Health Care Department Operations Manual

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Chapter 1 – Health Care Governance and Administration

Article 2 – Health Care Program Governance

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1.2.10 Mortality Review and Reporting

  • Policy

    • California Correctional Health Care Services (CCHCS) shall complete an independent review of every death of individuals in the custody of the California Department of Corrections and Rehabilitation (CDCR), in an effort to promote a safe, high quality health care system.

  • Applicability

    • This policy applies to all deaths occurring while in the custody of CDCR. In addition to the review conducted under this section, each death classified as a suicide or suspected suicide shall also receive a Suicide Case Review, pursuant to the current Mental Health Services Delivery System (MHSDS) Program Guide.

  • Purpose

    • To utilize mortality data to mitigate patient harm within the department, to identify opportunities for improvement (OFI) related to patient safety, quality of health care services, patient outcomes, and to fulfill mandated reporting requirements.

  • Responsibility

    • Statewide

      • CDCR and CCHCS leadership, at all levels of the organization, within the scope of their authority, shall ensure administrative, custodial, and clinical systems are in place, and appropriate resources are available to ensure the mortality review and reporting process is maintained.

      • Headquarters (HQ) and regional executive representatives shall ensure progress is made on current mortality and morbidity initiatives and communicate new priorities to improve health care processes and patient outcomes and quality of services delivered.

      • Designated Medical Services Division (MSD) support staff shall comply with all federal and state reporting requirements. MSD support staff shall enter mortality review findings into the electronic Health Care Incident Reporting (eHCIR) system and produce daily and weekly mortality reports and any required reports.

    • Regional

      • Regional Health Care Executives have overall responsibility for ensuring implementation of this policy at the subset of institutions within an assigned region.

    • Institutional

      • The Chief Executive Officer (CEO) has overall responsibility for ensuring implementation of this policy at the assigned institution.

      • The institution is responsible for patient safety oversight as described in the Health Care Department Operations Manual (HCDOM), Section 1.2.7, Institution Patient Safety Program.

  • Procedure

    • Daily Mortality Reporting from Institutions to Headquarters

      • All in-custody deaths shall be entered in the health record on the Initial Inmate Death Record no later than 1200 hours on the next business day following the patient’s death. For a suicide, an Initial Inmate Suicide Report shall also be completed, pursuant to the current MHSDS Program Guide.

      • Deaths occurring in the following locations shall be reported:

        • An institution

        • A fire camp

        • A contracted facility

        • In a county facility while out-to court

        • An outside hospital or other medical facility setting

        • A skilled nursing facility or other long-term care facility

        • A re-entry facility, if not paroled

        • In transit

      • Deaths occurring in the following locations and populations are not required to be reported:

        • Sacramento Control Office

        • Western Interstate Corrections Compact

        • Parole

        • County incarcerated persons being housed with CDCR

    • Collecting Clinical Records for Review

      • Institution

        • Within five calendar days of the death, institution health records staff shall complete the scanning of any paper documents into the health record, including outside community documents related to emergency medical response and hospitalization.

      • Medical Services Division

        • Within five calendar days of the death, MSD support staff shall:

          • Contact the county coroner’s office to determine whether an autopsy will be conducted. If an autopsy is conducted, MSD support staff shall request the report from the county coroner and distribute the final report, when available to the institution. Final reports shall be distributed to the institution, HQ Health Information Management (HIM), and the Mental Health Program within seven calendar days of receipt. Reports shall be scanned into the health record by HQ HIM staff upon receipt.

          • Obtain the CDCR 837-A, B, and C, Crime/Incident Reports, from the Strategic Oversight Management System or request the reports from custody representatives at the institution where the death occurred.

          • Request CDCR 602 HC, Health Care Grievances, and responses for the six months prior to the death.

        • If the requested documents above are not received within five calendar days, MSD support staff shall notify the appropriate health care or custody staff to request assistance acquiring the documents.

    • Institution Mortality Review

      • Within 30 calendar days of the death, the institution CEO, or designee(s), shall complete a multidisciplinary review of the significant events leading to the patient’s death.

      • The review shall focus on identifying OFI at the institution and be submitted to MSD support staff at mortalityreview@cdcr.ca.gov for inclusion in the final mortality review at the discretion of the HQ mortality reviewers.

    • Headquarters Mortality Case Review

      • Each death shall be assigned to a nurse and provider reviewer.

        • The nurse reviewer shall be a Nurse Consultant Program Review Registered Nurse, assigned by the Deputy Director (DD), Nursing Services, or designee.

        • The provider reviewer shall be a board-certified physician or advanced practice provider assigned by the DD, Medical Services, or designee.

      • Initial training for all mortality case reviewers shall occur prior to starting mortality review responsibilities. Training shall be in accordance with the most current community standards for mortality review. Ongoing training shall be provided on an as-needed basis and periodically throughout the calendar year.

      • The nurse and provider reviewers shall complete the mortality review using the most current electronic form or data entry program.

      • The provider reviewer and the nurse reviewer shall coordinate in the reviewing of the deceased patient’s clinical records, which are relevant to the history of the patient’s cause of death, and use the information to complete the executive summary. This will include, at a minimum, records up to six months prior to the death; however, reviewers may include older records if necessary or relevant to determine the trajectory of the terminal event. Relevant records may include, but are not limited to:

        • Initial Inmate Death Record and Initial Inmate Suicide Report, if applicable.

        • Progress notes, diagnostic results, and other clinical information.

        • Records from an outside hospital or other medical facility.

        • CDCR 837-A, B, and C, Crime/Incident Reports.

        • Emergency response records.

        • Autopsy reports.

        • CDCR 602 HCs and subsequent responses.

        • Institution Multidisciplinary Mortality review.

      • The nurse reviewer shall document any findings related to the cause of death and any other possibly actionable findings that are discovered during the review and include relevant OFI received from the institution multidisciplinary review.

      • The provider reviewer shall add or modify the nurse review findings and OFI as needed in collaboration with the nurse reviewer.

      • If at any time during the review process, either reviewer identifies circumstances or processes that may represent an immediate patient safety issue, the nurse or the provider reviewer shall submit an eHCIR pursuant to the HCDOM, Section 1.2.6, Statewide Patient Safety Program, and the HCDOM, Section 1.2.7, Institution Patient Safety Program.

      • When a cause of death is unknown, including in potential drug overdose cases, reviewers shall work in collaboration with mental health case reviewers who are assigned to conduct reviews pursuant to the current MHSDS Program Guide to:

        • Collect and share information.

        • Determine if the cause of death could have been the result of suicide.

        • For suicides or suspected suicides, ensure timely sharing of information and findings.

        • Final mortality reports for suicides and final suicide reports shall be distributed to both disciplines.

      • For each death classified as a homicide or suspected homicide, if clarification is needed regarding custodial or security elements, a Division of Adult Institutions (DAI) staff shall be consulted.

      • The preliminary mortality reports shall be completed by reviewers within 60 calendar days of the death, absent a showing of good cause for an extension, in which case an extension may be granted by the DD, Medical Services, or designee.

    • Regional and Institution Review

      • The preliminary mortality reports shall be submitted electronically to health care leadership for review.  Health care leadership staff are assigned headquarters Chief Nurse Executives and headquarter and regional physician managers who generally are supervisors for the provider reviewers.

      • Health care leadership shall review the report and accept or reject the mortality report within 14 calendar days of receipt.

        • If rejected, health care leadership shall facilitate any edits and necessary clarification with the nurse and provider reviewers.

      • The mortality review is considered final once health care leadership has accepted the report.

        • A final mortality report may be amended if new information that is material and relevant to the mortality review is obtained subsequent to the report being finalized. The amended report shall be submitted to health care leadership seven calendar days prior to redistributing to the stakeholders listed in Section (e)(6)(A). A response is not required from health care leadership unless the amended report is disputed.

    • Mortality Report Distribution

      • Finalized original and amended mortality reports shall be distributed to the following stakeholders:

        • The relevant institution and regional executives responsible for the patient’s health care prior to death. If multiple institutions were involved with the health care of the patient during the period of review and there are findings from that time period, a report shall be submitted to the leadership of each institution and region that were involved.

        • The Health Care Incident Reporting Committee and Statewide Patient Safety Program, uploaded via the eHCIR system. If appropriate, a recommendation for review by the Health Care Reporting Committee or Statewide Patient Safety Program shall be included.

        • DAI and institution Warden, if related to a drug overdose, suicide, homicide, or other deaths where a potential custody-related opportunity for improvement was identified.

    • Public Reporting

      • Upon the death of any person in departmental custody, MSD support staff shall provide the information identified in Section (e)(7)(B) below to the CCHCS Communications Office via the ServiceNow portal to facilitate posting on CCHCS’s public website.

      • Except as provided in Section (e)(7)(C) below, within 10 days of the death, the following information shall be posted on CCHCS’s public website:

        • The full name of the agency with custodial responsibility at the time of death.

        • The county in which the death occurred.

        • The facility in which the death occurred, and the location within that facility where the death occurred.

        • The race, gender, and age of the decedent.

        • The date on which the death occurred.

        • The custodial status of the decedent including, but not limited to, whether the person was awaiting arraignment, awaiting trial, or incarcerated.

        • The manner and means of death.

      • If CDCR seeks to notify the next of kin pursuant to the CDCR Department Operations Manual, Section 51070.10, Notification of Contact Listed and is unable to do so within 10 days of death, CDCR shall be given an additional 10 days to make good faith efforts to notify the next of kin before the information is publicly posted.

      • CCHCS shall update any publicly posted information within 30 days of a change of information.

    • Conflict of Interest

      • A provider, nurse, or health care leader shall:

        • Not participate in any decision under the breach of professional clinical peer review process if the individual has a personal conflict of interest (COI) or has provided direct patient care to the decedent.

        • Disclose any potential and actual COI prior to participating in decision-making.

      • A personal COI is a professional, financial, or other obligation or interest that is likely to limit the reviewer’s ability to participate impartially in decision-making.

    • Confidentiality

      • It is critical that the records of the mortality review process be maintained as confidential and not be made available to unauthorized persons or organizations.

      • All staff participating in the mortality review process discussed in this procedure shall adhere to these provisions regarding confidentiality.

      • The mortality review process is intended for improvements in the quality of patient care and shall be maintained as confidential and protected from discovery to the extent permitted by law.

  • References

    • Federal Death in Custody Reporting Act of 2000 (Public Law 106-297)

    • California Government Code, Title 2, Division 3, Part 2, Chapter 6, Article 2, Section 12525

    • California Penal Code, Part 3, Title 7, Chapter 1, Section 5021

    • California Penal Code, Part 3, Title 10, Section 10008

    • National Commission on Correctional Health Care, Standards for Health Services in Prisons (2016)

    • National Commission on Correctional Health Care, Standard P-A-10, Procedure in the Event of an Inmate Death

    • California Department of Corrections and Rehabilitation, Department Operations Manual, Article 7, Sections 51070.1 through 51070.20

    • California Department of Corrections and Rehabilitation, Mental Health Services Delivery System Program Guide, Chapter 10, Suicide Prevention and Response, Section E, Suicide Reporting, and Section F, Suicide Death Review

    • Health Care Department Operations Manual, Chapter 1, Article 2, Section 1.2.1, Complete Care Oversight Team Committee

    • Health Care Department Operations Manual, Chapter 1, Article 2, Section 1.2.3, Quality Management Program Overview

    • Health Care Department Operations Manual, Chapter 1, Article 2, Section 1.2.4, Quality Management Program, Statewide Governance

    • Health Care Department Operations Manual, Chapter 1, Article 2, Section 1.2.5, Quality Management Program, Institution

    • Health Care Department Operations Manual, Chapter 1, Article 2, Section 1.2.6, Statewide Patient Safety Program

    • Health Care Department Operations Manual, Chapter 1, Article 2, Section 1.2.7, Institution Patient Safety Program

    • Health Care Department Operations Manual, Chapter 1, Article 2, Section 1.2.15, Utilization Management Program

    • California Correctional Health Care Services Annual Inmate Mortality Reviews (2006-2022)

  • Revision History

    • Effective: 08/2008
      Revised: 10/06/2025