Morbidity Mortality Review Meeting GD if 707882
Date: August 14, 2015
Place: Superintendents Conference Room

 

Chairperson: Lynne Glilis HSA

Attendees: See attached attendance list and signature: Superintendent Michael Marks, Assistant Superintendent Michael Frost,

Lynne Gillis RN HSA, Dr Arun Chaudhary, and Samantha Spagnuola MHC

 

VII.



IX.

Call to Order:

Old Business
None.

Facts: Attached are Physician and HSA reviews. All relevant documentation.

Procedures Followed 
incident report and code sheet attached.
Post-code, the patient was transferred to Beverly Hospital. Time of death 16:12 hrs.

Staff Training
Staff responded appropriately. Documentation complete.

Reporting
Summaries were reviewed.

Root-Cause Analysis


Recommendations

There will be some research as to why the inmate was sent to administrative segregation. The
day of suicide he was exhibiting some medical as well as mental health issues. Was there 3 MH
hold in place since nothing was documented in the chart about a hold.

Autopsy: none at this time

Adjournment