Body Mix-Ups, Erroneous Coroner Charges Hurt Grieving Families in San Joaquin

Mishandling of death investigations and alleged wrongdoing by the sheriff's office in San Joaquin County has had devastating consequences for families, according to a KQED investigation prompted by the protest resignations of two county pathologists last year.

World-renowned medical examiner Dr. Bennet Omalu and pathologist Susan Parson made a number of serious accusations against Sheriff Steve Moore before resigning from their posts in 2017.

A KQED investigation into those allegations confirmed that the coroner’s office, under Sheriff Steve Moore, released the wrong bodies to families in 2016 and 2017, and once lost track of a body in the morgue for months.

The coroner also charged hundreds of families hundreds of dollars each to transport their loved ones to the morgue — unnecessarily, the doctors say.

In other instances, sheriff’s deputies — who are also charged with coroner duties — failed to report deaths to the forensic pathologists that the county was legally required to investigate in a timely manner. The doctors said that prevented them from performing the autopsies and tests necessary to determine how and why the people died.

KQED was able to obtain legal records pertaining to some of the cases mentioned above. The documents paint a portrait of a department in turmoil.

According to KQED, inadequate tracking of bodies in the morgue dates back to at least 2013.

In recent years Omalu has recommended purchasing a Laboratory Information Management System (LIMS) for tracking bodies and specimens, a standard tool used by hospitals. He said the sheriff told him it was too expensive.

There are now growing calls for a separation between the coroner’s office and the sheriff’s department. Moore has said he would support the idea “if the Board of Supervisors and residents want it.”


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