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Headshot of author Kendra KuehnBuilding Collaborations: Fatality Review Team

by Kendra Kuehn, MSW, APS TARC Team

Adult protective services (APS) and partners continue to look at how to build stronger systems to support and empower older adults and persons with disabilities. Fatality review teams (sometimes referred to as death review teams) are one such multidisciplinary effort. Reviews originated with the goal of bringing professionals together to look at cases to identify systems gaps and improve services in areas such as sudden childhood death, fetal and infant mortality, and domestic violence cases. In 2019, the American Bar Association Commission on Law and Aging (ABA) identified 13 states with a fatality review team at the state, regional, or county level that reviewed elder deaths.
Teams may vary from the county to the state level but collaboration and commitment by partners is a common theme. The ABA’s Elder Abuse Fatality Review Teams: Replication Manual, notes “There are two hallmarks of successful fatality review teams. Open and honest discussion of system flaws and ideas for fixing those flaws cannot be fostered without them. The first is a culture of avoiding 'blame and shame.' The second is an environment that treats team discussions as confidential and prohibits their disclosure outside the team.”
Below, three fatality review teams share insights into their work.

County Level: California - San Diego County Elder and Dependent Adult Death Review Team

In 2001, California passed legislation allowing the creation of elder death review teams. This legislation included recommended members and addressed information disclosure. The San Diego County Elder and Dependent Adult Death Review Team (EDADRT) was started in 2003 and was expanded to include younger adults with a disability in 2011. EDADRT was one of the first elder death review teams in the country. The team is chaired by the Medical Examiner’s Office, Aging & Independence Services/APS, and the District Attorney’s Office. Members of the team include relevant county agencies, law enforcement, social services, healthcare professionals from six hospitals, and mental health services among others. An APS member also serves as the coordinator and works with the chairs to set meetings, choose cases, and develop agendas. Meeting three to four times a year, the team covers cases involving the death of an elder person or dependent adult under suspicious, tragic, or criminal circumstances, generally presented by law enforcement or the District Attorney’s Office. During a roundtable discussion, APS and other agencies who have touchpoints with the individual or suspect will also share history. The team does not have dedicated funding, but APS currently provides funding for lunch and snacks as an added enticement for attendance at meetings. The team’s goal is to work towards identifying gaps in services and making recommendations for prevention and response.
Rami Djemal, San Diego APS Collaboration & Resource Administrator, notes the main challenges for the team are around finding cases that meet review team coverage criteria and have an impact among all participants as well as the difficulties of implementing systemic change. The team’s main success is the buy-in and participation of its members who attend meetings, share insights, provide recommendations, and are respectful in all discussions. Coming out of the COVID-19 pandemic Djemal sees “the EDADRT making advances in how to implement the ideas and recommendations that come out of our meetings.”

Regional Level: Virginia - Northern Region Adult Fatality Review Team

In 2015, Virginia enacted legislation allowing development of local and regional adult fatality review teams in order to develop intervention and prevention strategies. While not yet funded, Virginia law also authorizes a state level fatality review team. With support from the Virginia Office of the Chief Medical Examiner, the Northern Region Adult Fatality Review Team (NRAFRT) started meeting in November 2016 to develop protocols and train members. It began to review cases in 2018. The team suspended reviews in 2020 due to the COVID-19 pandemic but started back in 2022 with adjusted procedures to allow for virtual reviews. The region includes 25 localities and members including the medical examiner, local APS, adult licensing, Veteran’s Affairs, the community services board, the public guardian program, health departments, area agencies on aging, victim witness providers, prosecutors, and law enforcement.
Under NRAFRT’s protocols anyone may refer a case for review. Cases must be from NRAFRT’s region, and the victim must meet the following statutory requirements:

  • was an older adult or a younger adult who was incapacitated,
  • was someone who was the subject of an APS or law-enforcement investigation,
  • was someone whose death was due to abuse, neglect, and/or exploitation, or whose death was identified as suspicious.

A review is delayed until any criminal investigations are completed, or the state allows a review prior to completion of the investigation. The team has developed tools for both case presentation and assessment of factors that may have contributed to the death. These tools and the process have helped guide both member agency work and initial recommendations from the team which include strengthening community education and awareness of resources, strengthening interagency collaboration for continuity of services such as through multidisciplinary teams, and reducing barriers to services and training for caregivers. Andrea Jones, Virginia Department for Aging and Rehabilitative Services APS Division Regional Consultant, noted “getting this [recommendations] report out to local Department of Social Services and other community partners is the biggest accomplishment, and has helped to legitimize the effort as an abuse prevention strategy.”

State Level: Maine Elder Death Analysis Review Team & Aging and Disability Mortality Review Panel

At the state level, Maine has two teams that are able to review the deaths of older adults. In 2003, legislation passed establishing the Maine Elder Death Analysis Review Team (MEDART). The statute outlines both the development of the team and confidentiality of proceedings and records. The sixteen-member team includes the Office of the Attorney General, the Department of Health and Human Services which includes APS, law enforcement, medical professionals, and victim advocates. The team reviews cases brought forward by members for both specific actions that may need to occur (e.g., filing a complaint with a licensing board) and any policy or legislative recommendations. As in San Diego and Virginia the team does not have dedicated funding, limiting the capacity of the team. Erin Salvo, Maine APS Associate Director, notes “A strength of MEDART is that the enabling statute related to the work permits the group to access information and records needed for the review that may not otherwise be made available – having this authority clearly defined in statute is valuable.”

In 2021, statute created the Aging and Disability Mortality Review Panel which has authority to review preventable or suspicious deaths and serious injuries of adults receiving home and community-based services (HCBS) from Maine’s Medicaid agency, MaineCare. This group is appointed by the Commissioner of the Maine Department of Health and Human Services and includes representatives from the Department of Health and Human Services, the Office of the Attorney General, the protection and advocacy agency, and the HCBS community. The team includes a coordinator who reviews deaths and collects information. While APS is not a panel member, they provide records and responses on APS involvement in the cases. Similar to MEDART, the goal is to provide recommendations for systems improvement.

Takeaways: Starting a Team

In concluding, Djemal notes “For any other jurisdictions looking to start a team, there must be buy in from the upper echelons of all the major partners. The initial MOU for San Diego in 2003 included four signatories: The District Attorney, APS, The Medical Examiner’s Office, and the San Diego Sheriff’s Department. Jurisdictions exploring this option should come to San Diego or a nearby jurisdiction to attend a meeting and experience it themselves. The meetings themselves are simple to organize and impactful. There just needs to be the prioritization by all involved to attend the meetings and work towards soliciting partners around the county to present their cases.”   

Contributions by:

  • San Diego County Elder and Dependent Adult Death Review Team: Rami Djemal, APS Collaboration & Resource Administrator; Dr. Steven Campman, Chief Medical Examiner; Jennifer Sovay, Deputy Director, Aging & Independence Services; Scott Pirrello, Deputy District Attorney
  • Northern Region Adult Fatality Review Team: Andrea Jones, APS Division Regional Consultant
  • Maine Elder Death Analysis Review Team & Aging and Disability Mortality Review Panel: Erin Salvo, APS Associate Director


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