Overview of Fatality Review

Fatality review involves the review of facts and circumstances associated with deaths by a multidisciplinary team. Through team discussion of the details of the victim’s life and death as discovered through investigation records and other reports of community contact with the decedent, the following are identified: gaps in a community’s response to abuse, neglect or exploitation; risk and protective factors at work in the decedent’s life; and opportunities for improved response and intervention in similar cases.

In order to accomplish the goals of fatality review, there are seven areas of activity for teams:

  1. Assembling a multidisciplinary team of key stakeholders who can commit to and assist with death review meetings and who represent service providers, first responders, investigators and advocates in the community.
  2. Identifying which types of death cases will be reviewed by the team.
  3. Reviewing cases with the goal of describing and documenting gaps and strengths in the community response to adult abuse, neglect and exploitation, as well as missed opportunities for intervention and prevention.
  4. Summarizing team findings and conclusions.
  5. Developing recommendations for prevention and improved interventions.
  6. Sharing findings and recommendations with the community and with local agencies and organizations responsible for public health, safety and protection.
  7. Tracking what happens to recommendations to assure that needed social changes are being made in your community.

Guidance on these and other aspects of fatality review as it pertains to local and regional Adult Fatality Review Teams in Virginia are covered in more detail on the Resources Page.

For more information about Adult Fatality Review in Virginia:
Ryan Diduk-Smith, PhD
Virginia Department of Health, Office of the Chief Medical Examiner
(804) 205-3856