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

Appendix A - Structured judgement review flow chart

1. Initial review

  • Patient’s death is reported on Datix as a serious incident
  • The team responsible completes the 48 hour management report
  • The case is reviewed either in Trust-wide SI and Mortality Panel, by Datix death notifications, by downgrade requests outside of the Panel, or by a complaint.
  • If the case meets serious incident criteria, it is reported on STEIS to be investigated by means of a Root Cause Analysis (RCA).
  • If no care and service delivery problems identified or learning was not contributory to the death, the incident is downgraded depending on the level of harm caused by any acts or omissions
  • If the patient had a diagnosis of a learning disability, The Learning Disabilities Mortality Review (LeDeR) will need to be informed and an SJR will not be required.

2 Criteria for Structured Judgement Reviews/Allocation

  • The “red flag” criteria will be measured against each incident in Trust-wide SI and Mortality Panel:
  • All patients where family, carers or staff have raised concerns about the care provided
  • All patients with a diagnosis of psychosis or eating disorders during their last episode of care, who were under the care of KMPT services prior to their death, or who had been discharged within the six months prior to their death.
  • All patients who were an inpatient in a mental health unit at the time of their death or who had been discharged from inpatient care within the last month
  • All patients who were under a Crisis Resolution and Home Treatment Team (CRHT) at the time of their death

If SJR criteria is met, the Mortality Review Manager will proceed with allocation to SJR trained staff. A sample of randomly selected cases will be chosen by the Mortality Review Manager and allocated accordingly.

3. Structured Judgement Review form

  • Please type your findings in the form provided when allocated as the information will need to be transferred to Datix.
  • Start at Section 1. This includes patient demographics and “red flag” tick boxes to evidence why SJR is required. The Mortality Review Manager will advise you why SJR is required for each case.
  • Once section 1 is complete, move onto section 2. Fill in each box where relevant (some may not apply to the case you are reviewing).
  • Remember to make explicit judgements about the relevant area of care followed by the rating of care for each phase.

Top tips

  • Explicit judgement statements in each section should be short and to the point.
  • For each explicit judgement statement you may rate the level of care, for example; “Physical health observations were not completed regularly- this is poor care”
  • Remember to include good practice, we can learn from this too!
  • Care that covers the essential aspect of what is required is usually deemed as adequate care. Anything below this should be rated as poor or very poor.
  • Your review of care quality should be based on the current professional and national standards, such as NICE guidelines, and should be based on your professional perspective and understanding of how services are run, including your own experience.
  • Your review should be unbiased and should NOT include opinions, presumptions or blame.
  • Remember, Structured Judgment Reviews are very different to RCA investigations and should be treated as such. There may be times where you require the expertise from another colleague and/or professional, such as a pharmaceutical review. This is acceptable however you do not need to delve into why the issue occurred.


Do you have significant concerns about the care provided or do you feel the criteria for SJR was misjudged?

  • If 'Yes' go to point 4
  • If 'No' go to point 5


  • You may identify acts or omissions in care that could have contributed to the patient’s death or may feel as though the “red flag” previously identified is incorrect.
  • If you have significant concerns about the care provided, and feel serious incident criteria is met, please stop the Structured Judgement Review process immediately and inform Mortality Review Manager or Head of Patient Safety in her absence.
  • If you come to learn that the patient had a diagnosis of a learning disability, please also stop the Structured Judgement Review Process immediately and:
  • Report the death to the Learning Disabilities Mortality Review (LeDeR) by following the link. Learning Disabilities Mortality Review Programme | School for Policy Studies | University of Bristol
  • Inform Mortality Review Manager or Head of Patient Safety in her absence.

5. Recommendations

  • Learning identified during a Structured Judgement Review should lead to recommendations for the treating team and care group, and in some cases a Trust-wide recommendation will be required to address the concern.
  • Recommendations should be concise and clearly documented in the review.

6. What happens when you have completed the SJR

  • Once you have completed the Structured Judgement Review form, please send to Frances Lowrey, Mortality Review Manager, frances.lowrey@nhs.net
  • The information is then transferred to Datix under the Structured Judgement Review section of the incident.
  • The review will be shared with the Serious Incident and Complaints Investigation Lead to determine if there are recommendations to be added to Trust-wide action plans.
  • The responsible team will also receive the review and create actions from each local recommendation (those not included in Trust-wide action plans) to ensure learning is embedded. These must be shared with the Mortality Review Manager, who will add to Datix.
  • If the patient’s family was informed that a review would be completed, the findings from the SJR will need to be shared with them by the team involved.

7. Monitoring

  • Monitoring of the Trust-wide actions will be completed by the Serious Incident and Complaints investigation Lead and the
  • Mortality Review Manager. Monitoring of local actions will be completed by the Mortality Review manager.
  • The Mortality Review manager will produce quarterly mortality reports for Trust-wide Patient Safety and Mortality Review Group and Quality Committee.

8. Advice and support

you require any support please contact Frances Lowrey, Mortality Review Manager either by email frances.lowrey@nhs.net or phone 07747862097.