death investigationJul 29, 2022

Washington State Passes Law Requiring Review of Unexpected Fatalities



An unexpected fatality – through suicide or otherwise – can be traumatic to staff and the incarcerated within the facility. In addition to the personal toll, it can call into question the mental and medical health care provided and the policies in place in the jail or prison. Washington State has passed a law requiring review of unexpected fatalities; in addition, it is a best practice required by NCCHC standard J-A-09  Procedure In the Event of an Inmate Death.

For those wondering how to get started putting this practice into place, the first element is good documentation. Any administrative review will include a review of the incident and facility procedures used.

The next step is to evaluate the elements below.

Self-Assessment for Identifying Potential Challenges in Your Facility

Review Policy and Procedures

  • Does your facility have policies and procedures in place to conduct a thorough death review? Should include:
    • Clinical mortality within 30 days of death
    • Administrative review conducted in conjunction with custody staff
    • Psychological autopsy performed on all death by suicide within 30 days of the event for ensuring the safety of inmates who are acutely or non-acutely suicidal
  • Do the policies and procedures address all aspects of the NCCHC standard?
  • Does the policy or procedure address the implementation of a mortality log?
  • Does the procedure address staff responsibilities including who will lead the review in the event of staff turnover (e.g., at the time of the death and involvement in the death review)?
  • Does the log include all components required by the NCCHC standard?
    • Patient name or identification number
    • Age at time of death
    • Date of death
    • Date of clinical mortality review
    • Date of administrative review
    • Cause of death (e.g., hanging, overdose, respiratory failure)
    • Manner of death (e.g., natural, suicide, homicide, accidental)
    • Date pertinent findings review(s) were shared with staff
    • Date of psychological autopsy completed, if applicable

Talk with Custody and the Healthcare Team

  • Ask custody staff if they have been involved in an administrative review. Talk with them about the process according to your policy.
  • Ask the team if they have been trained on procedures surrounding an inmate death. Ask the team if they know who to call, when to call and how to document the incident.
  • Ask the treating staff or correctional health staff if they have been informed of all pertinent findings of all reviews.
  • Discuss the death review procedures with custody and health staff to see if they understand the process.

Assess the Environment

  • Pull the mortality or death log at your facility and review the log for completeness.
  • Check to see if psychological autopsies were completed within 30 days post-suicide.
  • Check to see if the clinical mortality reviews were completed within 30 days post-death.
  • Check to see that an administrative review was conducted in conjunction with custody staff and that a thorough evaluation or root cause analysis was completed.

Key Takeaways

  • Any issues that come up during your discussions might include opportunities or policy, procedural or even organizational changes.
  •  CQI process studies are a great way to understand specific root causes and will help focus improvement efforts where needed.

Share what you learned with your custody staff and the health care team.

If you would like assistance with a fatality review, contact us at [email protected].

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