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

8. Section 2 Structured Judgement review


The following criteria would automatically require a structured judgement review (SJR) (section 2 see appendix B):

  • 8.1.1 All patients where family, carers, or staff have raised concerns about the care provided;
  • 8.1.2 All patients with a diagnosis of psychosis or eating disorders during their last episode of care, who were under the care of services at the time of their death, or who had been discharged within the 6 months prior to their death;
  • 8.1.3 All patients who were an in-patient in a mental health unit at the time of death or who had been discharged from in-patient care within the last month;
  • 8.1.4 All patients who were under a Crisis Resolution and Home Treatment Team at the time of death;
  • 8.1.5 There may also be locally determined ‘red flags’, identified by KMPT on a regular or ad hoc basis. On occasions, there may be a need to complete an SJR to review deaths of patients with e.g. a substance misuse diagnosis, or quality of end of life care in people with dementia, or when a change to service is planned. When this occurs, a decision should be made through the Trust-wide Patient Safety and Mortality Review Group about whether to complete a care review tool for all of these patients, or whether a sample of this patient group should be selected. This may be requested by the SI and Mortality Panel, through groups or committees, care groups, Care Quality Commission or other regulators, audits or by other means when this is concern or when learning could be developed through good care.
  • 8.1.6 A random sample of case notes should also be selected to be reviewed.


should be followed and the mortality review process (section 1 and 2) would not be necessary. There may be cases that begin as a mortality review and it becomes clear that the death should have been reported as a serious incident. The serious incident process should be triggered at that stage. The serious incident investigation supersedes the mortality review processes.


It is also important to note that there are currently recognised processes and programmes which focus on deaths of children deaths of people with learning disabilities, and homicides linked to mental disorder. The Care Review Tool should therefore not be used in these circumstances as the other processes should be followed. NB Learning disability was not included as a red flag as all deaths of people with learning disability are reviewed by the LeDeR programme.


Staff completing an SJR must be trained in the process. The review must be completed by a senior clinician who was not involved in the patient’s care.


The SJR form (section 2 – see appendix B) should be used. In this section, judgements should be made about different phases of care. Not all phases of care will be relevant in individual cases and only the relevant sections need to be completed. Phases of care include:

  • The allocation and initial review or assessment of the patient;
  • The ongoing care of the patient, including both physical health and mental health;
  • Care during admission;
  • Care at the end of life and
  • Discharge planning.


In the text boxes in section 2, the reviewers should make explicit judgements about the relevant area of care and then rate the overall quality of the phase of care in question. The judgement should be based on current professional standards, such as the National Institute for Health and Care Excellence guidelines, or the reviewers’ professional perspective based on their own experience.


It is important that the person conducting the review has the appropriate expertise to make such judgements. Additional expertise may need to be sought at times, for example input from a pharmacist. Ideally, these explicit judgement statements should be short and to the point. Examples include:

  • “Physical observations were not completed regularly”;
  • “A significant deterioration in physical health was not recognised”
  • “The patient’s blood sugars were monitored appropriately and appropriate action was taken when issues were identified”
  • “There was evidence of good multidisciplinary working to support the individual’s needs and wishes”


Reviewers must also specify if care was judged to be excellent, good, adequate, poor, or very poor for each phase of care, as well as for the overall care. There are a wide range of situations which the reviewers will need to judge the care on. Care that covers the essential aspects of what is required would be adequate care. Where the team have gone above and beyond the usual care, the care may be rated very good or excellent. Poor care will be rated when the overall issues in that section were below the standard expected.


It is important to consider whether there was any harm that occurred to the patient, to note areas of good practice, and to identify areas where learning may occur from the deaths. The learning may be identified from areas of good practice as well as from poor practice.


Determining which point in care to commence the care review from is a clinical decision, and there is no timescale set nationally. For example, the review could commence from the point of referral to services, the last relapse of the patient’s illness, the lead up to a hospital admission, or a point of deterioration or change in the patient’s health.

8.b Actions following the review


The review will be completed on Datix.


The recommendations from the SJR will be reviewed by the Head of patient Safety, the Mortality Review manager and the Serious Incident and Complaints Investigation Lead. They will determine if any of the recommendations will be added to the Trust-wide SRJ action plan. If so this will be disseminated to the patient safety care group leads for information and action.


If no Trust-wide action is required, the SJR and recommendations will be shared by the Mortality Review manager with the appropriate care group patient safety team who will pass to the team involved. The team involved will develop actions from the recommendations and will then send them to the Mortality Review Manager who will add them to Datix.


The actions will be monitored by the Mortality Review Manager who will escalate to Trust-wide Patient Safety and Mortality Review Group as required.