Study shows California counties overseen by a coroner who is also sheriff underreport officer-involved deaths
Sheriffs who assume the role of coroner underreport officer-involved homicides compared with departments where the roles are separate.
Sheriffs assume the duties of the coroner in 48 of California’s 58 counties.
Political pressure by sheriffs may play a role in recording and classifying the cause of death when police officers are involved.
High-profile incidents of deaths by police officers, such as in the cases of George Floyd in Minneapolis and, more recently, Tyre Nichols in Memphis, Tennessee, have been lightning rods for social movements demanding systemic change in American policing, with calls for greater accountability and transparency, and equal protection for all.
Yet, another persistent but less publicized issue is that sheriff departments grossly undercount officer-involved homicides in official databases that record and categorize these incidents.
Perhaps more worrisome, in counties where sheriffs assume the role of coroner, officer-involved homicides are underreported more often than in those where the functions are separate. This may lead to inaccurate recording of the cause of death, according to a first-of-its-kind study led by researchers at the USC Dornsife College of Letters, Arts and Sciences.
In the study, titled “Do Sheriff-Coroners Underreport Officer-Involved Homicides?,” Maria Prados, associate economist at the USC Dornsife Center for Economic and Social Research, Brian Finch, professor (research) of sociology, and their colleagues drew data from two national databases: the Federal Bureau of Investigation’s Supplementary Homicide Reports (SHR) and Multiple Cause-of-Death files from the Centers for Disease Control’s National Vital Statistics System (NVSS). They then compared the data they compiled with data from Fatal Encounters, an open-source database that tracks officer-involved homicides.
Looking at California data from 2000 to 2018 from both national databases, they found significantly greater underreporting of officer-involved deaths in sheriff-coroner counties compared with counties where the agencies were separate.
In the SHR system, the study concluded, the undercount is due to both a lack of response by state and county law enforcement agencies and the omission of relevant incidents. In the NVSS system, the reasons vary — from errors in classification and certification to more controversial reasons, including pathologists and coroners being pressured by sheriffs to influence their findings.
Since different public agencies, each with their own unique pressures and criteria to classify homicides, manage the SHR and NVSS systems, the disparity suggests that political pressure may play an outsized role in classifying these deaths.
Finch found huge undercount in officer-involved deaths
In prior research, Finch found that these official sources typically undercount annual homicides anywhere between 50% and 250%. The present research finds that this undercount is amplified in California counties with sheriff-coroners.
“Our research found that there is a significant discrepancy between the actual number of officer-involved homicides and the number reported by sheriff-coroners in California,” Finch explained. “This underreporting is a major issue that needs to be addressed, as it undermines the public’s trust in the justice system and hinders efforts to hold law enforcement accountable.”
One case in 2017, in San Joaquin County, demonstrated the lengths to which one sheriff would go to protect his law enforcement officers. In this incident, the sheriff-coroner was accused of changing the cause of death from “homicide” to “accident.” The doctors and technicians, including the chief forensic pathologist, Bennet Omalu, resigned in protest, leading the county Board of Supervisors to strip the sheriff of coroner duties.
Testifying before the state Senate Governance and Finance Committee, Omalu said, “California has the most backward system in death investigation, is the most backward in forensic science and in forensic medicine.”
In another example in 2020, a Contra Costa County sheriff-coroner’s office deemed Angelo Quinto’s death a result of “excited delirium,” a term sometimes attributed to sudden unexplained deaths of individuals while in police custody.
According to The Mercury News, Quinto lost consciousness after an officer knelt on his neck for nearly five minutes. He later died in police custody. No charges were filed against any officers involved in the incident; however, it did lead to Angelo’s Law, which bans restraint tactics and facedown holds that could cause asphyxiation in California.
The American Medical Association and the American Psychiatric Association have dismissed the term “excited delirium” as a diagnosis of death.
Officials call for state policy on independent coroner’s offices
Citing a need for greater transparency among California’s sheriff departments, Assemblymember Mike Gipson sponsored a 2022 bill requiring counties to separate the offices of sheriff and coroner. Said Gipson: “When you have a sheriff’s department overseeing a medical examiner’s office, and a ruling may come back questionable, we want to make sure that we remove those questions.”
The California Medical Association supported the bill, stating, “A consistent statewide policy towards independent coroner’s offices would help to ensure that medical examinations and investigations of sudden, violent, or unexplained/suspicious deaths are conducted objectively.”
The bill failed to pass in the state Senate.
Finch remains hopeful that studies such as his will help policymakers as they work to enact reforms.
“Without accurate data, we cannot effectively and fairly address the issue of police violence and ensure that law enforcement is held accountable for their actions when appropriate,” he said.