18 V.S.A. § 7258: Review of adverse community events

The Department of Mental Health shall establish a system that ensures the comprehensive review of a death or serious bodily injury occurring outside an acute inpatient hospital when the individual causing or victimized by the death or serious bodily injury is in the custody of the Commissioner or had been in the custody of the Commissioner within six months of the event. The Department shall review each event for the purpose of determining whether the death or serious bodily injury was the result of inappropriate or inadequate services within the mental health system and, if so, how the failure shall be remedied.