology technicians following current California Department of Health standards by the end of September 2024

Last year, Governor Newsom signed Senate Bill 519 into law which requires public disclosure of investigations into local in-custody deaths and created the position of Director of In-Custody Death Review under the Board of State and Community Corrections.

California Government Code 27491.55 provides the conditions when an independent medical examination or investigation could be performed:

§27491.55. In any case where a coroner is required to inquire into a death
pursuant to Section 27491, the coroner may delegate his or her jurisdiction over
the death to an agency of another county or the federal government when all of the
following conditions have been met:
(a) The other agency has either requested the delegation of jurisdiction, or
has agreed to take jurisdiction at the request of the coroner
(b) The other agency has the authority to perform the functions being
(c) When both the coroner and the other agency have a jurisdictional interest
or involvement in the death.

Article Topic Follows: Santa Barbara - South County
community oversight
grand jury report
in-custody death investigation
santa barbara county
Santa Barbara County Grand Jury
Santa Barbara County Sheriff's Office Coroner Bureau
santa barbara county sheriff's office
SB 519

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Andrew Gillies

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