Management of investigations and serious incidents policy

The purpose of this policy is to ensure that risks associated with serious incidents are identified and managed in accordance with best practice and in line with the expectations of the NHS Resolution, the Health and Safety Executive, the Care Quality Commission, NHS England and NHS Improvement, Clinical Commissioning Groups and the public.

Publication date:
01 September 2019
Date range:
September 2019 - September 2022

Appendix 5 Inpatient death

SI and mortality panel decision making following completion of the Datix management report. 

Click here to view the SGV version of the flowchart.


Key: Q = Question. 

Where there are likely to be safeguarding/HR/Police/another organisation’s involvement, ensure joint investigation by liaison with correct department/organisation/GP. 

Flowchart starts:

1. Report to the CQC—via the Trust Compliance & Assurance Manager
2. Where the person has a learning disability, report to LeDeR
3. Was the person held under the MHA or subject to DoLs?

  • If 'Yes'

  • If 'No'

    Was the death expected? E.g palliative care.
    • If 'Yes' or 'No'

      Go to next question.

4. Were there any acts, omissions or concerns in the care provided by KMPT that contributed? Complete a timeline to evidence.

  • If 'Yes'

  • If 'No'

    Has the death been reported to the Coroner or are there complaints/concerns raised by any individual or organisation about KMPT care that may warrant further investigation?
    • If 'Yes'

      STEIS or internal investigation
    • If 'No'

      Not a KMPT incident.