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Report on Massachusetts Department of Mental Health Service Recipient Mortality 1991-1993




The Critical Incident Reporting Task Force


This report describes the results of a task force that investigated deaths among persons served by the Massachusetts Department of Mental Health (DMH) in recent years. The report has sections addressing the trend in the mortality rate, recommendations for improvement in data systems, preventable or postponable deaths, and the investigation process. The task force specified 38 recommendations to the DMH for system improvement. The Evaluation Center@HSRI provided technical assistance to the task force and is now disseminating the report in hopes that it may serve as a model for similar analyses elsewhere.

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