Every death in custody warrants careful review. Beyond determining what happened in an individual case, a well-conducted mortality review can identify opportunities to strengthen clinical practices, custody procedures, emergency response, communication, training, and other systems that affect safety.
NCCHC Resources conducts an annual independent review of in-custody deaths for a large county jail. The NCCHC Resources team recently conducted an on-site review of two deaths.
The project illustrates the value an experienced outside party can bring to mortality review—and how an independent perspective can help facilities move beyond reviewing an individual event to identifying opportunities for broader system improvement.
The Value of an Outside Perspective
Facility staff know their operations better than anyone. That knowledge is essential to understanding an in-custody death, but an independent reviewer brings a different perspective.
External experts can examine an event without the assumptions that naturally develop when people work within a system every day. They also bring experience from other correctional environments, allowing them to recognize patterns, vulnerabilities, and potential solutions that may not be readily apparent internally.
“An independent death review is not about coming in after a tragedy and looking for someone to blame,” said Fred Meyer, MA, CJM, CCHP, managing director of NCCHC Resources. “It is about taking an objective, comprehensive look at what happened, understanding how the health care and custody systems worked together, and identifying practical changes that can reduce risk and make the facility safer going forward.”
Independent review can also give facility and county leadership greater confidence that difficult questions have been examined objectively and that recommendations are grounded in correctional health care expertise and recognized standards.
Looking Beyond the Medical Record
An effective death review requires more than a chart review.
NCCHC Resources examined medical records, emergency department records, coroner reports, policies and procedures, and administrative and clinical reports. The review also included a facility tour, interviews with medical and custody staff, review of jail video, and examination of the emergency response to each event. A physician consultant separately reviewed the medical charts and records for both individuals. Recommendations were developed with reference to NCCHC Standards.
This comprehensive approach is particularly important in corrections, where an adverse event may involve multiple systems and staff members. Intake procedures, medication administration, observation, communication between health and custody staff, emergency equipment, emergency response, and compliance with established policies can all affect outcomes.
From Findings to Action
The greatest value of a mortality review comes from what happens afterward.
The 2025 review identified opportunities to strengthen systems at the jail, including standardizing the inventory of emergency carts and bags and checking them daily, reinforcing procedures intended to prevent medication diversion, and increasing custody involvement during medication administration to help ensure required mouth checks are completed.
Importantly, the annual review also provides an opportunity to see whether previous recommendations have resulted in meaningful changes.
During the most recent site visit, NCCHC Resources observed that the jail had acted on prior recommendations, including refining withdrawal treatment and hydration practices, changing licensure requirements for intake medical staff, and placing emergency equipment in pre-booking areas.
That longitudinal approach turns mortality review into more than a response to a single event. It becomes part of an ongoing quality improvement process.
Bringing Health Care and Custody Together
Deaths in custody rarely fit neatly within the boundaries of a single department. That makes collaboration between health care and custody particularly important.
One finding from the 2025 review, for example, led to a recommendation to retrain both medical and custody staff on medication administration procedures and the importance of mouth checks to reduce medication diversion.
An independent reviewer with correctional expertise can evaluate those points of intersection and help leaders determine whether policies are not only appropriate on paper but are working as intended in day-to-day operations.
Creating a Culture of Continuous Improvement
No mortality review can change what has already occurred. But a thorough, objective review can help a facility learn from a critical event and use those lessons to strengthen future care and operations.
Regular independent reviews also provide something a one-time assessment cannot: the ability to identify recurring issues, evaluate progress, and determine whether corrective actions are producing sustained improvement.
As this project demonstrates, outside mortality review can provide correctional leaders with an objective assessment, specialized expertise, and actionable recommendations—while helping health care and custody professionals work together toward a shared goal: safer people and stronger systems.
NCCHC Resources provides mortality reviews, technical assistance, accreditation readiness assessments, correctional health care consulting, and other services to correctional systems nationwide.