Deaths in custody: the independent autopsy.
When someone dies in custody, the examination of their death is examined in turn, by families, the public, the press and the courts. It must be complete, independent and documented to withstand any scrutiny. From January 1, 2027, California law requires that independence in counties where the sheriff also serves as coroner.
Medically reviewed by Evan W. Matshes, MD, FRCPC, D-ABP, Medical Director and Chief Forensic Pathologist · Updated
- Deaths in custody require a complete autopsy with toxicology, layered neck dissection, full documentation of injury and formal peer review.
- Independence is essential: the examining physician must have no stake in the outcome.
- California AB 1108 (Government Code § 27491.56) takes effect January 1, 2027.
- In combined sheriff-coroner counties, the sheriff-coroner may not determine cause and manner in an in-custody death; an independent coroner, medical examiner or qualified private provider must.
- Families may also arrange an independent second autopsy once their loved one is released.
What must a complete in-custody autopsy include?
- Review of the circumstances, including video, use-of-force and restraint reports, and medical records from custody.
- A complete external and internal examination, with photographic documentation of every injury, including injuries revealed only by dissection.
- Layer-by-layer neck dissection, and examination of the back and extremities for restraint injury.
- Toxicology, with interpretation in the light of the circumstances.
- Cardiac and neuropathology examination where indicated, and postmortem imaging.
- Formal peer review by a second board-certified forensic pathologist.
Why does independence matter?
A death in custody involves the agency that held the person. If that agency also determines how the person died, the finding may be doubted however carefully it was made. An independent forensic pathologist, with no relationship to the agency involved, protects the family’s trust, the agency’s credibility and the integrity of any later proceeding. Independence must also be real in practice: the examining physician must exercise independent judgment, without direction from the agency.
What does California AB 1108 require?
AB 1108 added Government Code § 27491.56. From January 1, 2027, in a county where the offices of sheriff and coroner are combined, the sheriff-coroner may not determine the circumstances, manner and cause of death in an in-custody death. The determination must instead be made by an independent coroner or medical examiner from another county, or by an independent private provider whose physicians meet the qualifications of Government Code § 24010.
- The findings go to the sheriff-coroner, the district attorney, the county health officer, the board of supervisors and the decedent’s next of kin.
- The cause and manner on the death certificate must match the independent determination.
- The board of supervisors selects and enters the service agreement each year.
- A private provider holding a county’s AB 1108 agreement may not, during that term, examine that county’s other coroner cases.
The law does not require a county to restructure its coroner operations or give up investigative authority. See NAAG’s AB 1108 Independent Autopsy Program.
This is general information, not legal advice. Counties should confirm their obligations with County Counsel.
What can families do?
Families may ask for an independent second autopsy once their loved one is released, and may request records and findings through the appropriate legal process. An attorney can help obtain photographs, slides and retained tissue for review. NAAG performs second autopsies and second-opinion reviews for families and their counsel.
What can agencies do now?
Sheriff-coroners should identify their AB 1108 provider before January 1, 2027, take the agreement to the board of supervisors, and set up a referral route. NAAG provides a draft MOU and briefs County Counsel and boards. coroner@naagforensic.com.
Frequently asked questions.
When does AB 1108 take effect?
January 1, 2027.
Which counties does AB 1108 affect?
Counties in which the offices of sheriff and coroner are combined.
Who can perform an AB 1108 examination?
An independent coroner or medical examiner from another county, or an independent private provider whose physicians meet the qualifications of Government Code § 24010, such as NAAG Forensic.
Can a family get an independent autopsy after a death in custody?
Yes. Once the decedent is released, the family may arrange an independent second autopsy, and counsel can obtain the original materials for review.
Is toxicology included in NAAG’s AB 1108 examinations?
Yes, for standard, complex and criminally suspicious examinations, with no supplementary toxicology invoice.
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