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Forensic psychiatrists and psychologists tend to focus primarily on the individual cases they work on. However, they also have a significant public health role — especially on fatality review teams.
These multi-disciplinary, multi-agency teams look back on individual deaths to determine whether reasonable medical, educational, social, legal, or psychological interventions might have prevented the death. The team makes public health, mental health, and legislative recommendations based on their findings.
Drs. Susan Hatters Friedman and Josh Friedman discussed fatality review teams during the February 13, 2025, International Forensic Psychiatry Lecture Series. (You can watch a recording of the lecture online.)
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Fatality Review Team Membership
These teams include agencies that interacted with the person before their death or collected information afterward. They may include:
- Law enforcement and the justice system, who provide information from their death scene investigation and witness interviews as well as any criminal record;
- Forensic pathology, who report on the cause of death (for example, suffocation, blunt force trauma, drowning, specific medical disorder) and manner of death (for example, homicide, suicide, natural cause, accidental, undetermined), including autopsy and toxicology findings;
- Health services, who provide the person’s medical, psychiatric, and substance use health histories;
- Social services, who provide information about education, child protective services, and corrections;
- Tribal or band council, depending on the location;
- Military; and
- Clergy.
Child fatality review teams may also include a child abuse pediatrician (like Dr. Friedman), school officials, and agencies providing food, housing, and legal aid.
Role of Forensic Mental Health Professionals
Forensic mental health professionals (like Dr. Hatters Friedman) bring valuable knowledge and expertise to fatality review teams. They help reduce stigma and clarify what mental illness is and is not. They can also share information about public policies affecting mental health, addictions, and the law.
They help the team better understand the mental health of the perpetrator or victim. That includes diagnoses, addictions, the relationship between mental illness and violence, and risk factors for suicide and homicide.
In maternal-infant fatality reviews that focus on deaths during pregnancy and the first year after, mental health professionals can share their knowledge about postpartum depression and postpartum psychosis, including how to screen and treat these conditions.
When it comes to elder abuse fatality review teams, they can explain guardianship, decision-making capacity, and age-related conditions like dementia and delirium. They may also provide insights into the criminal exploitation of the elderly.
How Fatality Review Teams Work
The team can begin its work when a death meets its complex criteria. For example, a domestic violence fatality review team may only examine cases involving intimate partner deaths. However, another team’s criteria may also include related deaths, such as when a woman’s ex-partner kills her new partner.
Each member shares their agency’s data to build a more complete story of the death than any one agency could provide alone. To allow the teams to be as open as possible, members sign strict confidentiality agreements, and the closed sessions are protected from subpoenas and discovery.
The team identifies gaps and overlaps in their services and finds ways for their agencies to better work together. Their reviews can even improve the accuracy of death certificates.
The team publishes annual aggregate reports and recommendations, so no one case can be identified.
Recommendations may include educating health providers about domestic violence screening and reporting or training police to use lethality assessment protocols when responding to such incidents.
Opioid overdose fatality review teams consider recurring and emerging drug trends to guide public health and policy recommendations.
Some recommendations have led to safe haven laws for newborn babies and firearm laws.
Written by Virginia St-Denis and approved by Dr. Susan Hatters Friedman and Dr. Josh Friedman.
