Marin County Suicide and Overdose Fatality Review Committee

In formalizing the review of a variety of records data collection after a suicide or overdose death, the Suicide and Overdose Fatality Review (SOFR) process allows County behavioral health and public health departments and local mental health, substance use/addiction, and medical providers to track near real-time trends, determine which populations in Marin are most at risk, and consider systemic changes that could potentially prevent future suicides and overdose related deaths. The Marin County SOFR Committee has received training and technical assistance by Dr.  Kimberly Repp, a nationally recognized expert in Suicide Fatality Review as well as the guidance of other national suicide and overdose review teams. To learn more about the review committee process,  please view this webinar. 

The Marin County SOFR Committee launched in September 2024. If you have questions about the SOFR process, please email: HHSSOFR@MarinCounty.gov

If you or someone you know is in distress, contact the Marin County BHRS Access Line: (888) 818-1115 or the 988 Suicide & Crisis Lifeline.  Additional resources can be found by visiting the Marin County Suicide Prevention Collaborative or OD Free Marin.

An Overview of the SOFR Process and Committee

The SOFR Committee is led by Marin County Public Health Department and the Division of Behavioral Health and Recovery Services. By keeping SOFR local, case reviews can lead to community-informed recommendations. The  SOFR Committee has a variety of members from the Coroner's Office, healthcare, public safety, mental and behavioral health, social services, education, and other agencies that share and evaluate information.

The SOFR is not a peer review process or an opportunity to second guess agency policy or practice. In light of the impact of overdose and suicide in our community, the SOFR is an opportunity for community leaders to determine where there were missed opportunities for prevention/intervention, and how, across all agencies, practices/procedures can be improved to prevent future deaths by suicide or overdose.

As a part of the review process, the Committee will identify any key trends, review risk/protective factors, analyze the data to inform specific recommendations, and design policy or interventions that reflect any key trends or issues that may have emerged as a result of the review.

The Goals of the SOFR

The SOFR Goals are to:

  • Identify missed opportunities for prevention and gaps in the system
  • Build working relationships between local stakeholders on suicide and overdose prevention
  • Recommend policies, programs and legislation to prevent future suicide and overdose deaths
  • Implement data-driven prevention and intervention activities

Guiding Principles

The ultimate goal of the SOFR team is to reduce deaths due to overdose and suicide. Our goals are guided by the following principles:

  • Overdose and suicide deaths are preventable
  • Substance use is a chronic, treatable disease
  • Use of multi-sector data will inform response strategies
  • Evaluation and improvement of the SOFR processes is continuous