Fatality Review Referral Form Instructions Rev. 05/07/2017
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1. The purpose of Fatality Review is to ensure that court processes, procedures and actions minimize the risk of harm
to people who use the courts. The goals of Fatality Review are to: (a) examine referred court cases where a death
has occurred to identify any patterns or trends that may have been present; (b) examine court records and procedures
to determine whether proper steps were taken; (c) review applicable statutes and rules to determine whether
amendments are needed; and (d) assess whether court officers and staff, as well as other involved agencies followed
required processes and whether there was a coordinated effort among agencies to address the issues in the case.
2. To be considered for review, cases must involve deaths: (a) that may have resulted from abuse or neglect of a child
involved in, or closely associated with, an abuse and neglect case or a family law court case; (b) of juveniles who
are detained in a secure juvenile facility or in an out-of-home placement by virtue of a court order; and (c) that result
from domestic violence while the decedent was the subject of a domestic violence case.
3. The referral form should be completed to the best of your ability based upon the information available for review.
The form must be typed or legibly hand-printed in blue or black ink only. Do not use pencil. Please attach any
documents that you have which you think may assist in the investigation including, but not limited to, any of the
items set forth in No. 11 of the referral form.
4. The referral form should be submitted to:
Gary Johnson, Administrative Director
West Virginia Supreme Court of Appeals
Building One, Room E-100
1900 Kanawha Blvd, East
Charleston, WV 25305-0830
(304) 558-1212 (fax)
5. The Administrative Director of the Supreme Court of Appeals of West Virginia or the Administrative Director's
designee will submit the referral to Chief Counsel for the Judicial Investigation Commission (JIC) for further action.
Referring a case does not guarantee that it will be investigated or reviewed.
6. JIC Counsel and/or Investigators will conduct any investigation and present findings to the Regional and State
Fatality Review Team ("the State Team"). As part of the investigation, JIC Counsel and/or Investigators may contact
you for further information.
7. In order to facilitate a complete investigation, clerks and other judicial staff of all Circuit, Family and Magistrate
Courts of this State shall provide JIC Counsel/Investigators access to all case records, whether or not confidential,
including recordings of hearings and to provide copies of any such case records and recordings upon request,
without cost. Additionally, all law enforcement agencies shall provide to JIC Counsel and Investigators information
and records, without cost, regarding criminal investigations of any fatality under review.
8. All proceedings and records of the
State Team are confidential and are not subject to subpoena, discovery or
introduction into evidence in a civil or criminal action. The records, which include oral and written
communications, are also not subject to the Freedom of Information Act.
9. The State Team shall report its findings and recommendations in a report that may be submitted to the public. The
Report may contain general statistical data regarding deaths as well as findings and recommendations related to case
reviews. However, the report shall not contain case specific information.
Fatality Review Referral Form Rev. 05/07/2017
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TO: Gary Johnson, Administrative Director
West Virginia Supreme Court of Appeals
Building One, Room E-100
1900 Kanawha Blvd, East
Charleston, WV 25305-0830
Fax: (304) 558-1212
All documents provided will be kept confidential.
Personally identifying information is removed
from all fatality review reports. Documents
obtained during investigations are destroyed once
the State Fatality Review report is submitted and
accepted by the Supreme Court.
Today's date:
/ /
Your name & title:
Your telephone no.:
( )
Your e-mail address:
1. Name of decedent including aliases:
2. Decedent's last known address:
3. Date of decedent's death:
/ /
4. Date of decedent's birth:
/ /
5. If decedent is a minor, name of parents/guardians:
6. Most recent case number and type of case involving decedent and the county where the matter was filed:
7. Cause of decedent's death:
8. If decedent's death was caused by another, please provide the name of the person you believe responsible, any aliases,
last known address, and any court case number, type of case and county where the matter was filed:
9. Date of Birth of person you believe responsible for the death:
/ /
10. Relationship of the decedent to the person you believe responsible for the death:
11. Please attach copies of the following documents (if you have them):
Autopsy Report
Plea of Guilty
Presentence Report (excluding sentence recommendation)
Death Certificate
Police Report
Plea Agreement
Sentencing Order
Case Docket Sheets
Abuse & Neglect File
12. A short explanation of why you think the death should be reviewed (use additional pages if necessary):
The State Fatality Review Team welcomes any other information you may wish to provide which would help in
understanding the history and circumstances of the fatality.
, or approximate age: