June 8, 2023
Final Reports
San Mateo Courts - Civil Grand Jury

2001 Final Report:

Reengineering the San Mateo County Coroner's Department

Summary | Background | Findings | Recommendations | Responses


The 2001-2002 Grand Jury studied the San Mateo County Coroner's Department to determine how productive it is, given its current organization and practices. In order to gain perspective, the Grand Jury also reviewed the operation of several other coroners' departments around the state. All members of the San Mateo County Coroner's Department with whom we spoke seemed dedicated and interested in providing a quality service to the citizens.

The Grand Jury found that the county Coroner's Department has significant conflicts, both within the department and with other departments, that result in reduced effectiveness. The Pathology Section is in need of greater management support to properly address facilities and equipment problems. The overall distribution of staff positions in the department and their schedules should be evaluated to determine best use of resources and maximize departmental cohesiveness.

If San Mateo County wishes to be on a technological par with other California counties of comparable size and sophistication, it should carefully evaluate the benefits of restructuring the department to be headed by a medical examiner, who would have training in all areas of forensic science and be able to provide the most comprehensive approach to the position of coroner.


1. What measures can the Coroner's Department take to operate more efficiently and effectively?

2. How might the Coroner's Department save money and improve interdepartmental coordination within the Criminal Justice Department?

3. Would the county be better served by having a medical examiner in the position of coroner?


The defined responsibility of a coroner's department is determining the causes of all manners of deaths, unless the decedent has been under a physician's care within the last 20 days. This is accomplished by a combination of investigations and autopsies. The 2001-2002 Grand Jury undertook an investigation of the organization of the San Mateo County Coroner's Department, its operation and its interaction with the Sheriff's Crime Lab. For comparison, the Grand Jury reviewed the organization and operations of neighboring counties that have filled the coroner's position with a medical examiner. Unlike the position of coroner, where no special technical certification, credentialing or experience is required, a medical examiner must be a board-certified forensic pathologist.

In San Mateo County, the coroner is an elected position. The office was held for nearly 40 years from 1953 to 1991 by Paul Jensen. Adrian "Bud" Moorman held the position for 10 years from 1991 until his death in 2001. Beginning in April 2001, Chief Deputy Coroner Robert Foucrault assumed the duties of coroner. In March 2002 he was elected to the position.

The department has 16 full time equivalent positions on staff, as well as two independent forensic pathologists who provide services through a contract with the county. These staff members and contractors work out of two locations. The coroner, administrative support staff and the Investigative Division are located at Veterans Boulevard in Redwood City. The Pathology Support Section is located at San Mateo County Family Health Center (the Hospital) on 39th Avenue in San Mateo.

Staff work schedules are nonstandard, ostensibly to enable greater round-the-clock coverage. Pathologists work alternating weeks, and investigators work two 20-hour shifts distributed during the week to allow them the greatest continuous number of days off. Toxicology testing is provided by contract with an independent laboratory in Fresno. The department has a budget of $2,225,593 for 2001-2002 and an adopted budget for 2002-2003 of $2,251,293.

In addition to interviewing key department members, crime lab personnel, and other interested county management in San Mateo, the Grand Jury spoke with and reviewed organizational and budgetary information from officials at coroner's and medical examiner's departments in Los Angeles, San Diego, San Francisco, Santa Clara, Santa Cruz, Shasta, Sonoma, and Ventura counties. Among the documents reviewed by the Grand Jury were "Comparative Analysis of Coroner's Services" prepared by the San Mateo County Coroner's Services Task Force, dated March 2001, and "The Report on Coroner-Administrator Organizational Options and Update on Various Issues", prepared by Solano County Administrator, dated May 1996.


The fact that the office was held for nearly 50 years by only two people led to continuation of practices long after they were useful. There are significant structural and organizational problems within the department, such as:

  • Housing the department in two locations, several miles apart, hinders effective interaction among its staff members. The fact that the pathologists are independent contractors further exacerbates the difficulties of building a cohesive team.

  • The creation of a Coroner's Office Investigative Report requires the cooperation and expertise of individual pathologists and investigators. Because schedules are so different, individuals are not always available to respond to each other's questions when needed.

  • The pathology facility, located within the San Mateo County Family Health Center morgue, is not regularly cleaned or well maintained.

  • Pathology equipment is minimal, very old and antiquated. Current procedures for ordering pathology equipment, supplies and repair are inadequate. Neither situation well serves the citizens of the county.

  • Comparing the organization chart from San Mateo County to those of Santa Clara and San Francisco shows that both other counties have a higher percentage of their staff in the area of pathology, 30% and 21% respectively versus 19%, and a significantly lower percentage of their staff working in their investigative units, 35% and 32% versus San Mateo County at 56%.

In addition to issues within the department, there seems to be little connection between the Coroner's Department and the Sheriff's Crime Laboratory. The following statement is made in the Coroner's Department Adopted Budget, FY 2001-2002, FY 2002-2003: "The County is currently planning the construction of the new crime laboratory for the Sheriff's Office at the Tower Road Facilities and will include space for the Investigation and Administration Divisions of the Coroner's Department. This new location will increase collaborative efforts of the Coroner and Sheriff's Offices as well as provide Coroner's Investigators with better access to crime lab services, resulting in quicker turnaround time on Investigation Reports." There was no discussion, however, between the two groups during the planning process for construction of the new laboratory facility. Potential cost reductions in this area and other areas of synergy between these two groups are only just now beginning to be discussed. Crime Lab officials told the Grand Jury that with the proper training, little or no additional staff, and very minor additions to equipment they could process Coroner's Department samples (currently being sent to an independent contract lab for testing) for many drugs of abuse.

In its considerations of the relative merits of having a medical examiner in the position of coroner, the Grand Jury found that medical examiners are most common in counties with higher populations and greater technological awareness. In California, these include Los Angeles, San Diego, San Francisco, Santa Clara, and Ventura counties. Unlike coroners, medical examiners must be trained forensic pathologists. According to the Ventura County Medical Examiner, "The medical examiner is able to provide a comprehensive approach to an investigation in order to determine the cause of death. A coroner often relies on a pathologist to determine cause of death. The reality of a coroner/pathologist team is that neither has a complete understanding of the case at hand and may be making incorrect assumptions as to cause of death by not having all case facts available." This sentiment was echoed by the San Francisco County Medical Examiner. Medical examiners are trained in all areas of forensic medicine including toxicology as well as evidence collection and processing and are, therefore, qualified to testify about the technical aspects of the determination of the cause of death. They are trained in, and generally personally perform, some significant portion of a county's autopsies.

When the Grand Jury raised the option of a medical examiner overseeing the Coroner's Department, interviewees were concerned with: (1) whether the number of autopsies performed (workload) warranted a medical examiner, and (2) the likelihood that department costs would increase. The Grand Jury's review of counties that have medical examiners did not support those concerns. As an example, Table 1, below, shows comparative information from Santa Clara County and Ventura County that have medical examiners.

Note the relative high cost of the San Mateo County Coroner's Department under its current structure.

Autopsies per year
Staff Positions
Annual Budget
Santa Clara
San Mateo

In the "Report on Coroner-Administrator Organizational Options and Update on Various Issues," an extensive comparison prepared by the Solano County Administrator, dated May 1996, the Administrator states, "Solano County is on the cusp of the caseload size needed for such a system." That statement was made in a county that at the time had a population of 340,000 residents and an autopsy caseload of approximately 263. While budgetary information was not available from San Francisco in a comparable form , full time positions (exclusive of their toxicology lab) numbered 38 in a department that handles approximately 1,500 autopsies.

Clearly restructuring the department with a medical examiner at the helm need not lead to a larger departmental budget or a higher cost per autopsy. Redistributing personnel among investigative, pathology, and administrative groups could offset any increased costs.


1. The entire department should be in one location to foster camaraderie and effective interaction. If not practical, the Coroner's Department should be managed to dramatically improve communication and smooth functioning between all work groups.

2. Employees' schedules should be revised to enhance departmental efficiency and to facilitate prompt dispatch of cases. The Investigative Division and Pathology Section need a better understanding of common goals, which would reduce friction and infighting.

3. The coroner should review the staff allocation between investigative, administrative and pathology services to ensure that the county residents receive the required level of service with the greatest economy. He should explore why this county has such a large percentage of its staff involved in the Investigative Division in comparison to other counties.

4. The current pathology facility must be upgraded including the provision of modern inspection devices, cameras, computer data base management capabilities, and adequate office furnishings. Purchasing of equipment, supplies and repair of pathology equipment should be decentralized with logical expenditure controls.

5. The coroner needs to work with the management at San Mateo County Family Health Center to improve cooperation and maintenance at the pathology facility.

6. In keeping with the coroner's own "Objective Based Management" objective in the 2001-2002 Adopted Budget, the County Board of Supervisors should direct the Crime Lab and the Coroner's Department to work together to save money, for example, by conducting the coroner's toxicological testing at the Crime Lab.

7. As a priority, to enhance the office's technical capability and make it equivalent to other modern urban county coroners' offices, the Board of Supervisors should undertake a study of placing a medical examiner in the position of coroner. Such a study should be started well in advance of the end of the current coroner's term in order to allow ample time to make any legal modifications necessary to effect this change.

© 2023 Superior Court of San Mateo County