Cole Fuller, second from right, and his brothers Clayton, left, and Callahan, right, pose for a family photo with their dad, Jeff Fuller.


In the wake of a Milton teen’s suicide, the Rock County Human Services Crisis Intervention Unit will update its policies and retrain staff in accordance with a plan of correction approved by the state.

The county was required to submit a plan of correction after the state Department of Health Services Division of Quality Assurance investigated how the department handled the case of a Milton teen who died by suicide.

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The plan was submitted to the state Sept. 24 and accepted Oct. 14, according to an email from a state quality assurance analyst to Rock County Human Services Director Kate Luster.

Family members of Cole Fuller, who died by suicide April 4, believe Rock County officials failed to help Cole during the 45 days he was under county supervision for a Chapter 51 mental health commitment.

Cole’s father, Jeff, filed a complaint with the state, hoping the county would be held accountable for failing his son.

The investigation identified four deficiencies in how Cole’s case was handled.

The changes proposed in the plan will be implemented by Oct. 30, according to the document.

The plan focuses on:

  • Actions to assure clients under Chapter 51 commitments who enter the Rock County system from another county go through the same processes as those committed in Rock County.
  • Improved procedures for timely access to appropriate care.
  • Strengthening fidelity to best practices in risk assessment and response for clients at risk of suicide.

Crisis staff under revised policies will complete an “after visit summary” document to improve communication with clients, according to the plan.

The county’s venue transfer procedure will be updated to better coordinate transition between counties, according to the plan.

Under the revised procedure, a legal change of venue will not occur until treatment resources have been identified and coordination of care has occurred.

A policy will be developed to identify procedures and expectations for referral and linkage to services for clients at high risk of suicide, according to the plan.

Client crisis plan documents will be updated to include focuses on high-risk clients and provide clarity about when a plan is complete, according to the correction plan.

Grievance training will be developed to teach staff how to identify a complaint, how to document complaints and how to assist clients in filing grievances, according to the plan.

Crisis services will develop a policy regarding staff appointment cancellations and rescheduling, according to the plan. The policy will include identifying client needs and a process to cover appointments with other staff.

Investigators found prompt and adequate services were not provided to Cole “as evidenced by delayed case management appointments, a lack of referrals, and under-assigned risk potential.”

The most recent examination of Cole before his death determined he was at “high-risk of crisis, including suicidal and violent behavior” and had a history of losing progress when not receiving constant treatment, according to the report.

Cole’s family feels crisis workers did not take the result of Cole’s examination seriously, according to the report.

A crisis worker rescheduled meetings with Cole twice because of health problems, delaying Cole’s access to treatment.

The behavioral health division manager will review and update policies to ensure they reflect best practices for suicide screening and assessment, response, safety planning, assessing access to lethal means and lethal means counseling.

Other changes will update the crisis unit’s documentation procedures, according to the report.

“The policy changes and other actions referenced in the Plan Of Correction are well underway and the Crisis Intervention Unit remains committed to continuous quality improvement in our daily work with Rock County citizens experiencing complex behavioral health needs and risks,” Luster said in an email to The Gazette.