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Overdose Fatality Review

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 Program Contacts

Becky Karns, MPH
216.201.2000 ext 1607
Manreet Bhullar, MPH
Forensic Epidemiologist
216.721.5610 ext 1263

Cuyahoga County Overdose Fatality Review

Under the leadership of Dr. Thomas Gilson, the Cuyahoga County Overdose Fatality Review (CCOFR) is co-coordinated between the Cuyahoga County Medical Examiner’s Office and the Cuyahoga County Board of Health. Beginning in 2012, the CCOFR reviewed all fatal overdoses occurring in Cuyahoga County, Ohio. However, due to the increase in drug-overdose fatalities, a transition was made in 2019 to employ a selective overdose fatality review which examines exemplar cases.

Twelve different agencies comprise the CCOFR, including law enforcement, local hospitals, mental health agencies and public health. The goal is to use in-depth, data-driven case reviews of system touch points to facilitate the implementation of public health intervention and policy recommendations in order to reduce future fatalities.

The CCOFR respects and honors the lives of the individuals involved in case reviews and strives to learn from those who lost their lives to overdose.

In November 2021, the CCOFR was awarded the Ohio Department of Health’s Ohio Injury Prevention Partnerships’ Promising Practice Award.



The main goal of CCOFR and its partners is to create recommendations that will prevent future deaths. We hope other community stakeholders utilize this information to inform needs and fill gaps.

The most current recommendations can be found here (updated December 2021)


CCOFR Partners


Cuyahoga County Medical Examiner’s Office
Overdose statistics

Cuyahoga County Overdose Data Dashboard
Data dashboard

CCOFR Reports

2021 Overdose Fatality Review Annual Report

2020 Overdose Fatality Review Annual Report

Linkage to Care Resources

Cuyahoga County Diversion Center – call FrontLine Services at 216.623.6888

Harm Reduction Site 

National Alliance on Mental Illness Greater Cleveland – call 216.875.7776

Veterans Crisis Line – text or call 1.800.273.8255

Opioid Resource Page



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