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NCCHC Jail Commander

Conversations: Inmate Deaths

The Jail Commander • a clinical mortality review com- • The facility had three suicides
Conversations document is pleted within 30 days; and since last survey but failed to
an easy-to-use tool that gives • a psychological autopsy if the conduct psychological autop-
commanders an in-depth look death is by suicide. sies for any of the deaths.
at frequently missed standards. These three processes com- • A psychological autopsy was
This tool helps commanders to prise a death review. not performed on all deaths
initiate conversations with their by suicide within 30 days or
custody and health care teams During a survey, NCCHC shared with key personnel.
about facility operations. surveyors review the death/
mortality log maintained by the • Custody and correctional

Purpose of the Inmate facility. The death/mortality log health staff were not involved
in the post-mortem review
Death Standard includes patient name and/or processes or discussions.
This standard provides a identification number, age at time
structure to conduct a thorough of death, date of death, date of • Review findings were not
review of all in-custody deaths. clinical mortality review, date of shared with treating or cor-
Its purpose is to evaluate and administrative review, cause of rectional health staff.
improve care processes to avoid death (e.g., hanging, overdose,
preventable deaths such as respiratory failure), manner of Potential Contributing Factors
suicides. death (e.g., natural, suicide, homi- • Policies and procedures were
cide, accidental), date pertinent not clear on how to conduct
review(s) findings were shared an evaluation of inmate
Why Is This Important? with staff, and date of psycho-
Although both health and logical autopsy completed, if deaths.
custody staff strive to avoid applicable. • Policies and procedures
preventable deaths, the reality included the administrative
is that suicide is a leading cause and psychological autopsy
of death in jails, accounting for NCCHC Sample Survey procedures, but were missing
nearly a third of all in-custody Observations from NCCHC the clinical mortality review
deaths. Surveyors procedure.
When an inmate death occurs, Observations Related to Inmate • Facility does not understand
the event is reviewed to determine Deaths the three components of a
the appropriateness of clinical care • Facility has not maintained a death review.
and to ascertain whether changes mortality log for the survey • Facility staff turnover; the
are needed to screening protocols, team to review. death-review process was
policies, and procedures. NCCHC not assigned to a person in
advocates for a three-pronged • Clinical mortality reviews were the interim and therefore not
approach when evaluating inmate not conducted within 30 days. completed.
deaths regardless of the cause: Most reviews were completed • The facility lacks training on
more than 60 days after the
• an administrative review con- death occurred, which is not in the procedure for correctional
ducted with custody staff, compliance with the standard. health and custody staff.
which may include a detailed
after-action report or root • The administrative reviews
cause analysis; were not conducted in con-
junction with custody staff. Checklist for self-assessment
on next page.

AMERICANJails JULY | AUGUST 2021 | 55