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Reportable Deaths (December 1999 - Revised 2004)

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• Introduction
• Key message
• Relevant legislation
• Implications for mental health services
• Procedure to be followed in the event of a reportable death
• Role of the Chief Psychiatrist
• For Further Information

Introduction

The Chief Psychiatrist is responsible for the medical care and welfare of persons receiving treatment or care for a mental disorder in Victoria.

The Mental Health Act 1986, establishes a requirement for psychiatric services to forward notification of reportable deaths to the Chief Psychiatrist.

Review of information relating to the occurrence of reportable deaths is one of the mechanisms by which the Chief Psychiatrist ensures that appropriate standards of treatment and care are being provided.

Key message

Relevant legislation

Legislation governing the notification of a reportable death is detailed in the Mental Health Act 1986 and the Coroners Act 1985. Relevant Sections of these Acts are located at Appendix 1 of this Guideline.

Which services report?

Section 106A of the Mental Health Act 1986 requires that deaths of patients of "psychiatric services" that meet the defining criteria of the Coroners Act 1985 as "reportable deaths" (Appendix 1) are to be reported to the Chief Psychiatrist.

"Psychiatric service" as defined by section 106 of the Mental Heath Act means an

• approved mental health service;
• a child and adolescent psychiatry service;
• any premises licensed under section 75; (to perform electroconvulsive therapy {ECT})
• a hospital admitting or caring for people with a mental disorder;
• a mental health service of a community health centre;
• a psychiatric out-patient clinic;
• a community mental health service;
• an agency providing community support services

This definition encompasses the majority of the private mental health care facilities operating in the state of Victoria as most are licensed to perform ECT. It also covers all Psychiatric Disability and Rehabilitation Support Services (PDRSS) and agencies funded by the Secretary to provide services to individuals with a mental disorder.

Which client deaths need to be reported?

All unnatural/unexpected deaths, and suspected suicides among clients of mental health services (regardless of their legal status) must be reported to the Chief Psychiatrist.

The requirement to report unnatural/unexpected deaths and suicides (suspected or otherwise) is considered by the Chief Psychiatrist to extend to unregistered clients in the process of assessment and also includes previous clients who have been in contact with mental health services within 6 months of their death, where the service is aware of the death.

As well, individuals are deemed to be clients of a mental health service until their case is formally closed, and the individual is formally notified of this closure. In those cases in which it is not possible for a service to inform an individual of the closure of their case, the service can be considered to have done so once all reasonable avenues have been pursued.

All deaths (from any cause) of persons, who are involuntary, security, or forensic patients, must be reported to the Chief Psychiatrist.

The term involuntary patient pertains to all those detained pursuant to Division 2 of Part 3 and section 16 (3)(a) of the Mental Health Act 1986, and includes individuals who are subject to a Community Treatment Order, a Restricted Community Treatment Order, and those on a leave of absence. This term also includes those detained as involuntary patients pursuant to section 93 (1)(d) of the Sentencing Act 1991.

Security patient refers to those persons detained pursuant to section 93 (1)(e) of the Sentencing Act 1991, or section 16(3)(b) of the Mental Health Act 1986.

The death (from any cause) of an individual who is detained in an approved mental health service subject to a custodial supervision order, or in the community on a noncustodial supervision order, under the Crimes (Mental Impairment and Unfitness to be Tried) Act 1997 must also be reported to the Chief Psychiatrist.

Persons receiving treatment for a mental disorder in a private hospital (licensed under section 75 of the Mental Health Act) who die during an anaesthetic, or whose death is a result of an anaesthetic and not due to natural causes, meet the "reportable deaths" criteria under the Coroner's Act 1985 and must be reported to the Chief Psychiatrist by the person in charge of the facility.

Importantly, the deaths of all persons (regardless of legal status) receiving treatment as inpatients of an approved mental health service, are reportable to the Chief Psychiatrist.

Implications for mental health services

If staff remain unsure as to the interpretation of the definitions that delineate those deaths that are "reportable deaths" within the meaning of Coroners Act 1985 and the individuals to whom section 106 A applies, they should contact either the State Coroners Office (Phone 9684 4368) to make enquiries regarding the definition of a "reportable death", or the Office of the Chief Psychiatrist (Phone 9096 7571) to seek further clarification of the reporting process.

Reporting process

Fulfilment of legislative requirements involves the forwarding to the Chief Psychiatrist of a:

• PSY 25 Notice of Death (as soon as possible),
• Clinical Summary (within two weeks) for all suicides and violent/unexpected deaths, and
• PSY 25 (a) Interim Notification of Death Report (within 24 hours) for all inpatient suicides or violent deaths.

The requirement to report the occurrence of a "reportable death" among clients of the mental health service to the Chief Psychiatrist cannot be fulfilled by the undertaking, or completion, of any other reporting processes.

Procedure to be followed in the event of a reportable death

1. The body should be disturbed as little as possible.
2. Promptly inform relevant parties (authorised psychiatrist next of kin/carers) of the death.
3. The State Corner's Office is to be contacted for all reportable deaths within the meaning of the Coroner's Act 1985. The Coroner's assistant will require details of the deceased, the circumstances of death and whether a death certificate can be completed. They are responsible with the police or funeral director, for coordinating the removal of the body.
4. The clinical record should be copied, and the original and any other materials requested, forwarded to the Coroner. If there is a requirement for further entries to be made in the clinical record, for instance following contact with the family, this should be placed in a temporary file for later incorporation into the original record. Under no circumstances should retrospective entries be inserted into the clinical record, or material removed from the record.
5. Clinical staff involved with the deceased should provide appropriate support and debriefing to people who may have been affected by the death such as family, friends, staff or others who may have witnessed the death.
6. In the case of an inpatient suicide or violent death, staff are required to notify the Chief Psychiatrist on the day of the death (Interim Notification of Death Report). The authorised psychiatrist is required to forward a detailed clinical summary to the Chief Psychiatrist within 2 weeks. The preparation of this report should not delay the forwarding of the PSY 25 Notice of Death.
   The Chief Psychiatrist
   Level 17, 50 Lonsdale Street
   Melbourne VIC 3000
7. In the case of all other reportable and inpatient (involuntary and informal patients) deaths, notification should be forwarded as soon as possible on a PSY 25 Notice of Death.
8. Appropriate completion of the PSY 25 and clinical summary, should include the following:
   • Personal details and legal status of the deceased
   • Names of the relevant treating personnel (including the consultant and treating psychiatrist or supervising medical practitioner and case manager)
   • Circumstances of the death including evidence of alcohol consumed or other prescribed/non-prescribed drugs at the time of death
   • Diagnosis (primary, secondary and co morbid conditions) and treatment history
   • Detailed history of management prior to death
   • Date of discharge (where appropriate)
   • Date of last contact with mental health services (where appropriate)
   • Contact made with next of kin
   • Contact made with the State Coroners Office
9. Where the death appears to have resulted from a suicide or violent incident, or where the authorised psychiatrist has concerns about clinical practice or treatment, clinical staff involved with the deceased should conduct a clinical review of the person's treatment and management. Such a review may prepare staff for any subsequent coronial investigation and may rovide a basis for reviewing clinical and management practices and contribute through quality processes to improved service delivery. N.B. Services are expected to develop their own local detailed procedures and policies in accordance with legislative requirements.

Role of the Chief Psychiatrist

The Chief Psychiatrist:

• Receives and reviews PSY 25 Notice of Death forms
• Maintains a database detailing the occurrence of reportable deaths among clients of mental health services in Victoria
  
• May request the findings of coronial investigations
  
• Reviews the contents of the clinical reports forwarded by services, with the aim of identifying systemic/management issues.
  
• May undertake an investigation pursuant to the Chief Psychiatrist's functions detailed in section 106 of the Mental Health Act 1986.
  
• May respond to the issues raised by any investigation.
  
• May respond to issues raised by the Coroner during or following an investigation.
  
• Will identify statewide issues and develop appropriate Guidelines.

For Further Information

Acknowledgements
Published by the Mental Health Branch, Metropolitan Health and Aged Care Services Division Victorian Department of Human Services

About Chief Psychiatrist's Guidelines The information provided in this guideline is intended as general information and not as legal advice. If mental health staff have queries about individual cases or their obligations under the Mental Health Act 1986, service providers should obtain independent legal advice.

Appendix 1 - Legislative definitions relating to reportable deaths, Response Flow Chart and Appendix 2 - Interim notification of death report PSY 25 (a) available in PDF format at top of page.