OCO FY2024 Unexpected Fatality Review — 26 unexpected prisoner deaths, 13 without corrective action plans
The OCO FY2024 Unexpected Fatality Review Annual Report, published January 10, 2025, documents 26 unexpected prisoner deaths in DOC custody during Fiscal Year 2024. Thirteen of those deaths — 50% — generated no DOC Corrective Action Plan. DOC designated 71% of all UFR Committee recommendations as non-binding “Consultative Remarks” with no tracking mechanism. Overdose was the leading cause of unexpected death (7); suicide was second (5). Two deaths occurred in solitary confinement units.
What happened
Under RCW 72.09.770, DOC is required to conduct an Unexpected Fatality Review (UFR) for each death in custody that is unexpected. The UFR process involves representatives from DOC, the OCO, and the Department of Health, who review the circumstances of each death and may generate recommendations. DOC may create associated Corrective Action Plans (CAPs) or designate recommendations as “Consultative Remarks” — advisory comments that are not required to be tracked, assigned, or implemented.
FY2024 overview (July 1, 2023 – June 30, 2024):
- Total deaths in DOC custody: 46
- Deaths classified as unexpected and reviewed by the UFR Committee: 26
- UFR reports resulting in Corrective Action Plans: 13 (covering 26 individual CAP action items)
- UFR reports without any Corrective Action Plan: 13
- Total UFR Committee recommendations: 89
- Recommendations designated as binding CAPs: 29%
- Recommendations designated as non-binding Consultative Remarks: 71%
- CAP action items completed: 20 of 26
- CAP action items in progress or pending funding: 6 of 26
Causes of unexpected death:
| Cause | UFRs |
|---|---|
| Overdose | 7 |
| Suicide | 5 |
| Cancer | 4 |
| Vascular Disease | 3 |
| Infection/Sepsis | 3 |
| Respiratory | 3 |
| Diabetes | 1 |
Solitary confinement connection: Two of the 26 unexpected deaths occurred while the person was housed in solitary confinement — one at Washington Corrections Center, one at Monroe Correctional Complex.
OCO’s concerns and recommendations:
The OCO expressed particular concern about:
- The pattern of DOC designating the majority of UFR Committee recommendations as Consultative Remarks rather than binding CAPs, which removes accountability tracking for most recommendations.
- The absence of consistent tracking for Consultative Remarks: when OCO reviewed DOC’s tracking system, there was no evidence of completion or staff assignment for Consultative Remarks.
- Overdoses and suicides as the leading causes of unexpected death, calling for universal substance use disorder treatment availability and systemwide access to the 988 Suicide and Crisis Lifeline inside DOC facilities.
DOC agreed to three OCO recommendations following negotiations: (1) convene quarterly UFR Committee meetings; (2) track and respond to Consultative Remarks going forward; (3) prioritize 988 access inside prisons. DOC did not agree to change the CAP/Consultative Remark designation framework.
What the primary source says
The OCO FY2024 UFR Annual Report states: “The OCO is also concerned with WADOC’s designation of CAP versus Consultative Remark when it comes to Committee recommendations.” The report notes that DOC’s designation of 71% of recommendations as Consultative Remarks means that the majority of UFR Committee findings carry no binding implementation obligation.
Status
DOC has agreed to prospectively track Consultative Remarks and to convene quarterly UFR Committee meetings. The structural question — whether DOC may designate recommendations as non-binding for any unexpected death, including suicides in solitary confinement — remains unresolved by statute. The FY2025 UFR Annual Report was forthcoming as of the FY2025 Annual Report publication.
Why it’s in the registry
A 50% CAP rate on unexpected prisoner deaths is a documented accountability gap. When half of all reviewed deaths produce no binding corrective action obligation, the UFR process functions as documentation without remediation — the same structural pattern documented across the OCO’s broader work. The concentration of unexpected deaths in overdose and suicide categories, combined with the OCO’s finding that 988 access does not exist systemically inside DOC facilities, identifies a specific, preventable harm with a specific gap in the corrective mechanism.
Reform implication
Two reforms address the structural gap identified here. First, RCW 72.09.770 should be amended to require a DOC Corrective Action Plan for every unexpected death reviewed by the UFR Committee — removing the discretion to designate findings as non-binding Consultative Remarks for any case involving an unexpected death. Second, for deaths in which the cause is unknown at the time of the UFR Committee review, a statutory timeline should be established for coroner determination, with a fallback to independent medical review if that timeline is not met. The current structure allows DOC to close the accountability loop on a death without a binding corrective action and without a complete cause-of-death determination. See [reform: prison_medical_care] and [reform: independent_inspector_general].
Reform implication
The OCO UFR Annual Report presents a structural accountability problem embedded in DOC's implementation of RCW 72.09.770, which requires the department to conduct an unexpected fatality review for each unexpected death in custody. The law requires DOC to produce the review and may generate Corrective Action Plans; it does not require DOC to produce a CAP for every death. The result in FY2024: 13 of 26 unexpected deaths — 50% — produced no Corrective Action Plan. DOC designated 71% of all UFR Committee recommendations as "Consultative Remarks" — advisory comments with no staff assignment, no tracking mechanism, and no completion requirement. The OCO has consistently raised concerns about this designation pattern since 2022, and DOC agreed to begin tracking Consultative Remarks as part of the FY2024 report negotiation — but only after OCO's sustained pressure, and only for the prospective period. The overdose and suicide data are the most acute findings: 7 deaths by overdose (the leading cause), 5 by suicide (the second leading cause), with two suicides occurring in solitary confinement units specifically. The OCO's recommendation to provide universal access to the 988 Suicide and Crisis Lifeline inside DOC facilities was accepted by DOC in the report — but the fact that 988 access does not yet exist systemically inside Washington prisons is itself a documented gap. Prison medical care oversight requires either: (a) a statutory requirement that DOC produce a Corrective Action Plan for every unexpected death reviewed by the UFR Committee, removing the CAP/Consultative Remark discretion that DOC currently exercises; or (b) independent medical review authority for in-custody deaths, exercised by the OCO or an independent medical examiner, with binding findings. The current structure gives DOC the discretion to designate away the accountability mechanism in half of reviewed deaths. See [reform: independent_inspector_general] and [reform: prison_medical_care].
Sources
- Unexpected Fatality Review Recommendations — FY 2024 Annual Review of UFR Reports, Committee Recommendations, and Corrective Action Plans“WADOC chose to designate 71% of the recommendations as Consultative Remarks for WADOC to consider.”