The death of a person undergoing medical treatment is cause for serious reflection on the part of caregivers. Historically, procedures have been developed to help understand the circumstances of such deaths.  These procedures range from a focus on the person (e.g., such as a medical status review and/or psychological autopsy of the deceased patient) to a broader focus on the caregiving environment and caregiving procedures (e.g., mortality review committees).  Such procedures have become routine within hospitals and other health care organizations and have expanded to encompass a broad spectrum of agencies, including organizations addressing issues of child welfare and family violence.  The expectations of such reviews have been extended to accredited addiction treatment organizations, but such reviews in my experience have focused primarily on patients’ deaths that occur during detoxification or during inpatient or residential treatment.  More common and less addressed is the death of a patient in the days, weeks, or months after primary inpatient or outpatient treatment has been completed.

Families who have lost a family member to addiction following one or more episodes of addiction treatment are beginning to move beyond their own grief and guilt to ask questions about the quality of addiction treatment their family member received and how treatment assumptions and procedure could be improved to prevent such tragedies for other families.  Bill Williams is one such family member who is turning his grief into advocacy.  The post below is one worthy of serious reflection by addiction professionals and treatment administrators.  It suggests two obvious first steps:  1) every person entering addiction treatment (regardless of subsequent discharge status) should receive assertive recovery check-ups for at least one year (and preferably for five years), and 2) the death of any patient within one year of discharge following addiction treatment should be rigorously reviewed with a focus on identifying any changes in service practices that could potentially prevent such deaths.