lacounty.gov

Department History

Since California became a state, each County has had a coroner. The Coroner was an elected official (often the Sheriff) who was charged with determining cause and manner of death in specific cases.

In 1848, under the treaty of Guadalupe Hidalgo, the part of Mexico called Alta California became part of the United States. Two years later, California became a state including, among its original counties, Los Angeles County. The County seat was located in a town founded in 1777 and originally known as El Pueblo del Rio de Nuestra Senora la Reina de Los Angeles de Porciuncula.

The first Coroner of Los Angeles County, Alpheus P. Hodges, was also the Mayor of the City of Los Angeles. During the administrative transition from Mexican law to United States law, it was difficult to police an area such as Los Angeles, which had no rail or telegraph connection with the rest of the country. The homicide rate between 1847 and 1870 averaged 158 per 100,000, which was about ten to twenty times the rate in New York.

Coroner’s cases were recorded in a ledger book, with each case given one line. Frequent causes of death included “consumption” (tuberculosis),” apoplexy” (sudden death with loss of consciousness) and “dropsy” (accumulation of excess fluid in the body). In 1850 all of the top ten causes of death were infectious diseases.

The Coroner’s job was not at first a full-time job. In 1852 the duties of Coroner and Public Administrator were merged. The Coroner, who reported to the County Clerk, determined the cause of death based on the available information. In difficult cases the Coroner summoned an inquest jury, took testimony, and reported the jury’s verdict.

The Ft. Tejon earthquake (estimated magnitude 7.9) in 1857 is the most recent earthquake on the southern section of the San Andreas Fault. The recorded death toll was only two, as the County was sparsely populated.

A smallpox epidemic in 1863-64 decimated the Native American population of Los Angeles County, which had no natural immunity to the disease. In 1871, racial tensions led to the China Riots, in which 19 died. In 1905 Los Angeles County required formal death certificates to replace the often incomplete records kept by local churches and courts.

In 1906, the District Attorney called for elimination of the Coroner’s jury, saying, “A Coroner’s verdict binds no one. It cannot be used in court and might just as well be written in mud.” Coroner-elect Dr. Roy Lanterman asked for a clerk and a detective to help with the overwhelming workload of the Coroner. The first public morgue in Los Angeles County was established during Dr. Lanterman’s tenure.

In 1911 the Coroner’s office acquired its first permanent home in room 902 of the Old Hall of Records, located at 220 N. Broadway in Los Angeles. The inquest was the main way of determining cause, manner and responsibility for death. Autopsy was reserved for cases where the cause of death was unknown or where poisoning was suspected.

By the 1920s the Old Hall of Records was running out of space. The Coroner, as well as other County agencies dealing with criminal cases, moved to the new Hall of Justice at 211 W. Temple in Los Angeles in 1926. The Coroner’s office, located in room 100, was equipped with facilities for scientific processing of cases, including autopsy tables, embalming tables, refrigeration, an inquest room, and a viewing room.

The worst multi-fatality incident in the history of Los Angeles County occurred on March 12, 1928 when the St. Francis Dam broke. Although the number of deaths is unknown, it was estimated at more than 400. In response to this disaster, the California State Legislature in 1929 updated the dam safety program and created the State Board of Registration for Civil Engineers.

With the discovery of penicillin in 1928 and streptomycin (for tuberculosis) in 1944, infectious diseases began to move out of the list of the top 10 causes of death. At the same time, with increased use of the automobile came an increase in motor vehicle deaths.

World War II was a period of rapid growth for Los Angeles County. In 1942 a toxicology laboratory was administratively transferred from the Health Department to the Coroner. The number of Coroner’s cases was about 5500 per year. In 1954 the Model Postmortem Examinations Act was created, leading to a spurt in conversions from elected coroners to physician medical examiners.

1956 was an important year for the Coroner’s office. In that year, an amendment to the Los Angeles County Charter required that the Coroner be a certified pathologist. The Coroner’s office was separated from the Public Administrator’s Office. The Board of Supervisors appointed Dr. Theodore Curphey as the first Chief Medical Examiner-Coroner in 1957. Dr. Curphey had previously been the Chief Medical Examiner of Nassau County.

In 1959 the American Board of Pathology recognized forensic pathology as a specialty, allowing forensic pathologists to become board certified. In the late 1950s, Edwin Shneidman, Norman Farberow and Robert Litman developed the technique of psychological autopsy in collaboration with Los Angeles County Coroner. This technique is used internationally to determine manner of death in equivocal cases.

Dr. Curphey retired from his position in 1966 and Dr. Thomas Noguchi, a staff pathologist at the Coroner’s office, became the Chief Medical Examiner-Coroner. During Dr. Noguchi’s tenure, the Coroner’s office established positions for specialists in the investigation of forensic deaths (Coroner’s investigators), and also established a forensic pathology fellowship for training pathologists in the subspecialty of forensic pathology.

In 1972 the office moved to the Forensic Science Center, located at 1104 N. Mission Rd. in Los Angeles on the grounds of LAC+USC Medical Center. This office contains offices, autopsy rooms, an in-house toxicology laboratory, and an electron microscopy laboratory (opened in 1973).

In 1983 Dr. Noguchi left the Coroner’s office for an academic position at the University of Southern California. Dr. Ronald Kornblum, former Chief Medical Examiner-Coroner of Ventura County, became Acting Chief Medical Examiner-Coroner and was appointed to the permanent post in 1987. Dr. Kornblum, a nationally-recognized expert on chokehold deaths, presided over an office with a dramatically increased workload (over 17,000 cases in 1990-91). In the late 1980s anthropologist Dr. Judy Suchey, in collaboration with the Coroner’s office, developed the Suchey-Brooks system of skeletal aging. This is currently a standard system used in forensic identification of skeletons.

Upon Dr. Kornblum’s retirement in 1990, the Board of Supervisors appointed an acting Chief Medical Examiner-Coroner, Dr. J. Lawrence Cogan, and a Director, Ilona Lewis, as heads of the Department. Dr. Cogan was responsible for medical matters and the statutory functions of the Coroner, while Ms. Lewis was responsible for all other Department functions. During this period the Coroner’s office developed its first Department wide computer system.

In 1992, Dr. Lakshmanan Sathyavagiswaran, who was the Chief of Forensic Medicine at the Coroner’s office, was appointed permanent Chief Medical Examiner-Coroner. Upon Ilona Lewis’ retirement in 1993, Anthony T. Hernandez was appointed Director.

The ensuing years saw increasing computerization of the Department, including a major computer upgrade in 2000, an Internet site, participation in the State’s Electronic Death Registration System in 2008, and a multi-year program to digitize the Coroner’s case files. The Coroner’s office physically expanded to include adjacent office buildings at 1102 N. Mission Rd. and in the County Hospital’s Old Administration Building.

In March 2012, the Director, Anthony T. Hernandez, retired and Dr. Sathyavagiswaran was appointed Chief Medical Examiner-Coroner/Interim Director. Upon Dr. Sathyavagiswaran’s retirement in 2013, the Board of Supervisors established a single department head, the Chief Medical Examiner-Coroner. Dr. Mark Fajardo, previously Chief of Medicine at Riverside County Coroner, was appointed to this position in August 2013.

After three years with the office, Dr. Fajardo left Los Angeles County service in 2016. The next year, the Board of Supervisors hired Dr. Jonathan R. Lucas to lead the department. He served as the Chief Medical Examiner-Coroner until November 2022.

Dr. Lucas was succeed by Dr. Odey C. Ukpo, who was appointed by the Board to serve as Interim Chief Medical Examiner-Coroner. Dr. Ukpo is the first African American to serve as Chief Medical Examiner-Coroner since the office was established in 1850.

Los Angeles County Coroners

1850-1851 Alpheus P. Hodges, M.D.

1852 Rafael (Ralph) C. Guirado

1853 Joseph Stillman Mallard

1854-1855 Thomas A. Mayes

1856 Q. A. Sneed

1857 James Brown Winston, M.D.

1858 A. Cook

1859 Henry A. Miles

1860-1861 H. P. Swain

1862-1865 J. S. Griffin, M.D.

1866-1867 J. L. Smith

1868-1869 Vincent Gelcich, M.D.

1870-1873 Joseph Kurtz, M.D.

1874-1875 N. P. Richardson

1876-1877 Joseph Kurtz, M.D.

1878-1879 J. Hannon

1879-1884 Louis Hubert Nadeau, M.D.

1885-1886 Andrew McFarland, M.D.

1887-1890 J. M. Meredith

1891-1893 William Amasa Weldon, M.D.

1893-1895 Horace Getchell Cates, M.D.

1895-1899 George Walter Campbell, M.D.

1899-1902 L. T. Holland, M.D.

1902-1907 John Henry Trout, M.D.

1907-1908 Roy Stanley Lanterman, M.D.

1908-1920 Calvin Hartwell

1920-1921 F. T. Williams

1921-1945 Frank Albert Nance

1945-1953 Ben Harlan Brown

1953-1957 E. A. Winstanley

Chief Medical Examiner-Coroners

1957-1966 Theodore Joslyn Curphey, M.D.

1966-1983 Thomas T. Noguchi, M.D.

1983-1990 Ronald Kornblum, M.D.

1990-1992 J. Lawrence Cogan, M.D. (Acting)

1992-2013 Lakshmanan Sathyavagiswaran, M.D.

2013-2016 Mark A. Fajardo, M.D.

2016-2017 Lakshmanan Sathyavagiswaran, M.D.(Interim)

2017 Christopher Rogers, M.D. (Acting)

2017-2022 Jonathan R. Lucas, M.D.

2022-present Odey C. Ukpo, M.D., M.S. (Interim)

Directors

1990-1993 Ilona Lewis

1993-2012 Anthony T. Hernandez

2012-2013 Lakshmanan Sathyavagiswaran, M.D. (Interim)

Glossary of Terms

Autopsy

also known as a post-mortem examination, necropsy (particularly as to non-human bodies), autopsia cadaverum, or obduction — is a highly specialized surgical procedure that consists of a thorough examination of a corpse to determine the cause and manner of death and to evaluate any disease or injury that may be present. It is usually performed by a specialized medical doctor called a pathologist.

Biological specimens

blood, sections of organs, vitreous, bile, and urine.

Cause of death

an injury or disease that ultimately leads to death of the individual, generally determined by medical examiners or coroners.

Certificate of Religious Belief

in California, in order to execute a certificate of religious belief, a person must be 18 years of age or older and must state in clear and unambiguous language that any postmortem anatomical dissection or that specified procedures would violate the religious convictions of the person. The certificate must be signed and dated by the person in the presence of at least two witnesses. Each witness must also sign the certificate and must print on the certificate his or her name and residence address. California law allows the state to override religious objection if the coroner "has a reasonable suspicion that the death was caused by the criminal act of another or by a contagious disease constituting a public health hazard."

Chain of custody

a method of keeping track of who has handled a piece of evidence and when.

Class A type autopsy

is a complete autopsy of a complex case, including the following types of cases: homicide or suspected homicide, undetermined mode of death, hit-and-run accident, sudden infant death, officer-involved death, death in custody or during involuntary psychiatric hospitalization, unidentified decedents, therapeutic misadventures, and skeletonized remains, or any autopsy that takes more than 3 hours.

Class B type autopsy

is a complete autopsy of a less complex case, for example: natural disease, overdose cases hospitalized less than 24 hours, traffic death with charges, except hit-and-run cases, death at work, except natural deaths where there is a clear history of serious disease, electrocution, unwitnessed drowning, and fire deaths.

Class C type autopsy

is a limited autopsy including dissection and evaluation of internal organs for pathology. For example: opening the chest for bullet recovery, contagious disease, religious objection to a complete autopsy, or a partial autopsy where the brain is examined for possible non-homicidal head trauma.

Class D type autopsy

is an external examination, with incisions only for collection of toxicology specimens, small biopsy of an external lesion, or a skin incision for bullet removal. For example: hanging, except hanging in custody, suicidal gunshot wounds without bullet recovery, traffic accidents without charges, natural death of males 50 and over or females 60 and over, overdose cases hospitalized over 24 hours, suicide by plastic bag over head, suicide by jumping, suicide by carbon monoxide inhalation, or natural death in person with documented serious illness. Note that jugular blood, femoral blood, and vitreous must be obtained in Class D cases whenever possible.

Coroner

is a public official whose principal duty is to inquire into any death that appears to be unnatural. Coroners often possess both legal and medical qualifications, but the office is sometimes filled by laypersons, including undertakers, sheriffs, and justices of the peace. In many states the office has been replaced by that of the medical examiner, who is usually a licensed pathologist.

County Disposition

The County of Los Angeles will cremate the remains of a decedent and hold the cremains (ashes) for a period of time (about 3 years) before the ashes are interred in a common gravesite at the LA County Cemetery.

Decomposition

the disintegration of body tissues after death.

Evidence

any physical items such as bullets, hairs, fibers, biological fluids, etc., documents and statements that are included in a legal investigation for the jury’s or judge’s consideration in the determination of an individual’s guilt or innocence.

Forensic pathologist

A medical doctor who specializes in the sub-specialty of pathology that focuses on determining the cause of death by examining a corpse. The autopsy is performed by the pathologist usually during the investigation of criminal law cases and civil law cases in some jurisdictions.

Forensic Science

Forensic Science is the application of all forms of science to aid legal investigations.

Indigency

The lack of ability to pay as a legal reason for having certain required fees waived; being declared eligible for free services.

Manner of death

is how the death came about. Natural - due entirely (or nearly so) to natural disease processes. Homicide - due to a volitional act of another person. Suicide - due to injury that occurred with the intent to induce self-harm or cause one’s own death. Accident - due to injury when there is no evidence of intent to harm. Undetermined - inadequate information regarding the circumstances of death to determine manner; example: individual found unconscious with massive subdural hemorrhage; in the absence of information on the events leading up to death, it is impossible to determine if the hemorrhage is due to accidental fall, homicidal violence, etc.

ME-C

Medical Examiner-Coroner

Medical examiner

is a medically qualified forensic pathologist and government official whose duty is to investigate deaths and injuries that occur under unusual or suspicious circumstances, to perform post-mortem examinations, and in some jurisdictions to initiate inquests.

Medicolegal Autopsy

a medicolegal autopsy is done with the possibility of litigation in mind. The autopsy is designed to determine the cause of death, properly document findings, and collect evidence. A primary objective is to try to reconstruct the circumstances and events that led to the death so that a mode (natural, accident, suicide, homicide, or undetermined) can be established. A medicolegal autopsy differs from a hospital autopsy. A hospital autopsy is designed to confirm a known or suspected disease and gain further knowledge of the disease. The emphasis is placed on the gross and microscopic examination of internal organs. In a medicolegal autopsy the emphasis is shifted to the external examination and the description of external and associated internal injuries. Microscopic examination is done only when indicated. Information about identification of the remains, time of death, evidence of drug use, age of injuries, etc., becomes important and must be recorded carefully. It is imperative that findings be recorded clearly and objectively. Any forensic pathologist should be able to interpret the findings years later without difficulty. The forensic autopsy protocol must be standardized and reproducible.

Next of Kin

aNearest relative: if married, the spouse, if no spouse then adult children, or surviving parents, or blood relative, according to California State Law, unless otherwise specified in a legal document.

Toxicology

or postmortem (after death) toxicology analyzes biological specimens collected at autopsy for the presence of drugs, toxins, and poisons to help determine cause and manner of death.