OPA: Fatality Review Board

Fatality Review Board for Persons with Disabilities

Spanish

The Fatality Review Board for Persons with Disabilities (FRB) was established by Executive Order in 2002.  It is supported by the Office of Protection and Advocacy for Persons with Disabilities (OPA) and operates independently of the Department of Developmental Services (DDS) mortality review structure.  The FRB tracks all reported DDS client deaths and pursues preliminary inquiries as well as a limited number of investigations into the circumstances surrounding certain selected deaths. 

 

The FRB is comprised of five experts appointed by the Governor, and is chaired by the Executive Director of OPA, Mr. Craig Henrici.  Its members include Professor Timothy Palmbach, a law enforcement professional with a background in forensic investigations; Attorney John DeMattia, a representative from the office of the Chief State’s Attorney; Ms. Patricia Mansfield, R.N., an intellectual disability professional with a medical background; Dr. Gerard Kerins, a medical professional with a background in internal medicine and geriatrics; and Mr. James McGaughey, a developmental services professional.  The Commissioner of DDS, or his/her designee, is represented on the FRB as a non-voting member.

 

Between January 2002 and December 31, 2015, two thousand eight hundred and eighteen (2,818) deaths were reported to the FRB by DDS. 

 

FRB staff receive, review and log into a database reports of all deaths known to DDS.  Reports of deaths occurring under unusual circumstances, those of unknown cause or those suggesting possible deficiencies in care are identified for further in-depth review and/or preliminary investigation.  Information concerning these cases is prepared for the Board to review.  The Board then makes recommendations for further review, investigation or action in each case, or, if warranted, makes recommendations to DDS and other agencies.  FRB staff also work jointly with OPA Abuse Investigation Division (OPA/AID) Investigators in the investigation of those deaths where abuse or neglect are suspected to have played a role.  The FRB monitors the progress of all such investigations.

 

Since its first meeting in September 2002, approximately seven hundred and seventy-one (771) deaths have been subject to in-depth review, discussion and monitoring by the FRB.

 

Examples of Major Initiatives

 

·       The FRB has issued bi-annual reports and full investigation reports summarizing issues, which have emerged in the untimely deaths of DDS clients.  As a results of these investigations, and included in the bi-annual reports, recommendations have been made to DDS to lessen the risk of similar occurrences for other DDS clients.

 

·       In response to concerns that have emerged concerning the deaths of DDS clients living in nursing homes, and in collaboration with the Developmental Disabilities Council, OPA hosted a symposium, “Including our Elders with Disabilities: A Symposium on Aging in Place” for policy makers, people with disabilities, advocate, and public and private service providers.

 

·       The FRB initiated a review of a sample of deaths of DDS clients occurring in nursing homes over a five-year period.  The primary purpose of the inquiry was to examine variables which might influence nursing home placement and the length of nursing home stays.  The results of the Board’s inquiry, “A Pilot Study Analyzing Mortality of Adults with Developmental Disabilities Residing in Nursing Homes in Connecticut,” were published in the Journal of Policy and Practice in Intellectual Disabilities.

 

·       FRB member Dr. Gerard Kerins and FRB staff  participated in a series of trainings designed to increase the ability of service system personnel to advocate for their clients’ needs in health care environments.  The training highlighted real-life stories, drawn in part from cases reviewed by the FRB.  It focused on practical solutions to improve medical care for people with intellectual disabilities at the doctor’s office, in the emergency department, in the hospital and in nursing home settings.  Training attendees represented public and private administrators, residential services staff, nurses, case managers, healthcare coordinators, and family members.

 

·       In March 2013, the Hartford Courant released a series of articles, which focused on death investigations involving adults with intellectual/developmental disabilities that were completed by either the FRB, the OPA/AID, or the State of Connecticut Department of Public Health. These investigations occurred in response to suspicions that abuse or neglect may have contributed to a client’s death.  Material for the newspaper articles was taken from a report prepared by the FRB and the OPA/AID, which spanned a seven-year reporting period from January 4, 2004 through December 31, 2010.  The report concluded with a comprehensive summaries of allegations reported to the OPA/AID over this seven-year time period, where abuse or neglect was suspected to have contributed to the death of a client of the DDS system. 

 

2016 FRB Meeting Schedule

Minutes published here prior to the next Board Meeting are in draft form and not considered official until approved and voted on by the Board.

 Date Adobe file Word document  Adobe file  Word document 
1/20
Agenda (11kb)
Agenda (14kb)
Minutes
Minutes
3/16
Agenda
Agenda
Minutes 
Minutes 
5/18
Agenda
Agenda
Minutes
Minutes
7/20
Agenda
Agenda
Minutes
Minutes 
9/21
Agenda
Agenda
Minutes
Minutes
11/16
Agenda
Agenda
Minutes
Minutes

Connecticut’s System for Reviewing the Deaths of Individuals with Intellectual Disabilities; Lessons Learned from 10 Years of Mortality Reviews and Investigations.pdf (580kb)

Executive Summary.pdf (57kb)

Archived Agendas and Minutes



Content Last Modified on 2/4/2016 3:03:21 PM