Learning from Deaths Policy

Kent and Medway NHS and Social Care Partnership Trust believes that concentrating attention on the factors that cause deaths will impact positively on all persons who use services, reducing complications, length of stay and readmission rates through improving pathways of care, reducing variability of care delivery, and early recognition and escalation of concerns.

Publication date:
31 January 2021
Date range:
January 2021- September 2022

7. Initial review following a death section 1


All deaths of patients who have been under KMPT within the year before their death will have the death reported on Datix. The manager of the service (or deputy) under which the death occurred should complete the 48 hour management report on Datix, This report is then discussed and scrutinised at the Serious Incident and Mortality Panel.


All deaths of service users should be identified, for example using NHS Spine, through information from families, information received from Her Majesty’s Coroner or other agencies such as the police. This review should take place to support the identification of the individual deaths which will require a more detailed review.


The Serious Incident and Mortality Panel will determine cases that require a Structured Judgement Review.

The tool (section 1) will be used as a brief screening instrument. It will be completed by the Mortality Review Manager.


Section 1 covers demographic details, past medical history, past psychiatric history and treatment, past medical history, medication, and a background history in addition to relationships. The diagnosis is the primary diagnosis that the patient was receiving treatment for, covering both mental and physical health.


Patients would be classed as being within the last 12 months of life if there was a documented discussion about end of life care planning or it was documented that palliative care processes were utilised, for example the Gold Standards Framework was applicable.


Those cases that then meet the mandatory criteria (“red flags”) (see section 7), should be subject to section 2, if they are not already subject to a clinical review or a serious incident investigation.