1. (1) In the event of any adult in custody death, Health Services will determine whether the death is expected or unexpected in a manner consistent with national standards, and inform the Inspector General of that determination.

   1. (a) When the death is expected, the Inspector General will retain any information related to that determination in a manner that complies with applicable patient privacy laws, including ORS 179.495 and ORS 179.505.
   2. (b) When the death of an adult in custody is unexpected, the Inspector General will initiate an Unexpected Death Review as provided in this rule. The initiation of any Unexpected Death Review, and way it is conducted, shall occur at a time and in a manner that is mindful of, and does not interfere with, any existing, pending, or anticipated law enforcement investigations (including death investigations under ORS Chapter 146).
2. (2) The Inspector General may initiate an Unexpected Death Review under this rule for any adult in custody death, including when an adult in custody’s death was expected, when the Inspector General determines, in their discretion, that a review would be appropriate.

3. (3) The Inspector General will select and convene an Unexpected Death Review Committee that will include appropriate department representatives with applicable professional expertise and no previous involvement in the incident.

   1. (a) Appropriate representatives may include, but are not limited to, an assigned Special Investigations Unit manager, an Assistant Superintendent of Security, a Medical Services manager, or a Behavioral Health Services manager.
   2. (b) In cases in which self-harm is involved or suspected, the Unexpected Death Review Committee should include a Behavioral Health Services manager.
4. (4) The Unexpected Death Review Committee will conduct a review and prepare a report that includes the results of the review and a statement of any recommended changes in practices, policies, or procedures to strengthen safety and health protections for adults in custody and to reduce risk of adult in custody death or serious injury.
5. (5) The review by the Unexpected Death Review Committee, and the results of this review, should exclude the data, reports, or contents of any peer review conducted by a medical employee committee of the Department of Corrections pursuant to ORS 41.675.

Statutory/Other Authority

ORS 146.100, 179.040, 423.020, 423.030 & 423.075

Statutes/Other Implemented

ORS 146.100, 179.040, 423.020, 423.030 & 423.075

History

DOC 22-2026, minor correction filed 06/08/2026, effective 06/08/2026
DOC 18-2026, adopt filed 06/08/2026, effective 06/08/2026
DOC 7-2026, temporary adopt filed 03/24/2026, effective 03/31/2026 through 09/19/2026