SOP 508.03: Death Notification, Critical Incident Notification, and Investigation

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name:Death Notification, Critical Incident Notification, and Investigation|Policy Name:Death Notification, Critical Incident Notification, and Investigation|Policy Name:Death Notification, Critical Incident Notification, and Investigation|
|Policy Number: 508.03|Effective Date:7/13/2020|Page Number: 1 of 6|
|Authority:
Commissioner|Originating Division:
Health Services Division
(Mental Health)|Access Listing:
Level I: All Access
|

I. Introduction and Summary:

It is the policy of the Georgia Department of Corrections (GDC) to conduct a clinical
investigation of a death or Critical Incident. Specifically, a clinical investigation may
be conducted in the event an offender commits suicide, homicide, or engages in
behavior that constitutes a Critical Incident or one that potentially puts the offender at
risk to either their health or the health of others, or if an offender receiving mental
health services dies of unusual circumstances.

II. Authority:

A. Ga. Comp. R. & Regs. 125-2-4-.20 Death and Interment;

B. O.C.G.A. § 31-7-133;

C. GDC Standard Operating Procedures (SOPs): 208.03, Death of an Offender and

507.04.67, Offender Death and Mortality Reviews;

D. ACA Standards: 2-CO-4E-01, 5-ACI-6C-16 (ref. 4-4425), 5-ACI-6D-02 (ref. 4
4410 Mandatory), 4-ALDF-4D-23, and 4-ACRS-7D-15; and

E. NCCHC Standards.

III. Definitions:

A. Critical Incident - Any actual or alleged event or situation that creates a

significant risk of loss of life.

B. Communicable Disease - An infectious disease transmittable by direct contact

with an infected individual, the individual's discharges or by indirect means.

C. Serious Self-Injury - An intentional injury to one’s self requiring transfer to an

infirmary and/or community hospital setting, for treatment beyond first aid.

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name:Death Notification, Critical Incident Notification, and Investigation|Policy Name:Death Notification, Critical Incident Notification, and Investigation|Policy Name:Death Notification, Critical Incident Notification, and Investigation|
|Policy Number: 508.03|Effective Date:7/13/2020|Page Number: 2 of 6|
|Authority:
Commissioner|Originating Division:
Health Services Division
(Mental Health)|Access Listing:
Level I: All Access
|

D. Unusual Death - Any unanticipated loss of life that is not due to a natural death

or disease and is not the clear result of a suicide.

E. Clinical Peer Review - An assessment by a Clinical Peer Review team of the

clinical care provided and the circumstances leading up to a death. Its purpose is
to identify areas of patient care or system policies and procedures that can be
improved.

F. Psychological Autopsy - A written reconstruction of an offender’s mental health

status with an emphasis on factors that led up to and may have contributed to the
individual’s death. It is usually conducted by a psychologist or other qualified
mental health professional.

IV. Statement of Policy and Applicable Procedures:

A. Notification of Death or Critical Incident:

1. The Mental Health Unit Manager will notify the State Mental Health Program

Supervisor/designee as soon as possible after the death or Critical Incident
involving offenders receiving mental health services.

2. For Critical Incidents involving non-mental health offenders, a mental health

referral may be initiated.

3. For any unusual deaths of offenders receiving mental health services and/or for

any offender (Level 1 - 6) who commits suicide, a Psychological Autopsy or
review of the circumstances surrounding the death shall occur.

4. The Mental Health Unit Manager/designee will provide a copy of the

offender's mental health records to the State Mental Health Program
Supervisor/designee for administrative review and coordination of the
psychiatric/psychological autopsy or review.

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name:Death Notification, Critical Incident Notification, and Investigation|Policy Name:Death Notification, Critical Incident Notification, and Investigation|Policy Name:Death Notification, Critical Incident Notification, and Investigation|
|Policy Number: 508.03|Effective Date:7/13/2020|Page Number: 3 of 6|
|Authority:
Commissioner|Originating Division:
Health Services Division
(Mental Health)|Access Listing:
Level I: All Access
|

5. The Health Services Administrator (HSA) will be contacted to provide the

medical record to the State Mental Health Program Supervisor/designee for
administrative review and coordination of the psychiatric/psychological
autopsy or review, and

6. The death notification procedures stated in SOP 507.04.67, Offender Death

and Mortality Reviews, will be followed for all offenders receiving mental
health services and for all completed suicides.

B. Clinical Peer Review Process:

1. A Clinical Peer Review process will examine suicides, unusual deaths and

Critical Incidents of offenders receiving mental health services.

2. Clinical Peer Review, which is confidential and non-discoverable per

O.C.G.A. § 31-7-133, will be conducted in an open and honest manner with
contributions encouraged from all staff involved in the clinical care of the
deceased offender in order to:

a. Improve the quality of care; and

b. Help prevent unnecessary loss of life due to injury or suicide.

3. Critical Incidents will be reviewed in order to ascertain institutional

compliance with the Standard Operating Procedures.

4. The Clinical Peer Review Team will be comprised of the Mental Health Unit

Manager, Clinical Director, and those involved in the direct care of the
deceased offender.

5. The team may also include a mental health nurse, a Multifunctional

Correctional Officer (MFCO), and other clinical staff as needed and
appropriate.

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name:Death Notification, Critical Incident Notification, and Investigation|Policy Name:Death Notification, Critical Incident Notification, and Investigation|Policy Name:Death Notification, Critical Incident Notification, and Investigation|
|Policy Number: 508.03|Effective Date:7/13/2020|Page Number: 4 of 6|
|Authority:
Commissioner|Originating Division:
Health Services Division
(Mental Health)|Access Listing:
Level I: All Access
|

6. In the event of an offender’s death or Critical Incident, Attachment 1, Form

M03-01-01 (Offender Death Notification Form) or Attachment 2, Form M0301-02 (Offender Critical Incident Notification Form) will be completed by the
Mental Health Unit Manager within one (1) week; and

7. The Mental Health Unit Manager/designee will forward the form to the State

Mental Health Program Director/designee and the facility Warden.

C. Central Office Clinical Peer Review Team:

1. The Statewide Medical Director, Statewide Mental Health Director and Chief

Psychiatrist/designee will establish a Clinical Peer Review team whose
function will be:

a. To conduct an in-depth clinical analysis of all suicide cases, and

b. Any unusual Critical Incidents determined to be clinically significant by

the Statewide Mental Health Director.

2. The Statewide Medical Director, Statewide Mental Health Director, and Chief

Psychiatrist/designee will determine the exact composition of the Clinical Peer
Review team which will depend on the nature of the incident to be reviewed.

3. The focus of the Clinical Peer Review will be to:

a. Identify what happened in the case under review;

b. Identify what can be learned to help prevent future incidents;

c. Identify areas of patient care that can be improved; and

d. Identify system policies and procedures that can be improved.

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name:Death Notification, Critical Incident Notification, and Investigation|Policy Name:Death Notification, Critical Incident Notification, and Investigation|Policy Name:Death Notification, Critical Incident Notification, and Investigation|
|Policy Number: 508.03|Effective Date:7/13/2020|Page Number: 5 of 6|
|Authority:
Commissioner|Originating Division:
Health Services Division
(Mental Health)|Access Listing:
Level I: All Access
|

4. The Clinical Peer Review team will carefully review the quality of care

provided in the particular case.

5. The review will involve a thorough investigation and group discussion of each

Critical Incident or offender suicide.

6. The Clinical Peer Review discussion will cover the psychological state of any

offender(s):

a. Involved in the Critical Incident;

b. The offender who committed suicide, or

c. The history and the procedures followed by the facility’s mental health

staff.

7. The Clinical Peer Review team will interview other appropriate staff members

and offenders, and review written reports prepared by other staff relative to the
incident.

8. Any additional information relative to a particular case will be fully explored.

9. Meetings of the Central Office Clinical Peer Review Team will be scheduled

within ten (10) working days and occur within thirty (30) days after the
incident.

10. A designated team member will take the responsibility for making sure that the

institutional record, mental health treatment record and medical record are
available to the team at the time of the review.

11. The team will be advised in advance of the date, time and place of the review

meetings.

|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|Policy Name:Death Notification, Critical Incident Notification, and Investigation|Policy Name:Death Notification, Critical Incident Notification, and Investigation|Policy Name:Death Notification, Critical Incident Notification, and Investigation|
|Policy Number: 508.03|Effective Date:7/13/2020|Page Number: 6 of 6|
|Authority:
Commissioner|Originating Division:
Health Services Division
(Mental Health)|Access Listing:
Level I: All Access
|

12. At the conclusion of the review, the chairperson of the team will make a written

confidential report to the Statewide Medical Director and Statewide Mental
Health Director of their findings and make recommendations to improve the
quality of care, and

13. Appropriate recommendations will be utilized as the basis for local and

statewide in-service trainings.

V. Attachments:

Attachment 1: Offender Death Notification Form (M03-01-01)
Attachment 2: Offender Critical Incident Notification Form (M03-01-02)

VI. Record Retention of Forms Relevant to this Policy:

Upon completion, Attachments 1 & 2, shall be placed in the offender’s mental health
file. At the end of the offender’s need for mental health services and/or sentence, the
mental health file shall be placed within the offender’s health record and retained for
ten (10) years.