In a California county where the sheriff is also the coroner, families seek change

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In Riverside, California, the families of several people who have died in the county’s jails are mounting an uphill battle: to force the creation of an independent coroner’s office.

Their fight comes amid a headline-making spike in jail deaths in this sprawling county east of Los Angeles. In 2022, at least 19 people died while held in Riverside county detention facilities, according to California department of justice data. That’s a higher rate of jail deaths than in LA county that year, which had three times as many inmates. Last year, at least 14 people died in the Riverside county detention centers.

But the high number of deaths isn’t the only reason behind the families’ quest. In Riverside county, as in 48 of California’s 58 counties, the coroner’s office is run by the sheriff’s department – the same agency that runs the jails.

That structure, legal experts say, presents at least the perception of a conflict of interest when someone dies in jail, in police custody, or following police use of force.

Many families of people who have died in Riverside county jails agree. That’s because Chad Bianco – the Riverside county sheriff and a rabble-rouser who was once affiliated with the Oath Keepers and recently endorsed Trump by saying “I think it’s time to put a felon in the White House” – has deflected responsibility for the deaths on his watch. When the California attorney general in 2023 announced an investigation into Bianco’s department, he dismissed it as a political maneuver by his detractors in Sacramento. “Every single one of these inmate deaths was out of anyone’s control,” Bianco told Riverside’s Press-Enterprise. “The fact of the matter is that they just happened to be in our custody.”

In another instance, Bianco used his personal Facebook account to respond to an article posted by the Press-Enterprise about deaths in his jails, most of which were due to drug overdoses or suicide. “Did [inmates’ families] ever demand their family members not commit suicide or consume drugs while they were in custody?” he wrote. “Did they ever demand that their family members not commit crimes in the first place?”

And in an interview with the Guardian in March, Bianco doubled down. “It’s not my fault that someone is going [to] extraordinary lengths to smuggle fentanyl into the jail,” he said. “When are we going to say that it’s not the government’s fault or the government’s responsibility to take care of all this?”

Lisa Matus’s son Richard died of a fentanyl overdose at Riverside county’s Cois M Byrd detention center in 2022. The autopsy performed by Bianco’s office ruled Matus had died of a fentanyl overdose. But it also found that his left anterior descending artery, which provides half the heart’s blood, was 80-90% closed. Matus’s family alleges he was not given adequate medical attention while in jail, despite requesting care on multiple occasions.

Richard was awaiting trial with his brother Raymond for attempted murder and attempted robbery when he was found unresponsive in his cell, according to the coroner’s report. Matus said she called the sheriff’s department multiple times to locate Richard’s body but couldn’t get answers until she got an attorney involved.

“How do you trust somebody that’s bashing you [on] social media, but is also in charge of letting us know what happened inside the jail?” she said.

Matus has filed a civil suit against the department, which is ongoing.

When the Guardian asked Bianco about his social media remarks, he softened his stance. He said his comment was not meant to single out Matus or imply she was to blame for her son’s death. If given the opportunity to speak to Matus in person, he said: “I would make it perfectly clear to her that that’s not what I meant. And never would I think or accuse her of that.”

‘Not to satisfy law enforcement but to get to the truth’
If the idea of a law enforcement agency overseeing a coroner’s office sounds unusual, that’s because it is. California is one of just four states that uses a sheriff-coroner system, according to the US Centers for Disease Control and Prevention.

Generally speaking, a coroner is an administrative figure who oversees autopsies conducted by physicians who are also board-certified forensic pathologists. In California, anyone 21 or older with a high school diploma and no felony convictions meets the minimum requirements to become a coroner.

Several experts said allowing law enforcement officials to serve as coroners in their own jurisdictions, as is the case in Riverside, is problematic. “The job of the person doing an autopsy is not to satisfy law enforcement but to get to the truth,” said Thomas Mauriello, a former police officer and federal investigator who teaches at University of Maryland’s department of criminology and criminal justice. Law enforcement agencies and coroners, he said, “should be separate and distinct”.

Marcella Fierro spent 14 years as the chief medical examiner for the Commonwealth of Virginia, and has written extensively on death investigations for the National Academy of Sciences. “Death investigations and forensic science investigations need to be separate from law enforcement, unequivocally,” she said.

Over the years, there’ve been reports about the relationship between sheriff’s departments and coroners impacting investigations elsewhere in the state. In a high-profile California case, two forensic pathologists in San Joaquin county accused their boss, then sheriff-coroner Steve Moore, of meddling in a death investigation that might have implicated his deputies, and resigned. Moore denied the allegations. The San Joaquin county board of supervisors later stripped Moore of his duties, separated the sheriff- coroner office and implemented a new system.

And there’s been research into the topic. A 2023 study by researchers at University of Southern California found that California counties that use a sheriff-coroner system “grossly undercount” deaths involving officers.

The Riverside county sheriff’s department, which oversees 4,000 people incarcerated across five detention facilities, recently faced scrutiny over one such death: Christopher Zumwalt died in 2020 after sheriff’s deputies raided his jail cell with pepper spray and shocked and restrained him, according to recent reporting by the New York Times. The sheriff’s department determined Zumwalt’s cause of death to be cardiac arrest, according to the Times, and the coroner ruled it a justified homicide.

Law enforcement agencies are required to report such incidents to the state. But the Guardian could not find a similar case in the California justice department’s use-of-force database, where the information would ordinarily be.

Bianco did not respond to a request for comment about whether his department reported the use-of-force to the state, or the accuracy of the Times’s reporting.

‘Tired old false argument’
Aided by the ACLU, Matus and other family members of people who died in Bianco’s jails have had some success putting the issue on the agenda of local leaders. In December 2023, Riverside county supervisors Kevin Jeffries and V Manuel Perez authored a proposal to study the separation of the coroner from the sheriff. “While there is no evidence of any improprieties in Riverside county regarding the operations of the coroner’s office under the sheriff,” they wrote, “the optics of a potential conflict of interest can lead to a loss of confidence in our institutions.”

The group that conducted the study ultimately advised against separating the sheriff from the coroner, citing costs.

But Jeffries, Perez and advocates scored a small victory. In March, the board voted in favor of a new arrangement: autopsies for people who die in the county’s detention facilities will be outsourced to neighboring agencies. Luis Nolasco of the ACLU said that’s a step in the right direction, but he worries that law enforcement employees look out for each other regardless of jurisdiction, and “there may be some influencing [between] neighboring counties”.

Bianco bristles at Nolasco’s suggestion. “That’s a tired old false argument,” he said. “There is no law enforcement officer that looks out for themselves.”

The argument over which county coroner examines a body is beside the point, experts say. The real problem is the fact that coroners exist at all. Fierro said coroners typically have limited training and juggle responsibilities with other duties. “This is not a part-time, do-it-on-the-weekend job,” she said. “Coroners should be done away with unless the coroner is an MD.”

Many states, like Virginia, Maryland and Massachusetts, use state-run systems made up of forensic pathologists overseen by medical examiners, who are either physicians, forensic pathologists or both; those systems are not associated with law enforcement agencies.

Some California counties, such as Los Angeles, San Joaquin and San Diego, have medical examiners’ departments that are also separate from law enforcement.

But replacing coroners with medical examiners, in California or anywhere else, is challenging. In the US, there are only about 700 forensic pathologists across roughly 2,400 death investigation systems, according to a 2022 study in the journal Missouri Medicine.

“It’s a very rare career choice,” said J Keith Pinckard, president of the National Association of Medical Examiners. “It is a lower-paying specialty compared to other branches of medical practice,” he said, “and salaries in government may not be comparable to the private sector”.

‘Less headache’
The ACLU of Southern California and the families say they’re not done fighting for the separation of the sheriff and the coroner.

There’s some attention on the issue at the state level, too. California assemblymember Mike Gipson, who in 2021 introduced a bill to separate coroners and sheriffs statewide that failed over budget concerns, says he plans to reintroduce his bill after the November elections, when the state legislature has new members.

The Riverside county sheriff, meanwhile, has his hands full. The California attorney general’s investigation into his department is ongoing. And the department has been under a federal consent decree due to poor jail conditions since 2016, prior to Bianco’s election. Bianco has been working with court-appointed attorneys to comply with the decree, which calls for improvements and better staffing of medical and mental health units, and improved conditions in mental health settings.

Two inmates have died in Bianco’s jails since the Riverside county supervisors’ decision earlier this year to outsource jail death autopsies to neighboring counties. The procedures were done by the San Bernardino county sheriff-coroner’s department; San Bernardino county has not fulfilled a request for autopsy reports.

Bianco said sending the bodies of people who die in his jails out of the county is fine by him. He even said he would be open to having someone else serve as coroner. “Would I be open to less responsibility? Would I be open to less scrutiny? Would I be open to less headache? Would I be open to less calls in the middle of the night? Absolutely,” he said. “Absolutely.”

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