Death: Procedure in the Event an Offender's

Idaho
Department of
Correction

Standard
Operating
Procedure

Operations
Division

Operational
Services
Control Number:
401.06.03.011
Version:
2.4
Page Number:
1 of 7
Adopted:
11-12-1998
Reviewed:
6-11-2012 Title:
Death: Procedure in the Event of an
Offender’s

This document was approved by Shane Evans, director of the Education,
Treatment, and Reentry Bureau, on 6/11/12 (signature on file).
Open to the public: Yes
BOARD OF CORRECTION IDAPA RULE NUMBER 401
Medical Care
POLICY CONTROL NUMBER 401
Clinical Services and Treatment
DEFINITIONS
Standardized Terms and Definitions List
Clinical Mortality Review: An assessment of (a) the clinical care provided; (b) the
circumstances leading up to death; and (c) any areas of inmate healthcare, policies, or
procedures that can be improved.
Contract Medical Provider: A private company or other entity that is under contract with
the Idaho Department of Correction (IDOC) to provide comprehensive medical, dental,
and/or mental health services to the IDOC’s incarcerated inmate population.
Facility Health Authority: The contract medical provider employee who is primarily
responsible for overseeing the delivery of medical services in an Idaho Department of
Correction (IDOC) facility.
Facility Medical Director: The highest ranking physician in an Idaho Department of
Correction (IDOC) facility.
Health Authority: The Idaho Department of Correction (IDOC) employee who is primarily
responsible for overseeing or managing the IDOC’s medical services. (The health authority
is commonly referred to as the health services director.)
PURPOSE
The purpose of this standard operating procedure (SOP) is to establish procedures that
must be followed as a result of an inmate’s death, to include but not limited to, clinical
mortality reviews, psychological reconstructions, and postmortem examinations.
SCOPE
This SOP applies to all Idaho Department of Correction (IDOC) healthcare services staff,
inmates, contract medical providers, and subcontractors.
Control Number:
401.06.03.011
Version:
2.4
Title:
Death: Procedure in the Event of an
Offender’s
Page Number:
2 of 7

RESPONSIBILITY
Health Authority
The health authority is responsible for:
• Monitoring and overseeing all aspects of healthcare services, and
• The implementation and continued practice of the provisions provided in this
SOP.
When healthcare services are privatized, the health authority will also be responsible for:
• Reviewing and approving (prior to implementation) all applicable contract medical
provider policy, procedure, and forms; and
• Monitoring the contract medical provider’s performance, to include but not limited
to reviewing processes, procedures, forms, and protocols employed by the
contract medical provider to ensure compliance with all healthcare-related
requirements provided in respective contractual agreements, this SOP, and in
National Commission on Correctional Healthcare (NCCHC) standard P-A-10,
Procedure in the Event of an Inmate Death. (See section 5 of this SOP.)
Contract Medical Provider
When healthcare services are privatized, the contract medical provider is responsible
for:
• Implementing and practicing all provisions of this SOP, unless specifically
exempted by written contractual agreements;
• Ensuring that all aspects of this SOP and NCCHC standard P-A-10 are
addressed by applicable contract medical provider policy and procedure;
• Ensuring that procedures are in place to immediately notify the health authority of
an inmate’s death and provide pertinent information regarding the conditions and
events related to the inmate’s death;
• Ensuring facility health authorities utilize all applicable contract medical provider
policy, procedure, forms, and educational information to fulfill all healthcare-
related requirements provided in this SOP, NCCHC standard P-A-10, or as
indicated in their respective contractual agreement(s); and
• Ensuring all applicable contract medical provider policy, procedure, and forms
are submitted to the health authority for review and approval prior to
implementation.
Note: Nothing in this SOP shall be construed to relieve the contract medical provider(s)
of any obligation and/or responsibility stipulated in respective contractual agreements.
Facility Medical Director
The facility medical director and facility health authority (or designees) will be jointly
responsible for convening a clinical mortality review within 30 days of the inmate’s death,
and preparing a narrative for the contract medical provider’s Clinical Mortality Review
Report.
Control Number:
401.06.03.011
Version:
2.4
Title:
Death: Procedure in the Event of an
Offender’s
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Facility Health Authority
The facility health authority will be responsible for:
• Ensuring the presence of an adequate number of appropriately trained staff and
materials are available to meet the requirements of this SOP;
• Establishing and monitoring applicable contract medical provider policy and
procedure to ensure that all elements of this SOP and NCCHC standard P-A-10
are accomplished as required;
• Ensuring that within 24 hours of the inmate’s death, written notification is
provided to the health authority;
In addition, the facility health authority and facility medical director (or designees) will be
jointly responsible for convening a clinical mortality review within 30 days of the inmate’s
death, and preparing a narrative for the contract medical provider’s Clinical Mortality
Review Report.
Facility Head
The facility head will be responsible for following SOP 312.02.01.001, Death of an
Inmate.
Table of Contents
General Requirements ......................................................................................................... 3
1. Notification Requirements............................................................................................... 3
When an Inmate who is Housed in an IDOC Facility Dies ......................................... 4
When an Inmate who is Housed in a Non-IDOC Facility Dies ................................... 4
2. Healthcare Record Handling ........................................................................................... 4
3. Postmortem Examination Requirements ......................................................................... 5
When the Coroner Declines to Conduct a Postmortem Examination......................... 5
4. Suicides .......................................................................................................................... 5
5. Clinical Mortality Review Report Requirements .............................................................. 5
Review of the Report ................................................................................................ 6
Pertinent Information Received after Report Completed ........................................... 6
6. Compliance .................................................................................................................... 6
References ........................................................................................................................... 6
GENERAL REQUIREMENTS
1. Notification Requirements
When an inmate who is under the jurisdiction of the IDOC dies in a non-IDOC facility or
IDOC facility, healthcare services staff shall notify the following personnel, in the order
provided:
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Death: Procedure in the Event of an
Offender’s
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• Shift commander (shall notify the facility head)
• Health authority (or designee), and
• Director of the Education, Treatment, and Reentry Bureau (or designee).
Note: Whenever there is a death to an inmate, steps must be taken to ensure the death is
reported in accordance with SOP 105.02.01.001, Reporting and Investigation of Major
Incidents.
Note: As applicable to healthcare services staff and facility administrative staff, SOP
312.02.01.001, Death of an Inmate, or SOP 401.06.03.010, Next of Kin: Emergency
Notification, should also be referred to.
Note: If the inmate is a foreign national, the facility head will be required to contact the
nearest consulate representing the inmate’s country of origin. (See SOP 312.02.01.001,
Death of an Inmate.)
When an Inmate who is Housed in an IDOC Facility Dies
Within 24 hours of the inmate’s death, the facility health authority (or designee) shall
provide written notification to the health authority (or designee) that includes, but is not
limited to, the following:
• The inmate’s name and IDOC number;
• The date, time, and location of the inmate’s death;
• The cause of death (if known); and
• All known medical diagnoses.
When an Inmate who is Housed in a Non-IDOC Facility Dies
Contact the health authority (or designee), who will begin the notification process
described above. The health authority shall ensure that all notifications (verbal and
written), postmortem examinations, clinical mortality reviews, and psychological
reconstructions are requested or conducted as described in this SOP.
2. Healthcare Record Handling
Within two (2) hours of an inmate’s death, healthcare services staff shall place the inmate’s
complete healthcare record in a bag (orange in color), envelope, or box.
Note: The complete healthcare record shall include any of the following as applicable: the
current file, all extended files, infirmary or long-term care (LTC) files, and all loose filings.
Note: The healthcare record shall not include any other documentation (written notifications,
postmortem examination, clinical mortality review report, memoranda, and information
reports) described in this SOP.
Healthcare services staff shall ensure that the bag, envelope, or box is locked and/or sealed
(as applicable) and delivered to the shift commander. The shift commander, in consultation
with the health authority (or designee), shall make arrangements to transfer the bag,
envelope, or box to the Medical Unit (located at Central Office). The transfer of the
healthcare record shall be in accordance with the special conditions identified in SOP
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Title:
Death: Procedure in the Event of an
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120.03.05.002, Central and Medical Files: Control, Maintenance, and Disposition of (see the
applicable appendix).
3. Postmortem Examination Requirements
The facility health authority (or designee) shall (a) request that the coroner perform a
postmortem examination, and (b) provide documentation of the request to the health
authority.
Upon receipt of the written postmortem examination, the facility health authority shall
provide a copy to the health authority (or designee).
When the Coroner Declines to Conduct a Postmortem Examination
If the coroner declines to perform a postmortem examination, the facility health authority
shall write a statement regarding that fact, attach it to the request, and submit both to the
health authority.
4. Suicides
If the cause of death is suicide, the IDOC’s chief psychologist (or designee) will schedule
and perform a psychological reconstruction, to include all elements required by policy 315,
Suicide Risk Management, and directive 315.02.01.001, Suicide Risk Management and
Intervention Program.
5. Clinical Mortality Review Report Requirements
Within 30 days of the inmate’s death, the facility health authority and facility medical director
(or designees), shall jointly conduct a clinical mortality review, and submit a written report to
the health authority. Both individuals shall ensure that the report is complete and accurate
(based on the information available to them before the report is completed), and contains
the following:
• The inmate’s name and IDOC number;
• The inmate’s age;
• The date, time, and location of the inmate’s death;
• Past medical history, recent medical history, pertinent physical findings, and
medications prescribed at the time of death;
• Procedures, surgeries, consultations, and clinical diagnoses prior to death;
• Events leading to the terminal event;
• Diagnosis as established at the time of the clinical mortality review;
• The primary cause of death, to include one of the following:
♦ Natural;
♦ Normal progression of a chronic illness;
♦ Acute exacerbation of a chronic illness;
♦ Acute illness—onset less than 24 hours prior to death;
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Title:
Death: Procedure in the Event of an
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♦ Acute illness—onset more than 24 hours prior to death;
♦ Suicide;
♦ Accidental; or
♦ Other.
• For the period prior to the terminal event—the timeliness and appropriateness of
diagnoses, treatments, preventive measures taken, and staff responses;
• For the period of the terminal event— the timeliness and appropriateness of
diagnoses, treatments, preventive measures taken, and staff responses;
• The reviewer’s opinion of whether the level of housing and available healthcare was
appropriate; and
• A narrative—prepared and signed by the facility medical director and other
participants in the clinical mortality review process, to include conclusions, findings,
and the reviewer’s recommendations for improvement.
Review of the Report
The health authority (or designee) shall review the completed and signed Clinical
Mortality Review Report (and other relevant documentation) to determine whether the
death may be part of an emerging pattern or indicative of opportunities for improvement
in the overall healthcare delivery system.
Pertinent Information Received after Report Completed
In the event pertinent information (e.g., the completed postmortem examination report,
memoranda, information reports) is received after completion of the Clinical Mortality
Review Report, the facility health authority (or designee) shall update the report, append
the new information, and resubmit to the health authority in as timely of a manner as
possible.
6. Compliance
Compliance with this SOP and all related IDOC-approved protocols will be monitored by the
health authority (or designee) by using various sources to include: this SOP, clinical practice
guidelines, routine reports, program reviews, and record reviews.
The health authority (or designee) must conduct two (2) audits per year, per facility (or more
frequently as desired based on prior audit results). The audits must consist of monitoring
applicable contract medical provider, IDOC policy and procedures, applicable NCCHC
standards, and the review of all deaths that occurred over a 12-month period.
REFERENCES
Directive 315.02.01.001, Suicide Risk Management and Intervention Program
National Commission on Correctional Health Care (NCCHC), Standards for Health Services
in Prisons, Standard P-A-10, Procedure in the Event of an Inmate Death
Policy 315, Suicide Risk Management
Control Number:
401.06.03.011
Version:
2.4
Title:
Death: Procedure in the Event of an
Offender’s
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Standard Operating Procedure 105.02.01.001, Reporting and Investigation of Major
Incidents
Standard Operating Procedure 312.02.01.001, Death of an Inmate
Standard Operating Procedure 401.06.03.010, Next of Kin: Emergency Notification
– End of Document –