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Spotlight on the Standards
In
the Event of an Inmate Death
Whether
expected or not, whether from natural, accidental or other
causes, a death always raises questions of adequacy of care:
“Did we do all we could? Was there something we failed to
identify?”
When
the death occurs in a correctional setting, health service and
custody requirements intertwine in a complex matrix of
investigations and reviews that may seem to be at cross
purposes. Further, no matter how professional their approach,
health staff cannot totally overcome the tendency to see death
as a defeat, and many correctional authorities still follow the
directive, “No one dies during my watch.” Such responses and
attitudes contribute to the feeling that there is a hunt for
someone to blame, especially when the death is unexpected or
from suicide.
Why
Death Reviews
The possible need for criminal investigation and the oversight
of the facility’s legal representatives require cooperation
between health and correctional authorities. These activities,
however difficult, do not negate the need for a clinical review.
NCCHC
views death as a natural process (standards G-12 Care for the
Terminally Ill and I-04 End-of-life Decision Making). However,
it also intends that preventable deaths are avoided in
correctional settings.
Standard
A-10 Procedure in the Event of an Inmate Death states that “In
all deaths, the responsible health authority: determines the
appropriateness of clinical care; ascertains if corrective
action in the system’s policies, procedures, or practices is
warranted; and, identifies trends that require further study.”
This review is to be initiated within 30 days of the death. If
an autopsy is required or requested, the mortality review still
must be held within 30 days of the death with an addendum later
when autopsy results are available.
Focusing
on the standard’s three directives will clarify expectations
and provide guidance through the maze of potentially conflicting
processes.
The
first directive—“determines the appropriateness of clinical
care”—is the traditional clinical mortality review to answer
questions centering on the health care itself. The process is
the same as that in a hospital or clinic setting, and findings
usually are protected under a confidential classification. This
designation allows physicians to complete a clinical review with
their peers that permits full disclosure and opportunity for
corrective action and learning among the care providers.
Optimally,
the review includes the autopsy results and focuses on the
following questions: Could the medical response at the time of
death be improved? Was an earlier intervention possible?
Independent of the cause of death, is there any way to improve
patient care?
The
clinical review meeting can be done at facility, corporate,
state or consultant levels, and may or may not involve staff
other than physicians, depending on facility procedures. In all
cases, sufficient feedback about treatment and care must be
shared with treating staff.
The
second directive—“ascertains if corrective action in the
system’s policies, procedures, or practices is
warranted”—requires a review of the circumstances of death
by representatives of both custody and health staff, preferably
at the same meeting, so that concerns and questions can be
shared and answered.
The
intent is to correct system failures or identify potential
problems, and the issues reviewed may be quite diverse. For
instance, did the emergency phone notification system worked?
Was the ambulance delayed for clearance at the gate? Was the
emergency bag sufficiently supplied? Could the nurse on duty
have arrived at the emergency site faster? Was the booking
officer trained on what to do when an intoxicated inmate arrives
for admission? Does the holding cell contain potential self-harm
items? Is there a backup system when the electronic gate fails?
The
full potential of such a review can be realized only in a
nonjudgmental atmosphere in which the goal is to identify
problems in order to correct them, and where participants view
themselves as part of a team of professionals, each of whom
brings special expertise to the situation.
The
final directive—“identifies trends that require further
study”—perhaps entails the most collaboration and sharing
among authorities. Patterns may appear within a facility, across
the many prisons of a state system, or between the separate
units or satellites of a jail complex.
With
suicides, it is fairly obvious what trends to look for. These
include but are not limited to patterns of time, place and
method. What do the inmates have in common, e.g., histories of
depression, recent loss, crime similarity? What weaknesses are
seen in the suicide prevention plan?
Even
deaths by natural causes may have troubling patterns. For
example, five deaths by different immediate natural causes in
inmates with insulin dependent diabetes may point to inadequacy
in the proactive ongoing care of diabetics. If a system has two
facilities similar in population and operation but one
experiences unexpected deaths by natural causes while the other
almost never does, a study may uncover procedures that need
revision.
The
Accreditation Perspective
Deaths are seen as red flags, so NCCHC accreditation surveyors
will look at deaths since the time of the last site survey (or,
for initial surveys, within the last 12 months).
The
surveyors will review policy and procedures; death records and
mortality reviews; and other documentation that can shed light
on the deaths, such as minutes of quality improvement committee
meetings, and staff or administrative meetings. If the actual
reviews and records are not available during the survey,
alternate documentation must provide verification that the
threefold purpose of the standard has been met.
Surveyors,
and later the Accreditation Committee, will ascertain whether
recommendations or corrective actions identified by the death
review process have been implemented and followed.
Facilities
with infirmaries or hospice programs, or those that are regional
medical units, may have a significant number of deaths related
to the natural course of inmates’ illnesses. While all deaths
must be considered, and even natural deaths present learning
opportunities, the unexpected and deaths by suicide require more
comprehensive review to determine whether facility procedures
are inadvertently contributing to the deaths.
Death
reviews may be done for different purposes by various entities
(health service contractor, corporate or state medical director,
legal authority, security specialist) and thus may not address
all three goals of the standard in one meeting or document.
Still, if the sum of activities meets the intent of the standard
and has included a physician’s review and sharing of results
with clinical staff, compliance is met. Best practice would
entail a multidisciplinary review that brings together all the
findings in a comprehensive manner.
Although
standard A-10 is classified as “important,” review of deaths
must be included as part of essential standard A-06 Continuous
Quality Improvement. Review of any death by suicide is also
required by essential standard G-05 Suicide Prevention Program.
Therefore, while a facility may achieve accreditation without
full compliance with important standard A-10 Procedure in the
Event of an Inmate Death, it could not be accredited if any
deaths are not at least reviewed as part of the CQI program
(essential A-06) and, in the case of suicide, by reviewing it
under the suicide prevention requirements (essential G-05).
(This article first appeared in the
Fall 2003 issue of CorrectCare.)
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