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Rhode Island Suicide Fatality Review Team

Definition: A community-driven process that allows local, state, and tribal fatality review teams to evaluate the chain of events leading up to a suicide and use the data to share insights to promote suicide prevention. In Rhode Island, the Suicide Fatality Review Team (SFRT) shares this data back out to the public, state officials, and suicide prevention partners in the form of an annual report containing the systems-level recommendations stemming from the case reviews. It is our hope that the annual report and the recommendations within can help to inform grant proposals, state budget line items, and other important suicide prevention initiatives in Rhode Island.

Goal/Objectives: The Rhode Island Suicide Fatality Review Team (SFRT) is a multidisciplinary group established in 2025 (RI Gen. Laws § 23-4-3) to reduce the prevalence of suicide deaths in Rhode Island by identifying areas for systems change. To accomplish this goal, there are 5 objectives:  

  • Identify and review cases representative of suicides within Rhode Island.  
  • Make recommendations aimed at improving suicide prevention and treatment infrastructure based on case review.  
  • Communicate and promote recommendations to state and community agencies, and the public.  
  • Ensure multi-disciplinary SFRT membership representative of the Rhode Island population.  
  • Foster interagency collaboration for the advancement of the SFRT and their recommendations.  

Confidentiality: To ensure privacy for the individuals who have died by suicide and their families, the SFRT meetings are closed to the public, and all meeting attendees are required to sign confidentiality agreements before participating or receiving case documents. Attendees are not allowed to discuss cases with anyone outside of the SFRT. In addition, they are asked to securely store and/or destroy notes related cases to reduce accidental disclosure of sensitive information. While our case abstractors/meeting facilitators and epidemiologists have access to identified information, names of people and organizations are removed from narratives prior to distributing to the larger team to ensure privacy for the decedent and their family. 

Case Definition: The SFRT reviews a subset of deaths among Rhode Island (RI) adults over 21 years old that occurred in RI and have been classified as suicides by the Office of the State Medical Examiner (OSME). Suicide deaths among those 21 and younger are excluded as these deaths are reviewed by the Rhode Island Child Fatality Review team. 

Case Selection/Identification process 

  • Each quarter using suicide death data provided by the OSME, the team at the Rhode Island Department of Health (RIDOH) selects a topic or theme to explore (e.g. older adults, decedents with recent legal trouble, divorced individuals, etc.). Topics are chosen based on epidemiological data, anecdotal evidence from team members, and trends noted in previous case review meetings. Circumstances associated with suicide deaths are entered as part of the Rhode Island Violent Death Reporting System (RIVDRS), and these data are used to help identify themes and facilitate review.   
  • Once the topic is confirmed, the epidemiologist selects a random sample of suicide fatalities from that population. Cases are screened to ensure there is enough data present to complete a thorough review and that the random sample is representative of the population. The SFRT reviews 2-4 cases each meeting. 

Agencies represented by Team Members  

  • Bradley Hospital  
  • Brown University  
  • Brown University Health  
  • Burrillville Police Department  
  • Butler Behavioral Health 
  • CODAC Behavioral Health 
  • Community Care Alliance 
  • Crisis Intervention Teams of Rhode Island  
  • Elevated Results Consulting  
  • JSI Research and Training Inc.   
  • The Providence Center  
  • Providence VA Medical Center  
  • PTR Ministries  
  • Rhode Island Department of Behavioral Health, Developmental Disabilities,   
    and Hospitals  
  • Rhode Island Department of Health  
  • Rhode Island Office of the State Medical Examiner 
  • Rhode Island District Court, Pretrial Services Unit 
  • Rhode Island Overdose Fatality Review team  
  • South Kingstown Fire Department  
  • TVTP Solutions 

Data sources 

  • RI SFRT uses documents in the Office of the State Medical Examiner’s case files to create a case narrative in which all personal information (name, dates, addresses, names of hospitals, etc.) have been removed. 
  • In addition, medical, criminal justice, and behavioral health records are requested from specific organizations identified within the OSME case files. 
  • Records may include: 
  • Police report from the incident 
  • Medical Examiner Investigator report from the incident 
  • Emergency Medical Services (EMS) report from the incident 
  • Autopsy and death certificate information  
  • Toxicology Information 
  • Medical history 
  • EMS history 
  • Hospital Discharge Data 
  • State behavioral health records 
  • Private behavioral health records 
  • Prescription Drug Monitoring Program report 
  • Medicaid claims summary 
  • Legal history 
  • Employment summary 
  • Obituary 
  • Social Media/Internet information 

Definitions 

  • Multi-Disciplinary Teams - A group of professionals from different fields who work collaboratively to address a common goal, such as reviewing a complex case. This approach is used in various sectors like child protection, elder justice, and healthcare to improve outcomes by sharing information, coordinating services, and making decisions together. MDTs are characterized by shared decision-making, a partnership between disciplines, interdependence, and a structured process for accountability. 
  • Manner of Death (MOD) - The general classification of how the death occurred, which can be natural, accident, suicide, homicide, or undetermined. Manner is the “how”. 
  • Cause of Death (COD) - The specific disease or injury that initiates the chain of events leading to death. Cause is the “what”.

The SFRT puts forth an annual report containing a set of prevention recommendations for the Suicide Prevention Advisory Committee and all state agencies working on suicide prevention. The SFRT will continually review cases and update recommendations annually based on their findings.

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