This report is the 10th Annual Mortality Report of the Virginia Department of Behavioral Health and Development Services (DBHDS). The information contained in this report is based on reviews of the deaths of individuals with a developmental disability that occurred during FY 2024, as reported in the DBHDS incident reporting systems.

As of January 5, 2024, there were 16,852 individuals enrolled on a Virginia Developmental Disability (DD) Home and Community Based Services (HCBS) waiver. DBHDS authorizes many specialized services to thousands of residents for the following waivers: Community Living, Family and Individual Supports, and Building Independence.

As a commitment to the Commonwealth of Virginia, the DBHDS Intellectual and Developmental Disabilities (IDD) Mortality Review Committee (MRC or Committee) contribute to system of care improvements through integration of clinical evidence, data driven determinations, and evidenced-based quality improvement recommendations. Deaths of all individuals who were receiving a service licensed by DBHDS within 90 days of their death, and who were diagnosed with IDD, are reviewed.

Analysis of the mortality trends, patterns, and problems can identify opportunities for system improvements that reduce risks to all IDD individuals receiving behavioral health and/or developmental services. DBHDS seeks to prevent instances of abuse, neglect, exploitation, and unexplained or unexpected death by identifying and addressing relevant factors during mortality reviews. Mortality review determinations are then utilized to develop quality improvement initiatives (QIIs) to reduce mortality rates to the fullest extent practicable.

Key Findings

The MRC’s key findings for FY 2024 are found below. A definition of terms is included in Appendix A.

• The DBHDS IDD MRC reviewed 370 deaths in FY 2024, a ten percent increase from FY 2023 when 336 deaths were reviewed.

• The MRC utilizes a two-tier review process, which allows a more precise focus on Tier 1 unexpected (UXP) or unexplained deaths. These deaths are categorized as Tier 1 or Tier 2, per criteria listed below. Of the 370 deaths reviewed in FY 2024, 203 deaths (54.9 percent) were categorized as Tier 1. 167 deaths (45.1 percent) were categorized as Tier 2.

• The median age at time of death was 58 years old, an increase of one year from FY 2023.

The mean age at death was 54 years old in the previous three years.

• The leading cause of death in FY 2024 was cancer with metastasis, as compared with FY 2023 when the leading cause was failure to thrive/slow decline.

• The MRC determined more deaths were expected (XP) (288 deaths, 77.8 percent) than UXP (81 deaths, 21.9 percent) with one death ruled as unknown (unable to determine cause due to limited information received).

• Deaths were also grouped into disease categories based on the International Classification of Diseases-10 (ICD-10) to capture potential underlying diseases experienced by the population reviewed. The top category of expected deaths was Genetic Malformations, Deformations, and Chromosomal Abnormalities. The top category of UXP deaths was Cardiovascular Disease (CVD).

• Four deaths (one percent) were determined to be potentially preventable (PP) in FY 2024, a decrease from FY 2023 when 11 deaths (three percent) were determined to be PP. All four involved a failure to execute established protocols. Three involved failures to coordinate and optimize care.

• Failure to Thrive (FTT), a condition in which an individual loses weight or does not maintain weight that results in serious illness, and Protein Calorie Malnutrition (PCM) leading to muscle wasting, accounted for 21 of 370 (5.7 percent) deaths in FY 2024.