How reviewing deaths can save lives

Imagine a room full of people discussing records spanning your entire life. Maybe it’s your grades in school, hospital visits, run-ins with the local police or even church attendance.

They’re talking about ways they could’ve prevented your death. 

This is what fatality reviews are all about: finding the gaps in a community where people fall through. 

This is the second year the Laramie County coroner has been a leader in such reviews of people who’ve died from suicide. The office is working with  people from all parts of the community, including Veterans Services, mental health providers and even the fire department. 

Already, they’ve identified ways to help residents by distributing resources at RV parks and training employees at funeral homes and animal shelters, where desperate people may show up to make arrangements.

“People will surrender their animals,” said Chief Deputy Coroner Char Madden. “So if somebody’s in crisis, we have trained some of those other organizations to hopefully recognize and try to help those people, or at least call somebody that can help.”

Starting Thursday, a similar but new process will begin in Laramie County: overdose fatality reviews.

“Our overdose deaths have gone up tremendously,” Madden said. “We want to see what we can do as community leaders … to try to prevent some of these overdose deaths.”

As of late June, Madden said Laramie County was the only one in Wyoming performing the fatality reviews. However, the coroner and health officials did talk at the coroner’s association conference to others interested in overdose fatality reviews.

“I did get some feedback and interest on doing an overdose fatality review in a couple of other counties,” said Dr. Angela Vaughn, a community health project director through Cheyenne Regional Medical Center. “So hopefully, we see that up and coming because we have had a lot of really great recommendations come out of the suicide fatality review.”

Suicide has been on the minds of many in a state with the nation’s highest rate as of 2021, though recent state data shows the numbers fell significantly last year. Meanwhile, an opioid crisis driving increases in overdose deaths started to sink its teeth into Wyoming in the last few years. 

With limited local overdose data, counties and towns often turn to those on the front lines of the opioid crisis to decide how best to spend the millions in opioid settlement funds now flowing into the state. 

However, even local health workers and law enforcement could be missing areas where they could better work together to prevent tragedy, Vaughn said. 

“We know that there are gaps in our community systems, just like there are in any community system,” Vaughn said. “But we’re really passionate about prevention and learning from other people’s experiences to ensure that we can provide people with a better, more cohesive system to rely on.”

Fatality review origins 

Local officials in Los Angeles convened the nation’s first fatality review in 1978 to analyze and prevent the death of children, according to research by the Legislative Analysis and Public Policy Association.

Since then, several other kinds of reviews have cropped up, ranging from suicides to homicides.

Overdose fatality reviews, or OFRs, are a relatively new response to the nation’s opioid crisis, according to Melissa Heinen, an overdose fatality review manager with the Institute for Intergovernmental Research.

While Maryland likely had the first OFRs in 2013, Heinen said the national OFR framework grew out of homicide reviews in Wisconsin in 2019. After that, the reviews gained swift support — and some funding — from federal agencies, she added. Adoption has been rapid ever since.

“We have over 40 states that either have [an] OFR, or we know are actively starting one,” she said. “And then when you look at actual OFRs … we’ve estimated anywhere around 300.”

These reviews are predicated on the idea that people with substance use disorders can be helped, Heinen said. 

“I think a big part of an OFR is understanding that overdoses are preventable … and addiction is a disease and recovery is possible,” she said. “You need, really, everyone at the table to buy in, understand and agree to those core aspects of the work.”

“At the end of the day, these are family members, friends, neighbors. These are people who, when resources and services are available and they access them and recovery happens, can lead thriving lives.”

The review process can also combat stigma, Heinen added. 

“By participating in an OFR, just by doing that, we begin to humanize the victims of overdose,” she said. 

There are even efforts to pass state laws to make room for and support these reviews, something Heinen has discussed with other national organizations.

However, the review going on in Laramie County doesn’t have much direct funding behind it, according to Vaughn, often managed by those already working on adjacent efforts. 

Asked why the Laramie County Coroner’s Office and others are taking this on beyond everything else they’re required to do, Madden said it’s because they believe they can make a difference.

“It’s because the people that work here, we all have a vested interest in helping the community,” she said. “Every one of us do. And, you know, if we can prevent a death, then we want to do that.”

Coroner Rebecca Reid added via email that they need to raise awareness, be transparent and, “we need these types of programs in our community.”

“[W]e need to end suicide and help put a stop to drugs. I feel with everyone working together it will be possible.”

Privacy

An individual’s and family’s privacy is paramount, Madden said. Laramie County’s OFR requires family buy-in via a consent form to even start the process.

While the majority of families opt into a review, some have declined, and Madden said she understands.

“You’re trying to move on,” she said. 

With familial consent, participants like law enforcement and mental health providers can search their records for that person, which they will present verbally to the group.

Even notes taken during the reviews will be confiscated and shredded at the end of the meeting: No private information leaves with someone it shouldn’t, Madden said. 

The review of each person’s life takes about an hour, Madden said, and the review group is expected to work for three to four hours every three months. Breaks are built into every meeting because it can be hard hearing the details of exactly how someone died. 

“We review the case: when we were called, what we saw, so they’re getting all of the details about that death,” Madden said. 

From a national perspective, Heinen said OFRs can look at everything from adverse childhood experiences to whether police let a school know if a child’s parent has had an overdose in the home. The suggested changes are a unique reflection of the nuanced communities where the reviews are conducted, she said. 

“So it really is infinite in all the different ways that communities are realizing that there are gaps or missed opportunities in people’s lives where prevention and intervention could have occurred, and figuring out together, how to make sure that doesn’t happen again,” she said. 

For Madden, this isn’t a process to shame agencies for what they haven’t done, but to identify what could be done. 

“We don’t point blame at any one agency or any one person or anything like that,” she said. “It’s more of: how could we do better?”

To add records and participate in these Laramie County OFRs, prospective group members can contact Vaughn at angela.vaughn@crmcwy.org. Madden said her office is also more than happy to share information with other interested coroners’ offices. 

If you or someone you know is having suicidal thoughts, you can call or text The National Suicide Prevention Lifeline at 988.