Fatality Review

Executive Summary FY2017

Table of

Contents

FATALITY REVIEW EXECUTIVE

SUMMARY……………………………………………………………………………………………….………………………………..……………………….2

DEPARTMENT/DIVISION…………………………………………………………………………………………………………………..…………………4

FIVE-YEAR COMPARISON ....................................................................................................................................... 5

AGE AT TIME OF DEATH ......................................................................................................................................... 6

ACCIDENTAL DEATHS ............................................................................................................................................. 7

HOMICIDE DEATHS ................................................................................................................................................ 7

SUICIDE DEATHS .................................................................................................................................................... 8

ABUSE/NEGLECT DEATHS....................................................................................................................................... 8

CHART VII .............................................................................................................................................................. 8

MEDICAL EXAMINER’S DETERMINATION ............................................................................................................... 8

MANNER OF DEATH ............................................................................................................................................... 8

CHART VIII ............................................................................................................................................................. 9

DECEDENT’S RACE .................................................................................................................................................. 9

FATALITIES BY DIVISION AND REGION ................................................................................................................... 9

DIVISION OF AGING AND ADULT SERVICES ...............................................................................................................9
DIVISION OF CHILD AND FAMILY SERVICES .............................................................................................................10
DIVISION OF SERVICES FOR PEOPLE ........................................................................................................................10
DIVISION OF JUVENILE JUSTICE SERVICES ...............................................................................................................10
OFFICE OF PUBLIC GUARDIAN .................................................................................................................................11

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 DEPARTMENT OF HUMAN SERVICES
FATALITY REVIEW EXECUTIVE SUMMARY

July 1, 2016 – June 30, 2017

Department of Human Services (DHS) Fatality Review Policy requires a review of the deaths of all
individuals for whom there is an open DHS case at the time of death or in cases where the individuals or
their families received services through DHS within 12 months preceding the death. Information
obtained from case reviews provides insight into systemic strengths and highlights areas in which
changes or modifications could enhance systemic response to client needs.

During Fiscal Year 2017 (FY17), 244 deaths of current or past DHS clients were reported to the Office of
Services Review (OSR), including three suicide deaths and one homicide. The deaths of eight individuals
were ruled accidental. The reviews indicate that abuse and/or neglect were contributing factors in six of
the 244 deaths. The Division of Child and Family Services (DCFS) reported four children who died as the
direct result of abuse or neglect by their parents, caretakers, or family members. No child died of abuse
or neglect while in the custody of DCFS.

There were 21 fatalities reported by DCFS. Formal committee reviews were held for all cases with no
reviews pending. Fifty-seven of the 69 reported fatalities from the Division of Services for People with
Disabilities (DSPD) were reviewed and 12 reviews were waived, with no reviews pending. Five Division of
Juvenile Justice Services (DJJS) fatalities were reviewed. On-site reviews were held for all of the 12
reported Utah State Developmental Center (USDC) fatalities. Utah State Hospital (USH) conducted an
on-site review for three reported fatalities. There were two cases that were reviewed by both DCFS and
DSPD, since the families were receiving services from both agencies.

The deaths of 112 individuals who received services through the Division of Aging and Adult Services
(DAAS) were reported. Two individuals were also receiving services though DSPD during the time they
received services through DAAS.

The Office of Public Guardian (OPG) reported the deaths of 18 individuals for whom they provided
services. OPG provided the Fatality Review Coordinator with comprehensive written reports detailing
services provided by the office and information relating to the deaths.

Formal fatality reviews continue to be conducted for individuals served at the Utah State Hospital (USH).
There were three individuals who met the criteria for a formal review.

There were 130 reported deaths of male clients and 114 reported deaths of female clients. Reported
deaths included: seven infants under the age of one year, 27 individuals between the ages of one to 19
years, 38 individuals between the ages of 20 to 49 years, 73 individuals between the ages of 50 to 69
years, 74 individuals between the ages of 70 to 89 years and 25 individuals between the ages of 90 to

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100 years. Included in the 239 reported fatalities were three Asians, two Black/African Americans, 219
Caucasians, 15 Hispanics, two Pacific Islanders and three American Indians.

Suicides declined substantially in FY17. Last year there were 15 suicides from four different agencies.
This year there were three suicides. Two were from JJS and one from DCFS. There is an increase in
deaths of JJS cases. This is due in part to the fact that there are new ways to identify youth who have
died and had services within the past year.

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 DHS DIVISION SUMMARY
FY17

Number of Cases Open Committee

Committee Reviews
DEPARTMENT/DIVISION Reported at Time of Reviews Female Male
Reviews Held Pending
Deaths Death Waived

DEPARTMENT OF HUMAN SERVICES 244 221 101 13 0 114 130

DAAS (Division of Aging and Adult

Services)
112 110 N/A N/A N/A 59 52

DCFS (Division of Child and Family

21 7 21 0 0 7 15
Services)

DCFS/DSPD (Division of Child and

Family Services/Division of Services for 2 1 2 0 0 1 1
People with Disabilities)

DJJS (Division of Juvenile Justice Services

5 3 5 0 0 0 5
)

DSPD – COMMUNITIY PLACEMENT

(Division of Services for People with 69 68 57 12 0 32 37
Disabilities)

DSPD/DAAS (Division of Services for

People with Disabilities/Division of 2 2 1 1 0 1 1
Aging and Adult Services)

DSPD/OPG (Division of Services for

People with Disabilities/Office of Public 5 5 0 0 0 1 4
Guardian)

OPG (Office of Public Guardian) 13 13 N/A N/A N/A 5 8

USDC (Utah State Developmental

12 10 12 0 0 6 6
Center)

USH (Utah State Hospital) 3 2 3 0 0 2 1

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 CHART 1
FIVE-YEAR COMPARISON
FY13 – FY17
FY13 FY14 FY15 FY16 FY17
DHS Reported Deaths 191 214 270 218 244
DAAS 57 73 87 83 112
DCFS 28 35 37 33 21
DCFS/DSPD 1 1 0 2 2
DCFS/DSA/MH 0 1 0 0 0
DJJS 1 1 2 1 5
DJJS/DCFS 0 0 0 0 0
DJJS/DSAMH 0 0 1 0 0
DSAMH 18 32 47 0 0
DSPD 64 51 66 74 69
DSPD/DAAS 1 1 1 2 2
DSPD/DSAMH 1 2 1 0 0
DSPD/OPG 4 2 3 1 5
DSPD/OPG/DSAMH 0 1 0 0 0
OPG 11 7 13 11 13
USDC 3 0 6 10 12
USDC/DAAS 0 1 1 0 0
USDC/OPG 1 4 3 0 0
USH 1 1 2 1 3
USH/DSPD 0 1 0 0 0

Cases Open at Time of

157 173 238 187 220
Death

Cases Reviewed 105 109 103 96 101

Abuse & Neglect

6 7 4 7 4
Deaths
Accidental Deaths 9 16 17 11 8

Homicides 2 6 4 4 1

Suicides 13 7 18 15 3

Undetermined 4 11 10 5 3

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 CHART 2
AGE AT TIME OF DEATH
AGE IN
DHS DAAS DCFS DCFS/ DJJS DSPD DSPD/ OPG OPG/ USDC USH
YEARS
DSPD DAAS DSPD

<1 7 7

1–3 1 1

4-6 2 2

7 - 10 3 3

11 - 14 2 2

15 - 19 19 6 2 5 6

20 - 29 9 9

30 - 39 13 2 10 1

40 - 49 16 2 13 1

50 - 59 30 9 13 1 1 1 5

60 - 69 43 18 10 5 2 5 3

70 - 79 43 28 8 1 2 2 1

80 - 89 32 29 3

90 – 100 25 24 1

TOTALS 239 112 21 2 5 69 2 13 5 12 3

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 CHART 3
ACCIDENTAL DEATHS

CAUSE OF DEATH DHS GENDER AGE DIVISION

Overdose 1

Male 18 DCFS

Drowning 2

Male 8 DCFS

Male 7 DCFS

Falls 2

Female 78 DAAS

Female 69 DAAS

Vehicular Accidents 2

Train/Pedestrian Male 18 DCFS/System of Care

Motor Vehicle Female 14 DCFS

Aspiration/Choking 1

Male 18 DCFS/DSPD

TOTAL 8

CHART 4
HOMICIDE DEATHS

MANNER OF HOMICIDE DHS GENDER AGE DIVISION

Gunshot Wound 1 Male 19 JJS

TOTAL 1

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 CHART 5
SUICIDE DEATHS
MANNER OF SUICIDE DHS GENDER AGE DIVISION

Asphyxia (Hanging) 1
Male 17 JJS
Drug Toxicity 2
Male 16 JJS
Female 18 DCFS

TOTAL 3

CHART 6
ABUSE/NEGLECT DEATHS
CAUSE OF DEATH DHS GENDER AGE DIVISION

Blunt Force Trauma 2

Female 6 months DCFS
Male 22 months DCFS
Drug Intoxication 1
Female 4 months DCFS
Vehicle Accident/Neglect 1
Female 4 months DCFS

TOTAL 4

CHART 7
MEDICAL EXAMINER’S DETERMINATION
MANNER OF DEATH
DCFS DSPD DSPD
MANNER OF DEATH DHS DAAS DCFS DJJS DSPD OPG USDC USH
/DSPD /DAAS /OPG
Accident 10 2 6 1 1

Can Not Be Determined 7 5 2 2

Homicide 1 1
Natural
213 101 11 1 65 1 5 13 11 3
Causes
Pending 10 4 1 2 2 1

Suicide 3 1 2

TOTALS 244 112 21 2 5 69 2 5 13 12 3

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 CHART 8
DECEDENT’S RACE

DCFS/ DSPD/ DSPD/

RACE DHS DAAS DCFS DJJS DSPD OPG USDC USH
DSPD DAAS OPG

American Indian 3 1 2

Asian 3 2 1
Black/African
2 1 1
American
Caucasian 219 102 21 1 1 63 2 5 11 10 3

Hispanic 15 5 1 3 4 1 1

Pacific Islander 2 2

TOTAL 244 112 21 2 5 69 2 5 13 12 3

CHART 9
FATALITIES BY DIVISION AND REGION

DIVISION OF AGING AND ADULT SERVICES

REGION TOTAL
Central 56
Eastern 2
Northern 29
Southeast 1
Southern 15
Southwest 9

TOTAL 112

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DIVISION OF CHILD AND FAMILY SERVICES

REGION TOTAL
Eastern 2
Northern 5
Salt Lake Valley 6
Southwest 5
Western 3

TOTAL 21

DIVISION OF SERVICES FOR PEOPLE

WITH DISABILITIES
(COMMUNITY BASED and
UTAH STATE DEVELOPMENTAL CENTER)

REGION TOTAL
COMMUNITY
PLACEMENT
Central 29
Northern 24
Southern 15
Western 1
TOTAL

USDC 12

TOTAL 81

DIVISION OF JUVENILE JUSTICE SERVICES

REGION TOTAL
Region I Ogden 4
Region II SLC 1
TOTAL 5

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 OFFICE OF PUBLIC GUARDIAN
REGION TOTAL
Central
Office of Public Guardian 13
Guardianship Associates 5

TOTAL 18

UTAH STATE HOSPITAL

DIVISION OF SUBSTANCE ABUSE AND MENTAL HEALTH
REGION TOTAL
USH 3

TOTAL 3

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