4-10/060.00 Critical Incident Review Committee - Suicidal Inmates

If Correctional Health Services (CHS) identifies serious self-injurious behavior, the Critical Incident Review Committee - Suicidal Inmates (CIRC-SI) will meet to review and analyze the incident within 30 working days. Refer to JMH Policy 50.1 Continuous Quality Improvement, and 50.2 Critical Incident Review.

The CIRC-SI is comprised of a Custody Services Division commander, Access to Care lieutenants (ATCs) from concerned facilities, management and command-level medical and mental health personnel from CHS, and Critical Incident Review Unit (CIRU) personnel from Custody Compliance and Sustainability Bureau (CCSB). The goal of CIRC-SI is to provide assistance to custody, medical, and mental health staff in their effort to implement proactive measures to prevent high-risk inmates from attempting or committing suicide.

The review will consider whether violations of policy or laws were a factor in the incident. The review will also consider whether improvements to policy, training, operations, programs or to the facility are warranted. Refer to JMH Policy 50.2, "Critical Incident Review," for JMH review procedures.

CIRC-SI MEETING

For each critical incident the following information shall be reviewed:

• Events preceding and following the incident
• Incarceration history
• Mental health and health history
• Prior suicide attempts or other serious self-injurious behavior
• Location of incident
• Method and lethality of self-injurious act
• Demographic information and proximity to court date
• Use of clinical restraints
• Psychotropic medications
• Access to care, timeliness of service, and utilization of the Forensic In-Patient Unit (FIP)
• Elements of documentation and use of medical records
• Identify necessary corrective action

Corrective action plans (CAP) which identify areas in need of improvement and propose solutions will be developed and documented in accordance with CDM section 2-00/070.00, "Custody Compliance and Sustainability Bureau."

The concerned facility or unit will be responsible to prepare and submit a response to the CAP to CCSB within the time allotted by the respective commander, depending upon the urgency or complexity of an issue. The concerned facility or unit will be responsible to address the identified issue(s), as well as provide a projected completion date(s).

The CCSB will follow up with the concerned units through the completion of the corrective action. Upon being notified that a CAP item has been completed, CCSB will collect supporting documentation and update the CAP as complete.

All other significant incidents shall be reported to the appropriate units as described in Custody Division Manual (CDM) section 4-07/010.00, "Notification and Reporting of Significant Incidents."

JOINT QUALITY IMPROVEMENT COMMITTEE

The Joint Quality Improvement Committee (JQIC) meets monthly to provide a status update of any issues identified as potential CAP items during the CIRC-SI meetings. The JQIC attendees include those who attend the CIRC-SI and ATCs; a commander may be present but is not required to attend. Also discussed during the meeting is the effectiveness of the actions and improvements of recommended solutions in prior reporting periods. Custody and CHS personnel collaborate to address on-going or newly identified issues regarding serious self-injurious behavior, suicidal behavior, and other behaviors identified by mental health personnel.

Topics addressed during these meetings include, but are not limited to:

• Prior suicide attempts or other serious self-injurious behavior
• Locations, methods, lethality, demographic information, and proximity to court date
• Use of clinical restraints
• Psychotropic medications
• Access to care, timeliness of service, and utilization of the Forensic In-Patient Unit (FIP)
• Elements of documentation and use of medical records