Appendix 4 Death in the community and mortality panel decision making

Flowchart

Key: Q = Question

Note: Where the person has a learning disability, report to LeDeR

Where there are likely to be safeguarding/HR/police/another organisation's involvement, ensure joint investigation by liaising with correct department. 

Click here to view the SGV version of the flowchart.

Flowchart starts:

1. Has the person been open to KMPT? (this includes those in receipt of care within the last six months but this is a guide and eachcase should be considered individually - it may be appropriate to declare a serious incident for a homicide by a person discharged from mental health care more than six months previously.)

• If 'No'
  

  Not a KMPT incident.

• If 'Yes'

  • Was the death expected? E.g. end of life care.

    • If 'No'
      

      Go to next question.

    • If 'Yes'

      Go to next question.

2. Were there any acts, omissions or concerns in care provided by KMPT that contributed to the person's death (management report)? (It may be that the post mortem/coroner's conclusion is required)

• If 'Yes'

  STEIS report

• If 'No'

  Not a KMPT incident (complete a timeline to evidence). Go to next question. 

3. Has the death been reported to the coroner or are there complaints/concerns raised by the SI and mortality panel or any individual or organisation about KMPT care that may require further investigation?

• If 'Yes'

  STEIS report, internal investigation or structured judgement review (SJR)

• If 'No'
  

  Not a KMPT SI