HD30 - Virginia Adult Fatality Review Team: Preventing Fatal Abuse and Neglect of Virginia's Vulnerable Adults


Executive Summary:
The purpose of this report is to provide the Governor and General Assembly with information on the operation of adult fatality review teams, as required by the 2004 General Assembly. The 2004 General Assembly passed legislation to amend the Code of Virginia relative to Adult Protective Services (APS). The fourth enactment clause in Chapters 1011 and 749 of the 2004Acts of Assembly directs the Secretary of Health and Human Resources, in consultation with the Departments of Social Services and Health, to develop a model protocol, procedures and cost estimates for the operation of adult fatality review teams. The fourth enactment clause further requires the Secretary to report on this information to the Governor and General Assembly by November 1, 2004.

All people deserve to live and die with dignity, but many older adults die from physical abuse or neglect by those who are responsible for their care. In other instances, many elders die from their own neglect and reluctance to seek help.

The Commonwealth of Virginia is taking an unprecedented step towards preventing needless deaths of vulnerable adults by investigating suspicious fatalities. Virginia will be the first state nationally to establish a fatality review team that investigates adult fatalities statewide. The following report is in response to the mandate that the Secretary of Health and Human Resources develop a model protocol and cost estimates for the operation of an adult fatality review team.

An adult fatality review team functions to examine suspicious deaths for the purpose of detection and prevention. By studying fatalities and determining the extent to which deaths were preventable, the Virginia Adult Fatality Review Team will be able to identify gaps in service delivery and interagency coordination. The process of reviewing the facts and circumstances of death will enable the Virginia Adult Fatality Review Team to advocate for improvements in policy, legislation, procedures, and best practices.

The Virginia Adult Fatality Review Team is modeled after the statewide child fatality review team which was organized to reduce preventable child deaths by reviewing sudden, violent, and unnatural deaths. Similar to the child fatality review team, the Virginia Adult Fatality Review Team will conduct retrospective examinations of decedents' records through an interdisciplinary panel comprised of a wide array of agency and system representatives. The mission statement of the Virginia Adult Fatality Review Team is:

"As a multidisciplinary team, we review and analyze violent and unnatural deaths of vulnerable adults in order to make recommendations for improved legislation, policy, interagency collaboration and coordination, and to enhance education, training, and service delivery so that ultimately, preventive measures are established and elderly individuals and adults with disabilities are protected from experiencing a violent, unnatural, or preventable death."

Protocols of the Virginia Adult Fatality Review Team include:

• The overall goals of the Virginia Adult Fatality Review Team include: detect deaths attributable to abuse/neglect of elderly individuals and adults with disabilities; identify social patterns contributing to fatal outcomes; identify service gaps; develop intervention strategies; educate the community about fatal abuse/neglect; and prevent fatalities of vulnerable adults due to abuse/neglect.

• The team will be comprised of 16 members appointed by the Governor, based on recommendations by the Commissioner of the Virginia Department of Social Services (VDSS) and the Chief Medical Examiner of the Virginia Department of Health. The team will represent a wide array of private, local, and state organizations. The team will be co-chaired by the Chief Medical Examiner and the Commissioner of VDSS.

• Statutory language will be proposed to permit release of records to the Adult Fatality Review Team. The language will also assure the confidentiality of information and discussions, and provide that records and documents will be exempt from the Freedom of Information Act.

• The team will present findings and recommendations to the Governor and the General Assembly no later than October 1 of each year.

The estimated annual cost for the Virginia Adult Fatality Review Team will be approximately $95,000 for a coordinator's salary and benefits, equipment, materials, and supplies. The costs will be requested by the Virginia Department of Social Services, which will transfer the $95,000 to the Department of Health. The Department of Health will provide office space and supervision for the coordinator.