Reporting of Client/Patient Death Attributable to Suicide, Restraint or Psychotropic Medication

Forms are fillable online, although you will not be able to save revised forms. You can also print off and photocopy forms to keep available as needed.

Reporting Requirements for Programs and Facilities

Within 24 hours after the death of a client, or learning of a death:

The program or facility that was providing care, treatment or services to the client is required under Wisconsin statutes to notify the Department of Health Services if there is cause to believe that the death was related to:

  • the use of a physical restraint or seclusion
  • the use of one or more psychotropic medications
  • the death is a suspected suicide.

Notification to the Department must be via the completed "Client/Patient Death Determination" form F-62470 (PDF, 239 KB).

The completed F-62470 form should be faxed to the appropriate Division of Quality Assurance Director or Chief listed in the right-hand column of the Reportable Death Contact Table included in the F-62470 form on page 5.

Background and Procedures:

Forms:

  • F-62470 (PDF, 239 KB), "Client / Patient Death Determination" (adults)
  • CFS-2183 (Word, 76 KB), "Residential Care Center Resident Death Determination" (children)

These forms and procedures are for reporting to the Department deaths that may have been related to the use of a physical restraint or seclusion, a psychotropic medication, or the death is a suspected suicide.

This reporting requirement is found under ss. 48.60 (5) (a), 50.035 (5), and 51.64, Wis. Stats.

The list in the Reportable Death Contact Table of programs and facilities required to report these deaths has been expanded to include those required to do so under Administrative Codes DHS 40 and DHS 75.

Also, please note that the category Comprehensive Community Services for Persons with Mental Illness under proposed Administrative Code DHS 36 is also included.

Comprehensive Community Services Programs certified under DHS 36 following its promulgation will be required to report these deaths.

The report should be faxed to the DQA Director for the respective program or facility reporting a death. The Reportable Death Contact Table on page 5 of form F-62470 identifies which DQA director should receive the report.

Use these revised procedures and form F-62470 to report a death to the appropriate DQA director. If a fax machine is not available, you may call the DQA director to obtain his or her mailing address.

Please review the reportable death procedures and the "Instructions" and "Client/Patient Death Determination Guidelines" in the F-62470 form.

These guidelines have been included in that form to assist programs and facilities determine if there is reasonable cause to believe the client/patient death may be related to the use of restraint/seclusion, the use of psychotropic medication or is a suspected suicide.

If you have any questions, please contact the DQA Director for your respective program or facility.

Last Revised: January 12, 2015