Full text of Dr. Dennis Kellar's independent review of McHenry County Coroner's Office

I was initially asked to evaluate the McHenry County Coroner’s office after the resignation of the last elected coroner.

Please refer to that report separately for additional details regarding state statute noncompliance.

This report details the absolute abhorrent and dysfunctional state of the department as observed during my initial evaluation with the Sheriff and his representative, a Deputy Coroner and the states attorney.

The Deputy Coroner had made it clear that the state of the office was the result of the Coroner’s direct actions and that she alone asserted sole authority. There was no other operational oversight.

Department Offices:

Initially walking into the department there was:

a conference room filled with the entire collection of the county coroner's records, dating back more than 100 years. These records had sustained “damage” while in possession of the department. These records were taken by the previous coroner for “digitizing”. This task was never completed, and it remained unclear if the records could be accurately accounted for at that point. The Coroner had refused to release these records back to the records department and had expressed disinterest in collaborating with others to seek proper preservation of these records. The Deputy Coroner was of the impression that the Coroner had wanted to solely control this process.

Evidence Storage:

The next room in the department;

Wide open unlocked and unsecured closet had open boxes of personal belongings of the deceased. Open boxes of loose and bottled prescription drugs totaling “thousands of pills” within arm's reach to anyone walking into the room. Previously the Coroner herself was “dumping” drugs into the sheriff’s department public drug disposal. She had been told to stop according to the sheriff’s department representative. According to the Deputy Coroner, the Coroner refused to use money from her budget for proper disposal. A bag of cash totaling over $20,000.00 dollars was sitting in an open file cabinet unsecured with no monitoring. There was no official “inventory” list to account for belongings, drugs or cash. We were told by a deputy coroner that they would just “throw things” in the room.

Tissue Storage:

The TISSUE and BODY FLUID EVIDENCE STORAGE area consisted of a 10-year-old white RESIDENTIAL REFRIGERATOR with broken racks a broken door and a pad lock latch on the side with no lock.

Specimens were in either “urine cup” types of containers or in plastic “Tupperware” types of containers or wrapped in what appeared to be plastic wrap. Specimens were labeled with a sharpie. In order to find a specimen or piece of “evidence” one would have to go through the dozens of these containers. NO temperature control, monitoring or quality control existed for the evidence/tissue storage refrigerator. There was no way to ensure specimen integrity. Per the Deputy Coroner, the Coroner refused to use funds from the department budget to procure proper temperature-controlled storage.

There was NO secure monitoring of any area in the department.

After reviewing the department with one of the Deputy Coroners, we were informed that he was THE ONLY Deputy Coroner that had completed the required initial educational training to perform the duty.

The other part-time Deputy Coroners had never completed any formal training as outlined in the state statute. It is also unclear if the Coroner herself had completed the required initial training.

None of the Deputy Coroners had been participating in the required continuing education requirements also as outlined in the state statue thus, not keeping up with current standards.

In summary; under the atrocious direction of the (elected) Coroner, the Department had never met the minimum standards for education for Deputy Coroners to perform their jobs. The department had not completed statute required education. The department had no standard operating procedures for performing duties of the office. The security of evidence and quality assurance of tissue and fluid specimens were nonexistent.

The Coroner was aware of all these deficiencies yet allowed the department to be deficient and non-compliant. Her unwillingness to work with other departments of local government and lack of internal leadership and essentially no oversight or accountability puts the county at incalculable liability exposure.

Direct authority and oversight over the Office of the Coroner could prevent this from reoccurring and ensure accountability, stability and service to the residents of McHenry County.

Respectfully submitted,

Dennis F. Kellar, MD DABSM FCCP

State statute noncompliance report

(55 ILCS 5/Div. 3-3 heading)

Division 3-3. Coroner REVIEW

(55 ILCS 5/3-3001)(from Ch. 34, par. 3-3001)     Sec. 3-3001

(b)(1) Within 30 days of assuming office, a coroner elected to that office for the first time shall apply for admission to the Coroner Training Board coroners training program. Completion of the training program shall be within 6 months of application. Any coroner may direct the chief deputy coroner or a deputy coroner, or both, to attend the training program, provided the coroner has completed the training program. Satisfactory completion of the program shall be evidenced by a certificate issued to the coroner by the Coroner Training Board. All coroners shall complete the training program at least once while serving as coroner.

Significant deficiencies: currently there are total of five Deputy coroners. Three full-time and two part-time. Currently only one full-time deputy coroner has completed the required coroner training program. The required yearly continuing education has not been fulfilled by four of the five Deputy coroners.

Recommendation:Time and funding to complete the continuing education would need to be budgeted. Staff would need to be directed to complete the continuing education in a specified time frame. In addition, the four of the five Deputy coroners would need to complete the original coroner training program. A position of chief deputy coroner is strongly recommended in order to guide the deputy coroners.

No significant issue:

(55 ILCS 5/3-3002)(from Ch. 34, par. 3-3002)     Sec. 3-3002

(55 ILCS 5/3-3003)(from Ch. 34, par. 3-3003)     Sec. 3-3003

Duties of coroner. The county coroner shall control the internal operations of his office. Subject to the applicable county appropriation ordinance, the coroner shall procure necessary equipment, materials, supplies and services to perform the duties of the office. Compensation of deputies and employees shall be fixed by the coroner, subject to budgetary limitations established by the county board. Purchases of equipment shall be made in accordance with any ordinance requirements for centralized purchasing through another county office or through the State which are applicable to all county offices.

Significant deficiencies:

there are currently no standard operating procedures, no written guidelines or documented protocols outlining internal operations of the office.

The department lacks the necessary equipment and protocols and currently has non-functional equipment to perform the duties of the office. This includes adequate tissue and specimen storage with temperature control,proper cataloging of tissue samples and adequate security of the storage site.This also includes inadequate storage and security for personal property and evidence.

The department currently does not have an electronic case management system.

Current compensation rates for deputy coroner are considered lower than national average and lower than the surrounding counties.Current deputy coroners are also actively looking for other employment with high likelihood of significant turnover in a very short period. Some deputy coroners are currently working other jobs.

Recommendations:

Creation of a chief deputy coroner position. Currently there is one deputy coroner that meets all training and continuing education requirements.The priority of this position should be to direct the current deputy coroners to achieve adequate training and continuing education. This position should also start implementation of writing standard operating procedures for the department as well as directing the deputy coroners to participate in the development of the standard operating procedures.Guidelines for writing the operating procedures are widely available from the coroner training board as well as adjacent county coroners.

The county facilities department should assist with procurement of equipment for adequate tissue storage as well as adequate controls. This should also include evidence storage.

Recommend the sheriff’s department and its compliance department assist in writing and creating policies, overseeing the intake of evidence, storage and cataloging including evidence and tissue. This would also include assisting with implementation of adequate security of the Department.

The continued presence of a designated coroner from the sheriff's department seems to be very helpful in maintaining operations support of the department.Recommend that this designated coroner work to create a chief deputy coroner from the current deputy coroners if possible.

Would also recommend that the county board administration assist the chief deputy coroner/temporary designated coroner,with an operational budget including funding for personnel as well as human resource policies and procedures including funding for deputy corners to achieve required continuing education.

Strongly recommend the procurement and implementation of an electronic case management software system.

No Significant issues:

(55 ILCS 5/3-3004)(from Ch. 34, par. 3-3004)

(55 ILCS 5/3-3005)(from Ch. 34, par. 3-3005)

(55 ILCS 5/3-3006)(from Ch. 34, par. 3-3006)

(55 ILCS 5/3-3007)(from Ch. 34, par. 3-3007)

(55 ILCS 5/3-3008)(from Ch. 34, par. 3-3008)

(55 ILCS 5/3-3009)(from Ch. 34, par. 3-3009)

(55 ILCS 5/3-3010)(from Ch. 34, par. 3-3010)

(55 ILCS 5/3-3011)(from Ch. 34, par. 3-3011)

(55 ILCS 5/3-3012)(from Ch. 34, par. 3-3012)

Sec. 3-3012. In-service training expenses. The county coroner may maintain a special fund, from which the county board shall authorize payments by voucher between board meetings, to pay necessary travel dues and other expenses incurred in attending workshops, educational seminars and organizational meetings for the purpose of providing in-service training.

Currently deficient. No funding made available for continuing education.

Recommendation: funding be available for required CME 3k/yr suggested. Would cover required CME for Deputy Coroners.

(55 ILCS 5/3-3013)(from Ch. 34, par. 3-3013)

…the coroner or medical examiner shall cause blood and buccal specimens (tissue may be submitted if no uncontaminated blood or buccal specimen can be obtained), whenever possible, to be withdrawn from the body of the decedent in a timely fashion. For proper preservation of the specimens, collected blood and buccal specimens shall be dried and tissue specimens shall be frozen if available equipment exists.

Currently deficient:proper storage facility and temperature control not within standards

Recommend:County Facilities Department manage procurement of proper equipment

(55 ILCS 5/3-3014)(from Ch. 34, par. 3-3014)

…No coroner may perform any autopsy required or authorized by law unless the coroner is a pathologist whose services are requested by the coroner of another county.

Currently deficient:pool of rotating (quality) pathologists had been minimal with significant difficulty securing services.

Recommend:recent changes have expanded the pool of available Pathologists. Increase in rates have also resulted in improved services.Recommend a grading and rotation system based on performance factors of the pathologists.

No significant issues:

(55 ILCS 5/3-3015)(from Ch. 34, par. 3-3015)

(55 ILCS 5/3-3016)(from Ch. 34, par. 3-3016)

(55 ILCS 5/3-3016.5)

(55 ILCS 5/3-3017)(from Ch. 34, par. 3-3017)

(55 ILCS 5/3-3018)(from Ch. 34, par. 3-3018)

(55 ILCS 5/3-3019)(from Ch. 34, par. 3-3019)

(55 ILCS 5/3-3020)(from Ch. 34, par. 3-3020)

(55 ILCS 5/3-3021)(from Ch. 34, par. 3-3021)

(55 ILCS 5/3-3022)(from Ch. 34, par. 3-3022)

(55 ILCS 5/3-3023)(from Ch. 34, par. 3-3023)

(55 ILCS 5/3-3024)(from Ch. 34, par. 3-3024)

(55 ILCS 5/3-3025)(from Ch. 34, par. 3-3025)

(55 ILCS 5/3-3026)(from Ch. 34, par. 3-3026)

(55 ILCS 5/3-3027)(from Ch. 34, par. 3-3027)

(55 ILCS 5/3-3028)(from Ch. 34, par. 3-3028)

(55 ILCS 5/3-3029)(from Ch. 34, par. 3-3029)

55 ILCS 5/3-3030)(from Ch. 34, par. 3-3030)

55 ILCS 5/3-3031)(from Ch. 34, par. 3-3031)

(55 ILCS 5/3-3032)(from Ch. 34, par. 3-3032)

(55 ILCS 5/3-3033)(from Ch. 34, par. 3-3033)

Disposition of property. When any valuable personal property, money or papers, are found upon or near the body which is the subject of a coroner's investigation, inquiry or inquest, the coroner shall take charge of the same and deliver the same to those entitled to its care or possession; but if not claimed, or if the same shall be necessary to defray the expenses of the burial, the coroner shall, after giving 10 days' notice of the time and place of sale, sell such property, and after deducting coroner's fees and funeral expenses, deposit the proceeds thereof, and the money and papers so found, with the county treasurer, taking his receipt therefor, there to remain subject to the order of the legal representatives of the deceased, if claimed within 5 years thereafter, or if not claimed within that time, to vest in the county.

Currently deficient:property area not secure. Unclear if notice is given or statue is followed

Recommend:Property be secured and procedure in place to comply with statue.

No significant Issues:

(55 ILCS 5/3-3034)(from Ch. 34, par. 3-3034)

(55 ILCS 5/3-3035)(from Ch. 34, par. 3-3035)

(55 ILCS 5/3-3036)(from Ch. 34, par. 3-3036)

(55 ILCS 5/3-3037)(from Ch. 34, par. 3-3037)

(55 ILCS 5/3-3038)(from Ch. 34, par. 3-3038)

(55 ILCS 5/3-3039)(from Ch. 34, par. 3-3039)

Sec. 3-3039. Vacancy. Whenever a vacancy occurs in the office of coroner, that vacancy shall be filled as provided in The Election Code. (Source: P.A. 86-962.)

This is currently being followed with the appointment of a temporary coroner from the sheriff’s department.

(55 ILCS 5/3-3040)(from Ch. 34, par. 3-3040)     Sec. 3-3040.Appointment of deputies. Each coroner may appoint one or more deputies as the coroner, in his or her sole discretion, determines necessary and appropriate, subject to county board appropriations. The appointment shall be in writing and signed by the coroner. A deputy's compensation shall be determined by the county board.

Recommend:There are currently five Deputy coroners three full-time two part-time. There is no chief deputy coroner designated.Recommend compensation be re-evaluated(by the county board)regarding part-time and full-time employee status as well as review of prior caseloads and required time to finish reports; to determine FTE’s needed.Implementation of an electronic case management software system should reduce the number of hours needed per case.This should prompt review of the number of deputy coroners actually needed.

(55 ILCS 5/3-3041)(from Ch. 34, par. 3-3041)     Sec. 3-3041. Oath of deputies. Each deputy shall, before entering upon the duties of his office take and subscribe an oath or affirmation, in like form as required of coroners, which shall be filed in the office of the county clerk.

End of Statute Review

Summary of report.

The structure of this report is based upon the Illinois general assembly statute for the office of coroner. After review of the department and discussion with Deputy coroners as well as the appointed coroner, deficiencies and recommendations are listed under each paragraph of the statute.

There are several operational deficiencies as outlined under each appropriate paragraph of the statute. In addition,there appears to be significant discourse among the deputy coroners including one who is very likely to leave in the short term. This deputy coroner is the highest qualified and has completed the appropriate training courses. This individual also is the best candidate for chief deputy coroner. After extensive conversation with this person it is apparent that he is extremely reluctant to stay in his current position as well as take on chief deputy coroner for fear of job loss or the demotion if there is a newly elected or appointed coroner. This appears to be a significant driving factor for this individual to seek employment elsewhere.

The deficiencies in the department appear to stem from prior leadership and leadership style. The lack of proper equipment the lack of an electronic case management system and inadequate leadership structure has created significant deficiencies from an operational standpoint in the department. There are no standard operating procedures and there is no adherence to the coroner statute regarding educational requirements of the deputy coroners. This would seem to place the county at significant liability risks.

With the current temporary acting coroner from the sheriff's department in place, it would make sense to utilize that departments resources to improve evidence handling including security equipment procurement,security monitoring and appropriate operating procedure.This is also outlined in the appropriate statute for recommendation.

In addition ,it would make sense to utilize county resources regarding implementation of an HR policy and reviewing the pay scale of the current deputy coroners and support staff. This would also include the creation of a chief deputy coroner and appropriate job description and pay scale. This would facilitate setting the stage for leadership within the Deputy coroners to start work on standard operating procedures and implementing an electronic case management system. Utilizing the county facilities management resources would also be helpful for procurement of needed equipment that Is required to contain tissue samples as well as evidence and personal belongings from the deceased.

Regarding the actual position of coroner, currently this is an elected position with no requirements for any significant law-enforcement or medical experience or background. From an operational standpoint this position appears to be more of a management role rather than a role that would involve direct investigations, law-enforcement or direct role in an autopsy. The deputy coroners are responsible for investigative procedures as well as reports. Pathologists on contract are responsible for autopsies. A strong focus of a stable department would include having confident strong deputy coroners with leadership within,which would include a chief deputy coroner.

Suggestions for the county coroner would include:

Continuing with regular elections and continuing with prior protocols as stated in the current statutes

Exercising an option in the current statute to put forth by referendum a choice to the voters in regard to the future of the position. This may include an option to eliminate the position as an elected position. This may include elimination with a provision to appoint by an appropriate body, to create a medical examiner position in place of the current elected coroner position or consideration of merging the duties of coroner with another coroner's office near McHenry county.

The major concern raised by all parties consulted was being able to maintain independence and objectivity during investigations without undue influence from the states attorneys office or the sheriffs department.

A consideration for an appointed position may include an independent sub group within the McHenry County board totaling three individuals (A newly defined coroner board) who would have no undue influence upon them by the sheriff’s department or the states attorney or the president of the board. The goal would be to have independent objective opinion on the potential candidate for coroner. This appointed coroner from an independent board of three could operate as a manager within the coroner's department with the title coroner. They would function as the coroner. The department’s internal operations would follow McHenry County protocols regarding facilities, HR and pay grades. A budget would be proposed by the appointed coroner and presented to the coroner board for further board review and consideration, (The entire McHenry county board or board supervisor).This would follow standard budget proposals within McHenry county.

Consideration of“contracting” or merging the coroner's office with another local coroner's office may prove challenging regarding budget control. This has been difficult to estimate during the current time frame of this evaluation. This would also need to factor in the average yearly case load of the department over a several year time frame. I was not able to determine an accurate case load count from the deputy coroners.

Creating a Medical Examiner position is also a consideration. However, a brief search for qualified individuals has proved to be challenging. It is likely that the position would be vacant for some time while a search is performed. The cost of this individual would likely be higher than the current Coroner salary.

End of Summary

Respectfully submitted

Dennis F. Kellar, MD, DABSM, FCCP