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Reporting Procedures for Statutorily Reportable Deaths: DHS Responsibilities

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Reportable Death Review Purpose

Some of the most vulnerable citizens of the State of Wisconsin are served by a variety of institutional, residential and community-based treatment programs overseen by the Department of Health Services.

Wisconsin Statutes (exit DHS), Sections 48.60 (5), 50.035 (5), 50.04 (2t), 51.03 (2), and 51.64 establish the reporting requirements, enumerate the types of deaths to be reported and authorize a Department investigation.

When there is reasonable cause to believe that the death of a client of one of these programs may have been related to:

  • the use of a physical restraint or seclusion
  • a prescribed psychotropic medication
  • a suspected suicide

the Department has a responsibility to investigate the death. The Division of Quality Assurance does the field investigation.

To fulfill this responsibility the Department does the following:

  1. Investigates the death of a client of a Department licensed or certified program or facility when there is reasonable cause to believe that the death was:

    • related to the use of a physical restraint

    • related to the use of a psychotropic medication

    • or a suspected suicide.

  2. Determines if minimum standards were followed in the use of seclusion and/or restraints, psychotropic medications, and the prevention of a suicide.

  3. Takes appropriate action based on the findings of the death investigation which may include, but not be limited to:

    • the provision of technical assistance to the care/treatment providers

    • development of needed training

    • publication of special alerts and bulletins

    • certification or licensing action.

Investigation by the Department

Wisconsin statutes require that the Department investigate a death no later than 14 days after the date the death is reported to the Department.

The Division of Quality Assurance conducts reportable death field investigations for programs and facilities serving adults.

The Department of Children and Family Service, Bureau of Regulation and Licensing conducts these investigations for Residential Care Centers for Children and Youth.

All reportable death investigations are reviewed.

The Department has the authority and responsibility to conduct a thorough investigation using whatever customary means and techniques are, at the Health Services Specialist’s discretion, appropriate and warranted to conduct a thorough investigation including, but not limited to all of the following:

  • individual interviews with staff, clients and other persons
  • a review of treatment, medication and somatic treatment records
  • a review of policies and procedures of the program/facility
  • inspection of any buildings and their contents.

Department Health Services Specialists have access under ss. 51.30 (4) (b), Stats. to all treatment and medication records without the informed written consent of the client (or guardian when applicable), and may request:

  • a copy of any documentation from the client’s treatment and medication records
  • the program’s/facility’s policies and procedures.

Annual Report

The Division of Quality Assurance (DQA) generates an annual report of selected information about:

  • the reportable death reports received each year
  • any enforcement actions taken by the DQA from their investigation of reported deaths.

For information about the annual report, contact:

Cindy Lindgren
Division of Quality Assurance
P. O. Box 2969
Madison, WI 53701-2969
Phone: (608) 261-0657
FAX: (608) 261-0655
E-mail: Cindy.Lindgren@dhs.wisconsin.gov

Last Updated: January 13, 2014