NYS Justice Center Annual Report 2025

MORTALITY REVIEWS

MORTALITY REVIEWS The Protection of People with Special Needs Act requires the deaths of all individuals receiving services from a residential facility or program licensed, certified, or operated by OPWDD, OMH, OASAS or OCFS to be reported to the Justice Center. In addition, the death of any person who received services from the above facilities in the 30 days prior to their death must also be reported. Any time a death is reported to the Justice Center where there is an allegation of abuse or neglect, a separate notification is sent to both the district attorney and the medical examiner.

The Justice Center developed a protocol that it follows for reviewing abuse or neglect cases where a death is involved. Initial review involves input from a supervising investigator, a criminal investigator, a lead Justice Center investigator, the regional nurse, the Assistant Special Prosecutor for the region and a representative from the Office of General Counsel. This comprehensive approach allows team members with varied backgrounds to advise on the approach for the investigation. The team is presented with information including medical and clinical history of the individual receiving services, a synopsis of the circumstances surrounding the death, involvement by local law enforcement, medical examiner or district attorney and history of any concerns regarding the program or facility. Cases of abuse or neglect involving the death of a person receiving services does not necessarily mean the abuse or neglect caused the death. The Justice Center evaluates causational versus corresponding links when assigning category levels of substantiated cases. The Justice Center’s Special Prosecutor also reviews cases of abuse or neglect with death involved, in addition to notifications to the local district attorney. MEDICAL REVIEW BOARD The Justice Center Medical Review Board (MRB) advises on cases as needed or requested. The MRB consists of up to 15 physicians with expertise in forensic pathology, psychiatry, internal medicine, and addiction medicine. In 2025, the Justice Center referred 13 cases to the MRB. The Justice Center also consults with the MRB for all full death reviews. The MRB members offer their opinion on whether the provider met the standard of care for the deceased. The designated primary reviewer from the MRB for each case is given all information pertinent to the case (documents, summary reports, interviews/interrogations). The case is discussed at the next regularly scheduled MRB meeting. The primary reviewer provides their expert opinion and other members of the MRB can weigh-in on the discussion. The MRB can also consult or perform a full review for all abuse and neglect cases with death involved as needed upon request of an investigator. A consult routinely relates to a specific question while a full MRB review happens after the completion of the investigation and the investigatory question of whether abuse or neglect occurred remains. The MRB also reviews trend reports on completed mortality assessments at least annually.

Process of an Assessment or Investigation The requirement to report a death is not exclusive to those that may have been caused by abuse or neglect. Instead, the death of every service recipient in these residential settings, regardless of the circumstances, must be reported to the Justice Center. For this reason, the agency has divided investigations into two separate categories. EXECUTIVE LAW § 556 REVIEWS Most of the death reports received by the Justice Center fall under Executive Law § 556. This section of law requires administrators of residential programs licensed, operated or certified by OPWDD, OMH, OASAS, and OCFS to report all deaths of residents to the Justice Center, regardless of whether the death is unusual or expected. The purpose of this reporting is twofold: to monitor and examine whether quality of care issues may have contributed to an individual’s death and to make recommendations to improve future care of individuals receiving services and prevent the recurrence of similar issues. In 2025, the Justice Center… Completed 1,628 mortality assessments – 300 of those assessments were closed with Justice Center recommendations to the residential providers/state agency to support routine quality assurance efforts. Created 68 Justice Center investigations for abuse or neglect death allegations – 61 of those cases were discovered directly due to Justice Center assessment efforts. MORTALITY INVESTIGATIONS Mandated reporters under Justice Center jurisdiction are required to report any death for which they have reasonable cause to suspect abuse, neglect, or a significant incident may have been involved. Any death report potentially involving abuse or neglect follows the same investigative process as other abuse or neglect reports: classification and assignment of unique case number, investigation, and determination. The Justice Center also notifies medical examiners and district attorneys of all deaths reported to the VPCR.