In San Joaquin County and most other California counties a forensic pathologist determines the cause of all sudden, suspicious or violent deaths. Then the elected sheriff-coroner decides whether it was an accident, homicide, suicide, natural or undetermined manner of death.

A KQED investigation found at least two cases involving civilians killed by law enforcement officers where the sheriff ignored the forensic pathologists' opinions that the deaths should be classified as homicides and instead certified them as accidents.

An independent audit of the department released last week found “several” in-custody deaths in 2016 with similar discrepancies. At Tuesday’s board meeting, the author, Dr. Roger Mitchell, told the board that a medical examiner is needed in San Joaquin County.

He told county supervisors they need to bring in someone with experience to hire and train the investigators for that department.

Mitchell, who is the chief medical examiner in Washington, D.C., made a number of recommendations to address deficiencies in how the county investigates deaths. For example, he suggested the county end the practice of sending patrol deputies with virtually no training to handle coroner cases where they may have to observe details at death scenes and collect evidence.

KQED previously reported that a lack of training for coroner deputies may have contributed to costly mistakes.

Moore told supervisors that the audit also shows “everyone is doing the best they possibly can ... there is no negligence or malice of thought in anything that was done.”

County officials still need to work out the details for how to establish the new medical examiner system, which relies on physicians and civilian investigators, and how much it will cost. So far there is no timeline, but Mitchell estimated it could take at least a year.