1. ONELEGACY AND CORONER’S CASES Christopher Rogers, M.D. Los Angeles County Coroner

2. OBJECTIVES  OneLegacy-Coroner protocol  Building trust and developing relationship  Organ and tissue procurement legislation  Case studies

3. Coroner vs. Medical Examiner What is the difference?  All California counties have a Coroner  In most California counties, the Coroner is an elected official, either the Sheriff or the Public Administrator  In Los Angeles, San Francisco, San Diego and Ventura Counties the Coroner is an appointed forensic pathologist (a medical examiner)

4. Three components of Coroner relationship 1. Establishment of protocols for the timely notification of donors suitable for donation who may come under medical examiner or Coroner jurisdiction. 2. Written and photographic documentation of procedures and findings during the organ procurement. 3. Documentation and collection of evidence.

5. California Health & Safety Code Section 102850 A physician and surgeon, physician assistant, funeral director, or other person shall immediately notify the coroner when he or she has knowledge of a death that occurred or has charge of a body in which death occurred under any of the following circumstances:

6. Health & Safety 102850 (a) Without medical attendance (b) During the continued absence of the attending physician and surgeon (c) Where the attending physician and surgeon or the physician assistant is unable to state the cause of death (d) Where suicide is suspected (e) Following an injury or an accident (f) Under circumstances as to afford a reasonable ground to suspect that the death was caused by the criminal act of another

7. National Association of Medical Examiners Position Paper It is the position of the National Association of Medical Examiners (NAME) that the procurement of organs and/or tissues for transplantation can be accomplished in virtually all cases without detriment to evidence collection, postmortem examination, determination of cause and manner of death, or the conducting of criminal or civil legal proceedings

8. OneLegacy Coroner Protocol  OneLegacy follows a specific coroner protocol.  Any and all hospital medical documentation is shared with the coroner’s office in an attempt to obtain clearance for the organs and tissues to be recovered  Coroner may request additional diagnostic testing from OneLegacy

9. Law Enforcement Involvement  There may be law enforcement involvement in the case  The Coroner’s office will consult with law enforcement about organ and tissue procurement  The coroner has jurisdiction over the body and is the final decision-maker on which organs and tissues to release for donation

10. Forensic Pathologists in the Operating Room  In rare instances, the Coroner’s office will send their forensic pathologist to attend the organ recovery in the operating room  This is most often the case with alleged child abuse cases

11. California Health & Safety Code Section 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. 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.

12. California Health & Safety Code Section 7151.20 (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. 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.

13. CASE STUDY #1  14-month-old female with non-accidental subdural hemorrhage and bruising on the legs and arms  Law enforcement and Child Protective Services involved  Mother’s boyfriend allegedly responsible for injuries

14. CASE STUDY #1 What are the challenges in child abuse cases?  Law enforcement and Child Protective Services have a stake in the outcome  Hospital staff trying “to do the right thing”  Concerns about valid consent if the next of kin is also the alleged abuser

15. CASE STUDY #1 Case Conclusion:  Heart, liver, and kidneys were recovered and transplanted  The Coroner attended the recovery in the operating room as part of the forensic investigation  Law enforcement was present during the autopsy

16. CASE STUDY #2  Middle-aged male Latino  Auto vs. pedestrian  No identification  Hospitalized for four days and then progressed to brain death

17. Case Study #2 What are the challenges when the decedent is unidentified?  Identify the person with authority to consent to organ and tissue donation  Make a “reasonable effort” to locate that person

18. California Health & Safety Code Section 7151.40 (a) Anatomical gift can be made by (in order): 1) An agent of the decedent at the time of death who could have made an anatomical gift immediately before the decedent's death 2) The spouse or domestic partner 3) Adult children 4) Parents 5) Adult siblings 6) Adult grandchildren 7) Grandparents

19. Health & Safety 7151.40 (a) 8) An adult who exhibited special care and concern for the decedent during the decedent's lifetime 9) The persons who were acting as the guardians or conservators of the person of the decedent at the time of death 10) Any other person having the authority to dispose of the decedent's body, including, but not limited to, a coroner, medical examiner, or hospital administrator, provided that reasonable effort has been made to locate and inform persons listed in paragraphs (1) to (9), inclusive, of their option to make, or object to making, an anatomical gift

20. CASE STUDY #2  Hospital Social Services conducted a diligent search with the assistance of local law enforcement  Fingerprints were taken but no match came back  Once the patient was declared brain dead, hospital administrative consent was obtained  Coroner released organs. Note: By policy, the Coroner does not give administrative consent in this situation

21. CASE STUDY #2 Case Conclusion:  Liver and kidneys were recovered and transplanted