Death of an Adult Service User - bcpft.nhs.uk

Death of an Adult Service User Policy

Version 1.1 July 2018

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Death of an Adult Service User

Target Audience

Who Should Read This Policy

All Clinical Staffs



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Ref. Contents Page

1.0 Introduction 4

2.0 Purpose 4

3.0 Objectives 4

4.0 Process 4

5.0 Procedures connected to this Policy 5

6.0 Links to Relevant Legislation 5

6.1 Links to Relevant National Standards 6

6.2 Links to other Key Policies 7

6.3 References 8

7.0 Roles and Responsibilities for this Policy 9

8.0 Training 9

9.0 Equality Impact Assessment 10

10.0 Data Protection and Freedom of Information 10

11.0 Monitoring this Policy is Working in Practice 11

Appendices

1.0 Flowchart Following The Death Of An Adult Service User 12

2.0 Infection control precautions are necessary for the safe handling of the

bodies of patients who have died with known or presumed infection. 13

3.0 Last Offices-Equipment and Procedure 17

4.0 Guidelines for the Verification of Death. 20

4.0a Clinical Signs Of Death 22

4.0b Flow Chart for Verification/Confirmation of Expected Death by Nursing Staff ..

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4.0c Black Country Partnership Foundation Trust Certificate of Verification of

Death Competency 24

4.0d Recommendations from H.M. Coroner – Robin J Balmain 25



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Explanation of terms used in this policy Expected death – a patient who has been identified formally by the medical team as expecting to die and relevant documentation completed. This will be communicated to nursing staff and relatives and whenever possible all known religious and cultural requests should be ascertained and any advance directive/statement referred to and documented. Sudden unexpected death – this is defined as unforeseen death. As well as the collapse and death of an apparently healthy person, it also applies to death as a result of an overdose, self-harm, homicide or other suspicious circumstances. Sudden death is a traumatic event for the family, friends and professionals involved. Staffs involved have a vital role to play in ensuring that the situation is managed in a dignified and professional manner and the families assisted sensitively. Verification of death sometimes referred to as ‘pronouncing death’ or ‘confirming death’ is the procedure of determining whether a person is actually deceased. All deaths should be subject to verification that life has ended. The verification of death must be recorded. Death can be verified by all doctors and, in situations where there is an explicit organisational policy, associated protocols and appropriate training and assessment, it can also be undertaken by registered nurses. Verification of death is separate to the certification process. Certification of Death is the process of completing a Medical Certificate of Cause of Death and can only be carried out by a Medical Practitioner. This certificate details the cause of death and enables the family of the deceased to register the death and make funeral arrangements. A nurse cannot legally certify death since this is one of the few activities that the law requires to be performed by registered medical practitioners. Last offices is the term for nursing care given to the deceased patient which demonstrates continued respect for the patient as an individual and also focuses on attending to health, safety and legal requirements, making the body safe to handle and pleasant for others to see, whilst also respecting religious beliefs and cultural norms.



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1.0 Introduction Within any NHS setting it is inevitable that there will be instances when the death of an adult service user occurs and nursing care should not stop when the patient dies. Every patient has the right to die with dignity, without pain and in their own familiar surroundings with people they know and trust nearby. The quality of care a patient receives after death is as important as the quality of life they experienced prior to this time.

2.0 Purpose The purpose of this policy and procedure is to ensure that staffs from the Black Country Partnership Foundation Trust (hereafter called the Trust) handle the death of an adult service user in an appropriate manner including verification/confirmation of expected death by registered nurses. This policy and procedure applies to the death of all adult service users in Trust premises. It also applies to the death of adult service users in the community who are discovered by staff employed by the Trust.

3.0 Objectives To establish a framework to ensure that:

relatives and carers are informed as soon as possible death certificates are appropriately issued any suspicious deaths are investigated any necessary arrangements are made with the coroner and appropriate funeral directors

This policy and procedure is based on the belief that all deaths should be managed in a dignified manner.

4.0 Process Patient deaths fall into three categories - expected death, sudden unexpected death and suspicious death. In the case of all deaths, the patient’s nearest relative and person with whom they had the closest relationship should be informed as soon as possible following verification of death. (See also appendix 4 – guidelines for the Verification of Death). For expected deaths, the appropriate doctor should certify the death. Wherever possible, a patient’s last wishes and preferences would have been determined in advance e.g. advance directive, end of life books. If an end of life care plan is in place, which incorporates an advance directive, it should be referred to at this stage. Nurses need to take into account the different religious and cultural rituals that may accompany the death of a patient. Following the Last Offices, (see Appendix 3) arrangements should be made with the Funeral Director for removal of the body.



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If the deceased has no next of kin and dies intestate (no will) the cremation/funeral is arranged by the Trust and paid from the patient’s estate. If there are insufficient funds, the Trust bears the cost. No property/monies should be handed back to the next of kin by ward staff. All patients’ property, except those items which would be appropriately left with the deceased patient (e.g. wedding ring) must be checked in the presence of another nurse and taken into safekeeping. For sudden unexpected deaths, the coroner should be contacted by the doctor (police out-of-hours) who will decide what further action is necessary. For all suspicious deaths, the coroner and police should be contacted. For suspicious deaths and sudden unexpected deaths where the coroner and/or police need to attend the scene, the body should not be moved once death has been verified and the area should be vacated and left undisturbed. Following certification of death and approval by the police and/or Coroner, the Last Offices should be carried out (see appendix 3). All suspicious deaths and sudden unexpected deaths should be reported as serious incidents and an incident form completed (Datix). The appropriate Trust staff should be informed of the death (see Appendix 1). A record must be made when the body is removed indicating the date of death, any property left on the body, whose body the details refer to, where the body is being removed from (ward area), who released and received the body and when this occurred. Support should be provided for relatives, staff and other patients affected by the death by nursing staff who knew the patient or the chaplaincy team (0121 612 8067). Information can be provided for Bereavement Groups.

5.0 Procedures connected to this Policy There are no procedures linked to this policy.

6.0 Links to Relevant Legislation Health and Safety at Work Act 1974 This Act is the major piece of health and safety legislation in Great Britain. The Act introduced a comprehensive and integrated system to deal with workplace health and safety and the protection of the public from work activities. The Act places general duties on employers, employees, self-employed, manufacturers and importers of work equipment and materials. Responsibilities are placed to produce solutions to health and safety problems, which are subject to the test of reasonable practicability. Various regulations are made under the Act, which have the same scope, many of these evolving from European Directives, which enables the potential to achieve clear and uniform standards.

Health and Social Care Act 2012 The Health and Social Care Act introduces a number of key changes to the NHS in England. These changes came into being on 1 April 2013. The changes include: • Giving groups of GP practices and other professionals – clinical commissioning groups (CCGs)

– 'real' budgets to buy care on behalf of their local communities • Shifting many of the responsibilities historically located in the Department of Health to a new,

politically independent NHS Commissioning Board (this has now been renamed NHS England) • The creation of a health specific economic regulator (Monitor) with a mandate to guard against

'anti-competitive' practices



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• Moving all NHS trusts to foundation trust status Care Act 2014 Care Act 2014 sets out a clear legal framework for how local authorities and other statutory agencies should protect adults with care and support needs at risk of abuse or neglect. New duties include the Local Authority’s duty to make enquiries or cause them to be made, to establish a Safeguarding Adults Board; statutory members are the local authority, Clinical Commissioning Groups and the police. Safeguarding Adults Board must arrange Safeguarding Adult Reviews (SARs) as per defined criteria; publish an annual report and strategic plan. All these initiatives are designed to ensure greater multi-agency collaboration as a means of transforming adult social care.

6.1 Links to Relevant National Standards NHS England Serious Incident Framework (2015) The revised Serious Incident Framework published in March 2015 builds on previous guidance that introduced a systematic process for responding to serious incidents in NHS-funded care. It replaces, the National Patient Safety Agency (NPSA) National Framework for Reporting and Learning from Serious Incidents Requiring Investigation (2010) and NHS England’s Serious Incident Framework (March 2013). The framework takes account of the changes within the NHS landscape and acknowledges the increasing importance of taking a whole-system approach, where cooperation, partnership working, thorough investigation and analytical thinking is applied to ensure organisations identify and learn what went wrong, how it went wrong and what can be done to minimise the risk of the incident happening again. NHS England Serious Incident Framework: Supporting Learning to Prevent Recurrence (2015) The Framework seeks to support the NHS to ensure that robust systems are in place for reporting, investigating and responding to serious incidents so that lessons are learned and appropriate action taken to prevent future harm. NICE Clinical Guideline N6 - Excess Winter Deaths and Illness and the Health Risks Associated with Cold Homes The guideline is for commissioners, managers and health, social care and voluntary sector practitioners who deal with vulnerable people who may have health problems caused, or exacerbated, by living in a cold home. It will also be of interest to clinicians and others involved with at-risk groups, housing and energy suppliers. This guideline makes recommendations on how to reduce the risk of death and ill health associated with living in a cold home. The aim is to help:

Reduce preventable excess winter death rates

Improve health and wellbeing among vulnerable groups

Reduce pressure on health and social care services

Reduce ‘fuel poverty’ and the risk of fuel debt or being disconnected from gas and electricity

supplies

Improve the energy efficiency of homes



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National Institute for Health and Clinical Excellence (NICE) The National Institute for Health and Clinical Excellence (NICE) is the independent organisation responsible for providing national guidance on the promotion of good health and the prevention and treatment of ill health. We produce the following types of guidance: - Clinical guidelines – recommendations about the treatment and care of people with specific

diseases or conditions in the NHS in England and Wales. - Technology appraisal guidance and interventional procedures guidance – guidance on the

use of new and existing medicines, treatments and procedures in the NHS. - Public health guidance – guidance on ways of helping people improve their health and reduce

their risk of illness. NICE encourage stakeholders to get involved in the development of their guidance at all stages. Stakeholders include national organisations that represent patients and carers, local patient and carer organisations when there is no relevant national organisation, healthcare professionals, the NHS, organisations that fund or carry out research, and the healthcare industry.

Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Part 3) These regulations introduce the new fundamental standards, which describe requirements that reflect the recommendations made by Sir Robert Francis following his inquiry into care at Mid Staffordshire NHS Foundation Trust. They enable the Care Quality Commission to pinpoint more clearly the fundamental standards below which the provision of regulated activities and the care provided to people must not fall, and to take appropriate enforcement action where we find it does. Part 3 has two sections: Section 1 describes the requirements relating to persons carrying on or managing a regulated activity. Section 2 introduces the fundamental standards below which the provision of regulated activities and the care people receive must never fall. They came into force for all health and adult social care services on 1 April 2015.

Regulation 8: General Regulation 9: Person-centred care Regulation 10: Dignity and respect Regulation 11: Need for consent Regulation 12: Safe care and treatment Regulation 13: Safeguarding service users from abuse and improper treatment Regulation 14: Meeting nutritional and hydration needs Regulation 15: Premises and equipment Regulation 16: Receiving and acting on complaints Regulation 17: Good governance Regulation 18: Staffing Regulation 19: Fit and proper persons employed Regulation 20: Duty of candour Regulation 20A: Requirement as to display of performance assessments

6.2 Links to other Key Policies

Resuscitation Policy

Incident Reporting Policy

Policy for Patient Monies

Respect and Dignity

Policy guidelines for advanced decisions and advanced statements



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Identifying, Reporting, Investigating and Learning from Deaths in Care policy

6.3 References

The Royal Marsden Hospital Manual of Clinical Procedures Seventh Edition 2008, Blackwell Publishing, Oxford.

The Code: Standards of Performance and Ethics for Nurses and Midwives- Nursing and Midwifery Council May 2008

Report of the Committee of Death Certification – English Office CMND 4810 November 1971

Royal College of Nursing (2013) Confirmation (Verification) of Expected Deaths by Registered Nurses

Confirmation of Death – Nursing and Midwifery Council 2012 http://www.nmc-org/nmc/main/advice/conformationofdeath.html

NMC (2008) NMC Advice Verification of Death

http://www.nmc-org/nmc/main/advice/conformationofdeath.html

http://www.nmc-org/nmc/main/advice/conformationofdeath.html



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7.0 Roles and Responsibilities for this Policy

Title Role Key Responsibilities

Chief Executive

Accountable - The Chief Executive is responsible for assuring that this policy is implemented within the Trust.

- Operational responsibility has been delegated.

Trust Board

Strategic - The role of the Trust Board is to have a strategic overview and final responsibility for safe and high quality care within service areas across the Trust in accordance with its Assurance Framework and strategic priorities.

Executive Committee Accountable - A sub-committee of the Trust Board has delegated responsibility for ensuring that this policy is efficient and effective in accordance with the Board’s Assurance Framework and Strategic priorities.

Care Governance Responsible - The Care Governance Committee is responsible for overseeing the implementation of a systematic and consistent approach to this policy.

- The group is chaired by the medical Director and provides exception and progress reports to the Executive Committee.

Service Managers, Modern Matrons,

Ward Managers and Lead Nurses

Implementation - The above named are responsible for ensuring that:- - They are familiar with this policy and are responsible for adhering to the procedures.

- Staffs attend training applicable to their role and for implementing the guidance across their areas of responsibility. - Staff work to the standards set out in this policy.

Medical Staff

Adherence - Medical staff should be familiar with this policy and adhere to the procedures referred to within the policies.

Ward Staff

Adherence - All clinical staffs are responsible for ensuring that they are familiar with the policy and for adhering to the procedures

referred to within the policy.

8.0 Training Training is a key element to the successful implementation of this policy. All clinical staffs that provide patient care should have an awareness of this policy to better aid their understanding of the policy aims in demonstrating safe and effective patient care and provide a clear vision on the importance of their role in the process.

This can be supported by the following:

Reading and understanding the policy

Training around equality and inclusion to ensure all staffs are aware of the need in relation to the BAME population



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When staffs affected are affected by the death of a patient, appropriate support by the trust will be put in place. Staff will individually and collectively (outside any formal review or investigation) be provided dedicated time to reflect on the care provided to people who have died and any learning from this to inform their practice and the way that care is organised. The support available to staff before, during and after any review or investigation, including recognition that most problems in care will derive from systems and processes in place across the Trust. What aspect(s) of this policy will require staff training?

Which staff groups require this training?

Is this training covered in the Trust’s Mandatory and Risk Management Training Needs Analysis document?

If no, how will the training be delivered?

Who will deliver the training?

How often will staff require training

Who will ensure and monitor that staff have this training?

All aspects of the Policy

All clinical Staffs No Staffs to be made aware of the policy and to read

and understand it

Cascaded through all channels-team

meetings, handovers etc.

As new Staffs are employed

Service Managers, Modern Matrons, Ward Managers

and Lead Nurses

Equality and

inclusion training

All clinical staffs No By the equality inclusion

team

By the equality

inclusion team

As new Staffs

are employed

Service Managers, Modern

Matrons, Ward Managers and Lead Nurses

9.0 Equality Impact Assessment

Black Country Partnership NHS Foundation Trust is committed to ensuring that the way we provide services and the way we recruit and treat staff reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group. The Equality Impact Assessment for this policy has been completed and is readily available on the Intranet. If you require this in a different format e.g. larger print, Braille, different languages or audio tape, please contact the Equality & Diversity Team on Ext. 8067 or email [email protected]

10.0 Data Protection and Freedom of Information

Data Protection Act provides controls for the way information is handled and to gives legal rights to individuals in relation to the use of their data. It sets out strict rules for people who use or store data about individuals and gives rights to those people whose data has been collected. The law applies to all personal data held including electronic and manual records. The Information Commissioner’s Office has powers to enforce the Data Protection Act and can do this through the use of compulsory audits, warrants, notices and monetary penalties which can be up to €20million or 4% of the Trusts annual turnover for serious breaches of the Data Protection Act. In addition to this the Information Commissioner can limit or stop data processing activities where there has been a serious breach of the Act and there remains a risk to the data.

mailto:[email protected]



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The Freedom of Information Act provides public access to information held by public authorities. The main principle behind freedom of information legislation is that people have a right to know about the activities of public authorities, unless there is a good reason for them not to. The Freedom of Information Act applies to corporate data and personal data generally cannot be released under this Act. All staffs have a responsibility to ensure that they do not disclose information about the Trust’s activities; this includes information about service users in its care, staff members and corporate documentation to unauthorised individuals. This responsibility applies whether you are currently employed or after your employment ends and in certain aspects of your personal life e.g. use of social networking sites etc. The Trust seeks to ensure a high level of transparency in all its business activities but reserves the right not to disclose information where relevant legislation applies. The Information Governance Team provides a central point for release of information under Data Protection and Freedom of Information following formal requests for information; any queries about the disclosure of information can be forwarded to the Information Governance Team. 11.0 Monitoring this Policy is Working in Practice The Trust Care Governance Group is responsible for monitoring of compliance with this policy.

What key elements will be monitored?

(measurable policy objectives)

Where described in

policy?

How will they be monitored?

(method + sample size)

Who will undertake this monitoring?

How Frequently?

Group/Committee that will receive and

review results

Group/Committee to ensure actions

are completed

Evidence this has

happened

Implementation at the time of patient death

4.0 process Review as part of assurance reports

Divisional governance

As at when required

Divisional Quality & Safety Committee

Divisional Quality & Safety Committee

Assurance report

completed



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Appendix 1

Flowchart Following The Death Of An Adult Service User

This is a corporate procedure for the Black Country Partnership Foundation Trust. It is intended to provide a framework for services to meet the policy statements. 3.1 Flow chart illustrating the corporate procedure following the death of an adult service user

Member of staff discovering death 1. Inform member of staff responsible for team.

Member of staff responsible for team 1. Informs the doctor, the person in charge of the

hospital and the relatives.

Expected death Sudden unexpected death Suspicious death

1. Ensure arrangements made

for appropriate doctor to certify death.

2. Ensure appropriate arrangements made for Last Offices (in line with patient’s preferences and following discussion with carers and relatives- refer to Royal Marsden Procedures).

3. Ensure arrangements made with funeral directors for removal of the body (following discussion with relatives and carers).

4. Consider use of local funeral directors if no relatives or the mortuary (Edward Street Hospital).

5. Inform and offer support to relatives and/or next of kin.

6. Offer support of hospital chaplain or other religious leader or other appropriate person.

1. Inform Director Responsible

for Service (or Director on-call), carers and relatives.

2. The Doctor must inform the coroner.

3. Complete an Incident Report.

4. Ensure site undisturbed and await further advice from coroner.

5. Coroner will decide what action to take – usually an autopsy.

6. Inform and offer support to relatives and/or next of kin.

7. Offer support of hospital chaplain or other religious leader or other appropriate person.

Spiritual Care Team/ Bereavement Support Services 0121 612 8067 07972732748

1. Follow the sudden

unexpected death procedure.

2. The Doctor or a delegated person must inform the police.

Person In charge of the ward/unit 1. Inform Service Manager (Manager on-call) 2. Agree category of death referring to

verification of death policy.



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Appendix 2

Infection control precautions are necessary for the safe handling of the bodies of patients who have died with known or presumed infection.

Standard Infection Control Precautions should be used in the care of all deceased patients. This will include the use of plastic aprons and disposable gloves. Any additional transmission based infection control precautions taken during life should be continued after death, during hygienic preparation of the body, embalming or post mortem examination.

The Advisory Committee on Dangerous Pathogens (ACDP) has grouped infectious diseases into four categories depending on how infectious they are and the seriousness of the disease they cause. Categories 1 and 2 are mild diseases, which, although some can be transmitted quite easily, rarely cause serious or life threatening infections. Category 3 and 4 pathogens are those requiring the deceased to be handled with additional care to minimise the likelihood of cross-infections to staff and undertakers.

Category 3 pathogens

These organisms can cause significant disease to HCW’s and other additional precautions need to be taken when handling an infected body.

Category 4 pathogens

These are organisms that are extremely hazardous and may cause serious epidemic disease.

Definition of Hazard Category Group 4 - A biological agent that causes severe human disease and is a serious hazard to employees; it is likely to spread to the community and there is usually no effective prophylaxis or treatment available.

There are a number of rare infections which are caused by Category 4 pathogens. Examples of these diseases are: Rabies, Viral haemorrhagic fevers, Lassa fever, Marburg virus, Ebola virus and Pulmonary anthrax. Patients suffering from these and other dangerous diseases should be strictly isolated and transferred to the Regional Infectious Diseases Unit. Although there are no appropriate isolation facilities for these patients in most hospitals, a patient may be admitted and die before transfer. If the patient is suspected to be infected with a Category 4 pathogen, special precautions must be taken with the body.

Advice must be sought as a matter of urgency from the Infection Prevention & Control Team or the Consultant in Communicable Disease Control if any of these diseases are suspected.

Mortuary staff, funeral directors or embalmers must be informed of any infection risk, particularly tuberculosis.

Patients who present a particular infection hazard should be identified to the mortuary staff or funeral directors to ensure that the appropriate precautions are taken in the on-going care of the body.



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Cadaver bags (body bags) should be used where the containment of blood and body fluids is difficult or where there is a particular infection hazard (See table for specific infections in Guidance Table 1).

Tuberculosis (Open Pulmonary Only)

Patients with clinically suspected or diagnosed open pulmonary tuberculosis who have NOT completed two weeks of Chemotherapy are considered infectious.

When movement of the body is essential a disposable face mask should be placed over the mouth and nose of the deceased to prevent release of aerosols of infectious materials. Staff must also wear appropriate respiratory protection when performing any procedures or moving the patient, this is especially important in the case of MDR-TB.

Viewing the Body

If relatives become distressed because they cannot view a body, the medical staff that cared for the deceased should be asked to discuss the matter with them.

In the case where relatives or religious representatives wish to be involved in the performance of last offices including hygienic preparation of the body or religious rites, on a patient who presents an infection hazard, advice may be obtained on an individual patient basis from the Infection Prevention & Control Team.

Mortuary Staff and Funeral Directors

The clinical team looking after a patient have a duty to inform mortuary staff, funeral directors or embalmers about patients who present a particular infection hazard, particularly tuberculosis.

Nursing Staff

All relevant information is made available to persons handling/viewing the body so that they may take appropriate action to avoid acquiring an infection themselves.

This includes ensuring that mortuary staffs are aware of any known or suspected infection risk prior to transfer to the mortuary.

If a patient dies before a clinical diagnosis has been confirmed e.g. tuberculosis, meningitis, mortuary staff should be informed of the likely diagnosis.

While observing universal precautions, the body should be laid out and washed in the normal manner according to religious and cultural needs. Nurses/staff should wear disposable gloves and plastic aprons. All drains, catheters, etc., should be removed unless the case has been referred to the Coroner or medical staff request the lines to be left in. All vascular access e.g. drains and line sites, or wound sites should be totally occluded using the minimum padding required and waterproof tape (e.g. Sleek) to prevent leakage.

Inco-pad sheets must be placed in the bag if leakage is anticipated.

The body should be placed in a body bag (head placed at zip end) which must then be sealed. This is to enable viewing of the face only if necessary.



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The patient identity information should be completed. This information MUST be inserted in the body bag pocket (not on the body).

A number of mortuaries and undertakers provide service for inpatient sites. Each Ward/Unit should have the contact for this. These local services may expect their local forms to accompany the body for transportation and contact would need to be made directly for this information.

Those transporting the body must be informed when requesting that the body is moved:

Whether the bag is being used for infection control purposes or leakage of fluids.

SERVICE USER DIAGNOSIS MUST NOT BE DISCLOSED.

Medical Staff

Medical Staff must:

Advice relatives who may wish to view the body before it is placed in the body bag of the potential risk of infection to themselves and the appropriate measures to be taken when viewing the body.

When seeking permission for a hospital post-mortem examination on a body known or suspected of having an infectious condition, discuss with pathologists whether the post-mortem is necessary or practical.

Should it only subsequently become known that a service user was suffering from an infectious disease, the pathologist and senior mortuary staff should be informed by the clinical team caring for the service user in life as soon as possible.

If there is doubt as to whether or not the patient was suffering with an infectious disease, seek further advice from the Microbiologist. Universal infection control precautions should be applied.

Staff transporting the body:

Should wear a plastic apron and gloves when moving a body from the bed to the trolley if it is in a body bag. The gloves and apron should be discarded into the ward orange clinical waste bag. Hands should be washed before leaving the ward. It is not necessary for staff to wear gloves and aprons when transporting a body.

If the body is removed to a mortuary, the body should be placed in the refrigerated body store, the body should be placed on the lowest available shelf.

Any equipment associated with infected bodies must be cleaned and disinfected irrespective of whether or not they are soiled.

Gloves and apron must be removed and placed into the clinical waste bag provided.

Hands should be washed with soap and water before returning to other duties.



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Specific Infections Guidance: Table 1

Degree of risk

Infection Body Bag

Viewing Embalming Hygienic Preparation

Low Acute encephalitis No Yes Yes Yes

Low Chickenpox/shingles No Yes Yes Yes

Low Cryptosporidiosis No Yes Yes Yes

Low Dermatophytosis No Yes Yes Yes

Low Legionellosis No Yes Yes Yes

Low Lyme disease No Yes Yes Yes

Low Measles No Yes Yes Yes

Low Meningitis (except meningococcal) No Yes Yes Yes

Low Mumps No Yes Yes Yes

Low Meticillin-resistant Staphylococcus aureus (MRSA)

No Yes Yes Yes

Low Ophthalmia neonatorum No Yes Yes Yes

Low Psittacosis No Yes Yes Yes

Low Rubella No Yes Yes Yes

Low Tetanus No Yes Yes Yes

Low Whooping cough No Yes Yes Yes

Medium Acute poliomyelitis No Yes Yes Yes

Medium Cholera No Yes Yes Yes

Medium Diphtheria Adv* Yes Yes Yes

Medium Dysentery Adv* Yes Yes Yes

Medium Food poisoning No Yes Yes Yes

Medium Hepatitis A No Yes Yes Yes

Medium HIV/AIDS No Yes No Yes

Medium Leptospirosis (Weil’s disease) No Yes Yes Yes

Medium Malaria No Yes Yes Yes

Medium Paratyphoid fever Adv* Yes Yes Yes

Medium Q fever No Yes Yes Yes

Medium Relapsing fever Adv* Yes Yes Yes

Medium Meningococcal septicaemia Adv* Yes Yes Yes

Medium Scarlet fever Adv* Yes Yes Yes

Medium Tuberculosis Adv* Yes Yes Yes

Medium Typhoid fever Adv* Yes Yes Yes

Medium Typhus Adv* No No No

High Anthrax Adv* No No No

High CJD and TSE No Yes No Yes

High Group A streptococcal infection (invasive)

No Yes Yes Yes

High Hepatitis B and C Yes Yes No Yes

High Plague Yes No No No

High Rabies Yes No No No

High Smallpox Yes No No No

High Viral haemorrhagic fever Yes No No No

High Yellow fever Yes No No No

*ADV – advisable.



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Appendix 3

Last Offices-Equipment and Procedure

Equipment

Disposable plastic aprons Disposable plastic gloves Bowl of warm water, soap, the deceased’s own toiletries and face cloths or

disposable wash cloths and two towels Disposable razor or the patient’s own electric razor, comb and equipment for

nail care Equipment for oral care including equipment for cleaning dentures Identification labels x 2 Documents required by law and organisation policy Shroud or patient’s personal clothing Body bag if required ( in the event of actual or potential leakage of bodily fluids

and/or infectious disease) and labels for the body defining the nature of the infection/disease (see Appendix 2)

Gauze, waterproof tape, dressings and bandages if wounds are present Plastic bags for clinical and household waste Sharps bin if appropriate Laundry skip and appropriate bags for soiled linen Clean bed linen Record books for property and valuables Bags for patient’s personal possessions.

PROCEDURE (Appendix 3) Action Rationale Inform the nurse in charge of the ward/unit and medical staff of the patient’s death. Confirmation/verification of death must be given and recorded in the patient’s medical and nursing notes.(see Verification of Death guidelines)

A registered medical practitioner who has attended the deceased during their last illness is required to give a medical certificate of the cause of death. The certificate requires the doctor to state on which date he/she last saw the deceased alive and whether or not he/she has seen the body after death.

Inform and offer support to relatives and/or next of kin. Offer support of hospital chaplain or other religious leader or other appropriate person. If relative or next of kin not contactable by telephone, it may be necessary to inform the police

To ensure relevant individuals are aware of patient’s death and to provide sensitive care.

Ascertain if the patient had an infectious disease and whether this is notifiable or not. (Patient may need to be placed in a body bag) (See appendix 2)

Extra precautions required when patient has died from an infectious disease.

Last offices should be carried out within 2-4 hours of death

Rigor mortis can occur relatively soon after death and this time is shortened in warmer environments.



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If possible, determine from the family or carers the patient’s wishes for care after death or whether an end of life care plan incorporates an advance directive

Consideration must be given to requirements for people of different religious faiths, any cultural rituals that may accompany the death of a patient, and any patient wishes or preferences for care after death

Wash hands and put on disposable gloves and disposable plastic apron.(Personal Protective equipment - PPE)

PPE must be worn when performing last offices and is used to both protect yourself and all of your patients from the risk of cross infection.

If the patient is on a pressure relieving mattress or device, consult the manufacturers’ instructions before switching off or changing settings.

Nurses must act at all times to maintain the patient’s safety when using a pressure relieving mattress or device.

Lay the patient on his/her back – remove all but one pillow. Support the jaw by placing a pillow or rolled-up towel on the chest or underneath the patient’s jaw (do not bind the patient’s jaw with bandages – can leave pressure marks). Straighten the patient’s limbs.

To maintain the patient’s privacy and dignity and for future nursing care of the body.

Close the patient’s eyes by applying light pressure to the eyelids for 30 seconds. If this is unsuccessful then a little sticky tape such as micropore can be used and leaves no mark.

To maintain the patient’s dignity and for aesthetic reasons. Closure of the eyelids will also provide tissue protection in case of corneal donation.

Drain the bladder by applying firm pressure over the lower abdomen.

Because the body can continue to excrete fluids after death.

Leakages from the vagina and bowel can be contained by the use of incontinence pads respectively. Patients who do continue to have leakages after death should be placed in a body bag following last offices.

Leaking orifices pose a health hazard to staff coming into contact with the body. Ensuring that the body is clean will demonstrate a continued respect for the patient’s dignity. The packing of orifices is considered unnecessary as it increases the rate of bacterial growth and therefore increases odour when these areas of the body are not allowed to drain naturally.

Exuding wounds should be covered with a clean absorbent dressing and secured with an occlusive dressing.

The dressing will absorb any leakage from the wound site. Open wounds and stomas pose a health hazard to staff coming into contact with the body.

Wash the patient unless requested not to do so for religious/cultural reason’s or carer’s preference. Male patients should be shaved unless they chose to wear a beard in life. If shaving a man apply water-based emollient cream to the face.

For hygienic and aesthetic reasons. As a mark of respect and point of closure in the relationship between nurse and patient. To prevent brown streaks on the skin.

It may be important to family and carers to assist with washing thereby continuing to provide the care given in the period before death.

It is an expression of respect and affection and part of the process of adjusting to loss and experiencing grief.

Clean the patient’s mouth to remove debris and For hygienic and aesthetic reasons.



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secretions. Clean dentures and replace them in the mouth if possible.

Remove all jewellery (in the presence of another nurse) unless requested by the family to do otherwise. Jewellery remaining on the patient should be documented on the notification of death form. Rings left on the body should be secured with tape if loose.

To meet with legal requirements, cultural practices and relatives wishes. To maintain the security of the deceased’s possessions.

Dress the person in a shroud or personal clothing depending on organisational policy or relatives wishes.

For aesthetics for family and carers viewing the body or religious or cultural reasons and to meet family or carer’s wishes.

Ensure a correct hospital or organisational patient identification label is attached to the patient’s wrist and attach a further identification label to one ankle. Complete any documents such as notification of death cards – tape one securely to shroud or clothing.

To ensure correct and easy identification of the body in the mortuary.

Wrap the body in a sheet ensuring that the face and feet are covered and that all limbs are held securely in position.

To avoid possible damage to the body during transfer and to prevent distress to colleagues.

Secure the sheet with tape.

Pins must not be used as they are a health and safety hazard to staff.

If leakage of body fluids is a problem or is anticipated, place the body in a sheet and then a body bag.

Actual or potential leakage of fluid whether infection is present or not, poses a health hazard. The sheet will absorb excess fluid.

Action Rationale

Tape the second notification of death card to the outside of the sheet.

For ease of identification of the body.

All areas – contact local funeral directors for the removal of the body.

Decomposition occurs rapidly particularly in hot weather and in overheated rooms. Many pathogenic organisms survive for some time after death and so decomposition of the body may cause a health and safety hazard for those handling the body. Autolysis and growth of bacteria are delayed if the body is cooled.

Screen off the area where removal of the body will occur.

To avoid causing unnecessary distress to other patients, relatives and staff.

Remove gloves and apron. Dispose of equipment according to local policy and wash hands.

To minimise the risk of cross-infection and contamination.

Record all details and actions within the nursing documentation.

To record the time of death, names of those present and names of those informed.

Transfer property, patient records etc. to the appropriate administrative department.

The administrative department cannot begin to process the formalities such as the death certificate or the collection of property by the next of kin until the required documents are in its possession.



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APPENDIX 4:

Guidelines for the Verification of Death.

A nurse cannot legally certify death, since this is one of the few activities that the law requires to be performed by registered medical practitioners. S/he may, however, confirm that death has occurred, providing there is explicit local policy or protocol to allow such an action. The protocol should, however, only be used in situations where death is expected. These guidelines will not apply to the following

In cases of sudden and unexpected death In cases of death within twenty-four hours of admission, or in the community

setting, within 24 hours of the commencement community nurse visits, if no firm clinical diagnosis has been made.

Within seven days of surgical intervention. Within 24 hours of a fall In cases of expected death when death occurs in an unexpected manner or

unexpected circumstances Following an untoward incident e.g. drug error In cases of expected death where no note indicating death is expected has

been entered into the patients notes. Paediatric deaths of any sort. Any violent or unnatural death including any involving industrial disease. Any death where medical involvement (or non-involvement) may be a factor

MEDICAL RESPONSIBILITIES

Patient whose death is expected will be identified formally by the Medical Officer.

The discussions will include the views if appropriate, of the patient, relatives and nursing staff responsible for the patient

Any decision will be communicated to the nursing staff. The decision that death is expected will be documented in the clinical

notes/patient held records. Carers should also be made aware that as a consequence of the terminal

condition, cardiopulmonary resuscitation would not be appropriate and a record of this conversation should be documented in the clinical notes.

The doctor will communicate verbally with the nursing staff regarding those patients identified as an expected death. The doctor should document in the patient records that he has discussed this with the nursing team and has authorised them to verify death.

If the relatives of a deceased patient wish to speak with a doctor, this request should be honoured at a reasonably practical time.

The doctor of the deceased patient will complete the death certificate as soon as practical in readiness for collection by relatives/ Funeral Director.

A member of the medical/nursing team should always be prepared to speak to relatives when they collect the certificate.



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NURSING RESPONSIBILITIES

All nurses should adhere to the NMC Code of Professional Conduct (2008) Nurses should ensure that documentation in the patients’ clinical notes/patient

held records reflect the patients’ current condition/diagnosis and expected death (appendix ii)

Verification of death must only be carried out by those nurses, who have read and understood these guidelines, have received training and are confident and competent in recognizing “the clinical signs of death”. (appendix i and iii)

The nurse will record in the clinical notes/patient held records, the date and time of verification of death including documentation of clinical signs of death.

The nurse will record in the clinical notes/patient held records, the date and time the medical officer was informed of the patients’ death.

The nurse will arrange transfer of the deceased patient to local Funeral Directors following the wishes of the patients’ family.

PROCESS Registered nurses have an individual responsibility to ensure they feel confident and competent in the knowledge and skills of practice (NMC, 2008). All new nursing staff will be made aware of the content of these guidelines and will be required to confirm/demonstrate they are competent in recognising the clinical signs of death. If they are not confident in this area of clinical practice, this should be discussed with their line manager who will be responsible for organising training in carrying out the verification of death procedure. If the nurse has any doubt regarding verification of a death, they should not feel pressured to carry out the verification but encouraged to seek assistance/advice from the line manager and should not make the verification. All new medical staff will be aware of the roles and responsibilities relating to verification of expected death by receiving a copy of these guidelines. The “Guidelines for the Verification of Expected Death” will be available and understood by medical and nursing staff. TRAINING Registered nurses will have received guidance and instruction on recognizing clinical signs of death prior to verifying the death of patients (see Appendix i and iii) Where training is required, registered nurses will be made aware of the content of the guidelines and the process of verifying death.



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Appendix 4a

Clinical Signs Of Death

The following are commonly recognized clinical signs used when verifying death: 1. Absence of a carotid pulse over one minute. 2. Absence of heart sounds over one minute using a stethoscope. 3. Absence of respiratory movements and breath sounds over one minute. 4. Fixed, dilated pupils (unresponsive to lights). 5. No motor (withdrawal) response or facial grimace in response to painful stimuli. If there is any doubt, wait ten minutes and repeat the procedure.



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Appendix 4b

Flow Chart for Verification/Confirmation of Expected Death by Nursing Staff.

Doctor formally identifies a

patient whose death is expected.

Doctor discussed with nursing

staff and where appropriates the

patient and relatives.

Doctor to document that death is

expected in patient’s notes.

Doctor to communicate to nursing

staff that he/she is happy for them

to verify death and document in

medical notes.

Doctors of deceased patient to

complete death certificate ASAP

for collection by relatives.



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Appendix 4c

Black Country Partnership Foundation Trust Certificate of Verification of Death Competency

Name of Registered Nurse ………………………………….. Designation ……………………………………………………

Absence of heart sounds over one minute using a stethoscope

Absence of respiratory movements and breath sounds over one minute

Fixed, dilated pupils (unresponsive to lights)

No motor (withdrawal) response or facial grimace in response to painful stimuli. I certify that…………………………………………………….. is competent to verify expected deaths based on the above criteria. Authorised by………………………………………………….. Designation…………………………………………………



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Appendix 4d

Recommendations from H.M. Coroner – Robin J Balmain

The coroner is content for appropriately trained nursing staff from Black Country Partnership Foundation Trust to verify expected deaths. Any deaths, which are not expected, are to be verified by Medical Staff and referred to the Coroner. It is then permissible for the deceased to be transferred to local Funeral Directors whilst awaiting the Coroners investigations unless the Coroner gives instructions to the contrary. Not all cases referred to the Corner have Post Mortem examinations. All Post Mortem examinations are carried out by the Coroner. In cases of expected death which must be reported to the Coroner e.g. mesothelioma, the deceased may, subject to the coroner’s agreement, be transferred to local funeral directors.



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Policy Details

* For more information on the consultation process, implementation plan, equality impact assessment,

or archiving arrangements, please contact Corporate Governance

Review and Amendment History

Version Date Details of Change

V1.1 July 2018 Reviewed with no amendments as TCT did not take place

V1.0 Jan 2014 Newly aligned Policy for BCPFT

Title of Policy Death of an Adult Service User Policy

Unique Identifier for this policy BCPFT-CLIN-POL-0114-156

State if policy is New or Revised Revised

Previous Policy Title where applicable n/a

Policy Category Clinical, HR, H&S, Infection Control etc.

Clinical

Executive Director whose portfolio this policy comes under

Policy Lead/Author Job titles only

Practice Development Nurse Physical Health Matron

Committee/Group responsible for the approval of this policy

The Clinical Policy Alignment Group

Month/year consultation process completed *

n/a

Month/year policy approved July 2018

Month/year policy ratified and issued July 2018

Next review date September 2020

Implementation Plan completed * Yes

Equality Impact Assessment completed * Yes

Previous version(s) archived * Yes

Disclosure status ‘B’ can be disclosed to patients and the public

Key Words for this policy

Emergencies, death, flowchart, Infection Control Precautions, Guidelines for the Verification of Death, Clinical signs of death, Flowchart for verification/confirmation of expected death by nursing staff, Certificate of verification of death competency,

Death of an Adult Service User - bcpft.nhs.uk

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