Department for Community Based Services

Standards of Practice Online Manual

20.4 Adult Fatality Investigation

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

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Legal Authority/Introduction



Practice Guidance

  • If the death of an adult is the result of abuse or neglect, this will be referred to as an 'adult fatality'. 
  • 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.


The SSW:

  1. Forwards the Notice of Adult Fatality form within two (2) working days of becoming aware of the adult's death via email to the central office (CO) Adult Protection Branch at; 
  2. Attempts to interview the alleged perpetrator as soon as possible without interfering with the law enforcement investigation; ​1   
  3. Completes the adult assessment on the investigation of an adult fatality;
  4. 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;
  5. Documents reasons for delays in the investigation or interview with the alleged perpetrator or the alleged victim; ​2  
  6. Notifies law enforcement of all fatalities alleged to be as a result of abuse or neglect; ​3    
  7. Initiates phone contact with law enforcement and the coroner to clarify roles and establish a common channel of communication; and 
  8. If a death occurs during the course of an investigation, the SSW will consult with their supervisor and SRA (or designee) to determine if the death should be considered an adult fatality due to the alleged abuse or neglect.  4
    1. If the death is believed to be the result of abuse or neglect during the consultation, the SSW will forward additional information to centralized intake (CI) for screening.  

The FSOS or designee: 

  1. Provides the SRA and the ​Adult Protection Branch a copy of the DCBS-115 (by e-mail ​to of the adult fatality upon acceptance of the allegation; and 
  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; and  ​5  
  3. Meets with all DCBS staff involved in the case upon request by the FSOS. 6   



  1. ​If the alleged perpetrator refuses to be interviewed, this is documented.
  2. Staff are encouraged to consult with the Adult ​Protection Branch regarding findings of the adult fatality investigation.  
  3. A joint investigation is conducted, whenever possible.  
  4. Adult Protection Branch staff in CO is also available for consultation during this process. 
  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. Adult Protection Branch staff in CO is also available for consultation during this process. 


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