Department for Community Based Services

Standards of Practice Online Manual

20.4 Adult Fatality Investigation and Review

Cabinet for Health and Family Services

Department for Community Based Services
Division of Protection and Permanency
Standards of Practice Online Manual
Chapter 20-APS Investigations and Assessment
20.4 Adult Fatality Investigation and Review

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Legal Authority/Introduction



The SSW:

  1. Accepts all reports of adult fatalities that occur due to alleged abuse, neglect or exploitation, including domestic violence reports; 1
  2. Or service region staff contacts the Director of the Division of Protection and Permanency (DPP) or designee in central office to determine if the case should be treated as an adult fatality, if a death occurs during an investigation, and staff feel strongly that the death was unrelated to abuse, neglect or exploitation; 
  3. Forwards the Notice of Adult Fatality form via fax to the central office Adult Safety Branch at (502) 564-3096;
  4. Attempts to interview the alleged perpetrator as soon as possible without interfering with the law enforcement investigation; 2  
  5. Completes the adult assessment on the investigation of an adult fatality;
  6. Enters all information and submits it to the FSOS within thirty (30) working days unless the FSOS or designee grants an extension to complete the investigation;
  7. Documents reasons for delays in the investigation or interview with the alleged perpetrator or the alleged victim; 3 
  8. Notifies law enforcement of all fatalities alleged to be a result of abuse or neglect; 4   
  9. Initiates phone contact with law enforcement and the coroner to clarify roles and establish a common channel of communication.

The FSOS or designee: 

  1. Notifies the SRA and the Director of the Division of Protection and Permanency in writing (fax or e-mail) of the adult fatality upon acceptance of the allegation; 
  2. Assigns staff to investigate and is responsible for coordinating the investigation, which includes reviewing databases to determine any prior DCBS involvement or other information pertinent to the case.

The SRA or designee:

  1. Assumes responsibility for coordinating department activities, if the FSOS requests assistance; 
  2. Determines the appropriate staff person to investigate; 5 
  3. Meets with all DCBS staff involved in the case upon request by the FSOS. 6  

Practice Guidance

  • Investigations involving the death of an adult follow the guidelines in SOP  20.2 General Interviewing Guidelines.
  • Collateral contacts with law enforcement, medical personnel, coroner and  other appropriate persons may be made to assess potential danger to staff.
  • When the Office of the Inspector General (OIG) is involved in an investigation as outlined in SOP 20.6 Investigations in Alternate Care Facilities,  DCBS and OIG staff share information regarding the facility history and the investigation.
  • Whenever possible, the investigation is coordinated and conducted jointly.
  • If the investigation cannot be coordinated to perform an on-site visit with OIG staff within the designated time frames, the SSW proceeds with the investigation. However, ongoing communication with OIG staff regarding the case is maintained.


  1. In addition, if an abused and/or neglected adult dies during the course of a DCBS investigation, the case shall be treated as an adult fatality.  
  2. If the alleged perpetrator refuses to be interviewed, this is documented.
  3. Staff are encouraged to consult with the central office Adult Safety Branch regarding findings of the adult fatality investigation.  
  4. A joint investigation is conducted, whenever possible.  
  5. It may be advisable that staff who have had prior direct involvement with the case not be assigned to conduct the investigation. If feasible, the assigned investigator consults with staff who have direct knowledge of the case prior to initiating the investigation. 
  6. Central office staff is also available for consultation during this process. 


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