OPA: Fatality Review Board

Fatality Review Board for Persons with Disabilities


In February 2002, Governor Rowland issued Executive Order No. 25 in an effort to bring greater independence and oversight to the fatality review process for people with intellectual disability who receive services from the Department of Developmental Disabilities (DDS).  Among the changes the Executive Order created was the establishment of an independent Fatality Review Board for Persons with Disabilities (FRB), which is comprised of experts appointed by the Governor, and is chaired by the Executive Director of the Office of Protection and Advocacy (P&A).  The FRB meets once every two months.  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; Patricia Mansfield, an intellectual disability professional with a medical background; Doctor Gerard Kerins, a medical professional with a background in internal medicine and geriatrics.  Lakisha Hyatt, DDS Director of Health and Clinical Services, represents the Commissioner of DDS on the FRB as a non-voting member.

The Executive Order also stipulates that the deaths of all persons who are clients of the intellectual disability service system be reported to P&A.  In accordance with the Order, DDS provides P&A with information on all deaths on a weekly basis, as well as any additional information as requested.  In deaths where persons are minimally served by the DMR system, P&A makes contact with family members and DDS Case Managers in order to obtain additional information concerning the circumstances of the individuals' deaths. 

Between July 1, 2002 and June 30, 2003, one hundred fifty seven (157) deaths were reported to P&A by DMR.  Since its first meeting in September 2002, approximately twenty three (23) deaths have been subject to in-depth review, discussion and monitoring by the FRB.  During the same time period, the Executive Director of P&A, in his capacity as Chairman of the FRB, referred four (4) deaths for full investigations.          

In October 2003, the FRB issued its first report on the circumstances surrounding the death of a man with an intellectual disability who died following his admission to a Norwich nursing home.  The report tells the story of "Philip Sampson" (a pseudonym), a highly personable and spirited man who lived in a group home run by a private provider, where his complex medical needs were very well managed.  After being hospitalized for an acute medical condition, he entered a skilled nursing facility for short-term rehabilitation, which would enable him to return to the group home within a short period of time.  Everyone assumed that his healthcare needs would be taken care of in a healthcare environment, but they were not.  In fact, the FRB investigation uncovered a long list of problems and alarming oversights at the facility.  The FRB made recommendations to the Department of Developmental Disabilities, Department of Social Services and the Department of Health, which are intended to prevent the recurrence of similar deaths and to effect positive change and improvement in the quality of care and treatment for individuals who are similarly placed.  The national ARC distributed the story around the country, alerting member chapters not to assume that people will necessarily be well served in skilled nursing facilities.

Other major activities of the FRB:

  • P&A and DDS developed and implemented a Memorandum of Understanding, which provides P&A with information on all deaths, and allows P&A full access to client records and information as requested.
  • P&A developed collaborative relationships with the Office of the Child Advocate and the  Department of Public Health for purposes of sharing information and communicating care concerns.
  • DDS provided FRB staff with access to data maintained on the DDS Connecticut Automated Mental Retardation Information System (CAMRIS).
  • The FRB adopted by-laws, which were established in accordance with Executive Order No.25.
  • The Attorney General provided FRB members with information and advice on the Health Insurance Portability and Accountability Act (HIPAA), which became law in 1996. 

In December 2002, findings and recommendations were issued, which resulted from an investigation conducted by the Legislative Program Review and Investigation Committee pertaining to client health and safety in community living arrangements operated or licensed by DMR.  One of the Committee's recommendations was that all deaths where abuse and/or neglect is suspected should be investigated by P&A with appropriate resources.  New statutory authority (Public Act 03-146) was passed during the 2003 legislative session, which requires a position to be transferred to P&A from DDS.  P&A has hired a nurse investigator with these additional resources to support the P&A Abuse Investigation Division, which will be responsible for conducting these investigations.  

2014 Meetings

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.

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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)

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{FRB Members at Anniversary Luncheon}

The Fatality Review Board for Persons with Disabilities celebrated its 10th anniversary on July 18th at a Recognition Luncheon held at the Hartford Club. 

Pictured above are:  (front row, left to right side) Anne Broadhurst, OPA Investigator; Dory McGrath, R.N. DDS, Diana Lincoln, R.N., OPA; (Back row, left to right side) John DeMattia, Assistant State's Attorney, Patricia Mansfield, R.N.; Peter Hughes, OPA/AID Program Director; James McGaughey, OPA Executive Director; Gerard Kerins, M.D. (Absent: Tim Palmbach, J.D., Associate Professor, UNH)

    Archived Agendas and Minutes

Content Last Modified on 10/3/2014 11:36:47 AM