Mortality Review Office

What we do

The purpose of the DBHDS Mortality Review Office (MRO) is to focus on system-wide quality improvement by conducting mortality reviews of individuals; residing in a state operated facility (DBHDS Facility Mortality Review Committee or FMRC), and those with an intellectual and/or developmental disability (I/DD) diagnosis who were receiving a DBHDS licensed service in the community at the time of death (DBHDS Mortality Review Committee or MRC). The Mortality Review Committees provide ongoing monitoring and data analysis to identify trends and patterns, and make recommendations to promote the health, safety and well-being of said individuals to reduce mortality rates to the fullest extent practicable.


As a commitment to the Commonwealth of Virginia, DBHDS and the MRO contribute to the system of care improvements through integration of clinical evidence, data driven determinations, and evidenced based quality improvement recommendations. Review and analysis of the trends, patterns, and problems related to the deaths of these individuals can identify opportunities for system improvements to reduce risks to all individuals receiving behavioral health or developmental services. On an ongoing basis, DBHDS seeks to prevent instances of abuse, neglect, exploitation, and unexplained death by identifying and addressing relevant factors during mortality reviews.


The MRO provides ongoing monitoring and data analysis to identify trends and/or patterns and then makes recommendations to promote the health, safety and well-being of said individuals.

As part of the case review, both of the mortality review committees seek to identify and determine:

  • The cause of death
  • If the death was expected
  • Whether the death was potentially preventable
  • Any relevant factors impacting the individual’s death
  • Any other findings that could affect the health, safety, and welfare of these individuals
  • Any actions which may reduce these risk factors and findings (e.g. Provider training, education, and/or communication regarding alerts and risks)
  • Relevant recommendations and/or interventions for any identified actions

If any actions are identified as needed based on the individual’s case review, the DBHDS mortality review committees will then make and document relevant recommendations and interventions in their committee meeting minutes or notes. For the MRC, these are also documented on the Action Tracking Log, which is reviewed at every MRC meeting to ensure follow-up and completion.