H D S C CA A R S 2011-2016 - Santa Clara County, California...2016, mental health history was either captured from friends and family interviews or was captured in the medical records

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

2

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


3

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


4

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


5

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


6

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: Santa Clara County Medical Examiner-Coroner

Source: Shutterstock


7

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.


8

2011


9

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.

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%).

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.

Male 80%

Female20%

SEX2011

Male FemaleSource: Santa Clara CountyMedical Examiner-Coroner

60%

28%

6%2%

2% 2%

ETHNICITY2011

Caucasian

Hispanic

Black

Middle Eastern

Native American

OtherSource: Santa Clara County Medical Examiner-Coroner


10

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

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%).

0

1

2

3

4

5

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

NU

MB

ER O

F D

ECED

ENTS

AGE AT DEATH(YEARS)

AGE AT DEATH2011

Winter26%

Spring28%

Summer24%

Fall22%

DEATHS PER SEASON2011

Winter Spring Summer Fall




11

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.

0

5

10

15

20

25

Natural Accident Undetermined Suicide Homicide

NU

MB

ER O

F D

ECED

ENTS

MANNER

MANNER OF DEATH2011

0

2

4

6

8

10

12

14

16

Indoor Makeshift Living

Area

Outdoor Makeshift Living

Area

Outdoor (not living there)

Hospital ER Other Residence Nursing Home

NU

MB

ER O

F D

ECED

ENTS

LOCATION

LOCATION OF DEATH2011




12

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


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


13

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.

00.5

11.5

22.5

33.5

44.5

Emotional Medical Altercations (physical and verbal)

Law Enforcement

NU

MB

ER O

F D

ECED

ENTS

TYPE OF STRESSOR

RECENT STRESSORS2011



14

2012


15

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%).

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%).

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.

Male85%

Female15%

SEX2012

Male Female

66%

19%

8%

3%2% 2%

ETHNICITY2012

Caucasian

Hispanic

Black

Asian

Middle Eastern

Pacific Islander




16

The number of decedents per season were 14 in winter, 19 in spring, 15 in summer, and 14 in the

fall.

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%.

0

0.5

1

1.5

2

2.5

3

3.5

4

4.52

3 w

ee

k ge

st.

23

26

28

31

33

38

41

42

43

45

46

47

48

50

51

52

53

54

55

56

57

59

60

62

63

64

65

66

68

69

70

77

79

82

NU

MB

ER O

F D

ECED

ENTS

AGE AT DEATH(WEEKS AND YEARS)

Age at Death2012

Winter22%

Spring31%

Summer24%

Fall23%






17

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.

0

5

10

15

20

25

30


NU

MB

ER O

F D

ECED

ENTS

MANNER

MANNER OF DEATH2012




18

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.




Carboxyhemoglobin 1

Alcohol 26

Diazepam/Nordiazepam/Chlordiazepoxide 8

Theobromine 5

Morphine 2

Acetaminophen 1

Acetone 2


Delta-9 THC/ Delta-9 Carboxy THC 7

Diphenhydramine 1


Mitrazapine 2

0

2

4

6

8

10

12

14

16

Indoor Makeshift Living Area

Outdoor Makeshift Living Area

Outdoors (not living

there)

Hospital ER Hospice Other Residence

Motel Indoors (other)

NU

MB

ER O

F D

ECED

ENTS

LOCATION




19


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.

0

1

2

3

4

5

6


Law Enforcement

NU

MB

ER O

F D

ECED

ENTS

TYPE OF STRESSOR




20

2013


21

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%).

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%).

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.

Male87%

Female13%

SEX2013

Male Female

58%

23%

10%

8%1%

ETHNICITY2013

Caucasian

Hispanic

Black

Asian

Native American




22

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.

There were 33 natural deaths (42%), 30 accidental (38%), two undetermined (3%), eight suicides

(10%), and five homicides (6%) in 2013.

0

1

2

3

4

5

6

Un

kno

wn

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

NU

MB

ER O

F D

ECED

ENTS

AGE AT DEATH(YEARS)

AGE AT DEATH2013

Winter31%

Spring27%

Summer24%

Fall18%






23

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.

0

5

10

15

20

25

30

35


NU

MB

ER O

F D

ECED

ENTS

MANNER

MANNER OF DEATH2013




24

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.

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.


positive for each.




Carboxyhemoglobin 1

Alcohol 22

Diazepam/Nordiazepam/Oxazepam/Lorazepam/

Temazepam

8

Theobromine 2

Morphine 5

Acetaminophen 1

02468

101214161820

NU

MB

ER O

F D

ECED

ENTS

LOCATION




25

Acetone 3

Delta-9 THC/ Delta-9 Carboxy THC 4

Diphenhydramine 3


Mitrazapine 1

Methadone/EDDP 3

Caffeine 4

Venlafaxine 1

Nicotine/Cotinine 4

Isopropanol 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:


26

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.

0

2

4

6

8

10

12


Law Enforcement

NU

MB

ER O

F D

ECED

ENTS

TYPE OF STRESSOR




27

2014


28

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%).

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%).

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.

Male83%

Female17%

SEX2014

Male Female

58%30%

6%

3%2% 1%

ETHNICITY2014

Caucasian

Hispanic

Black

Asian

Pacific Islander

Middle Eastern




29

Twenty-eight deaths occurred in the winter in 2014, followed by 16 in spring, 12 in the summer,

and 13 in the fall.

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%.

0

1

2

3

4

5

6

7U

nkn

ow

n

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

NU

MB

ER O

F D

ECED

ENTS

AGE AT DEATH(YEARS)

AGE AT DEATH2014

Winter41%

Spring23%

Summer17%

Fall19%






30

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.

0

5

10

15

20

25

30

35


NU

MB

ER O

F D

ECED

ENTS

MANNER

MANNER OF DEATH2014



31

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.


positive for each.



Carboxyhemoglobin 2

Alcohol 24

Diazepam/Nordiazepam/Chlordiazepoxide/

Lorazepam

8

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

0

2

4

6

8

10

12

14

16

18




there)

Hospital ER Nursing Home

Other Residence

Transitional Housing

Motel

NU

MB

ER O

F D

ECED

ENTS

LOCATION




32

Paroxetine 1

Phencyclidine 2

Olanzapine 1

Hydromorphone 2

Nicotinamide 1

6-Monoacetylmorphine (6-MAM; heroin) 3

Quetiapine 1

Buspirone 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.

0

2

4

6

8

10

12

14


Law Enforcement

NU

MB

ER O

F D

ECED

ENTS

TYPE OF STRESSOR




33

2015


34

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%).

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%).

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.

Male81%

Female19%

SEX2015

Male Female

54%

20%

14%

4%3%

1%2%

2%

ETHNICITY2015

Caucasian

Hispanic

Black

Asian

Pacific Islander

East Indian

Native American

Unknown




35

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.

There were 45 natural deaths (53%), 27 accidental deaths (32%), eight undetermined (9%), three

suicides (4%), and two homicides (2%).

0

1

2

3

4

5

6

7

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

NU

MB

ER O

F D

ECED

ENTS

AGE AT DEATH(YEARS)

AGE AT DEATH2015

Winter27%

Spring25%

Summer28%

Fall20%






36

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.

0

5

10

15

20

25

30

35

40

45

50


NU

MB

ER O

F D

ECED

ENTS

MANNER

MANNER OF DEATH2015




37

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.


positive for each.



Alcohol 27


Lorazepam/Clonazepam/7 Amino

Clonazepam

9

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


Quetiapine 1

Promethazine 1

0

5

10

15

20

25

30




there)

Hospital ER Nursing Facility

Indoor (other)

Hotel Transitional Housing for Homeless Veterans

NU

MB

ER O

F D

ECED

ENTS

LOCATION




38

Fluoxetine/Norfluoxetine 2

Isopropanol 5

Chlorpheniramine 1

Phenobarbital 1

Oxycodone 1

Fentanyl 2

Metoclopramide 1

Midazolam 2

Naloxone 1

Sertraline/Desmethylsertraline 2

Aripiprazole 1


Mirtazapine 2

Trazodone 1

mCPP 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.

02468

10121416


Law Enforcement

NU

MB

ER O

F D

ECED

ENTS

TYPE OF STRESSOR




39

2016


40

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%).

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%).

Male82%

Female18%

SEX2016

Male Female

55%31%

6%

5%1%

1%

1%ETHNICITY

2016

Caucasian

Hispanic

Black

Asian

Pacific Islander

Native American

Other




41

Age at death ranged from two days to 80 years of age. The age with the greatest number of

decedents was 62 years.

Of the 132 cases in 2016, 35 occurred in the winter, 30 in the spring, 38 in the summer, and 29 in

the fall.

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.

0

1

2

3

4

5

6

7

8

9

2 D

ays 18

24

25

26

31

32

33

34

35

36

37

38

39

41

43

44

46

47

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

NU

MB

ER O

F D

ECED

ENTS

AGE AT DEATH(DAYS AND YEARS)

AGE AT DEATH2016

Winter26%

Spring23%

Summer29%

Fall22%






42

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%.

0

10

20

30

40

50

60

70

Natural Accident Undetermined Suicide Homicide Pending

NU

MB

ER O

F D

ECED

ENTS

MANNER

MANNER OF DEATH2016



43

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.


positive for each.



Alcohol 32


Lorazepam/7 Amino Clonazepam

6

Morphine 7

Acetone 1

Delta-9 THC/Delta-9 Carboxy THC/11-

hydroxy-Delta 9-THC

15

Diphenhydramine 2

Methadone/EDDP 1

Lidocaine 1

Codeine 5

Phencyclidine 4


0

5

10

15

20

25

30

35

NU

MB

ER O

F D

ECED

ENTS

LOCATION




44

Chlorpheniramine 1

Oxycodone 3

Fentanyl/Norfentanyl 1

Naloxone 1

Sertraline/Desmethylsertraline 2


Mirtazapine 1


Opiates 1

Nicotinamide 2

Oxymorphone 3

Duloxetine 1

Theobromine 3

Ketamine/Norketamine 1


Ibuprofen 2

Cotinine 2

Warfarin 1

Risperidone/9-Hydroxyrisperidone 1

Benzo 1

Dilaudid 1

Hydrocodone 2


Mephentermine 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.


45

0

1

2

3

4

5


Law Enforcement

NU

MB

ER O

F D

ECED

ENTS

TYPE OF STRESSOR




46


47

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

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

0

20

40

60

80

100

120

140

2011 2012 2013 2014 2015 2016

NU

MB

ER O

F D

ECED

ENTS

YEAR

HOMELESS DEATHS IN SANTA CLARA COUNTY2011-2016

Male83%

Female17%

SEX2011-2016

Male Female




48

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.

58%26%

8%

4%

1%1% 0%

1%

1% 0%

ETHNICITY2011-2016 Caucasian

Hispanic

Black

Asian

Pacific Islander

Native American

East Indian

Middle Eastern

Other

Unknown



49

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.


50

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.

0

5

10

15

20

25

2011 2012 2013 2014 2015 2016

NU

MB

ER O

F D

ECED

ENTS

YEAR

DECEDENTS 65 AND OVER2011-2016

0

50

100

150

200

250

Natural Accident Undetermined Suicide Homicide Pending

NU

MB

ER O

F D

ECED

ENTS

MANNER

MANNER OF DEATH2011-2016




51

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.

SUICIDES: The greatest number of suicides occurred in the years 2013 and 2016. The primary method of

suicide was hanging (46%).

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.

0

2

4

6

8

10

2011 2012 2013 2014 2015 2016

NU

MB

ER O

F D

ECED

ENTS

YEAR

HOMICIDES2011-2016

0

1

2

3

4

5

6

7

8

9

2011 2012 2013 2014 2015 2016

NU

MB

ER O

F D

ECED

ENTS

YEAR

SUICIDES2011-2016




52

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.

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.

0

20

40

60

80

100

120

140

2011 2012 2013 2014 2015 2016

NU

MB

ER O

F D

ECED

ENTS

YEAR

DEATHS PER SEASON2011-2016


0

1

2

3

4

5

6

7

8

9

10

2011 2012 2013 2014 2015 2016

NU

MB

ER O

F D

ECED

ENTS

YEAR

VETERANS2011-2016




53

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.

0

2

4

6

8

10

12

14

2011 2012 2013 2014 2015 2016

NU

MB

ER O

F D

ECED

ENTS

YEAR

VEHICLE ACCIDENTS AS CAUSE OF DEATH2011-2016


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


54

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

Deaths

Zip Code Number of

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

020406080

100120140160180

NU

MB

ER O

F D

ECED

ENTS

LOCATION

LOCATION OF DEATH2011-2016



55

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.

0

5

10

15

20

25

30

2011 2012 2013 2014 2015 2016

NU

MB

ER O

F D

ECED

ENTS

YEAR

CAUSE OF DEATH DUE TO DRUG/ALCOHOL INTOXICATION

2011-2016



56

The most popular drugs across all six years were alcohol and methamphetamine. At the time of

death, 152 decedents were positive for alcohol.

At the time of death, 122 decedents were positive for methamphetamine/amphetamine.

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.

0

5

10

15

20

25

30

35

2011 2012 2013 2014 2015 2016

NU

MB

ER O

F D

ECED

ENTS

PO

SITI

VE

FOR

A

LCO

HO

L

YEAR

PRESENCE OF ALCOHOL 2011-2016

0

5

10

15

20

25

30

35

40

45

2011 2012 2013 2014 2015 2016

NU

MB

ER O

F D

ECED

ENTS

PO

SITI

VE

FOR

M

ETH

YEAR

PRESENCE OF METHAMPHETAMINE2011-2016




57

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.

0

5

10

15

20

25

2011 2012 2013 2014 2015 2016

NU

MB

ER O

F D

ECED

ENTS

WIT

H A

MEN

TAL

ILLN

ESS

YEAR

MENTAL ILLNESS2011-2016

0

5

10

15

20

25

30

2011 2012 2013 2014 2015 2016

NU

MB

ER O

F D

ECED

ENTS

YEAR

RECENT STRESSORS2011-2016

Emotional Medical Altercations (physical and verbal) Law Enforcement




58

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.

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.



59

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.

http://www.npl.co.uk/science-technology/time-frequency/time/faqs/when-do-the-four-seasons-officially-begin-(faq-time)

http://www.npl.co.uk/science-technology/time-frequency/time/faqs/when-do-the-four-seasons-officially-begin-(faq-time)

http://repository.upenn.edu/spp_papers/140

https://www.hudexchange.info/resources/documents/2016-AHAR-Part-1.pdf


60

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

Documents

H D S C CA A R S 2011-2016 - Santa Clara County, California...2016, mental health history was either captured from friends and family interviews or was captured in the medical records