Procedure in the Event of an Inmate Death

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As correctional health care professionals, we strive to avoid preventable deaths. However, when there is an inmate death, it should be reviewed to determine the appropriateness of clinical care; to ascertain whether changes to policies, procedures or practices are warranted; and to identify issues that require further study (standard A-10 Procedure in the Event of an Inmate Death in the 2008 jail and prison manuals).

The best way to answer these questions is to take a three-prong approach to every inmate death, regardless of the cause: an administrative review, a clinical mortality review and a psychological autopsy if the death is by suicide. These three processes comprise a death review (Compliance Indicator #2). Note that a death that occurs off-site while the facility is responsible for the inmate should also be reviewed.

Administrative reviews assess correctional and emergency response actions surrounding an inmate’s death. The purpose of such a review is to identify areas where facility operations, policies and procedures can be improved.

The 2008 standard reflects a few changes from the 2003 version. A psychological autopsy (or psychological reconstruction) is now required for all cases of suicide. This written reconstruction of an individual’s life emphasizes factors that may have contributed to his or her death and is usually completed by a psychologist or other qualified mental health professional. The psychological autopsy may assist medical personnel in determining the mode of death; contribute to a clearer understanding of the person’s state of mind at the time of death, or why he or she chose that particular time or method; through interviewing fellow inmates, family and staff, provide a more accurate picture of the deceased in the days preceding the death; provide ways to better address the clinical needs of future suicidal inmates and to recognize behavioral patterns; and identify deficiencies in institutional policies.

The psychological autopsy not only helps us understand how and why, but through the process, also can help those involved with the deceased to heal.

Opportunity for Improvement
The clinical mortality review is an assessment of the clinical care provided and the circumstances leading up to a death. This review is an opportunity to identify areas of patient care or system policies and procedures that can be improved. At least three key questions can be asked: Could the medical response at the time of death be improved? Was an earlier intervention possible? Independent of the cause of death, is there a way to improve care?

Typically, clinical mortality reviews include a review of the incident and facility procedures that were implemented; training received by the staff involved; pertinent medical and mental health services and reports involving the inmate; and recommendations, if any, for changes in policy, training, physical plant, medical or mental health services, and operational procedures. When a death is expected, a modified review process focusing on relevant clinical aspects of the death and the preceding treatment may be used.

A clinical mortality review should be conducted separately from other formal investigations that might be required to determine the cause of death. It could be completed by a unit physician not involved in the patient’s treatment, a central office or corporate physician, or an outside medical group. When multiple deaths occur at a facility, an assessment should be done to determine whether any patterns require further study.

The clinical mortality review should not be delayed due to a pending medical autopsy. When a medical autopsy is completed after the clinical mortality review, the clinical review should be appended with information from the autopsy report. While the following is an optional recommendation from NCCHC, a postmortem examination can be beneficial and should be requested because such information can increase treating staff’s understanding of the pathology of disease.

All deaths are to be reviewed within 30 days. It is often misinterpreted that only the clinical mortality review needs to be conducted within 30 days of an inmate death, when in fact all three components of the death review should be completed in this time frame. There should be documentation that these three components were accomplished, as well as evidence that the results of the clinical mortality and administrative reviews were shared with treating staff (Compliance Indicators 1 and 3).

Corrective Follow-Up
Another important change to the 2008 standard is that corrective actions identified through the mortality review process should be implemented and monitored through the continuous quality improvement program for systemic issues, and through the patient safety program for staff-related issues (Compliance Indicator 4).

Systemic issues might include opportunities for policy and procedure or organizational change; CQI process studies are a great way to study specific root causes. Staff-related issues focus more on individual clinical performance and related needs, such as recommendations for additional training (these matters are generally not discussed in an open forum such as CQI committee meetings). Standards A-06 and B-02 provide more information on CQI and patient safety systems.

[This article first appeared in the Summer 2009 issue of CorrectCare.]

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