Homeless Deaths in Santa Clara County,Ca Aretrospective Study 2011-2016

HOMELESS DEATHS IN SANTA CLARA COUNTY, CA A RETROSPECTIVE STUDY 2011-2016 HOMELESS DEATHS IN SANTA CLARA COUNTY, CA A RETROSPECTIVE STUDY 2011-2016

STUDY Retrospective Data for 2011-2016 Published August 2017

PROJECT IDEA, STUDY DESIGN, DATA ANALYSIS: MICHELLE A. JORDEN, MD, CHIEF MEDICAL EXAMINER SANTA CLARA COUNTY MEDICAL EXAMINER-CORONER’S OFFICE

STUDY DESIGN, DATA COLLECTION AND ANALYSIS: KARIN WELLS, BA, STUDENT INTERN FOR THE CHIEF MEDICAL EXAMINER SANTA CLARA COUNTY MEDICAL EXAMINER-CORONER’S OFFICE Retrospective Homeless Study, Santa Clara County Medical Examiner-Coroner Office 2011-2016 TABLE OF CONTENTS

INTRODUCTION………………………………………………………………………………………………………………………………………….4

DEFINITIONS AND CLASSIFICATIONS…………………………………………………………………………………………………………………4 HOMELESSNESS LOCATION STRESSORS MENTAL ILLNESS SEASONS MANNER OF DEATH CAUSES OF DEATH

YEARLY STATISTICS…………………………………………………………………………………………………………………………………..…9 2011………………………………………………………………….………………………….8 2012…………………………………………………………………………….………………14 2013…………………………………………………………………………………………….20 2014…………………………………………………………………………….………………27 2015…………………………………………………………………………………………….33 2016…………………………………………………………………………………………….39

SUMMARY AND CONCLUSIONS…………………………………………………………………………………………………………….………47

RECOMMENDATIONS…………………………………………………………………………………………………………………………………58

REFERENCES……………………………………………….…………………………………………………………………………………………..59

ACKNOWLEDGEMENTS…………………………………………………………………………….…………………………………………………60

Retrospective Homeless Study, Santa Clara County Medical Examiner-Coroner Office 2011-2016 TABLE OF FIGURES

LOCATION OF DEATH FLOWCHART……………………………………………………………………………………………………….…………6

2011 GRAPHS AND TABLES…………………………………………….………………………………………………………………….……9-13

2012 GRAPHS AND TABLES……………………………………………………………………………………..…………………………...15-19

2013 GRAPHS AND TABLES………………………………………..………………………………………………………………………...21-26

2014 GRAPHS AND TABLES……………………………………..…………………………………………………………………………...28-32

2015 GRAPHS AND TABLES………………………………………..………………………………………………………………………...34-38

2016 GRAPHS AND TABLES…………………………………………………..……………………………………………………………...40-45

TOTAL HOMELESS DEATHS GRAPH………………………………………………..……………………………………………………………..47

2011-2016 TOTAL GRAPHS AND TABLES…………………………………..…………………..………………………………………..47-57

Retrospective Homeless Study, Santa Clara County Medical Examiner-Coroner Office 2011-2016 INTRODUCTION

This is a retrospective study of homeless deaths in Santa Clara County encompassing the years 2011 through 2016. It is the goal of this study to define homelessness as used by the Santa Clara County Medical Examiner-Coroner’s office, as well as illuminate trends in homeless deaths over the previous six years. Each year was analyzed separately for the following variables: decedent demographics; cause and manner of death; location of death; medical history; the presence and use of drugs; veteran status; and motor vehicle related deaths. The yearly data was compiled to demonstrate trends across the six year period. It is hoped that these data and trends presented in this study of homeless deaths will inform policy discussion and help identify service gaps for this vulnerable and growing population.

DEFINITIONS AND CLASSIFICATIONS

HOMELESSNESS: Homelessness is not well defined but according to the Centers for Disease Control and Prevention (CDC), the homeless can be defined, on a general level, as those who do not have customary and regular access to a conventional dwelling or residence.1

The Santa Clara County 2017 Homeless Census and Survey defined homelessness based on the definition used by Housing and Urban Development (HUD) and states that an individual is considered homeless if they are “living in a supervised publicly or privately operated shelter designed to provide temporary living arrangement,” or are living in any type of makeshift living space not normally designed for habitation. This definition does not include individuals living in hotels or motels.2

Any case falling under the jurisdiction of the Medical Examiner requires a medicolegal death investigation to render cause and manner of death. During the course of the Medical Examiner-Coroner investigation, the decedent will be positively identified and address of residence and next of kin notification will be determined, among many other demographics. A decedent is assigned into the homelessness category if the circumstances of the death occurred in an environment to suggest homelessness (e.g. homeless encampment) or was known to be homeless and/or public record searches do not identify a valid living address. In almost all cases, irrespective of this study, people who knew the decedent, such as family and friends, are further interviewed by the Medical Examiner-Coroner Investigator, either during the initial investigation or days to weeks later prior to closure of the case to verify homelessness. In this study, each case file was reviewed, number of deaths verified, and variables analyzed by the Chief Medical Examiner Michelle A. Jorden, MD, Interim Chief Investigator Rosa Vega, and student intern Karin Wells. The circumstances of the death and absence of a validated living address provide further support that an individual does not have access to a specific enclosed living area with amenities. Homelessness was determined by the Medical Examiner-Coroner’s Office if both/either criteria 1 and 2 as stated below were present:

1) People living on the street Those living in some type of homeless encampment, indoor makeshift shelter (i.e. storage facilities, warehouses, garages, etc.), inside of a motor vehicle, trailer, or recreational vehicle (RV), homeless shelters (i.e. emergency housing consortiums, transitional housing), hotels and motels, or any type of funded housing where the decedent is not personally paying rent or currently on a lease and does not demonstrate a stable economic source of income. This category excludes individuals living in

Retrospective Homeless Study, Santa Clara County Medical Examiner-Coroner Office 2011-2016 converted garages, basements, and sheds, even if they are not paying rent as these housing situations are for the most part considered more stable and can include amenities.

and/or

2) Public record searches do not identify a valid living address

The authors take this opportunity to provide and unveil a more precise definition of homelessness using the above stated two criteria.

LOCATION: Locations of death were separated into categories in order to illustrate the many types of areas where homeless deaths occur. It is the goal of these classifications to provide the reader the number of individuals dying in places where they lived and in which personal belongings were found, such as homeless encampments and other makeshift living areas both in- and outdoors, versus those dying in hospitals or care facilities. A classification of death outdoors was separated into two sub-categories to further distinguish between outdoor areas where decedents were living as evidenced by the presence of their personal belongings, such as homeless encampments, in contrast to areas where they did not appear to live, for example on the street without accompanying personal belongings. In some cases, there is overlap between these two outdoor distinctions. Therefore, determination of a makeshift living area supported by the individual’s personal belongings versus simply being found outdoors was determined by the descriptions in the investigative reports, as well as scene photographs. Indoor makeshift living areas include motor vehicles, trailers, RVs, storage rooms, outhouses, garages, and other nontraditional indoor living arrangements. Other locations of death include hospitals, emergency rooms, nursing homes, homeless shelters, hospice facilities, and other residences belonging to friends, family, or acquaintances.

A homeless encampment in San Jose. Photo taken by Michelle A. Jorden, MD

Retrospective Homeless Study, Santa Clara County Medical Examiner-Coroner Office 2011-2016

Source: Santa Clara County Medical Examiner-Coroner

STRESSORS: In this study, we also tried to identify stressors that occurred hours to days prior to death such as emotional stressors, physical and verbal altercations, medical stressors, and interactions with law enforcement. These events were categorized by the authors based on notations in the investigative reports. Emotional stressors included incidents such as recent breakups with family or with a loved one, loss of child custody, suicide attempts, 5150 holds, and evictions. Included in the medical stressor category were recent falls, visits to the emergency room, complaints of pain or illness, and those decedents found to have hair and/or body lice. Incidents involving law enforcement included recent arrests, releases from jail, active warrants, restraining orders, and being on parole.

Source: Shutterstock 6

Retrospective Homeless Study, Santa Clara County Medical Examiner-Coroner Office 2011-2016

MENTAL ILLNESS: We have included in this study data on mental illnesses among the homeless decedents. This includes both medical and observational diagnoses found during the investigative process. Prior to late 2016, mental health history was either captured from friends and family interviews or was captured in the medical records. In late 2016, this Medical Examiner-Coroner’s Office was able to pass legislation allowing the Medical Examiner-Coroner’s Office to obtain mental health records for cause and manner of death determination, and verify mental health diagnoses.

SEASONS: The season in which death occurred was determined in order to illustrate which, if any, season offered a particular vulnerability for the homeless population. This study defined seasons based on the dates of the equinoxes: the winter season ranges from December 21 to March 20; spring ranges from March 20 to June 20; summer ranges from June 20 to September 22; and fall ranges from September 22 to December 21 of any given year.3

MANNER OF DEATH: Manner of death is ruled by the medical examiner as natural, accidental, undetermined, suicide, or homicide.

CAUSES OF DEATH: All causes of death were analyzed in this study population. Specific causes of death were further analyzed as they relate to the homeless population and the environment in which this population is exposed including: motor vehicle related fatalities; drug and alcohol intoxication; and environmental heat and cold exposure. Examples of natural causes of death include chronic alcohol and drug abuse, cardiovascular disease, complications of diabetes, and community acquired illnesses.

TOTAL DEATHS: There were 50 homeless deaths in Santa Clara County in 2011, followed by 62 in 2012, 78 in 2013, 69 in 2014, 85 in 2015, and 132 in 2016. Between 2011 and 2016, the number of homeless deaths increased by 164%. These numbers reflect all homeless deaths in all cities in Santa Clara County.

Retrospective Homeless Study, Santa Clara County Medical Examiner-Coroner Office 2011-2016

2011

Retrospective Homeless Study, Santa Clara County Medical Examiner-Coroner Office 2011-2016 YEARLY STATISTICS 2011

DECEDENT DEMOGRAPHICS: In the year 2011, there were 50 homeless deaths. Of these 50, 40 (80%) were male and 10 (20%) were female. SEX 2011 Female 20%

Male 80% Source: Santa Clara County Male Female Medical Examiner-Coroner

Thirty of the 50 decedents were listed as Caucasian (60%), 14 were Hispanic (29%), three were Black (6%), one was Middle Eastern (2%), one was Native American (2%), and one was listed as other (2%). ETHNICITY 2011 Caucasian 2% 2% 2% 6% Hispanic

Black

28% Middle Eastern 60% Native American

Source: Santa Clara County Other Medical Examiner-Coroner

Age of the decedents ranged from 35 years to 73 years at time of death, with 53 years being the single age with the greatest number of decedents.

Retrospective Homeless Study, Santa Clara County Medical Examiner-Coroner Office 2011-2016

AGE AT DEATH 2011 5

NUMBER OF DECEDENTS OF NUMBER 1

0 35 37 38 40 42 43 45 46 47 48 50 51 52 53 54 55 56 58 59 60 62 63 64 65 69 73 AGE AT DEATH (YEARS) Source: Santa Clara County Medical Examiner-Coroner

For the year 2011, 13 deaths occurred in winter, 14 in spring, 12 in summer, and 11 in fall. DEATHS PER SEASON 2011

Fall Winter 22% 26%

Summer 24% Spring 28% Source: Santa Clara County Winter Spring Summer Fall Medical Examiner-Coroner

Of the 50 cases in 2011, 17 were natural (34%), 21 were accidents (42%), seven were undetermined (14%), three were suicides (6%), and two were ruled as homicides (4%).

Retrospective Homeless Study, Santa Clara County Medical Examiner-Coroner Office 2011-2016

MANNER OF DEATH 2011 25

5 NUMBER OF DECEDENTS OF NUMBER

0 Natural Accident Undetermined Suicide Homicide MANNER Source: Santa Clara County Medical Examiner-Coroner

Three of the 50 decedents (6%) were listed as veterans. Two of the three had some type of mental illness listed as a significant medical condition.

CAUSE OF DEATH: Eight percent of the 2011 cases were related to vehicle accidents where the decedent was struck by a vehicle while walking in or around the roadway. One of the four vehicle related incidents was a suicide by light rail, one incident occurred in the dark, and one of the decedents was not in a marked crosswalk. There was also one case of environmental cold exposure as a cause of death. This death occurred in the fall during the month of December.

LOCATION OF DEATH: The 2011 data on location of death were classified based on the previously mentioned criteria. Outdoor makeshift living areas, such as homeless encampments, were the most common location of death in 2011. LOCATION OF DEATH 2011 16 14 12 10 8 6 4 2

NUMBER OF DECEDENTS OF NUMBER 0 Indoor Outdoor Outdoor (not Hospital ER Other Residence Nursing Home Makeshift Living Makeshift Living living there) Area Area LOCATION Source: Santa Clara County Medical Examiner-Coroner

Retrospective Homeless Study, Santa Clara County Medical Examiner-Coroner Office 2011-2016

DRUG USE: The cause of death listed for 23 of the 50 decedents (46%) was related to drug and/or alcohol intoxication. Twenty-six of the 50 total decedents had drug and/or alcohol abuse included in their significant medical history. There were 37 decedents with positive toxicology reports. Alcohol was the most popular drug, appearing on 57% of the reports. The next most common drugs were morphine (19%) and methamphetamine/amphetamine (10%). Six of the 50 decedents were found with illicit drug paraphernalia, including pipes, syringes, substances, medications not prescribed to them, and/or alcohol at the time of death. The table below indicates each drug found based on toxicology results and the number of decedents positive for each.

Name of Drug Number of Decedents Atropine 1 Lidocaine 1 MEGX 1 Methamphetamine/Amphetamine 5 Beta-Phenethylamine 2 Carboxyhemoglobin 1 Alcohol 21 Diazepam/Nordiazepam/Chlordiazepoxide/Oxazepam 6 Theobromine 1 Morphine 7 Acetaminophen 1 Theophyline 1 Acetone 2 Dihydrocodeine/Hydrocodol 1 Codeine 4 Hydromorphone 1 6-Monoacetylmorphine (6-MAM; Heroin) 1 Bupropion/Hydroxybupropion 3 Morphine-6-glucuronide 4 Morphine-3-glucuronide 4 Hydrocodone 2 Phencyclidine 1 Oxycodone 1 Marijuana 1 Diphenhydramine 2 Papaverine 2 Phenylpropanolamine 1 Ibuprofen 1 Zolpidem 1 Mitrazapine 1 Trazodone 1 Citalopram/Escitalopram 1 Olanzapine 1 12

Retrospective Homeless Study, Santa Clara County Medical Examiner-Coroner Office 2011-2016 Methadone/EDDP 2 Ethosuximide 1

MENTAL ILLNESS: Of the 50 decedents, 13, or 26%, had some type of mental illness listed as part of their medical history. The most common mental illness was bipolar disorder at 30%.

RECENT STRESSORS: Thirteen of the 50 decedents in 2011 had some type of stressful event prior to death. Medical stressors were the most common type during this year, including emergency room visits, falls, and recent complaints of feeling ill. RECENT STRESSORS 2011 4.5 4 3.5 3 2.5 2 1.5 1 0.5 NUMBER OF DECEDENTS OF NUMBER 0 Emotional Medical Altercations (physical Law Enforcement and verbal) TYPE OF STRESSOR Source: Santa Clara County Medical Examiner-Coroner

Retrospective Homeless Study, Santa Clara County Medical Examiner-Coroner Office 2011-2016

2012

Retrospective Homeless Study, Santa Clara County Medical Examiner-Coroner Office 2011-2016 2012

DECEDENT DEMOGRAPHICS: There were 62 homeless deaths in the year 2012 in Santa Clara County, 12 more than the previous year. Fifty-three of the 62 decedents were male (85%) and nine were female (15%). SEX 2012 Female 15%

Male 85% Male Female Source: Santa Clara County Medical Examiner-Coroner

Forty-one of the 62 were listed as Caucasian (66%), 12 as Hispanic (19%), five as Black (8%), two as Asian (3%), one as Middle Eastern (2%), and one as Pacific Islander (2%). ETHNICITY 2012

2% 2% 3% Caucasian 8%

Hispanic

Black 19%

Asian

66% Middle Eastern

Pacific Islander

Source: Santa Clara County Medical Examiner-Coroner

The ages of the decedents in 2012 ranged from 23 weeks gestation to 82 years. The ages with the highest number of decedents were 47 years, 55 years, and 57 years.

Retrospective Homeless Study, Santa Clara County Medical Examiner-Coroner Office 2011-2016

Age at Death 2012 4.5 4 3.5 3 2.5 2 1.5 1

NUMBER OF DECEDENTS OF NUMBER 0.5

28 45 65 82 23 26 31 33 38 41 42 43 46 47 48 50 51 52 53 54 55 56 57 59 60 62 63 64 66 68 69 70 77 79 23 week gest. AGE AT DEATH (WEEKS AND YEARS) Source: Santa Clara County Medical Examiner-Coroner

The number of decedents per season were 14 in winter, 19 in spring, 15 in summer, and 14 in the fall. DEATHS PER SEASON 2012

Fall Winter 23% 22%

Summer 24% Spring 31%

Winter Spring Summer Fall Source: Santa Clara County Medical Examiner-Coroner

There were 20 natural deaths (32%), 25 accidental deaths (40%), 10 undetermined (16%), two suicides (3%), and five homicides (8%). The number of homicides from 2011 to 2012 increased by 150%.

Retrospective Homeless Study, Santa Clara County Medical Examiner-Coroner Office 2011-2016

MANNER OF DEATH 2012 30

NUMBER OF DECEDENTS OF NUMBER 5

0 Natural Accident Undetermined Suicide Homicide MANNER Source: Santa Clara County Medical Examiner-Coroner

Two of the 62 cases were listed as veterans, with one having a mental illness listed as a significant medical condition.

CAUSE OF DEATH: Five of the cases were related to vehicle accidents. Two of the five incidents occurred in the dark, with one decedent not in a marked crosswalk and wearing dark clothing. Three of the decedents were positive for alcohol at the time of the incident. There was one case where environmental cold exposure was a contributing factor to cause of death. This death occurred in December during the late fall season.

LOCATION OF DEATH: The 2012 data on location of death were classified based on the previously mentioned criteria. The number of deaths occurring in outdoor makeshift living areas, such as homeless encampments, remained mostly the same between 2011 and 2012. However, the number of deaths occurring in indoor makeshift living areas, including vehicles, decreased between the two years. The most common locations of death in 2012 were outdoor makeshift living areas and outdoor areas where the decedents were not living.

Source: Shutterstock

Retrospective Homeless Study, Santa Clara County Medical Examiner-Coroner Office 2011-2016

LOCATION OF DEATH 2012 16

4 NUMBER OF DECEDENTS OF NUMBER 2

0 Indoor Outdoor Outdoors Hospital ER Hospice Other Motel Indoors Makeshift Makeshift (not living Residence (other) Living Area Living Area there) LOCATION Source: Santa Clara County Medical Examiner-Coroner

DRUG USE: There were 16 total cases where cause of death was related to drug and/or alcohol intoxication. The most popular drug, comprising 63% of these cases, was methamphetamine. Forty of the 62 decedents (65%) had drug and alcohol abuse listed in their significant medical history. One additional case, a 23-week-gestation fetal demise, had a mother with a history of substance abuse. The most popular drug found at toxicology was alcohol, appearing on 26 of the 44 (59%) positive toxicology reports. This was followed by methamphetamine/amphetamine at 23%. Fourteen of the 62 decedents were found with illicit drug paraphernalia, including pipes, syringes, substances, medications not prescribed to them, and/or alcohol at the time of death. The table below illustrates the types of drugs found at toxicology, and the number of decedents positive for each.

Name of Drug Number of Decedents Methamphetamine/Amphetamine 14 Beta-Phenethylamine 1 Carboxyhemoglobin 1 Alcohol 26 Diazepam/Nordiazepam/Chlordiazepoxide 8 Theobromine 5 Morphine 2 Acetaminophen 1 Acetone 2 Morphine-3-glucuronide 1 Delta-9 THC/ Delta-9 Carboxy THC 7 Diphenhydramine 1 Phenylpropanolamine 1 Mitrazapine 2 18

Retrospective Homeless Study, Santa Clara County Medical Examiner-Coroner Office 2011-2016 Citalopram/Escitalopram 2 Methadone/EDDP 1 Caffeine 7 Fentanyl/Norfentanyl 1 Carisoprodol 1 Benzodiazepines 1 Trihexphenidyl 1 Venlafaxine 1 Nicotine/Cotinine 6 Isopropanol 2 Pseudoephedrine 1 Cocaine/Benzoylecgonine 1 Diltiazem 1

MENTAL ILLNESS: There were 19 decedents (30%) who had some sort of mental illness listed in their medical history. The most common illness for decedents in 2012 was schizophrenia at 26%, followed by prior suicide attempts at 21%.

RECENT STRESSORS: Eleven out of 62 decedents experienced some type of stressful event prior to death, the most common being incidents involving law enforcement, including recent arrests and active warrants. RECENT STRESSORS 2012 6

NUMBER OF DECEDENTS OF NUMBER 1

0 Emotional Medical Altercations (physical and Law Enforcement verbal) TYPE OF STRESSOR Source: Santa Clara County Medical Examiner-Coroner

Retrospective Homeless Study, Santa Clara County Medical Examiner-Coroner Office 2011-2016

2013

Retrospective Homeless Study, Santa Clara County Medical Examiner-Coroner Office 2011-2016 2013

DECEDENT DEMOGRAPHICS: In the year 2013, there were 78 homeless deaths in Santa Clara County. This is a 56% increase from 2011 and a 26% increase from 2012. Of the 78 decedents, 68 were male (87%) and 10 were female (13%). SEX 2013 Female 13%

Male 87% Source: Santa Clara County Medical Examiner-Coroner Male Female

Forty-five of the 78 decedents were Caucasian (58%), 18 were Hispanic (23%), eight were Black (10%), six were Asian (8%), and one was Native American (1%). ETHNICITY 2013 1% 8% Caucasian 10% Hispanic

Black

58% 23% Asian

Native American

Source: Santa Clara County Medical Examiner-Coroner

The ages at death ranged from 30 to 91 years, with one decedent of unknown age. The ages with the greatest number of decedents were age 46 years, 49 years, and 52 years.

Retrospective Homeless Study, Santa Clara County Medical Examiner-Coroner Office 2011-2016

AGE AT DEATH 2013 6

NUMBER OF DECEDENTS OF NUMBER 1

30 32 36 37 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 72 74 76 78 80 91 Unknown AGE AT DEATH (YEARS) Source: Santa Clara County Medical Examiner-Coroner

The season with the greatest number of deaths in 2013 was winter, with 24 cases. There were 21 deaths in the spring, 19 in the summer, and 14 in the fall. DEATHS PER SEASON 2013

Fall 18% Winter 31%

Summer 24%

Spring 27%

Winter Spring Summer Fall Source: Santa Clara County Medical Examiner-Coroner

There were 33 natural deaths (42%), 30 accidental (38%), two undetermined (3%), eight suicides (10%), and five homicides (6%) in 2013.

Retrospective Homeless Study, Santa Clara County Medical Examiner-Coroner Office 2011-2016

MANNER OF DEATH 2013 35 30 25 20 15 10

NUMBER OF DECEDENTS OF NUMBER 5 0 Natural Accident Undetermined Suicide Homicide MANNER Source: Santa Clara County Medical Examiner-Coroner

Two out of the 78 homeless decedents in 2013 were veterans.

CAUSE OF DEATH: There were five deaths related to vehicle accidents in 2013. All of the decedents had positive toxicology reports for drugs or alcohol and all were crossing illegally or approaching oncoming traffic in the road. Two of the 78 deaths were caused by environmental cold exposure. Both of these cases occurred in December, with one being classified in the fall and the other in the winter based on the dates of death and the seasonal cut off dates.

A homeless encampment in San Jose. Photo taken by Michelle A. Jorden, MD

Retrospective Homeless Study, Santa Clara County Medical Examiner-Coroner Office 2011-2016

LOCATION OF DEATH: The locations of death for the 2013 homeless cases were classified based on the previously outlined criteria. Twenty-three percent of the decedents were found outside in an area where they were not living or sleeping. The next two most common locations of death, both at 16%, were hospitals and outdoor makeshift living areas, including homeless encampments. LOCATION OF DEATH 2013 20 18 16 14 12 10 8 6 4 2

0 NUMBER OF DECEDENTS OF NUMBER

Source: Santa Clara County Medical Examiner-Coroner

LOCATION

DRUG USE: There were 21 deaths due to drug and/or alcohol intoxication in 2013, 13 of which involved methamphetamine/amphetamine. The use of methamphetamine increased by 300% between 2011 and 2013. The use of alcohol has remained consistently high and the most popular drug. Forty-five decedents had a history of drug and/or alcohol abuse listed as a significant medical condition. Fourteen of the 78 decedents were found with illicit drug paraphernalia, including pipes, syringes, substances, medications not prescribed to them, and/or alcohol at the time of death. The table below illustrates the types of drugs found at toxicology, and the number of decedents positive for each.

Name of Drug Number of Decedents Methamphetamine/Amphetamine 22 Beta-Phenethylamine 4 Carboxyhemoglobin 1 Alcohol 22 Diazepam/Nordiazepam/Oxazepam/Lorazepam/ 8 Temazepam Theobromine 2 Morphine 5 Acetaminophen 1

Retrospective Homeless Study, Santa Clara County Medical Examiner-Coroner Office 2011-2016 Acetone 3 Delta-9 THC/ Delta-9 Carboxy THC 4 Diphenhydramine 3 Phenylpropanolamine 1 Mitrazapine 1 Methadone/EDDP 3 Caffeine 4 Venlafaxine 1 Nicotine/Cotinine 4 Isopropanol 1 Cocaine/Benzoylecgonine 1 Doxylamine 1 Dextro/Levomethorphan 2 Chlorpheniramine 1 Opiates 2 Trazodone 2 Phenobarbital 1 Propofol 1 Mephobarbital 1 Canrenone 1 Lidocaine 1 Ibuprofen 1 Theophylline 1 Oxycodone/Noroxycodone 1 O-Desmethylvenlafaxine 1 Oxymorphone 1 Tramadol 1 Warfarin 1 Codeine 2 Paroxetine 1 Phencyclidine 1 Etomidate 1 Olanzapine 1 Phentermine 1 Doxylamine 1 Chlorpheniramine 1 Norbuprenorphine 1 Dihydrocodeine/Hydrocodol 1 Hydrocodone 2 Nicotinamide 1

MENTAL ILLNESS: Fifteen out of 78 (19%) of the homeless decedents in 2013 had some sort of mental illness listed as a significant medical condition. The most common illnesses were depression (46%) and schizophrenia (40%).

RECENT STRESSORS: 25

Retrospective Homeless Study, Santa Clara County Medical Examiner-Coroner Office 2011-2016 Of the 78 decedents in 2013, 18 experienced some type of stressful event prior to death, with medical stressors being the most common, including emergency room visits, falls, and recent complaints of feeling ill.

RECENT STRESSORS 2013 12 10 8 6 4

2 NUMBER OF DECEDENTS OF NUMBER 0 Emotional Medical Altercations (physical Law Enforcement and verbal) TYPE OF STRESSOR Source: Santa Clara County Medical Examiner-Coroner

Retrospective Homeless Study, Santa Clara County Medical Examiner-Coroner Office 2011-2016

2014

Retrospective Homeless Study, Santa Clara County Medical Examiner-Coroner Office 2011-2016 2014

DECEDENT DEMOGRAPHICS: There were a total of 69 homeless deaths in the year 2014 in Santa Clara County, a decrease in the number of deaths from 2013. Of these 69 decedents, 57 were male (83%) and 12 were female (17%). SEX 2014 Female 17%

Male 83% Male Female Source: Santa Clara County Medical Examiner-Coroner

Forty of the 69 decedents were Caucasian (58%), 21 were Hispanic (30%), four were Black (6%), two were Asian (3%), one was Pacific Islander (2%), and one was Middle Eastern (1%). ETHNICITY 2014

2% 1% 3% Caucasian 6%

Hispanic

Black

Asian 30% 58% Pacific Islander

Middle Eastern

Source: Santa Clara County Medical Examiner-Coroner

Age of death ranged from 25 years to 85 years, with one decedent of an unknown age. The age with the greatest number of decedents was 58 years.

Retrospective Homeless Study, Santa Clara County Medical Examiner-Coroner Office 2011-2016

AGE AT DEATH 2014 7

NUMBER OF DECEDENTS OF NUMBER 1

25 26 27 32 33 34 38 40 41 44 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 65 67 68 69 70 73 80 85 Unknown AGE AT DEATH (YEARS) Source: Santa Clara County Medical Examiner-Coroner

Twenty-eight deaths occurred in the winter in 2014, followed by 16 in spring, 12 in the summer, and 13 in the fall. DEATHS PER SEASON 2014

Fall 19%

Winter 41%

Summer 17%

Spring 23% Winter Spring Summer Fall Source: Santa Clara County Medical Examiner-Coroner

There were 33 deaths classified as natural (48%), 30 accidental (43%), two undetermined (3%), two suicides (3%), and two homicides (3%). The number of homicides decreased from 2013 to 2014 by 60%.

Retrospective Homeless Study, Santa Clara County Medical Examiner-Coroner Office 2011-2016

MANNER OF DEATH 2014 35

NUMBER OF DECEDENTS OF NUMBER 5

0 Natural Accident Undetermined Suicide Homicide MANNER Source: Santa Clara County Medical Examiner-Coroner

Four of the 69 decedents were veterans. Two had a history of mental illness listed as a significant medical condition.

CAUSE OF DEATH: Five of the 2014 homeless deaths were caused by vehicle accidents. All five decedents were positive for drugs or alcohol and four of the five were not in marked crosswalks. Two deaths were caused by environmental cold exposure. Both of the deaths occurred in the winter, in February and December.

LOCATION OF DEATH: The locations of death for the 2014 homeless cases were classified based on the previously outlined criteria. The most common locations of death, both at 23%, were outdoor makeshift living areas, such as homeless encampments, and outdoors in areas where the decedent was not known to be living.

Retrospective Homeless Study, Santa Clara County Medical Examiner-Coroner Office 2011-2016

LOCATION OF DEATH 2014 18 16 14 12 10 8 6 4

NUMBER OF DECEDENTS OF NUMBER 2 0 Indoor Outdoor Outdoors Hospital ER Nursing Other Transitional Motel Makeshift Makeshift (not living Home Residence Housing Living Area Living Area there) LOCATION Source: Santa Clara County Medical Examiner-Coroner

DRUG USE: Nineteen out of the 69 deaths, or 27%, were related to drug and/or alcohol intoxication. Twelve of the 19 cases involved methamphetamine. Thirty-one percent of the intoxication related deaths included heroin in 2014. Forty-eight decedents had a history of drug and/or alcohol abuse listed as a significant medical condition. Twenty of the 69 decedents were found with illicit drug paraphernalia, including pipes, syringes, substances, medications not prescribed to them, and/or alcohol at the time of death. The table below illustrates the types of drugs found at toxicology, and the number of decedents positive for each.

Name of Drug Number of Decedents Methamphetamine/Amphetamine 19 Carboxyhemoglobin 2 Alcohol 24 Diazepam/Nordiazepam/Chlordiazepoxide/ 8 Lorazepam Morphine 10 Acetone 2 Delta-9 THC/Delta-9 Carboxy THC 6 Diphenhydramine 1 Methadone 1 Caffeine 6 Nicotine 2 Cotinine 1 Canrenone 1 Lidocaine 1 Ibuprofen 1 Warfarin artifact 1 Codeine 9

Retrospective Homeless Study, Santa Clara County Medical Examiner-Coroner Office 2011-2016 Paroxetine 1 Phencyclidine 2 Olanzapine 1 Hydromorphone 2 Nicotinamide 1 6-Monoacetylmorphine (6-MAM; heroin) 3 Quetiapine 1 Buspirone 1 Morphine-6-glucuronide 1 Morphine-3-glucuronide 1 Dextromethorphan 1 Promethazine 1 Fluoxetine/Norfluoxetine 1 Ephedrine 1 Zolpidem 1 Atropine 1 Mephentermine 1

MENTAL ILLNESS: Thirteen out of the 69 cases, or 19%, had a mental illness listed as part of their significant medical history. The most common mental illnesses were depression (38%) and schizophrenia (31%).

RECENT STRESSORS: Sixteen of the 69 decedents had some type of stressful event prior to death, with medical stressors being the most common, including emergency room visits, falls, and recent complaints of feeling ill. There were no recent emotional stressors indicated. RECENT STRESSORS 2014 14 12 10 8 6 4 2

0 NUMBER OF DECEDENTS OF NUMBER Emotional Medical Altercations (physical and Law Enforcement verbal) TYPE OF STRESSOR Source: Santa Clara County Medical Examiner-Coroner

Retrospective Homeless Study, Santa Clara County Medical Examiner-Coroner Office 2011-2016

2015

Retrospective Homeless Study, Santa Clara County Medical Examiner-Coroner Office 2011-2016 2015

DECEDENT DEMOGRAPHICS: In the year 2015, there were 85 total homeless deaths in Santa Clara County. This is an increase of 23.19% from the previous year, and the highest number of deaths in a single year thus far. Of the 85 decedents, 69 were male (81%) and 16 were female (19%). SEX 2015 Female 19%

Male 81% Male Female Source: Santa Clara County Medical Examiner-Coroner

Forty-six decedents were listed as Caucasian (54%), 17 as Hispanic (20%), 12 as Black (14%), three as Asian (4%), two as Pacific Islander (3%), one as East Indian (1%), two as Native American (2%), and two as having unknown ethnicity (2%). ETHNICITY 2015 2% Caucasian 1% 2% 3% Hispanic 4% Black

Asian 14% Pacific Islander

East Indian 54% Native American 20% Unknown

Source: Santa Clara County Medical Examiner-Coroner

The ages at death for the 2015 year ranged from 23 to 80 years of age. The age with the greatest number of decedents was 53 years.

Retrospective Homeless Study, Santa Clara County Medical Examiner-Coroner Office 2011-2016

AGE AT DEATH 2015 7 6 5 4 3 2

1 NUMBER OF DECEDENTS OF NUMBER 0 23 27 29 32 33 37 40 42 44 45 46 47 48 49 50 51 52 53 54 55 56 58 59 60 61 62 63 64 65 67 68 70 72 75 78 80 AGE AT DEATH (YEARS) Source: Santa Clara County Medical Examiner-Coroner

There were 24 deaths in the summer season in 2015. This was followed by 23 in winter, 21 in spring, and 17 in the fall. DEATHS PER SEASON 2015 Fall 20% Winter 27%

Summer 28% Spring 25%

Winter Spring Summer Fall Source: Santa Clara County Medical Examiner-Coroner

There were 45 natural deaths (53%), 27 accidental deaths (32%), eight undetermined (9%), three suicides (4%), and two homicides (2%).

Retrospective Homeless Study, Santa Clara County Medical Examiner-Coroner Office 2011-2016

MANNER OF DEATH 2015 50 45 40 35 30 25 20 15 10 NUMBER OF DECEDENTS OF NUMBER 5 0 Natural Accident Undetermined Suicide Homicide MANNER Source: Santa Clara County Medical Examiner-Coroner

Nine of the 85 decedents were listed as veterans. Five of these decedents had a mental illness listed as a significant medical condition.

CAUSE OF DEATH: Eight of the 85 deaths were related to vehicle accidents. Five of the eight decedents had positive toxicology reports for drugs and/or alcohol and three decedents had a mental illness listed as a significant medical condition. There were two deaths involving trains, and one death where the decedent was the driver of the vehicle. In 2015, two deaths were caused by environmental cold exposure. Both of the deaths occurred during the winter in December.

LOCATION OF DEATH: The locations of death for the 2015 homeless cases were classified based on the previously outlined criteria. The greatest number of deaths occurred in hospitals (29%), followed by 21% of deaths occurring in outdoor makeshift living areas such as homeless encampments. Included in the “Indoor (other)” category for the year 2015 is an apartment where the decedent had recently been placed by a homeless healthcare group.

A homeless encampment in San Jose. Photo taken by Michelle A. Jorden, MD

Retrospective Homeless Study, Santa Clara County Medical Examiner-Coroner Office 2011-2016

LOCATION OF DEATH 2015 30

5 NUMBER OF DECEDENTS OF NUMBER 0 Indoor Outdoor Outdoors Hospital ER Nursing Indoor Hotel Transitional Makeshift Makeshift (not living Facility (other) Housing for Living Area Living Area there) Homeless Veterans LOCATION

Source: Santa Clara County Medical Examiner-Coroner DRUG USE: Seventeen of the 85 decedents in 2015 had a cause of death related to alcohol or drug intoxication. Seventy-six percent of these decedents were positive for methamphetamine. Fifty out of the 85 decedents (59%) had a history of drug and/or alcohol abuse listed as a significant medical condition. Twenty of the 85 decedents were found with illicit drug paraphernalia, including pipes, syringes, substances, medications not prescribed to them, and/or alcohol at the time of death. The table below illustrates the types of drugs found at toxicology, and the number of decedents positive for each.

Name of Drug Number of Decedents Methamphetamine/Amphetamine 23 Alcohol 27 Diazepam/Nordiazepam/Chlordiazepoxide/ 9 Lorazepam/Clonazepam/7 Amino Clonazepam Morphine 3 Acetone 8 Delta-9 THC/Delta-9 Carboxy THC 4 Diphenhydramine 1 Methadone/EDDP 1 Caffeine 9 Nicotine 2 Lidocaine 1 Codeine 3 Phencyclidine 2 Hydromorphone 1 6-Monoacetylmorphine (6-MAM; heroin) 2 Quetiapine 1 Promethazine 1 37

Retrospective Homeless Study, Santa Clara County Medical Examiner-Coroner Office 2011-2016 Fluoxetine/Norfluoxetine 2 Isopropanol 5 Chlorpheniramine 1 Phenobarbital 1 Oxycodone 1 Fentanyl 2 Metoclopramide 1 Midazolam 2 Naloxone 1 Sertraline/Desmethylsertraline 2 Aripiprazole 1 Phenylpropanolamine 3 Mirtazapine 2 Trazodone 1 mCPP 1 Citalopram/Escitalopram 1 Opiates 1 Metrinozole 1 Tramadol 1 Laudanosine 1

MENTAL ILLNESS: Twenty of the 85 decedents (24%) had some type of mental illness listed as a significant medical condition. The most common type of illness was schizophrenia at 35% and the next most common was depression at 20%.

RECENT STRESSORS: Of the 85 decedents in 2015, 27 experienced some type of stressful event prior to death. The most common type of stressor among the 2015 decedents was medical, including emergency room visits, falls, and recent complaints of feeling ill.

RECENT STRESSORS 2015 16 14 12 10 8 6 4 2 0 NUMBER OF DECEDENTS OF NUMBER Emotional Medical Altercations (physical Law Enforcement and verbal) TYPE OF STRESSOR Source: Santa Clara County Medical Examiner-Coroner

Retrospective Homeless Study, Santa Clara County Medical Examiner-Coroner Office 2011-2016

2016

Retrospective Homeless Study, Santa Clara County Medical Examiner-Coroner Office 2011-2016 2016

DECEDENT DEMOGRAPHICS: There were a total of 132 homeless deaths in Santa Clara County in the year 2016. That is an increase of 55.3% between 2015 and 2016 and an increase of 164% between 2011 and 2016. This is the highest number of deaths for a single year out of all six years analyzed in this study. There were 108 males (82%) and 24 females (18%). SEX 2016 Female 18%

Male 82% Male Female Source: Santa Clara County Medical Examiner-Coroner

Seventy-three decedents were listed as Caucasian (55%), 41 as Hispanic (31%), eight as Black (6%), six as Asian (5%), two as Native American (1%), one as Pacific Islander (1%), and one as other (1%).

1% ETHNICITY 1% 2016 1% 5% Caucasian 6% Hispanic

Black

Asian

55% Pacific Islander 31% Native American

Other

Source: Santa Clara County Medical Examiner-Coroner

Retrospective Homeless Study, Santa Clara County Medical Examiner-Coroner Office 2011-2016 Age at death ranged from two days to 80 years of age. The age with the greatest number of decedents was 62 years. AGE AT DEATH 2016 9 8 7 6 5 4 3 2 NUMBER OF DECEDENTS OF NUMBER 1

38 47 18 24 25 26 31 32 33 34 35 36 37 39 41 43 44 46 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 72 73 75 80 2 Days AGE AT DEATH (DAYS AND YEARS) Source: Santa Clara County Medical Examiner-Coroner

Of the 132 cases in 2016, 35 occurred in the winter, 30 in the spring, 38 in the summer, and 29 in the fall. DEATHS PER SEASON 2016

Fall Winter 22% 26%

Summer Spring 29% 23%

Winter Spring Summer Fall Source: Santa Clara County Medical Examiner-Coroner

There were 43 accidental deaths in 2016 (33%), 63 natural (48%), eight undetermined (6%), eight suicides (6%), nine homicides (7%), and one pending manner of death (1%). 2016 saw the highest number of homicides, increasing by 350% since 2011. This increase could be due to the overall increase in the number of homeless deaths during this year.

Retrospective Homeless Study, Santa Clara County Medical Examiner-Coroner Office 2011-2016

MANNER OF DEATH 2016 70 60 50 40 30 20

10 NUMBER OF DECEDENTS OF NUMBER 0 Natural Accident Undetermined Suicide Homicide Pending MANNER Source: Santa Clara County Medical Examiner-Coroner Three of the 132 decedents were listed as veterans, one of which had a history of mental illness listed as a significant medical condition.

CAUSE OF DEATH: Thirteen of the 132 causes of death (10%) were due to vehicle related accidents. Three of the decedents were not in a marked crosswalk, one was riding a bike against a red without a helmet, three of the cases were suicides, and there were two train versus pedestrian incidents. Twelve of the 13 decedents were under the influence of drugs or alcohol upon toxicological examination. Four of the 132 deaths in 2016 were related to environmental exposure. One of the four was caused by heat exposure during the summer season in July. The other three cases were caused by cold exposure, two of which occurred in the fall in November and December, and one during the winter in December.

LOCATION OF DEATH: The locations of death for the 2016 homeless cases were again categorized based on the previously outlined criteria. The most common location of death was the hospital, with 24% of deaths occurring here. This was followed by outdoor makeshift living areas at 22%.

Retrospective Homeless Study, Santa Clara County Medical Examiner-Coroner Office 2011-2016

LOCATION OF DEATH 2016 35 30 25 20 15 10

5 NUMBER OF DECEDENTS OF NUMBER 0

LOCATION Source: Santa Clara County Medical Examiner-Coroner

DRUG USE: Twenty-five of the 132 decedents (19%) had a cause of death due to drug and/or alcohol intoxication. Methamphetamine was the most popular drug in 2016, followed by alcohol, Delta-9 THC, and heroin. Seventy-three of the 132 decedents (55%) had a history of drug and/or alcohol abuse. Twenty- nine of the 132 decedents were found with illicit drug paraphernalia, including pipes, syringes, substances, medications not prescribed to them, and/or alcohol at the time of death. The table below illustrates the types of drugs found at toxicology, and the number of decedents positive for each.

Name of Drug Number of Decedents Methamphetamine/Amphetamine 39 Alcohol 32 Diazepam/Nordiazepam/Chlordiazepoxide/ 6 Lorazepam/7 Amino Clonazepam Morphine 7 Acetone 1 Delta-9 THC/Delta-9 Carboxy THC/11- 15 hydroxy-Delta 9-THC Diphenhydramine 2 Methadone/EDDP 1 Lidocaine 1 Codeine 5 Phencyclidine 4 6-Monoacetylmorphine (6-MAM; heroin) 5

Retrospective Homeless Study, Santa Clara County Medical Examiner-Coroner Office 2011-2016 Chlorpheniramine 1 Oxycodone 3 Fentanyl/Norfentanyl 1 Naloxone 1 Sertraline/Desmethylsertraline 2 Phenylpropanolamine 1 Mirtazapine 1 Citalopram/Escitalopram 1 Opiates 1 Nicotinamide 2 Oxymorphone 3 Duloxetine 1 Theobromine 3 Ketamine/Norketamine 1 Cocaine/Benzoylecgonine 2 Ibuprofen 2 Cotinine 2 Warfarin 1 Risperidone/9-Hydroxyrisperidone 1 Benzo 1 Dilaudid 1 Hydrocodone 2 Beta-Phenethylamine 2 Mephentermine 1 Morphine-3-glucuronide 1 Ephedrine 1 Levetiracetam 1 Buprenorphine/Norbuprenorphine 1

MENTAL ILLNESS: Twenty-three of the 132 decedents had some type of mental illness listed as a significant part of their medical history. The most common mental illnesses were bipolar disorder (30%), depression (22%), and schizophrenia (22%).

RECENT STRESSORS: Fourteen of the 132 decedents experienced a stressful event prior to death. Emotional and medical stressors, including emergency room visits, falls, and recent complaints of feeling ill, were equally as common among the 2016 decedents. Included in the emotional stressor category in 2016 was a recent eviction and the surrendering of a pet dog within the past month.

Retrospective Homeless Study, Santa Clara County Medical Examiner-Coroner Office 2011-2016

RECENT STRESSORS 2016 5 4 3 2 1 0 NUMBER OF DECEDENTS OF NUMBER Emotional Medical Altercations (physical and Law Enforcement verbal) TYPE OF STRESSOR Source: Santa Clara County Medical Examiner-Coroner

Retrospective Homeless Study, Santa Clara County Medical Examiner-Coroner Office 2011-2016

Retrospective Homeless Study, Santa Clara County Medical Examiner-Coroner Office 2011-2016 SUMMARY

Between 2011 and 2016, there were 476 homeless deaths in Santa Clara County. There was a dramatic increase in the number of homeless deaths in the year 2016. In The Santa Clara County 2017 Homeless Census and Survey Comprehensive Report, Applied Survey Research found “an increase of 13% since 2015” in the homeless population of Santa Clara County.2

HOMELESS DEATHS IN SANTA CLARA COUNTY 2011-2016 140 120 100 80 60 40

20 NUMBER NUMBER OF DECEDENTS 0 2011 2012 2013 2014 2015 2016 YEAR Source: Santa Clara County Medical Examiner-Coroner

DEMOGRAPHICS: Eighty-three percent of all homeless decedents were male, with only 17% being female. The higher number of male decedents is consistent with that found in the Applied Survey Research 2017 Homeless Census Survey.2 SEX 2011-2016 Female 17%

Male 83% Male Female Source: Santa Clara County Medical Examiner-Coroner

Retrospective Homeless Study, Santa Clara County Medical Examiner-Coroner Office 2011-2016 Between 2011 and 2016 there were 275 decedents listed as Caucasian, 123 as Hispanic, 40 as Black, 19 as Asian, five as Pacific Islander, six as Native American, 3 as Middle Eastern, one as East Indian, two as other, and two as unknown. ETHNICITY 1% 2011-2016 Caucasian 1% 0% 1% Hispanic 1% 0% 4% Black 8% Asian

Pacific Islander

Native American

East Indian

26% 58% Middle Eastern

Other

Unknown

Source: Santa Clara County Medical Examiner-Coroner

Retrospective Homeless Study, Santa Clara County Medical Examiner-Coroner Office 2011-2016 The ages with the greatest number of decedents per year were as follows:

Year Age (in years) 2011 53

2012 47, 55, 57

2013 46, 49, 52

2014 58

2015 53

2016 62

There were two fetal demises during the six year period.

HIGHLIGHTS OF THIS STUDY

1.) The number of homeless deaths in Santa Clara County increased 164% from 2011 to 2016. The number of deaths affecting the homeless population continues to rise with the most deaths observed to date occurring in 2016. 2.) Homeless deaths were more common among males than females, with Caucasians being the most predominantly represented ethnic group. 3.) Alcohol and drug abuse continues to claim a significant number of homeless deaths each year with alcohol and methamphetamine being the most commonly abused drugs. Heroin deaths are being monitored given the opioid epidemic. 4.) The number of elderly deaths over the age of 65 years has risen and is expected to rise given the aging baby boomer population. 5.) A significant percentage of the homeless are continuing to die in homeless encampments and on the streets with zip codes 95128 and 95116 being the hot spots currently identified for these deaths.

SUMMARY OF HIGHLIGHTS

THE AGING HOMELESS POPULATION: There has been a growing concern about the rise in the number of senior aged homeless individuals. Santa Clara County observed a 320% increase in the number of homeless decedents aged 65 and over in the 2011 through 2016 time period. Based on a study conducted by Dennis P. Culhane, the baby boomer generation has had a higher risk of homelessness for over two decades.4 He also identified that the average life expectancy of the aging homeless population is 64 years of age and these individuals are more susceptible to illness.5 Therefore, as the baby boomer population ages, so does the homeless population. This may account for the steady increase in the number of homeless decedents 65 and over in Santa Clara County.

Retrospective Homeless Study, Santa Clara County Medical Examiner-Coroner Office 2011-2016

DECEDENTS 65 AND OVER 2011-2016 25

NUMBER NUMBER OF DECEDENTS 0 2011 2012 2013 2014 2015 2016 YEAR Source: Santa Clara County Medical Examiner-Coroner

MANNER OF DEATH: There were 211 natural deaths (44%), 176 accidental deaths (37%), 37 undetermined manners of death (7%), 26 suicides (5%), 25 homicides (5%), and one pending manner of death (1%) for all six years.

MANNER OF DEATH 2011-2016 250

200

150

100

50 NUMBER OF DECEDENTS OF NUMBER

0 Natural Accident Undetermined Suicide Homicide Pending MANNER Source: Santa Clara County Medical Examiner-Coroner

Retrospective Homeless Study, Santa Clara County Medical Examiner-Coroner Office 2011-2016

HOMICIDES: There was an increase in the number of homeless homicides in 2016. The increase of homicides can partially be explained by the overall increase in the number of homeless deaths; however, the homeless population remains vulnerable to violent crimes. HOMICIDES 2011-2016 10

2 NUMBER OF DECEDENTS OF NUMBER 0 2011 2012 2013 2014 2015 2016 YEAR Source: Santa Clara County Medical Examiner-Coroner

SUICIDES: The greatest number of suicides occurred in the years 2013 and 2016. The primary method of suicide was hanging (46%).

SUICIDES 2011-2016 9 8 7 6 5 4 3 2

NUMBER OF DECEDENTS OF NUMBER 1 0 2011 2012 2013 2014 2015 2016

YEAR Source: Santa Clara County Medical Examiner-Coroner

DEATHS PER SEASON: The number of deaths per season for each year in the six year period remained fairly consistent. The steady occurrence of homeless deaths year round could be explained by the temperate weather in the Bay Area and overall safety of this area compared to other locations in the state and country.

Retrospective Homeless Study, Santa Clara County Medical Examiner-Coroner Office 2011-2016 DEATHS PER SEASON 2011-2016

Winter Spring Summer Fall

140 120 100 80 60 40

20 NUMBER OF DECEDENTS OF NUMBER 0 2011 2012 2013 2014 2015 2016 YEAR Source: Santa Clara County Medical Examiner-Coroner

VETERANS: The year 2015 had the highest number of homeless veteran decedents out of the six year period being studied. The Santa Clara County Homeless Census and Survey Report conducted in 2015 counted 703 homeless veterans in the county.2 While the number of veteran deaths decreased in 2016, this does not mean that this portion of the homeless population is no longer at risk. VETERANS 2011-2016 10 9 8 7 6 5 4 3 2

NUMBER NUMBER OF DECEDENTS 1 0 2011 2012 2013 2014 2015 2016 YEAR Source: Santa Clara County Medical Examiner-Coroner

CAUSE OF DEATH: The number of vehicle accidents as cause of death increased by 44.4% between 2015 and 2016. Many of these deaths occurred at night with the decedents typically not within a marked crosswalk or wearing dark clothing. Thirty-three of the 40 decedents involved in vehicle accidents tested positive for drugs and/or alcohol at the time of the accident. Four of the vehicle deaths were suicides.

Retrospective Homeless Study, Santa Clara County Medical Examiner-Coroner Office 2011-2016

VEHICLE ACCIDENTS AS CAUSE OF DEATH 2011-2016 14 12 10 8 6 4

2 NUMBER NUMBER OF DECEDENTS 0 2011 2012 2013 2014 2015 2016 YEAR Source: Santa Clara County Medical Examiner-Coroner

ENVIRONMENTAL EXPOSURE: Over the six year period, the number of deaths related to environmental exposure remained fairly consistent and relatively low and this in part can be explained by the joint efforts of the stakeholders in Santa Clara County working together and providing resources during periods of weather extremes. There were 12 total exposure related deaths between 2011 and 2016, 11 of which were due to cold exposure and one was due to heat exposure. The relatively low number of exposure related homeless deaths is further attributed to the temperate climate in the Bay Area.

LOCATION OF DEATH: According to the U.S. Department of Housing and Urban Development’s 2016 Annual Homeless Assessment Report to Congress, the majority of the homeless population in the state of California during the 2016 point in time survey were without shelter.6 This is consistent with data from Santa Clara County during the six year time period, as the majority of homeless deaths occurred outside of a permanent living area. Thirty-five percent of all 476 homeless decedents from 2011 through 2016 died in a hospital, emergency room, hospice, or nursing facility. The next most common locations of death were outdoor makeshift living areas, such as homeless encampments (22%). Twenty percent of the decedents were found dead outside, 10% died in an indoor makeshift living area, 5% died in another residence, 3% were found in other indoor locations, 3% were found in motels or hotels, and only 2% died in a homeless shelter or sober living environment. Our findings on the location of death demonstrate that the majority of homeless deaths between 2011 and 2016 in Santa Clara County were occurring at hospitals, emergency rooms, and nursing facilities, followed by outdoor makeshift living areas.

Homeless tents along a busy street. Photo taken by Michelle A. Jorden, MD 53

Retrospective Homeless Study, Santa Clara County Medical Examiner-Coroner Office 2011-2016

LOCATION OF DEATH 2011-2016 180 160 140 120 100 80 60 40 20

0 NUMBER OF DECEDENTS OF NUMBER

LOCATION Source: Santa Clara County Medical Examiner-Coroner

The death zip code locations for all six years were collected to determine where the greatest number of homeless deaths occurred in the county.

Zip Code Number of Zip Code Number of Deaths Deaths 94305 5 95014 1 95126 20 95120 2 95111 20 95113 7 95129 6 94040 10 95112 47 95037 7 95020 15 95132 4 95116 72 95035 4 95128 76 95119 13 95125 23 95136 5 94086 3 95127 3 95110 23 94087 3 95118 5 95123 5 95008 7 94085 2 95122 16 94306 3 95054 4 95117 2 95030 4 95032 2 95148 4 95138 1 95051 7 94089 3 95131 5 94304 1 95133 5 94041 2 94303 3 95033 1 95002 2 95121 2 95124 7 94022 1 54

Retrospective Homeless Study, Santa Clara County Medical Examiner-Coroner Office 2011-2016 94301 3 95050 10

The zip code where the greatest number of deaths occurred was 95128 in the Burbank neighborhood of San Jose. Valley Medical Center is also located in this zip code, which could account for the high number of deaths in this area. The second zip code with the greatest number of deaths was 95116 located on the East Side of San Jose. A possible explanation for the high number of deaths which occurred here is the location of Regional Medical Center within the 95116 zip code. The zip code with the third highest number of deaths was 95112 on the North Side of San Jose near the San Jose State Campus which does not have a hospital located within the zip code boundaries.

DRUG USE: The use of drugs and alcohol among the homeless decedents remained consistently high from 2011 to 2016. The number of deaths due to drug and/or alcohol intoxication was highest in the year 2016, but can be explained by the overall increase in the number of homeless deaths. There were a total of 121 decedents with a cause of death due to drugs and/or alcohol, with only 11 cases due to acute alcohol intoxication alone. Far more of the decedents were chronic alcoholics dying from complications of alcoholism as well as combining drugs and alcohol.

CAUSE OF DEATH DUE TO DRUG/ALCOHOL INTOXICATION 2011-2016 30 25 20 15 10

5 NUMBER OF DECEDENTS OF NUMBER 0 2011 2012 2013 2014 2015 2016 YEAR Source: Santa Clara County Medical Examiner-Coroner

Retrospective Homeless Study, Santa Clara County Medical Examiner-Coroner Office 2011-2016 The most popular drugs across all six years were alcohol and methamphetamine. At the time of death, 152 decedents were positive for alcohol. PRESENCE OF ALCOHOL 2011-2016 35 30 25 20 15

ALCOHOL 10 5 0 2011 2012 2013 2014 2015 2016

NUMBER NUMBER OF DECEDENTS POSITIVE FOR YEAR Source: Santa Clara County Medical Examiner-Coroner

At the time of death, 122 decedents were positive for methamphetamine/amphetamine. PRESENCE OF METHAMPHETAMINE 2011-2016 45 40 35 30 25 20

15 METH 10 5 0 2011 2012 2013 2014 2015 2016

YEAR NUMBER NUMBER OF DECEDENTS POSITIVE FOR Source: Santa Clara County Medical Examiner-Coroner

MENTAL ILLNESS: The number of decedents with a mental illness listed as a significant medical condition remained relatively constant over the six years; however, the most common types of illnesses varied by the year. In 2011, 26% of the decedents with a mental illness had bipolar disorder. Thirty-one percent of the mentally ill decedents in 2012 had schizophrenia. Nineteen percent of the mentally ill decedents in both 2013 and 2014 had depression. In 2015, 24% of the decedents with a mental illness had schizophrenia, and in 2016, 17% of the mentally ill decedents had bipolar disorder.

Retrospective Homeless Study, Santa Clara County Medical Examiner-Coroner Office 2011-2016

MENTAL ILLNESS 2011-2016 25

ILLNESS ILLNESS 5

0 2011 2012 2013 2014 2015 2016 YEAR

NUMBER OF DECEDENTS WITH A A WITHMENTAL DECEDENTS OF NUMBER Source: Santa Clara County Medical Examiner-Coroner

RECENT STRESSORS: As previously outlined, recent stressors were categorized into emotional, medical, physical and verbal altercations, and incidents with law enforcement. The most common type of stressor was medical, indicating that a significant portion of the homeless decedents have underlying medical conditions and may or may not be receiving consistent medical attention. RECENT STRESSORS 2011-2016

Emotional Medical Altercations (physical and verbal) Law Enforcement

30 25 20 15 10

5 NUMBER OF DECEDENTS OF NUMBER 0 2011 2012 2013 2014 2015 2016 YEAR Source: Santa Clara County Medical Examiner-Coroner

Retrospective Homeless Study, Santa Clara County Medical Examiner-Coroner Office 2011-2016 CONCLUSION

The number of homeless deaths in Santa Clara County increased 164% from 2011 to 2016. The majority of these individuals were dying in hospitals and on the streets. The use of drugs and alcohol has remained consistently high. Mental illnesses and stressful medical events are recurring issues in this population. It is the goal of this study to bring awareness to the increasing number of homeless deaths in our county.

Source: Shutterstock

RECOMMENDATIONS

1. Homelessness is a complex and multifactorial social issue as exemplified in this study. Housing is just one of many necessities. Access to consistent medical and mental health care as well as drug and alcohol services and employment resources are underscored. Mobile healthcare services may serve this population well.

2. The combination of drug and alcohol intoxication was shown to be the most prevalent lethal factor over the entire study period, with alcohol being the most popular drug found at toxicology, followed by methamphetamine. Methamphetamine continues to be a most commonly abused illicit drug. Ensuring that the homeless population has consistent access to drug and alcohol intervention services is warranted.

3. The current opioid epidemic can affect the homeless population including access to synthetic opioids. The distribution and use of Narcan (naloxone) should be considered in this population to prevent overdoses.

4. This study identified an increase in homeless deaths among those 65 years and older. With an increase of baby boomers becoming older, preventive healthcare in the form of vaccines (pneumonia/shingles), as well as treating chronic medical conditions such as hypertension and diabetes is underscored for this population and may help alleviate increased healthcare costs through emergency services as well as pain control/crisis.

5. The homeless population, like anyone, may be involved in relationships with others or pets that cannot be easily separated or accommodated in shelters or other facilities. We must remember and be sensitive to these, as well as transgender and LGBTQ issues that may affect this population.

Retrospective Homeless Study, Santa Clara County Medical Examiner-Coroner Office 2011-2016 REFERENCES

1Rossi PH, Wright JD, Fisher GA, Willis G. (1987). The Urban Homeless: Estimating Composition and Size. Science;235:1336-41

2Applied Survey Research. (2017). Santa Clara County Homeless Census and Survey Comprehensive Report.

3Seasons: Meteorological and Astronomical. Retrieved from http://www.npl.co.uk/science- technology/time-frequency/time/faqs/when-do-the-four-seasons-officially-begin-(faq-time). Accessed July 31, 2017.

4Culhane, D. P., Metraux, S., & Bainbridge, J. (2010). The Age Structure of Contemporary Homelessness: Risk Period or Cohort Effect? Penn School of Social Policy and Practice Working Paper, 1-28. Retrieved from http://repository.upenn.edu/spp_papers/140

5Culhane, D. P. (2015). No Place to Call Home: Late Boomers Face Homelessness, End of Life Difficulties. Aging Today Vol. 36 (6), 1-2.

6The U.S. Department of Housing and Urban Development (2016). The 2016 Annual Homeless Assessment Report (AHAR) to Congress. Retrieved from https://www.hudexchange.info/resources/documents/2016-AHAR-Part-1.pdf.

Retrospective Homeless Study, Santa Clara County Medical Examiner-Coroner Office 2011-2016 ACKNOWLEDGEMENTS

The authors would like to thank the following individuals for their time, effort, help, and thoughtful recommendations to this project.

Deputy Public Defender Andrew Gutierrez County of Santa Clara

Interim Chief Medical Examiner-Coroner Investigator Rosa Vega Santa Clara County Medical Examiner-Coroner’s Office