Department of Health

Key messages

  • This guideline is designed for designated mental health services and mental health community support services to follow in the event of a death of a person who was receiving, had received or sought mental health services. 
  • The guideline defines a 'reportable death' and outlines the reporting procedures. 
 

Purpose

Under the Mental Health Act 2014 (the Act), the Chief Psychiatrist must be notified of all reportable deaths within the meaning of the Coroners Act 2008.

The Chief Psychiatrist provides clinical leadership and expert clinical advice to mental health service providers in Victoria. Central to the role of the Chief Psychiatrist is to promote continuous quality improvement and the rights of people receiving mental health services. 

Monitoring and reviewing circumstances relating to reportable deaths is one way the Chief Psychiatrist ensures that quality mental health services are provided. 

This information is analysed for the monitoring, governance and quality and safety functions of the Chief Psychiatrist. Information about inpatient deaths also informs the Chief Psychiatrist’s three-yearly inpatient death review. 

Relevant legislation

The legislation governing the notifying of a reportable death is detailed in s. 348 of the Act and s. 4 of the Coroners Act 2008. Excerpts of these Acts are included in Appendix 2 of this guideline. 

Role of the Chief Psychiatrist

In relation to reportable deaths, the Chief Psychiatrist:

  • receives and reviews MHA 125 notice of death forms
  • maintains a database of reportable deaths of clients of mental health services in Victoria
  • routinely requests the findings of coronial investigations and contributes to coronial processes if requested to do so by the coroner
  • reviews the contents of the clinical reports forwarded by services, with the aim of identifying systemic or management issues
  • requests additional information, including copies of clinical files, to review individual treatment and care and broader systemic and management issues
  • undertakes an investigation pursuant to s. 122 of the Act, or conducts a clinical review pursuant to functions detailed in s. 130 of the Act
  • identifies statewide issues and provides guidance to mental health services.

Health services that must report

All mental health service providers must report deaths to the Chief Psychiatrist.

This includes all designated mental health services and all publicly funded mental health community support services.

Reportable deaths

The authorised psychiatrist or the person in charge of a mental health service must notify the Chief Psychiatrist in writing in the event of the death of the following people.

1.Inpatient 

Any inpatient death at a designated mental health service is to be reported, regardless of legal status, cause or location of death. This will help the Chief Psychiatrist understand the level of morbidity related to inpatient treatment and care in Victoria. 

A person who dies while on leave, who has absconded, who has been admitted to a medical ward during the admission to the mental health unit, or who dies soon after discharge from the mental health unit is considered an inpatient, and the death must be reported to the Chief Psychiatrist.  

2.Patients under the Mental Health Act 2014

The death of a patient under the Act must be reported to the Chief Psychiatrist. 

This includes all compulsory, security and forensic patients, as defined in s. 4 of the Act. 

Compulsory patients are those subject to: 

  • an assessment order 
  • a court assessment order
  • a temporary treatment order
  • a treatment order.

Forensic patients include those subject to a custodial supervision order under the Crimes (Mental Impairment and Unfitness to be Tried) Act 1997

A security patient is a person detained in a designated mental health service (regardless of whether they are absent with or without leave) and who is subject to:

  • a court secure treatment order
  • a secure treatment order.

3.Persons on non-custodial supervision orders

The death from any cause of a person in the community on a non-custodial supervision order under the Crimes (Mental Impairment and Unfitness to be Tried) Act 1997 must also be reported to the Chief Psychiatrist.

4.Other consumers, including previous consumers

The Chief Psychiatrist requires all unexpected, unnatural or violent deaths (including suspected suicides) of consumers to be reported. 
Consumers are defined in the Act as a person who:

  • has received mental health services from a mental health service provider 
  • is receiving mental health services from a mental health service provider 
  • was assessed by an authorised psychiatrist and was not provided with treatment 
  • sought or is seeking mental health services from a mental health service provider and was or is not provided with mental health services. 

People are considered to be consumers of a mental health service until their case is formally closed and they are formally notified of this closure. If it is not possible to inform an individual of the closure of their case, the service can be considered to have done so if it made all reasonable attempts to contact the consumer.

The Chief Psychiatrist considers the requirement to report all unexpected, unnatural or violent deaths (including suspected suicides) to extend to all people under the Act. 

If a person’s death is unexpected, unnatural or violent and occurs within three months of being a consumer, it must be reported to the Chief Psychiatrist. If a person’s death is unexpected, unnatural or violent and occurs within three months of being a consumer the death must be reported to the Chief Psychiatrist.

Reporting to the coroner

Health services may also be required to report a death to the coroner.

If unsure whether a death meets the definition of a reportable death, contact the Coroners Court for more information.

The immediate family of a deceased person may also report a death to the coroner, if the person was discharged from a designated mental health service within three months immediately before the person’s death. 

This definition is interpreted broadly to cover people receiving mental health treatment in the community or inpatient settings.

Procedures in the event of a reportable death

Inpatient deaths

All health services will have a policy and local procedures related to reportable deaths that includes the following:

  • The body should be disturbed as little as possible.
  • Promptly inform relevant parties (authorised psychiatrist, next of kin/carers) of the death.
  • Make contact with the Coroners Court of Victoria. If the death is reportable to the coroner, the coroner’s assistant will contact and inform the local police who will attend. 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.
  • The Chief Psychiatrist should be notified as soon as practicable of any inpatient death. The Chief Psychiatrist can be contacted outside of business hours through the authorised psychiatrist or person in charge.

All deaths

Clinical records

If the death is also reportable to the coroner, copy the clinical record, and forward the original and any other materials requested to the coroner. 

If there is a need to make further entries 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. 
It may be useful for health services to discuss the requirements with the coroner’s assistant so they can plan for the time it will take for the clinical record to be copied.

Open disclosure and support for those affected by the death

Health services should have an open disclosure policy and procedures that are used when working with family/carers after the death of a consumer. Ongoing open disclosure training should be provided for staff. 

The Department of Health has adopted the Australian Open Disclosure Framework to support clinical services with the open disclosure process. 

Under the Victorian Charter of Human Rights and Responsibilities Act 2006, public entities (including public health services) have a legal obligation to discuss adverse events with those affected, such as the family/carer of a person who dies while receiving, or has recently received, care from a mental health service provider.

The Open Disclosure Framework, along with the Victorian Clinical Governance Policy Framework.

Staff must be supported so that they can respond effectively and learn from adverse events to improve patient safety in the future. Health services should provide the right environment, resources and a blame-free culture to guide staff through the process of open disclosure.

  • Clinical staff involved with the deceased should provide appropriate support and referral to specialist services for people who may have been affected by the death, such as family, friends, other staff or others who may have witnessed or been affected by the death. 
  • Consider factors including but not limited to ethnicity, culture and religion.
  • The Coroners Court of Victoria offers family member support during the process of the coronial review. Provide the contact details of the Coroners Court to family and carers.

Incident review

The mental health service provider should conduct a review of the person’s treatment and management if the death is a reportable death or where there are any concerns about clinical practices, procedures or systemic issues.

Health services should establish a structured incident management review process consistent with best practice and reflective of their clinical governance policy. 

All Victorian publicly funded health services and agencies that provide health services on behalf of the Department of Health are subject to the Victorian health incident management policy and the Incident reporting instruction (May 2013). Access the incident management policy and the Incident reporting instruction

The policy is a comprehensive guideline that incorporates a standardised framework for the collection and management of incidents. The policy is consistent with the Australian Commission on Safety and Quality in Health Care (ACSQHC) National Quality and Safety Standards released in 2011. 

These standards act as both a quality assurance and quality improvement mechanism.

The policy covers three sections:

  • policy scope 
  • health service and agency requirements 
  • incident review process and open disclosure. 

The Victorian health incident management policy guide provides information to assist mental health services to identify, manage and review incidents as they occur. Access the incident management guide.

This policy guide should be read in conjunction with the Victorian health incident management policy.

The policy guide covers three sections:

  • incident management roles and responsibilities 
  • the incident management process 
  • incident severity rating. 

Health services are expected to have their own local detailed policies and procedures to ensure compliance with funding and service agreements, such as:

  • reporting of sentinel events to the Department of Health’s Sentinel Event Program
  • funded services (such as Mental Health Community Support Services) reporting category 1 and 2 incidents to the Department of Health.

Reporting requirements 

1.Inpatient deaths

If the person is under treatment as an inpatient, regardless of legal status, you must notify the Chief Psychiatrist within 24 hours by phone. Out-of-hours contact with the Chief Psychiatrist can be made through each health service’s appointed authorised psychiatrist, chief executive or delegate.

In addition, the MHA 125 notice of death should be forwarded to the Chief Psychiatrist as soon as practicable, but not later than three days.

The authorised psychiatrist or person in charge of a mental health community support service is also required to forward a detailed clinical report to the Chief Psychiatrist within 14 days or sooner if specifically requested by the Chief Psychiatrist.

2.Inpatient deaths in which suicide is suspected

Suicide is considered a sentinel event. Sentinel events are relatively infrequent, clear-cut events that occur independently of a patient's condition. They commonly reflect health system and process deficiencies, and result in unnecessary outcomes for patients. 

There are eight nationally defined sentinel events that cover the entire health system, including suicide in an inpatient unit. 

All health services that identify an incident that reflects a national sentinel event definition are required to report the incident to the Sentinel Event Program.

Step 1. Notify the Department of Health

Notify the department within three working days by emailing a completed sentinel event reporting form to sentinel.events@health.vic.gov.au

Access the form

Step 2. Commence a root cause analysis

A root cause analysis (RCS) should be completed for each inpatient suicide.

The RCA process should commence as soon as practical after the death. This includes convening a qualified and experienced RCA team.  

Access more information

Step 3. Document and submit a RCA report

Provide a de-identified RCA summary report to the department within 60 days of notification to sentinel.events@health.vic.gov.au

The RCA finding should be documented on the RCA summary report which includes a risk reduction action plan (RRAP).

Step 4. Review of submitted RCAs

The Clinical Incident Review Panel (CIRP) reviews and provides expert comment on submitted reports and recommendations. Based on these reviews, the department provides feedback to individual health services. 

Step 5. Closing the feedback loop on RRAPs

Health services must confirm they have completed the actions identified in the RRAP as per step 3. 

Submit the RRAP feedback report template documenting the completed actions to the department. 

The template is located at: www.health.vic.gov.au

3.Death of patients under the Mental Health Act and those on non-custodial supervision orders 

There is no requirement to notify within 24 hours if immediately before their death the person was a compulsory patient living in the community, or was in the community on a non-custodial supervision order. 

However, a MHA 125 notice of death should be forwarded to the Chief Psychiatrist as soon as practicable, but not later than three days. 

For people on a non-custodial supervision order, the mental health service provider and the Victorian Institute of Forensic Health (Forensicare) must provide a MHA 125 notice of death and a detailed clinical report to the Chief Psychiatrist. 

If the person was also receiving mental health services from a mental health community support service, that service must also submit a MHA 125. 

4.All other reportable deaths

In the case of all other reportable deaths, a MHA 125 notice of death should be forwarded to the Chief Psychiatrist as soon as practicable, but not later than three days. 

There is no need to forward a detailed clinical report unless asked to do so by the Chief Psychiatrist.

MHA 125 notice of death 

A mental health clinician or practitioner who was working with the person before their death and can accurately provide information may complete a MHA 125 notice of death. 

The authorised psychiatrist of the designated mental health service, or the person in charge of the community mental health support service should approve the report. 

The MHA 125 should be written and approved by a different person, if reasonably possible. For example, if the authorised psychiatrist was also the treating psychiatrist, it would be reasonable for a senior manager to authorise the form after it was completed by the treating psychiatrist. 

As per the instructions on the MHA 125, the circumstances surrounding death section must contain an outline of:

  • the events or circumstances leading up to and surrounding the death
  • the treatment and/or mental health services that were being provided to the person in the period leading up to the death including:
    • details of treatment (including any medication) being provided
    • names and designation of treating staff, including case manager, treating psychiatrist, clinician and practitioner 
    • last known mental state 
    • presentation or mental state on last contact
    • frequency of contacts or service usage and next scheduled appointment
    • identified risks and measures taken to address these
    • known medical conditions and monitoring and treatment in relation to these or recent medical examination and healthcare plan
    • contact made with carers and/or next of kin
    • contact made with Coroner’s Court
    • any other relevant information. 

If a person has had contact in the last three months with multiple mental health service providers, each service provider must complete a MHA 125 notice of death, and may be asked to provide a detailed clinical report.

Detailed clinical report

The treating psychiatrist should complete a detailed clinical report, which is reviewed by the authorised psychiatrist, chief executive or delegate. 

It should contain all the information contained in the MHA 125 circumstances of death plus a detailed history of treatment and management prior to death including:

  • detailed presentation/mental state on last contact
  • frequency of contacts and next scheduled appointment
  • identified risks and measures taken to address these
  • date and details of latest risk assessment
  • known medical conditions and monitoring and treatment in relation to these or recent medical examination and healthcare plan
  • any other relevant information or information requested by the Chief Psychiatrist.

The Chief Psychiatrist’s reporting requirements for reportable deaths cannot be fulfilled through any other requirement, for example, reporting to the Department of Health or the coroner.

Additional information required for inpatient deaths

In addition to the information required in the MHA 125, the following information must be included for all inpatient deaths:

  • if the death is a suspected hanging, dates and details on the latest ligature point review and the date of the next review
  • the level of nursing observations the patient was on and details in relation to whether these observations had increased or decreased in the 24 hours prior to death 

Contact details

Office of the Chief Psychiatrist

Phone. 1300 767 299 (business hours)

After hours contact with the Chief Psychiatrist can be made through each designated mental health service’s authorised psychiatrist or the person in charge of the mental health community support service.  

The MHA 125 and clinical report should be sent to the Chief Psychiatrist via email (preferred) to ocp@health.vic.gov.au or by fax to 03 9096 7697 or mail to 
The Chief Psychiatrist
Department of Health
GPO Box 4057
Melbourne Victoria 3001 

Coroner’s Court of Victoria

Phone 1300 309 519 (24 hours)

About Chief Psychiatrist’s guidelines

The information provided in this guideline is intended as general information and not as legal advice. Service providers should obtain independent legal advice if they have queries about individual cases or their obligations under the Mental Health Act 2014.

To receive this publication in an accessible format phone 1300 767 299. 

Reviewed 15 November 2021

Health.vic

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