Chapter 5 – Adult Custody and Security Operations

The Department shall treat the death, serious injury, or serious illness of an inmate or parolee with dignity and respect as is regularly accorded persons who are not incarcerated or on parole. The procedures to be followed after death, serious injury, or illness shall comply with the requirements of all applicable laws.

The purpose of this Section is to outline the duties of all staff involved when a death, serious injury, or illness of an inmate/parolee occurs. For purposes of this Section, parolee is defined as: a parolee currently incarcerated in a CDCRCalifornia Department of Corrections and Rehabilitation facility pending a revocation action by the Board of Parole Hearings, or in a CDCRCalifornia Department of Corrections and Rehabilitation facility based substance abuse treatment program.

An employee discovering a possible inmate/parolee death shall immediately summon medical assistance. Pending arrival of medical assistance, the employee shall make every effort to preserve life.

This may include first-aid, Cardio Pulmonary Resuscitation (CPR), and other life-saving measures for which the employee is trained. Life support measures shall be continued until the medical personnel arrive.

Medical personnel will continue life saving efforts unless one or more of the following signs of death are present. If one or more sign is present, the physician will determine if patient is deceased.

• Rigor mortis/dependent lividity.

• Tissue decomposition.

• Decapitation.

• Incineration.

Once started, CPR shall continue until:

• Resuscitation efforts are transferred to a rescuer of equal or higher level of training.

• The patient is determined to be deceased by an MD.

• Effective spontaneous circulation and ventilation have been restored.

• Emergency responders are unable to continue because of exhaustion or safety and security of the rescuer or others is jeopardized.

• A written valid Do Not Resuscitate order is presented.

If a medical officer is not present when the inmate dies, the medical personnel will, in addition to the above:

• Notify the Chief Medical Executive (CME), staff medical officer, or the Medical Officer-of-the-Day (MODMedical Officer of the Day) as appropriate.

• Notify the supervising nurse on duty, or on call.

• Notify the senior custody officer on duty.

A physician shall examine the patient at the earliest possible moment to determine if the patient has expired.

Only a doctor of medicine shall pronounce a person dead.

The Warden/RPARegional Parole Administrator or their designees shall:

• Effect all medical and legal requirements as soon as practicable.

• Ensure that all necessary requirements for care and maintenance of remains and artificial appliances following death are accomplished in accordance with instructions dictated by the appropriate coroner’s office and this manual.

The CME or MODMedical Officer of the Day on duty shall:

• Notify the watch commander or senior custody officer in the area of occurrence that the patient/victim has expired stating the time of death.

• Notify the coroner of the death and request their inquiry or release of the body.

• Upon obtaining the coroner’s permission, cause the body to be covered and removed to the morgue or a private room in the treatment facility.

• Notify the Warden or Administrative Officer-of-the-Day (AODAdministrative Officer of the Day), giving all significant points of administrative and medical/legal interest.

• Prepare a written summary of circumstances surrounding the death on CDCRCalifornia Department of Corrections and Rehabilitation Form 7229-A, Initial Inmate Death Report, or CDCRCalifornia Department of Corrections and Rehabilitation Form 7229-B, Initial Inmate Suicide Report, providing tactful wording of information that can be used in notifying the contact listed. Any last messages the deceased wished to be transmitted must be quoted.

• An original and five copies shall be prepared and routed to the Warden.

• Notify all required agencies of any communicable diseases discovered during examination.

• In the event the deceased inmate had a diagnosed communicable disease, the contract funeral director charged with the removal of the body from the facility shall be notified of such disease prior to the release of the body.

• Close out all medical records and transmit them to the records office for inclusion in the decedent’s C-File.

The CME or physician examining the body and pronouncing death will specifically determine whether he/she can sign the death certificate or must refer it to the coroner. H&SCHealth and Safety Code 10259 states the coroner will be notified and will sign the death certificate if death occurs:

• Without medical attendance.

• During the continued absence of the attending physician (vacation, etc.).

• Where the attending physician is unable to state the cause of death.

• Where suicide is suspected.

• Following an injury or accident.

• Under circumstances as to afford a reasonable suspicion that the death was caused by the criminal act of another.

The physician shall complete and sign their section of the death certificate within 15 hours of the death. An original and five copies will be prepared. The original will be forwarded to the undertaker for completion and the copies will be routed to the Warden. Pursuant to H&SCHealth and Safety Code 10204, the coroner shall complete the certification of death within three days after examination of the body.

Upon notification of a possible death, the senior custody staff or watch commander shall assure the following steps are accomplished:

• Make or cause to be made the decision for the need to secure the death/incident scene. Any evidence and areas surrounding the death/incident scene shall not be disturbed until an investigating officer is assigned and on the scene.

• Initiate investigation or other custody measures as indicated.

• Order all pertinent materials gathered, i.e., personal property, visiting information, mail card, etc.

The senior custody staff member shall arrange for identification of the deceased as soon as practical.

• Fingerprints

  • Arrange for the taking of a full set of the deceased’s fingerprints on the approved Fingerprint Card, signed by the employee taking the prints.

  • Required for legal identification of deceased.

  • If fingerprinting is impossible, positive identification must be made by other means (photograph, scars, etc.).

• Other

  • Identification by means other than fingerprinting requires a notarized affidavit.

  • Fingerprint cards or affidavit shall be forwarded to the C&PRClassification & Parole Representative.

• Exception to Fingerprinting

  • In circumstances involving suspected homicide, fingerprints shall not be taken. Each hand shall be wrapped in a paper container by the medical representative or the institutional investigator.

  • Fingerprinting shall be completed by the coroner/designee.

    • Notify the chaplain of the death giving the inmate’s religion if known.

    • Notify the Warden or AODAdministrative Officer of the Day and the CME or MODMedical Officer of the Day.

The highest ranking custodial officer or designee shall prepare and deliver within four hours of death a brief notice providing the decedent’s name, number, time and place of death, and other pertinent facts to:

• The Warden/RPARegional Parole Administrator.

• Chief Deputy Warden.

• CME.

• Associate Warden, Business Services.

• PIOPublic Information Officer/AA.

• Correctional Case Records Manager (CCRMCorrectional Case Records Manager).

• Correctional Captain.

• Parole agent or reentry facility administrator.

• Chaplain of the deceased’s faith.

Two-Hour Notification

• Any death of an incarcerated person in any facility of the department, including contract facilities, shall be reported within two hours of the death to the county sheriff and the coroner, or their designee of the county in which the facility is located, and if the facility is located within the city limits of an incorporated city, the chief of police in that city, or their designated representative.

Additional Notifications

• The death shall also be initially reported to the District Attorney or designee of the county in which the facility is located, to the Director, Division of Adult Institutions (DAIDivision of Adult Institutions (formerly Institutions Division)), and to the Director, Health Care Services, within 24 hours of the death.

Initial Report of Death

• The initial report of the death may be transmitted by telephone, direct contact, or written notification, and shall outline all pertinent facts known at the time the report is made and all persons to contact, in addition to any other information the reporting person or officer deems pertinent.

  • The Warden, Chief Deputy Administrator, or designee shall notify law enforcement personnel.

  • The facility Chief Medical Executive (CME) shall notify the coroner.

Written Report, Within Eight Hours of Death

• Within eight hours of the death of an incarcerated person in any facility of the department, including contract facilities, a written report Initial Inmate Death Report (CDCRCalifornia Department of Corrections and Rehabilitation Form 7229-A) or Initial Inmate Suicide Report (7229-B) shall be submitted by the Warden or Chief Deputy Administrator to those entities noted above. This written report shall include all circumstances and details of the death known at the time of report preparation, and shall include the names of all involved persons, and all persons with knowledge of the circumstances surrounding the death. A copy of the CDCRCalifornia Department of Corrections and Rehabilitation Form 7229-A or 7229-B shall be retained in the office of the CME and the investigative office until conclusion of any investigation; one copy shall be placed in the deceased incarcerated person’s C-File. In community based correctional facilities, the Chief Deputy Administrator shall retain one copy of the report until conclusion of any investigation.

Attorney General Notification

• The following reports and records shall be delivered to the Attorney General’s Office, Bureau of Criminal Statistics, Statistical Data Center within ten calendar days after the death:

  • Complete incident report or report of death as applicable.

  • Completed copy of death certificate.

  • Fingerprint card (two sets).

  • Coroner’s report (if applicable).

• If any of the information changes in (A) through (D) above or new information becomes available regarding the death, the updates shall be provided to the Attorney General within ten calendar days of the date of the change or the date the new information becomes available.

Receiving and Release (R&RReceiving and Release) staff in Reception Centers shall ensure that primary and alternate emergency contact information is entered in the Strategic Offender Management System (SOMSStrategic Offender Management)/Electronic Records Management System (ERMSElectronic Records Management System) application for each incoming inmate (new admissions and parole violators). The inmate is interviewed by R&RReceiving and Release staff upon his/her arrival from the county and the information is entered into SOMSStrategic Offender Management. The form is printed and signed by the inmate and then scanned into ERMSElectronic Records Management System. If the inmate refuses either to list a next of kin or to sign the form, staff shall indicate the refusal, date and sign the form. Facility classification staff at all CDCRCalifornia Department of Corrections and Rehabilitation facilities shall ensure the Notification in Case of Inmate Death, Serious Injury, or Serious Illness is updated:

• Annually as part of the classification review process.

• Upon recommendation of transfer by a classification committee.

• Whenever an inmate advises his or her correctional counselor of a desire to change the information contained in the SOMSStrategic Offender Management/ERMSElectronic Records Management System application.

In the event of a death, serious injury, or serious illness, the Warden or designee at the level of Correctional Lieutenant or Correctional Counselor II or above shall use all reasonable means to contact the person(s) identified on the Notification form. The senior custodial officer shall review the inmate’s C-File and Emergency Contact information contained in SOMSStrategic Offender Management/ERMSElectronic Records Management System and notify the contact listed as soon as possible.

• Telephone notification of contact listed should be used whenever possible. Custody staff shall not attempt to provide medical information regarding the inmate’s health or cause of death, but shall refer the contact listed to the facility CME or physician designee or to the County Coroner’s office. The staff member making contact shall verify the mailing address of the contact listed.

• In all cases of death, a tactfully worded letter, over the name of the Warden, shall be sent to the contact listed. Written notification shall be done by return-receipt mail.

The following format may be used in the event of a death:

• (Name of contact listed) “I regret to inform you of the death of your (relationship), name, and date. Remains have been released to (name of contracting mortuary, address and phone number of mortuary). They are awaiting further instructions for the final disposition of your (relationship) without expense to the State. If not claimed within 48 hours, disposition must be made as provided by law. Please notify (contract mortuary) whether you will claim the body. You may contact the County Coroner’s Office at (Area Code) XXX-XXXX if you have questions regarding the cause of death of your (relationship). We extend our sympathy in your loss.” If notification cannot be immediately made in the aforementioned manner, the Warden or designee at the level of Correctional Lieutenant or Correctional Counselor II or above shall use all reasonable means to make contact with family members including but not limited to:

  • Assigning Investigative Services Unit (ISUInstitution Services Unit) staff to utilize telephone signup sheets, Inmate Monitoring and Recording Systems, searching the inmate’s personal property (while preserving crime scene evidence), reviewing the inmate’s visiting file, contacting the previous Parole Agent (if any), contacting the local Coroner’s office, contacting the arresting agency, reviewing social media, and/or contacting the Office of Correctional Safety (OCSOffice of Correctional Safety), etc., to locate contact information.

  • Contact the appropriate consulate office if the inmate is a foreign national.

  • All efforts made to locate and notify the next of kin shall be documented on a CDCRCalifornia Department of Corrections and Rehabilitation 837-C, Crime/Incident Report Part C–Staff Report or General Chrono, CDC 128-B.

• If notification with the contact listed cannot be made within 72 hours, the Warden shall notify their respective Associate Director (AD) that all reasonable means for obtaining contact information have been exhausted. The AD shall make contact with the OCSOffice of Correctional Safety for any additional assistance in locating the next of kin.

The highest ranking custodial officer or their designee shall determine if the coroner has placed a hold on the body. If not, the custodial officer shall request the contract mortuary to pick up the body. The custodial officer shall obtain a body receipt form from the undertaker at the time the remains leave the facility. This form shall be completed in quintuplicate and distributed as follows:

• Original to the watch commander.

• One copy to control or the facility head.

• Two copies to the mortician (who leaves one copy at the gate).

• One copy to the CCRMCorrectional Case Records Manager.

The CCRMCorrectional Case Records Manager shall prepare a report supplying the information necessary to complete items 1A through 21D of the Certificate of Death, to the health services treatment facility (medical department).

The CCRMCorrectional Case Records Manager shall notify the persons or agencies who have requested such notification pursuant to PCPenal Code 11155(b).

Pursuant to Article 37 of the Vienna Convention, written notification within 72 hours of the official notice of death shall be made to the appropriate consulate post in the event of the death of a foreign, national inmate. The notification shall include the inmate’s name, CDC identification number, date and time of death, and the attending physician’s name. Consulate offices are located in major cities throughout California; and addresses and telephone numbers can be found in the local telephone directory under the name of the country of origin.

Any detainers pertaining to the deceased shall be returned to the issuing agency with a notice of the inmate’s death.

Upon receiving instructions and information from their supervisor concerning the death of an inmate, the Correctional Counselor shall carefully examine all available records, mail, visiting records, and personal property and prepare a report to the Warden or their designee consisting of:

• A list of names, relationship, and addresses of relatives, friends, organizations, or individuals who might be interested in the final disposition of the deceased without cost to the State.

• Answers to the below listed questions.

• Is the decedent a member of a fraternal order or lodge having burial insurance or death benefits?

• Is the decedent entitled to veteran’s or social security benefits?

• Is the decedent receiving a pension?

• Does the decedent have insurance payable at death?

Does the decedent have resources or income not held in trust at the institution? If the deceased inmate was an undocumented alien, notify the local office of Immigration and Customs Enforcement and the appropriate consulate post as referenced in DOMDepartment Operations Manual 51070.12.2. Notify victim(s) if there is a written request by the victim(s) in the inmate’s C-File that the victim(s) be notified of any change of the inmate’s status per PCPenal Code 3058.6, 3058.8, and 3058.9.

Upon notification of a death, the chaplain of the faith professed by the inmate will perform such duties as required:

• Attend to any special religious requirements.

• Consultation with family members as required or requested.

The property officer shall:

• Receive, inventory, and store all personal property of the deceased.

• Prepare a complete inventory report, sign and submit five copies to the watch commander to be distributed as follows:

• Warden/RPARegional Parole Administrator.

• Chief Deputy Warden.

• Associate Warden, Business Services.

• Accounting officer.

• Correctional Captain.

• Secure all personal property as evidence if directed by watch commander or investigative unit.

• Make personal property available to employees authorized to examine it.

• All personal property of the deceased at the scene of the death may be released to the coroner upon request for the purpose of assisting their investigation.

Upon completion of all investigations and release of property as evidence, all personal property of the deceased will be released to the Associate Warden, Business Services, for disposition.

The Associate Warden, Business Services, has a variety of duties pertaining to the death of an inmate that include, but are not limited to:

• Assure that the institution has a valid service agreement with local mortuaries to provide for such services as embalming, cremation, caskets, transportation, burial, and other related services in connection with the disposition of the deceased inmate.

• Assure that a process has been established for disposition of personal property, funds, and any other resources held in trust for the deceased.

• Provide burial clothing and make special arrangement for the use of State materials or services when necessary.

Deceased’s Funds

• When an institution holds U.S.United States Savings Bonds or other securities belonging to a deceased inmate and the institution is entitled to recover costs incurred in connection with the death of an inmate (PCPenal Code 5061), bonds or securities not exceeding the actual expenses and charges should be liquidated through the office of the public administrator of the county. Excess monies over actual expenses shall be credited to the deceased inmate’s trust account.

After all reasonable efforts have been exhausted to locate a claimant for the deceased and there is no one to direct disposition, the remains shall be considered an unclaimed dead body. If the body is not claimed for burial, at least ten days after all reasonable efforts have been exhausted to contact the individual(s) listed on the Notification in Case of Inmate Death, Serious Injury, or Serious Illness, it shall be cremated or buried by a licensed mortuary/undertaker in accordance with a previously approved service contract. In the absence of any known relative, or if not claimed by relatives, the Warden may use his/her judgment in offering the body to friends of the deceased or interested private agencies for interment at private expense or with the deceased inmate’s own funds. The coroner or Department may dispose of the unclaimed body pursuant to applicable laws.

The death of an inmate may occur in places other than an institution. This may include, but is not limited to:

• Reentry facilities.

• While under Parole supervision.

• Camps.

• In-transit between CDCRCalifornia Department of Corrections and Rehabilitation facilities.

• Off reservation work crews.

• Community hospital.

Upon the death of a parolee, the Parole Agent of record shall:

• Obtain a certified copy of the death certificate from the coroner or county clerk.

• Prepare a closing summary, CDCRCalifornia Department of Corrections and Rehabilitation Form 1502, Activity Report.

• Forward the closing summary and the death certificate to the regional records officer and the Division of Correctional Health Care Services.

In the event the death occurred in another state and the death certificate is not available, the Parole Agent shall obtain:

• A letter from a Parole Agent or law enforcement officer from the other jurisdiction verifying that the death certificate or autopsy report has been reviewed. This will serve as verification of death.

In the event of the death of an inmate at a reentry facility the administrator will follow the guidelines set forth in DOMDepartment Operations Manual 83080.7.

If a death occurs in a camp, while fighting fires, or while in transit between institutions, the Department’s officer in charge will take the following actions:

• Proper custodial support will be summoned as appropriate to the situation.

• The nearest available doctor will be called to pronounce death.

• The local coroner must be notified and their instructions followed.

• The Warden of the parent institution shall be notified by telephone or email and further instructions requested.

• Pending receipt of instructions, the body shall be turned over to a licensed mortuary/undertaker in the community where the death occurred.

• Notification of appropriate authorities as outlined in DOMDepartment Operations Manual 51070.9 shall be directed by the Warden or designee.

• A complete final report containing circumstances, investigations, arrangements, etc., will be submitted to the Warden of the parent institution without delay.

References

• CCRCalifornia Code of Regulations, § 3357. PCPenal Code §§ 3058.8, 5021, 5022 5061 and 11155(b). H&SCHealth and Safety Code §§ 7200, 10203, and 10250. GCGovernment Code §§ 12525 and 27491.

History

• Revised September 8, 2008.

• Revised September 6, 2013.

• Section 51070.9 revised March 25, 2025.