Every in-custody death is a tragedy. It also presents an opportunity for correctional systems to examine what happened, identify opportunities for improvement, and strengthen practices that can help prevent future deaths.
NCCHC Resources provides independent, expert in-custody death reviews for correctional facilities, health care providers, and government oversight agencies. Our multidisciplinary team conducts objective assessments designed to determine root causes, identify systems and individual errors, and recommend practical corrective actions that improve patient safety and operational performance.
“The purpose of an in-custody death review is not simply to determine what happened; it’s to understand why it happened and identify meaningful opportunities for improvement,” says Fred Meyer, managing director of NCCHC Resources. “By taking an objective, systems-based approach, we help our partners strengthen clinical practices, improve collaboration, and reduce the risk of similar events in the future.”
Driving continuous quality improvement
The true value of an in-custody death review lies in how organizations use the findings to improve their systems.
During a recent annual review for a county jail partner, NCCHC Resources found that the facility had successfully implemented recommendations from previous assessments, including enhancements to withdrawal treatment and hydration protocols, changes to intake staffing, and improved placement of emergency equipment.
The review also identified additional opportunities to strengthen operations, including:
- Standardizing emergency equipment inventories and daily readiness checks
- Reinforcing medication administration procedures to reduce the risk of medication diversion
- Strengthening mouth-check protocols during medication administration
- Improving quality assurance processes through regular equipment audits
- Enhancing intake screening and documentation practices
- Reinforcing collaboration between custody and health care staff during medication distribution.
These recommendations are practical, measurable, and designed to help facilities continuously improve both patient care and operational readiness.
Supporting safer correctional systems
Independent in-custody death reviews provide more than answers—they provide a roadmap for improvement.
By combining clinical expertise with an understanding of correctional operations, NCCHC Resources helps agencies identify systemic issues, strengthen policies and procedures, and foster a culture of continuous quality improvement. The result is a safer environment for incarcerated patients, correctional staff, and the communities they serve.
Whether supporting a single investigation or conducting ongoing annual reviews, NCCHC Resources delivers the objective expertise organizations need to learn from difficult events and build stronger, more resilient correctional health care systems.