Northern Ireland Audit: Dying, Death and Bereavement€¦ · bereavement care standards and...

Northern Ireland Audit:Dying, Death and Bereavement

Policies, procedures and practices in hospital and hospice settings

2009

Funded by the Regional Multi-professional Audit Group this important audit was the first piece of work undertaken by the Northern Ireland Health and Social Care Bereavement Network. Its findings form the basis of the Bereavement Strategy for Health and Social Care Services in Northern Ireland which is launched in 2009.

The findings have identified the excellent work in hospitals and hospices across Northern Ireland in supporting patients, relatives and staff at the time of and following bereavement. The audit also identified the significant pressures experienced by the services and the need for ongoing training and support.

Thanks must be given to the Area Bereavement Coordinators for their central role in the audit and in the development of the Bereavement Strategy. The audit would not have been achievable without the active cooperation and enthusiasm of the NI Hospices and HPSS Trusts, in particular the clinical and management staff to whom special thanks is given.

Dr Patricia DonnellyNI Health & Social Care Bereavement Network

Foreword

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N.I. Audit: Dying, Death & Bereavement

Contents Page

EXECUTIVE SUMMARY

1. INTRODUCTION 1

1.1 Background and purpose of the audit 1

1.2 Scope of the audit 2

1.3 Audit methodology 4

2. OVERVIEW OF HSC TRUSTS AND THEIR SERVICES 6

2.1 Demographics and organisations 6

2.2. Staff groups and services 9

2.3 Mortuary services 10

2.4 Palliative care services 11

2.5 Chaplaincy services 11

3. PROMOTING SAFE AND EFFECTIVE CARE 13

3.1 Policies, guidelines and practices 13

3.1.1 Bereavement checklists 15

3.1.2 Identification and labelling 16

3.1.3 Issue of death certificates 17

3.1.4 Transfer of patients 17

3.1.5 Information and communication 18

3.2 Knowledge and skills 20

3.3 Staff support 24

4. CREATING A SUPPORTIVE EXPERIENCE 26

4.1 Environment and facilities 26

4.2 Care and support 29

4.3 Information and communication 35

5. RECOMMENDATIONS 40

6. APPENDICES 41

7. REFERENCES 58

8. ACKNOWLEDGEMENTS 61

9. N.I. AREA BEREAVEMENT COORDINATORS CONTACT DETAILS 62

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The Department of Health, Social Services and Public Safety (DHSSPS), in response to the Northern Ireland Human Organs Inquiry 2002, established the Northern Ireland Bereavement Network and appointed five Area Bereavement Coordinators (ABCs) to coordinate and develop bereavement care standards and training across the province.

Approximately 14,000 to 15,000 people die each year in Northern Ireland, over half of them in hospitals. In 2006-07, an audit was undertaken of 35 HPSS hospitals and all 5 hospices in Northern Ireland. The aims of the audit were to map current services across the province and identify the profile of need for care of the dying and bereaved, to inform the development of the strategy for bereavement care for Northern Ireland.

The audit was undertaken by the Bereavement Coordinator in each Health and Social Services Board area on behalf of the Bereavement Network for Northern Ireland. The Bereavement Coordinators posts were funded by the DHSSPS, following recommendations 9, 10 and 12 of the Human Organ Inquiry 2002.

It is recognised that care of dying patients and support of bereaved relatives requires a multi-disciplinary approach therefore this audit was divided into eight strands: 1. Demographics – information on the profile of deaths across Northern Ireland.

2. Organisational – information on services provided in HPSS and hospice including governance arrangements underpinning services.

3. Ward visits – information from a sample of wards in different specialities, in respect of policies, procedures and practices. 4. Mortuary services within HPSS – information on facilities and practices.

5. Chaplaincy service in HPSS and hospices – information on services provided and how patients’ spiritual needs are met.

6. Palliative care services – information on the make-up of teams and services provided.

7. Porters and funeral directors services – information on the transfer and release of deceased patients.

8. Individual staff questionnaires – information on knowledge, skills and experience of caring for dying patients and their families.

The audit identified areas of good practice, as well as pressures faced by staff in the acute hospital setting and the need for appropriate staff training and support systems.

The main findings of the audit, together with the outcomes of a number of workshops, have informed the development of the Northern Ireland HSC Strategy for Bereavement Care, to be published in 2009.

Executive Summary

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1.1. Background and purpose of the audit

The Northern Ireland Human Organs Inquiry 2002 made specific recommendations 9, 10 and 12 in respect of bereavement care in public health services. In consequence the Northern Ireland Bereavement Network was established by the Department of Health Social Services and Public Safety (DHSSPS) as a partnership across Health & Social Care Trusts. Five Area Bereavement Coordinators (ABCs) were appointed to deliver the work of the Network, to coordinate and develop bereavement care standards and training within the health and social care sector across the province and to work in partnership with the non-statutory, voluntary and community sector

The Northern Ireland Audit on Dying, Death and Bereavement was commissioned by the DHSSPS and funded through the Regional Multi-professional Audit Group (RMAG). It is planned as a two stage audit with the second stage in years 2009/10 focusing on community services and user experience. The first stage undertaken in 2006/07, reported here, maps current services across the province and identifies the profile of need for the care of the dying and bereavement care in the HPSS and hospice service.

The audit assessed policies, procedures and practices in relation to death and bereavement care within hospitals and hospices across Northern Ireland. It was informed by national and regional standards alongside current legislation, core strategies, guidelines and literature, including the following:

• Births and Deaths Registration (Northern Ireland) Order (1976)

• Coroners Act (Northern Ireland) 1959 (Section 7)

• Human Tissue Act 2004

• DH (2003), NHS Chaplaincy: Meeting the Religious and Spiritual Needs of Patients and Staff

• DH (2005), When a Patient Dies: Advice on Developing Bereavement Services in the NHS

• DH (2006), Care and Respect in Death: Good Practice Guidance for NHS Mortuary Staff

• DHSSPS (2000), Partnerships in Caring: Standards for Service. A Review of Palliative Care

• DHSSPS (2003), Breaking Bad News: Regional Guidelines, Developed from Partnerships in Caring (2000)

• DHSSPS (2005), A Code of Good Practice on Post Mortem Examinations: A Careplan for Women who Experience a Miscarriage, Stillbirth or Neonatal Death

• DHSSPS (2005), Post Mortem Examinations - A Code of Good Practice: Rights of Patients and Relatives: Responsibilities of Professionals

• DHSSPS (2006), The Quality Standards for Health and Social Care: Supporting Good Governance and Best Practice in the HPSS

1. Introduction

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• DHSSPSNI, PSNI, Court Service NI and HSENI (2006), Memorandum of Understanding: Investigating Patient or Client Safety Incidents (Unexpected Death or Serious Untoward Harm)

• Equality Commission NI and DHSSPS (2003), Racial Equality in Health and Social Care - Good Practice Guide

• Human Tissue Authority (2006), Codes of Practice

• National Institute for Health and Clinical Excellence (2004), Improving Supportive and Palliative Care for Adults with Cancer

• NHS Executive (2000), Resuscitation Policy

• NHS Estates (2005), A Place to Die with Dignity: Creating a Supportive Environment

The main findings of the audit, together with the outcomes of a number of workshops, whose participants were drawn from across the statutory, voluntary, private and community sectors which included individuals from a diverse range of faiths and interests, have already informed the Northern Ireland Health and Social Care Services Strategy for Bereavement Care.

1.2 Scope of the audit

The most recent year for which official figures were available prior to the audit being carried out was January-December 2005. During this year 14,224 deaths were registered in Northern Ireland; of these (Figure 1) 57% were reported to have occurred in ‘hospitals’, a further 16% in ‘nursing homes and other hospitals, including psychiatric hospitals’, and the remaining 27% in ‘all other places, for example private residences or public buildings’ (Eighty-fourth Annual Report of the Registrar General 2005).

Figure 1: Number and location of deaths registered in Northern Ireland in 2005 (Registrar General statistics)

Given that the majority of deaths in Northern Ireland occur within the hospital sector, it was the care and practices in relation to end of life and bereavement care across the province’s hospitals (as well as in all five of its hospices, given the central purpose of hospices in the care of terminally ill patients) that formed the focus of the current audit.

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The population of Northern Ireland is estimated at just over 1.75 million. Table 1 shows the population distribution across the five current Health & Social Care Trusts; and the eighteen legacy HSS Trusts which were operational at the time of the audit. It is recognised that the Belfast Trust provides a number of specialist regional services to the wider population.

HSC Trust HSS Legacy Trusts Population

Belfast

HSC Trust

Belfast City Hospital Trust, Greenpark Trust, Royal

Group of Hospitals and Dental Hospital Trust, Mater Hospital Trust, South and East Belfast Trust, North

and West Belfast Trust.

340,000

Northern

HSC Trust

United Hospitals Trust, Causeway Trust, Homefirst

Community Trust.

450,000

South Eastern

HSC Trust

Ulster Community and Hospitals Trust, Down

Lisburn Trust.

335,000

Southern HSC Trust

Craigavon Area Hospital Group Trust, Craigavon and Banbridge Community Trust, Newry and Mourne

Trust, Armagh and Dungannon Trust.

343,000

Western

HSC Trust

Altnagelvin Hospital Trust, Sperrin Lakeland Trust,

Foyle Trust.

295,000

Table 1: Population and organisation of local HSC trusts

For ease of reference the remainder of this document will collate information and refer only to the new HSC Trust configurations.

The audit targeted every hospice as well as all the main acute and local hospitals and a significant proportion of minor and more specialist hospitals (specifically, in the areas of eldercare, mental health and learning disability) across Northern Ireland. The sample consisted of 35 hospitals (including an inpatient mental health unit) listed in Table 2 by HSC Trusts, and the 5 hospices listed by geographical location.

HSC Trust Hospitals Hospices

Belfast

HSC Trust

Belfast City Hospital, Royal Victoria Hospital,

Royal Jubilee Maternity Service, Royal Belfast Hospital for Sick Children, Mater

Hospital, Musgrave Park Hospital, Forster

Green Hospital, Muckamore Abbey Hospital, Knockbracken Healthcare Park.

Northern Ireland

Hospice Care

Northern

HSC Trust

Antrim Area Hospital, Mid-Ulster Hospital,

Whiteabbey Hospital, Causeway Hospital,

Moyle Hospital, Braid Valley Hospital, Dalriada Hospital, Robinson Memorial

Hospital, Holywell Hospital.

Northern Ireland

Children’s Hospice

South Eastern

HSC Trust

Ulster Hospital, Ards Hospital, Bangor

Hospital, Lagan Valley Hospital, Downe Hospital, Downshire Hospital.

Marie Curie

Hospice

Southern HSC Trust

Craigavon Area Hospital, South Tyrone Hospital, Daisy Hill Hospital, Lurgan Hospital,

Mullinure Hospital, Inpatient Psychiatry Unit,

St Luke’s Hospital, Longstone Hospital.

Southern Area Hospice Services

Western HSC Trust

Altnagelvin Hospital, Tyrone County Hospital, Erne Hospital.

Foyle Hospice

Table 2: Hospitals (n=35) and hospices (n=5) included in the audit

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1.3 Audit methodology

The Chief Executives with responsibility for each of the HSC hospitals and hospices referred to in Table 2 were invited to take part in the audit, and all agreed and signed up to the project. Trust and audit leads were identified to assist the Area Bereavement Coordinators in the collection of information.

The audit comprised eight strands and used a mixed methodology of both quantitative and qualitative data collection.

Demographics

Information on the profile of deaths occurring between 1st April 2005 and 31st March 2006 within each hospital and hospice was collected. This included the number and location of the deaths, the age profile of the deceased, including miscarriages, stillbirths and neonatal deaths, and also ‘consented’ (i.e. hospital) and ‘unconsented’ (coroners) post mortem examination activity.

Organisational

The identification and analysis of a number of aspects of service provision and governance arrangements was undertaken, including policies and protocols, which were in place for the care of dying and bereaved people within the various hospitals and hospices audited. Questionnaires were issued to the nominated leads within each hospice or trust.

Ward visits

Data collection proformas from specialties and wards within each hospital were completed by senior nursing staff: Semi-structured interviews were also used with managers of each ward (or their nominees or deputies) on a range of aspects of the care provided to dying and bereaved people.

Mortuary services

As the majority of patients who die in hospital are transferred to a mortuary, information was collected from pathology technicians or those with responsibility for policies, procedures and practices within each of those organisations which identified itself as having an ‘operational mortuary’ (i.e. one that has the facilities to carry out post mortem examinations and/or has refrigerated body storage). This included information on processes surrounding admission and release of the deceased, access to viewing facilities for bereaved people and the nature of training undertaken by staff.

Chaplaincy services

To assess how the spiritual needs of patients are met, information was collected on the services provided by chaplains, including their referral processes, the availability of literature and the facilities that are available for the use of chaplains. This was obtained either directly through meetings with lead chaplains or from managers with responsibly for chaplaincy services.

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Palliative care services

Given their close involvement with dying patients and bereaved relatives, information was obtained directly from team members about the services provided by palliative care teams within acute hospital settings. This included their referral processes, the challenges inherent in providing their services and the training undertaken by members of the team.

Porters and funeral directors

In the majority of hospitals, portering teams are directly responsible for the transfer of deceased patients to mortuaries and some are involved in undertaking mortuary duties directly. A number of hospitals have service level agreements with funeral directors for the transfer and release of deceased patients. Information about the duties undertaken and the challenges in providing these services was obtained from portering managers and, where applicable, the contracted funeral directors.

Individual staff questionnaires

Given the importance of a multidisciplinary team and inter-agency approach to patient care, the final strand of the audit was aimed at a significant cross section of health care employees from a range of professional backgrounds who might be expected to come into contact with dying and bereaved people. In particular, their views were sought on the environments in which bereavement care is provided, the nature of the care itself, and the skills, training and support required and available to staff in relation to end of life care. The Area Bereavement Coordinators distributed over 3,500 questionnaires to wards, departments and key professionals throughout individual Trusts, of which 1,633 were returned for analysis.

The eight strands and the scope of the audit are summarised in Table 3.

Audit Strand Sources of Information

(with Numbers Included/Returned)

Demographics Hospitals (35) and hospices (5)

Organisational Hospitals (35) and hospices (5)

Ward visits Wards (140) and hospices (5)

Mortuary services Staff in operational mortuaries (12)

Chaplaincy services Chaplaincy teams in hospitals and hospices (33)

Palliative care services Palliative care teams in acute hospitals (11)

Porters and funeral directors

Portering teams (15) and funeral directors with service level agreements for portering and mortuary duties (5)

Staff questionnaires Individual staff members (1,633)

Table 3: The strands and scope of the audit

The figures in Table 3, apart from individual staff questionnaires, represent the numbers of organisations (i.e. hospitals and hospices), individual wards (including hospices) and services (mortuary, chaplaincy, palliative care and portering) from whom information was both requested and returned. Although a total of 35 individual hospitals were included in the audit, a single, corporate response was provided in respect of the Ulster, Ards and Bangor Hospitals. Although all organisations had a dedicated chaplaincy service, a number of chaplaincy services operated across more than a single organisation therefore while 27 chaplaincy services participated in the audit they covered 33 individual hospitals and hospices. The figure in the table for the staff questionnaires refers to the number of individual returns that were received.

Information returned was not always complete, particularly the individual staff questionnaires. For that reason, the audit results are presented by percentages as well as number of returns actually received.

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2.1 Demographics and organisations

The types of inpatient care provided in each of the 35 hospitals and 5 hospices audited are presented in Figure 2. As expected, given the province’s increasingly aging population, a large majority of organisations (83%) provided elderly care facilities, with between 20% and 45% providing care in each of the acute, paediatric, maternity and mental health areas and fewer than 15% in any other major specialist area.

* Regional, ambulatory paediatrics (including outpatients), orthopaedic/rheumatology/neurology and elective

Figure 2: Types of care provided by hospitals and hospices in Northern Ireland (n=40)

The data is consistent with that presented in Figure 3, which shows the number of inpatient deaths recorded in each of the main specialist areas within the hospitals and hospices audited throughout the (financial) year 2005-06.

Figure 3: Inpatient deaths by specialist area (1 April 2005 to 31 March 2006)

2. Overview of HSC Trusts and Services Provided

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In 2005/2006 in Northern Ireland there were 7,944 recorded inpatient deaths in total: 7,359 in the 35 HPSS hospitals and 585 in the 5 hospices. General medicine (with almost 40% of all inpatient deaths) recorded the highest percentage, followed by elderly care (with almost 20%). However, there will have been significant overlap between these two areas since a high proportion of deaths in general wards are from the older age group. The next-highest numbers of deaths were general surgery (11%), intensive care units (8%), hospices (7.5%) and cardiology wards (almost 7%). No other speciality accounted for more than 3% of the total recorded inpatient deaths for the year.

Data was collected from every intensive care and neonatal unit, emergency department and hospice across the province, as well as other specialist areas. In all, 25 wards from each of general medicine and elderly care (where the highest numbers of inpatient deaths occur) were visited; together this represents approximately one-third of all visits undertaken.

The number of wards and hospices visited within all of the specialist areas, along with their associated percentages of the overall total of 145, is presented in Table 4. Most organisations have separate wards for obstetrics and gynaecology; however in two of the facilities visited these areas shared a common ward. For the purpose of this audit, the joint wards have been treated separately from the other obstetrics and gynaecology wards.

Area of Speciality Number (and % of Overall Total)

of Facilities Visited

General medicine 25 (17%)

Elderly care 25 (17%)

General surgery 16 (11%)

Emergency department 16 (11%)

Intensive care unit 13 ( 9%)

Cardiology 13 ( 9%)

Paediatrics 8 ( 6%)

Obstetrics 8 ( 6%)

Gynaecology 7 ( 5%)

Neonatology 7 ( 5%)

Hospice 5 ( 3%)

Obstetrics and gynaecology 2 ( 1%)

Table 4: Number (and percentage of the overall total) of wards and hospices visited within each specialist area

The Miscarriage Association estimates that about a quarter of all pregnancies end in miscarriage. Although not recorded legally as ‘deaths’ if they occur before the age of 24 weeks gestation, miscarriages have a significant impact on the parents concerned, as well as on the care and support they require from staff.

A breakdown of the deaths within the 35 hospitals and 5 hospices, as well as those resulting from miscarriage or stillbirth, are presented in Figure 4. As predicted, the highest number of deaths was in the age group 65 years and over, while miscarriages constituted the second largest group. Whereas the overall number of deaths of children under the age of 18 years is low, it is recognised that the death of a child is especially traumatic for families.

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Figure 4: Miscarriages, stillbirths and certified deaths in hospitals (n=35) and hospices (n=5), April 2005 – March 2006

Some hospital deaths, such as those that are unexpected or unexplained, require referral to the coroner and may be subject to a coroners (‘unconsented’) post mortem examination, while others may involve a hospital (‘consented’) post mortem examination being carried out.

Public confidence in the post mortem examination process decreased dramatically following the disclosure of the issues that led to the Human Organs Inquiry (2002). The subsequent introduction of new legislation (the Human Tissue Act 2004) has sought to address the shortcomings of earlier practices. The DHSSPS, for example, has introduced new codes of practice, consent forms and information booklets for use by staff and to support families of deceased patients who are undergoing hospital post mortem examinations. These include a careplan for women who experience a miscarriage, stillbirth or neonatal death.

For all of the miscarriages, stillbirths and deaths referenced in Figure 4, data was collected on the relative proportions of hospital (consented) and coroners (unconsented) post mortem examinations carried out within the different age ranges. This information is summarised in Figure 5.

Figure 5: Post mortems completed in respect of miscarriages, stillbirths and deaths in hospitals (n=35), 2005-2006

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While the highest percentage of deaths occurred in the over-65 age group, there were relatively few post mortem examinations carried out on this population, as most deaths at that age are expected to be from natural causes or disease processes. The highest number of post mortem examinations was carried out on children under the age of 18 years, with almost half of all children who die in neonatal units undergoing a hospital (consented) post mortem examination.

2.2 Staff groups and services

In addition to the 145 ward visits, over 3500 questionnaires were issued to a variety of healthcare staff groups to collect information on their involvement and experience of caring for dying patients and their families. Of these, 1633 questionnaires were returned. Figure 6 presents a breakdown of the staff groups who responded to the questionnaire, along with the lengths of service of the 94% (1540) who volunteered that information.

Figure 6: Lengths of service of staff responding to the individual questionnaires (n=1540)

Nurses, by far the largest professional group employed by HSC trusts, provided over 60% of the questionnaires returned. In addition, over half the nurses who responded had been in service for 10 years or over, so they represented a significantly experienced group of staff.

The individual questionnaires asked staff about the frequency of their contact with patients who are dying, their families or with other staff involved with the care of dying patients. As can be seen from Figure 7, around one-third of those staff who responded to the questionnaire often deal with dying patients or others directly affected by their deaths (i.e. at least weekly), with similar numbers having such experiences at least monthly and less than monthly respectively, and only just over 5% having no such contact at all.

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2.3 Mortuary services

Mortuaries are a vital part of the service the HPSS provides to patients who die in hospital and to bereaved families and friends (Care and Respect in Death, DOH 2005). There are four HSC Trust mortuaries where post mortem examinations are carried out – one in each of four of the five Trusts, with the fifth, the South Eastern Trust, having access to the post mortem facilities of the Belfast Trust.

Figure 8 summarises the different types of mortuary facility available in the hospitals and hospices included in the audit. A total of 18 organisations (45%) had access to a mortuary; 14 (35%) had designated areas where bodies could remain until collected by funeral directors; and in the remaining services (20%) it was practice for funeral directors to collect patients’ bodies directly from wards.

Figure 7: Frequency with which staff deal with issues of death and dying (n=1560)

Figure 8: Types of mortuary facilities within the 35 hospitals and 5 hospices

A total of 23 employees were identified as working within the mortuaries. Of these, 15 were qualified pathology technicians, 4 were mortuary attendants, and 2 each were designated porters and laboratory staff. Mortuary staff work a range of full-time, part-time and on-call hours, and some also have duties in other parts of the hospital.

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2.4 Palliative care services

The audit identified the profile of specialist palliative care services across the region, with eleven specialist teams within the acute sector across Northern Ireland – three in the Belfast Trust, and two in each of the other four Trusts – based in the Altnagelvin, Antrim, Belfast City, Causeway, Craigavon Area, Lagan Valley, Mater, Daisy Hill, Royal, Erne and Ulster Hospitals respectively. Some of these teams work across both hospital and community sites. Operational policies were in place for 60% of the teams.

Representatives of each palliative care service were asked to identify the different professions in their respective teams. The results are summarised in Figure 9, which shows that whilst all eleven teams comprised specialist nursing staff and 82% had a consultant physician, other disciplines were much less likely to be included.

Figure 9: Professional membership of the specialist palliative care teams (n=11)

Recent needs assessments carried out in the palliative care sector have led to the development and inclusion of a limited number of specialist practitioners from disciplines such as speech and language therapy, physiotherapy, occupational therapy, nutrition and dietetics, social work and psychology.

2.5 Chaplaincy services

In recognition of the fact that the quality of services provided to the dying and bereaved can be enhanced through access to different forms of spiritual care (When a Patient Dies, Department of Health 2005), information about chaplaincy services was also collected as part of the audit.

Figure 10 summarises the extent to which the main religious denominations are represented within the 27 chaplaincy teams which, between them, served 33 of the hospitals and hospices included in the audit. Most Trusts employed a chaplain from each of the four main denominations, while it was widely reported that the Methodist chaplain liaises with other appropriate religious/spiritual representatives as required. Within the Northern Ireland Hospice, the spiritual needs of patients are attended to by two generic chaplains. It is also recognised that patients and families often use the services of their home/community church or organisation.

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A policy relating to chaplaincy services was available in approximately 40% of the hospitals and hospices audited. During the ward and hospice visits, the majority of respondents (87%) reported that patients were asked on admission whether they wished their religious affiliation to be documented and if they permitted this information to be provided to the chaplaincy team. In situations where patients initially indicated they did not wish chaplaincy involvement, 78% of respondents advised that this decision would be revisited later, if appropriate, should the patient’s condition deteriorate.

As indicated in Figure 11, the chaplains themselves identified a range of facilities and support available to them in the performance of their duties.

Figure 10: Religious denominations represented within chaplaincy services (n=33 hospitals and hospices)

Figure 11: Facilities and support available to chaplaincy services (n=33 hospitals and hospices)

Over three-quarters of the chaplains indicated that they had dedicated offices, telephones and allocated time to meet together and for regular meetings with their respective directors. However, only about one-third had an opportunity for formal appraisal/development review, and just over 50% had access to each of a computer and administrative support.

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All HSC trusts and hospices have a duty to provide safe and effective care by having robust governance arrangements in place that are in compliance with national and regional guidelines and legislation (see section 1.1).

3.1. Policies, guidelines and practices

All 35 hospitals and 5 hospices provided information in respect of their policies, procedures and guidelines associated with end of life and bereavement care. This information was collected from the organisation leads and key individuals within the services audited.

It is acknowledged that the availability of a written policy does not necessarily mean that it has been fully operationalised within a facility, while at the same time many good practices and procedures may take place on a regular basis that are not formalised in a written policy.

Policies and procedures available are presented in Table 5, ranked in order of frequency of availability. Not all organisations provided information in respect of every policy or procedure.

Policy/Procedure Area

Hospitals

Hospices

Accessing translation services 94% 60%

Do not attempt resuscitation 94% 100%

Reporting cases to the coroner 91% 100%

Cultural and religious practices 88% 100%

Death certification 82% 100%

Breaking bad news 77% 100%

Care of the dying pathway 74% 100%

Care plan for women who experience a miscarriage, stillbirth or neonatal

death*

73% Not applicable

Post mortem processes 71% 40%

Cremation 69% 80%

Memorandum of understanding 68% 100%

Information for relatives 62% 100%

Burial by hospital (if no next-of-kin) 61% 60%

Advance directives 51% 60%

Identification of the deceased 49% 60%

Bereavement care 46% 80%

Chaplaincy/Spiritual care 46% 100%

Sudden death protocols 42% 20%

Table 5: Hospitals (n=31-35) and hospices (n=3-5) reporting compliance with bereavement-related policies and procedures (*Note: applicable to 19 hospitals only)

Hospices had evidence of a higher level of written policies in these areas, as expected in services specialising in end of life care. And while organisations generally had in place policies, procedures and guidelines relating to statutory or legal obligations in end of life and after death care, those that bore no statutory obligation to direct or enhance supportive care tended to be less evident within the hospitals, such as the policy on bereavement and spiritual care.

3. Promoting Safe and Effective Care

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To promote safe and effective care in both hospitals and hospices, it is clear that further development and standardisation of policies is required, for example hospitals need to develop protocols in relation to sudden death and identification of the deceased.

Policies relating to care after death are commonly referred to as ‘last offices’. As can be seen from Figure 12, they include a number of elements of care.

Figure 12: Hospitals (n=35) and hospices (n=5) reporting compliance with policies and procedures relating to “last offices”

As last offices are required for the management of every death and are carried out regularly in hospitals and hospices, it would be reasonable to anticipate 100% compliance in each of these areas. For some, however, most notably the removal of implants and viewing of the deceased, the compliance rate was as low as 60% or less.

Ward managers reported a variety of methods used to inform staff about policies and procedures (Figure 13). Ward induction was the most commonly used (in 95% of the wards and hospices for whom returns were provided), closely followed by team meetings (91%) and training courses (62%). Supervision and the intranet were identified in just under half of all facilities each, although it is likely that the use of these latter methods will increase in the future.

Figure 13: Methods used to inform staff about policies and procedures (n=140 wards and hospices)

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During the year for which audit demographic information was available (2005-06), 149 children died before the age of 18 years and 81 babies were stillborn (Figure 4). The death of a baby or child is always a difficult experience for family members as well as for staff, as was made clear by their responses to the audit. Specific policies are necessary to both support staff and to ensure that parents’ wishes are carried out in a safe and sensitive manner.

The audit identified 50 wards where parents may be expected to require support before, at the time of and/or after the death of a child. Different Trusts used a variety of checklists and booklets; there were not always written policies in place to support some of the practices that are carried out, such as those concerning information for parents wishing to take their deceased child directly to their home by car.

As the majority of patients who die in hospital are transferred to a mortuary, those individuals with responsibility for mortuaries were asked about the availability of written policies and procedures aimed at supporting their practices. The procedures and guidelines available are summarised in Figure 14, with a variation reported in the policies available in different mortuaries and some practices not always supported by written policies.

Figure 14: Policies, procedures and guidelines available within mortuaries (n=12)

3.1.1 Bereavement checklists

Some facilities use bereavement checklists to ensure that all necessary actions are taken at the time of a patient’s death and that families receive adequate information to assist them. These can be part of an end of life care pathway or a separate checklist which has been developed to address the needs of a specific area.

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Figure 15 summarises the availability of checklists across the different specialist areas. It demonstrates a degree of variability across areas, with obstetrics and gynaecology and neonatology units reporting the greatest use of bereavement checklists (100%) and emergency departments – with their high proportion of sudden deaths having fewest (20%).

3.1.2 Identification and labelling

Correct identification and labelling of a deceased patient is vital to avoid the risk of misidentification, which could lead in turn to the wrong body being released.

Ward managers identified the methods used in their respective departments to identify bodies before transfer out of their wards to the mortuary or a funeral director. The results are summarised in Figure 16.

Figure 15: Usage of death and bereavement checklists (n=141)

Figure 16: Use of identification accompanying bodies being transferred from wards and hospices (n=142)

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Three separate means of identification were listed by the ward managers: patient identification armbands, mortuary forms and patient identification labels. All three were said to be used by 62% of respondents, while 99% reported the use of at least one such form of identification. In the survey of policy and procedures (section 3.1) it is noted that only 46% of hospitals and 60% of hospices had a written policy/procedure for patient identification.

3.1.3 Issue of death certificates

In cases where death is due to natural causes, it is a legal requirement for a Medical Certificate of Cause of Death (MCCD) to be completed by a doctor who has treated the patient within the previous twenty-eight days. There are a number of situations, where, if the cause of death is unknown, unexpected or where there are suspicious circumstances, the doctor has a duty to report the death to the coroner.

In Northern Ireland it is usually the cultural practice for a short interval from death to burial/ cremation and it is good practice for the death certificate to be given to the family as soon as practicable to facilitate this. However, the audit identified that it is issued at the time of death in only 50% of cases. Ward managers specified the reasons for the delay in death certificates being issued, with responses presented in Figure 17.

Figure 17: Reasons offered by ward managers (n=95) for a delay in issuing a death certificate

Two reasons were identified for delay: the most common (accounting for 63%) was that changes in junior doctors’ working hours mean the duty doctor has not attended the patient personally, and the issue of the certificate has to wait for the return of a doctor who has treated the patient. The second reason (accounting for the 37%) was that the circumstances of the death may require discussion with a consultant and contact with the Coroner for advice as to whether a death certificate can be issued or if further investigation is required.

3.1.4 Transfer of patients

The audit identified three different methods of the transfer of deceased patients from wards:

• Removal by a designated funeral director, under a service level agreement, to a mortuary;

• Removal by portering staff to a mortuary or holding area;

• Removal by a family funeral director to external premises.

17

Portering managers and funeral directors were asked about the modes of transport used. For children and adults, concealment trolleys were the usual means of transport. For morbidly obese patients (bariatric patients) where the body mass is greater than 40, (National Clinical Excellence definition) transfer generally takes place in the patient’s bed. There were a number of different modes of transport available for the transfer of babies, with Moses baskets and small transfer boxes the most frequently used. Fifty per cent of respondents reported that the transfer of babies and children is a particularly difficult duty to perform.

Figure 18: Means of transportation used for the transfer of deceased patients within hospitals, as reported by portering managers and contracted funeral directors (n=20)

Figure 18 outlines the means of transportation used for the transfer of deceased patients within hospital sites. Half of all cases were reported to have been transferred by foot, 40% in a hospital van, and the remaining 15% in a funeral director’s vehicle, with bodies at times transferred by a combination of means.

3.1.5. Information and communication

Portering managers and those funeral directors carrying out portering and mortuary duties under service level agreements were asked about the information provided to them at the time of a deceased patient’s transfer from a ward. Their responses are summarised in Figure 19, which indicates that information provided by ward staff varied considerably particularly that provided when a request for a body to be removed was being made.

Figure 19: Information provided to porters and contracted funeral directors (n=20)when removing a body from a ward

18


Some of the porters and funeral directors were given information verbally and others through a mortuary identification form. Given the importance of effective communication on issues such as infection control, identification and release, these figures must be viewed as unexpectedly low.

The information reported as being provided by ward staff to mortuary staff and family funeral directors is presented in Figure 20. As expected, this is more than the information provided to those transferring bodies to the mortuaries (Figure 19). Ward staff appear to provide mortuary staff with a greater amount of information than they do to private funeral directors; although mortuary staff also communicate relevant information to the funeral directors.

Figure 20: Information reported by ward managers (n=145) as being provided to mortuary staff and family funeral directors

Trusts have their own individual mortuary forms which accompanied 75% of bodies being transferred to mortuaries with mortuary staff reporting a range of information being provided on the forms (Figure 21). The information provided varied according to whether the mortuary had, or did not have, a post mortem facility, although this was not consistent.

Figure 21: Information provided to mortuary staff (n=12) when receiving a body

19

Mortuary staff reported the information recorded when a patient’s body is released to funeral directors. Figure 22 shows that whereas all mortuaries with a post mortem facility recorded the date and time of release, the name of the staff member releasing the body and the name of the funeral director collecting the body, not all mortuaries without post mortem facilities recorded this information.

3.2. Knowledge and skills

It is essential that those involved in the care of people who are dying and the bereaved are skilled and experienced, so they feel confident about the care and support they give. They should have adequate opportunities to develop their knowledge, understanding, self-awareness and skills (When a Patient Dies, Department of Health 2005).

In both the ward visits and the staff questionnaires, respondents were asked about the availability and uptake of training specific to end of life and bereavement care. Figure 23 sets out the various topics in which staff had received training. It is recognised that while staff may not have had formalised training many have developed knowledge and skills in these subjects through experience and on-the-job training.

Figure 22: Information recorded in mortuaries when patients’ remains are released

20

Figure 23: Percentage of staff responding to the questionnaires who had trainingin care of the dying and their relatives (n=1633)


Staff were asked about their level of confidence in delivering end of life and bereavement care. The results are presented in Figure 24.

Figure 24: Percentages of staff expressing themselves confident in the delivery of end of life and bereavement care

The ward managers (who provided the information on the ward visits) reported themselves to be significantly more confident in the delivery of all aspects of end of life and bereavement care than did staff who responded by questionnaire, a possible reflection of the high level of experience of the ward managers. Talking to bereaved children and supporting people from different cultures were the most difficult duties for all staff to perform.

Staff were asked about additional training that would be helpful in the performance of their roles. Over 60% of both ward managers and individual staff members indicated they would find a range of training helpful as set out in Figure 25.

Figure 25: Percentages of staff who would find additional training helpful

21

Specialist palliative care team members reported on additional training they had received in bereavement care. As Figure 26 indicates, this ranged from postgraduate bereavement and/or local hospital or hospice courses, with over 25% of team members having attended both.

Figure 26: Additional bereavement care training undertaken by specialist palliative care team members (n=11)

Chaplains reported additional training in bereavement care they had undertaken (Figure 27), with local hospital/hospice chaplaincy training undertaken by more than half the chaplains audited.

Figure 27: Additional bereavement care training undertaken by chaplains (n=33)

In addition almost one-third of chaplains reported not having received additional end of life or bereavement care training. It is assumed they would have received training in the provision of spiritual care to the sick and dying as part of their initial professional training with such care also forming part of their respective ministries outside the hospital setting.

22


All funeral directors with service level agreements for portering and mortuary duties reported that they had already received training in all relevant areas. The nature and extent of the training provided to porters in relation to their mortuary duties is summarised in Figure 28.

Figure 28: Training courses for portering teams (n=15)

Most of the porters’ training to date had been in relation to manual handling and infection control, with at least 80% having received training in each of these areas, with fewer than 10% having received training in multi-cultural and religious practices; this has clear implications for the handling of deceased bodies. Over half of those audited identified that additional training in each of the areas of multi-cultural and religious practices, death, grief and bereavement, interpersonal and communication skills and multi-disciplinary working would be helpful. A number of portering managers also indicated the value of on-the-job training.

Mortuary staff reported on the training they had undertaken specific to their role, summarised in Figure 29.

Figure 29: Training courses accessed by mortuary staff

23

Some areas of additional training (e.g. in respect of bereavement care or health and safety) were identified by staff in all types of mortuaries. Some training such as that in coroners law were highlighted only by staff in mortuaries with post mortem facilities with others, such as in infection control or refrigeration control identified only by staff in mortuaries without post mortem facilities. However, some of this additional training will have been received by some mortuary staff as 15 of the 23 designated mortuary staff were qualified pathology technicians with recognised advanced training. 3.3. Staff support

It is essential that all those who care for and support dying and bereaved people, regardless of their roles, should be provided with support for themselves (When a Patient Dies, Department of Health 2005).

Staff participating in both the ward visits and the individual staff questionnaires were asked about the support systems in place throughout their organisations, with Figure 30 summarising the responses of both groups. The ward managers, reflecting their levels of experience, were more aware of appropriate staff support systems than individual staff members who responded to the questionnaires.

Figure 30: Staff support systems identified as being in place

Figure 31 summarises the responses given by mortuary staff on the availability of staff support systems. All mortuary staff recognised the value of peer support with all also aware on how to access the services of occupational health departments.

24


The chaplains included in the audit were asked about the services that they provide specifically to members of staff with responses presented in Figure 32.

Figure 31: Support systems available to mortuary staff (n=12 services)

Figure 32: Services provided by chaplains to members of staff (n=33)

This finding suggests that chaplains offer support to staff in three main ways: through direct contact/support, staff training (usually at staff inductions into new posts) and participation in hospital remembrance services. These were reported to be offered by approximately two-thirds, one-half and one-third of chaplains respectively. Staff training was considered by a number of chaplains to be helpful in building good relationships and informing staff of their roles within ward teams.

25

It is recognised that dying people and their families have a right to be treated with dignity and respect and to be cared for in an appropriate environment (section 1.1).

4.1. Environment and facilities

During ward visits, staff were asked to rate the suitability of the environmental aspects of their ward/department for meeting the needs of, and being supportive to, patients who are dying and their families. Their responses are presented in Figure 33.

Figure 33: Percentage of wards and hospices rated ‘excellent’ or ‘good’ overall by their ward managers (n=145)

As predicted hospices, with their central focus on the care of dying patients, were rated the highest overall in terms of the suitability of their environment for the provision of care to those who are dying and their families. General medical wards, the clinical area identified previously as having the highest death rate (Figure 3), but also amongst the busiest within the hospital sector, were rated the lowest.

Figure 34: Environmental aspects of wards/facilities rated ‘excellent’ or ‘good’ by staff

Staff in ward visits and questionnaires, were also asked to rate specific aspects of the environments. As Figure 34 indicates, the ward managers consistently rated all aspects of

4. Creating a Supportive Experience

26


their wards higher than did other members of staff. A significant number of staff in their individual questionnaire responses indicated a level of concern about the limitations of their respective environments for the provision of appropriate end of life care and bereavement support.

Figure 35: Availability of private areas designated for the use of relatives, as reported by ward managers (n=142)

Staff responses on the availability of private areas designated for the use of relatives are presented in Figure 35. Such areas were available in every neonatal unit and combined obstetrics and gynaecology ward included in the audit, and in over 85% of intensive care units and emergency departments. Appropriate facilities were least likely to be provided in dedicated obstetric wards. General medical wards, where most deaths occur, were rated as having fewer appropriate areas for such purposes as breaking bad news than most other clinical environments.

Difficult discussions with families were reported to take place in six different types of locations, summarised in Figure 36.

Figure 36: Locations where difficult discussions take place with relatives, as reported by ward managers (n=144)

27

Offices constituted by far the most common location for difficult discussions, such as those of ward manager, doctor or other health care professional (52%), with sizeable numbers taking place also in either designated quiet rooms or relatives’ spaces (26%) or in side wards or single rooms (12%), if available. While staff clearly made efforts to find quiet areas in which to have such difficult discussions with family members, a small number identified that, due to ongoing pressures in acute wards in particular, it was not always possible to identify appropriate locations. As a result, discussions did at times occur in wholly unsuitable places, including corridors and at patients’ bedsides.

Given the design of older hospitals in particular, the limited availability of single rooms and also a growing need for isolation rooms for patients with infectious conditions, it is often not possible to care for dying patients in single rooms. Ward managers were therefore asked to indicate the extent to which single rooms were allocated to dying patients. Their responses are summarised in Figure 37, according to clinical speciality.

Figure 37: Facilities in which dying patients are cared for in single rooms on more than 75% of occasions, as reported by ward managers (n=133)

Within the hospital sector, there was an inverse relationship between the number of deaths that take place within the speciality and the provision of single rooms, i.e. there was a greater likelihood of a dying patient being cared for in a single room in a speciality where relatively few deaths occur than in areas where deaths are more frequent. However 80% of deaths in hospices occurred in single rooms.

Mortuary staff were asked about their viewing facilities and other environmental factors for relatives. Figure 38 indicates that those mortuaries where post mortems are carried out have a greater range of facilities available.

28


It was evident in discussion with staff that, despite the availability of designated viewing areas in the vast majority of mortuaries, viewing by families was not encouraged in some of the smaller mortuaries. This appeared to be related to the presence of qualified staff.

Some of the most difficult situations that mortuary staff reported they had to deal with included the support of relatives viewing bodies brought directly to the mortuary following accidents and other traumatic incidents.

4.2. Care and support

When engaging in one-to-one contact, patients and families should be enabled to express their needs and preferences through sharing expertise and responsibility and facilitating informed choice (When a Patient Dies, Department of Health 2005).

Given the importance of working in partnership with patients and families, ward managers were asked about whether they explore the wishes and feelings of patients who are dying; figure 39 sets out the results. Every manager from an elderly or a gynaecology ward reported routinely exploring the wishes and feelings of their dying patients, where appropriate. This contrasts with just over 30% of staff from emergency departments reported doing so. The practice in emergency departments may not be unexpected given the higher frequency of sudden deaths that occur. It is recognised that these types of discussions may need to be carried out by experienced staff with advanced communication skills.

Figure 38: Viewing arrangements and other facilities available at mortuaries

29

Figure 39: Ward managers from different specialist areas who reported that they routinely explore the wishes and feelings of dying patients (n=137)

All managers were asked during ward visits about the use of a care of the dying pathway in their wards. Currently, only adult wards reported using this system with the development of a separate care of the dying pathway for use within a number of children’s services being considered. Only responses from managers of adult wards are reported in Figure 40.

Figure 40: Areas where the care of the dying pathway is operational, as reported by ward managers (n=124)

As expected, general medicine, as the clinical area with the highest number of inpatient deaths, is also the area within which the care of the dying pathway is most frequently used. It is also used extensively in cardiology wards, but rarely in obstetrics or emergency departments. Overall, staff comments were very positive about the benefits of the care of the dying pathway, which they felt helped to ensure a holistic approach to end of life care.

Figure 41 summarises the extent to which ward managers reported that relatives have the opportunity to speak to an appropriate nurse, doctor and/or hospital chaplain. Although staff reported it to be increasingly difficult to give families the amount of time they may need in busy clinical areas, staff were reported to often make themselves available (95-100%).

Figure 41: Extent to which relatives were afforded an opportunity to speak to a health care professional about their relative’s death, as reported by ward managers (n=145)

30


Senior staff were asked to identify those individuals and groups, from the statutory or voluntary sector, with a remit for care of the dying, after-death care or support for the bereaved. A total of 23 organisations were identified, the most frequently cited of which are presented in Figure 42.

Figure 42: Services most frequently identified by senior managers (n=37) as having a link to bereavement care

Cruse Bereavement Care was by far the most frequently identified organisation, cited by over 70% of the managers. Of the rest, only those services provided by palliative care teams, Macmillan nurses, SANDS and hospital chaplains were identified by more than 20% of respondents. And of the 12 services not included within Figure 42 – care of the dying pathway coordinators, clinical psychologists, Marie Curie services, bereavement volunteers, Bliss for Babies, Child Bereavement Trust, Miscarriage Association, Ulster Cancer Foundation, Area Bereavement Coordinators, community hospice nurses, occupational health services and PSNI Family liaison officers – each was identified by fewer than 10% of managers.

Specialist palliative care and chaplaincy teams were asked about the availability of written information on their respective services. As can be seen from Figure 43, 82% of the former and 67% of the latter indicated that such information is available.

Figure 43: Specialist palliative care teams (n=11) and chaplaincy services (n=33) for which written information was available

31

Appropriate and timely referral to specialist palliative care teams is essential to ensure that patients and families receive the support and advice they require. Specialist palliative care teams were consequently asked about both the source of their referrals and the nature of the services they provide.

As can be seen from Figure 44, all specialist palliative care teams reported that they received referrals from wards and that, given the nature of their illnesses, on admission some patients were already known to their services.

Figure 44: Sources of referral to specialist palliative care teams (n=11)

Figure 45 indicates that symptom management, advice and support were the core services provided by all specialist palliative care teams, followed by education and training, including the promotion of end of life care pathways (73%), referral on to community services (64%) and the provision of follow-up support (55%). It was evident from discussions with ward staff during the audit that the support and advice they received from the palliative care teams on the use of the end of life care pathway was particularly appreciated.

Figure 45: Services provided by specialist palliative care teams (n=11)

32

Patients are usually informed on admission of the availability of a hospital chaplaincy service and asked if they wish to have their religious denomination recorded and provided to the appropriate chaplain. Efforts are made by chaplains to visit as many patients on their lists as possible, but where this does not occur routinely the chaplains concerned were asked to indicate in what other ways they receive referrals to visit patients.

Figure 46 details the responses provided by the four chaplains concerned. All indicated that they receive requests directly from patients and/or their families, while in three cases the chaplains reported that they were either familiar with patients prior to their admissions or that they were informed of individuals either directly from the wards or during chaplains’ ward visits.

Figure 46: Referrals to chaplains where not all patients are visited (n=4)

The chaplains stressed the importance of timely referrals from ward staff, especially for patients who are dying, and indicated that in some instances they had been notified too late to be able to offer support to the patients, who had already died. The opportunity to build up a relationship with a patient’s family prior to his/her death can be of assistance when offering support at the time of the death and afterwards.

The various services which the chaplains provide are summarised in Figure 47.

Figure 47: Services provided by chaplains (n=33) to patients and/or their families

N.I. Audit: Dying, Death & Bereavement33

All chaplains carry out routine ward visits and visits to ill patients, and the vast majority (90%) provide the sacraments and undertake funeral services for patients without families. Some chaplains (40%) undertake a number of specifically child-related services, such as infants’ or children’s remembrance services or naming services for babies.

Portering managers and those funeral directors who were contracted to perform portering and mortuary duties were asked both about their duties and responsibilities in relation to hospital mortuaries and about their involvement with families. Figure 48 indicates their key responsibilities, both independently and under the supervision of mortuary staff.

Figure 48: Duties undertaken by portering teams and funeral directors with portering and mortuary duties (n=20)

It is clear that the porters and contracted funeral directors carry out most of their four key duties independently. However, it is also evident that no single duty was performed in any more than 50% of the sites that were audited.

The larger acute hospitals tended to have at least one qualified pathology technician or designated mortuary attendant in post, whereas in a number of smaller hospitals portering staff were responsible for mortuary duties required, in liaison with ward staff and funeral directors. It was notable during the audit that some of the senior portering staff had been carrying out their duties for many years and were very familiar with all the processes involved, as well as with the sensitivities required in dealing with bereaved families.

34


4.3. Information and communication

The audit identified a range of systems used by wards, departments and hospices to notify other professionals of a patient’s death (Figure 49). The most common means was through a senior nurse on duty contacting the patient’s GP directly (28%), although 5% of facilities had no recognised system at all in place for the notification of other professionals.

Figure 49: Systems in place for the notification of other professionals, as reported by ward managers (n=142)

It was also identified that no reporting system is entirely robust and that communication can break down at times, resulting in either a delay or the relevant professional not being informed of the patient’s death. This has the potential to cause undue upset to bereaved families, such as when they receive a letter offering an appointment to a person who has already died.

Ward staff were asked about the information provided to families at the time of a patient’s death (Figure 50). In nearly all cases families were informed if the coroner was contacted or if the Medical Certificate for Cause of Death has been issued. Other information commonly provided to families at the time of a patient’s death included potential health and safety risks, the return of the deceased person’s property and notification that the remains may be released. It is perhaps surprising, in light of the importance of these latter reasons, that each of them was identified by fewer than 100% of the staff who were audited as information that would routinely be provided to families.

Figure 50: Information given to the family by the ward, as reported by ward managers (n=102–121)

35

Following the recommendation of the Human Organs Enquiry 2002, the DHSSPS introduced new consent forms to be completed by the deceased’s next-of-kin in cases where a hospital post mortem examination is indicated, along with booklets aimed at supporting families through this process. Obtaining consent in such cases involves discussions with families aimed at enabling them to make informed choices. In the case of post mortem examinations directed by the coroner, consent for the procedure is not required, although the families’ wishes regarding the disposal of tissue does need to be sought. The Coroner’s Service NI has produced a booklet to support these processes.

It is expected that senior doctors and nursing staff will offer information and support to families at such difficult times, and Figure 51 summarises the responses in the audit of ward managers when asked about the information provided to families when a post mortem examination is required.

Figure 51: Information provided to families when a post mortem is required, as reported by ward managers (n=113-131)

Explanations and discussions with families, as well as answering their questions and providing them with relevant booklets were all identified practices within at least 97% of wards, although copies of consent forms were provided in only 94% of cases.

The nature of any written information provided to bereaved parents on those wards and departments which may be expected to experience the deaths of babies and/or children is summarised in Figure 52.

Figure 52: Written information provided to parents of deceased babies or children,as reported by ward managers (n=33-50)

36


Given that almost half of all children who die in a neonatal unit undergo a hospital post mortem, it is no surprise that information booklets in respect of post mortems on children and babies were the most commonly provided, in at least 80% each of the respective wards and departments. It is increasingly common for parents to take the bodies of their children directly home by car immediately following their deaths, where this was expected; only 20% of the relevant wards and departments had a written policy to support this practice.

Ward managers were asked about other information and resources they provided to bereaved families (Figure 53). There was evidence of families being directed towards a number of voluntary organisations (in particular, Cruse Bereavement Care) in 78% of wards and departments; 74% provided families with forms to assist in registering the death; 62% provided booklets specifically designed to assist bereaved people; and 54% provided information in relation to the arranging of funerals.

Figure 53: Other information and resources provided to bereaved relatives, as reported by ward managers (n=142)

Ward and hospice managers were also asked about arrangements for the collection of Medical Certificates of Cause of Death in situations where they had not been issued at the time of death. Their responses are provided in Figure 54.

Figure 54: The collection of death certificates in hospital and hospice settings, as reported by ward managers

37

Within the hospices, certificates were reported to be collected either from the ward (in 60% of cases) or from reception or a general office (20%). Collection from the ward was also reported as the most common procedure within the hospital sector (77%), where a further 28% reported their collection from a mortuary instead. However, it can be difficult for a family member to return to a mortuary or ward in which their relative had died a short time previously and a representative may be able to collect the certificate on a relative’s behalf. It is noted that 18% of the hospital ward managers in the audit indicated that death certificates were collected by funeral directors.

To facilitate the customary three-day burial practice in Northern Ireland, it is important for all organisations to ensure the timely issue of death certificates. It is also important that accurate and transparent records regarding the issue and collection of death certificates be maintained.

Ward managers were asked whether or not follow-up meetings to discuss a patient’s death were routinely offered to bereaved families. The percentages of units within each clinical area reporting that such follow-up meetings were always offered to families are presented in Figure 55.

Figure 55: Wards and hospices offering follow-up meetings with bereaved families, as reported by ward managers (n=143)

There were only two clinical areas where every ward concerned provided routine follow-up meetings with families: obstetrics and joint obstetrics and gynaecology services. Follow-up meetings were not routinely offered in the majority of other units, either in the hospital or the hospice sector, such meetings were reported as being provided at the request of families.

When asked about how families were provided with the results of post mortem examinations, the ward managers responded as set out in Figure 56.

38


The audit findings show that over 35% of ward managers were unable to identify how families received the results of post mortem examinations – suggesting there was often a lack of communication between the various parties involved. Of the others, the most common means was through face-to-face meetings with relevant professionals (identified by 32% of respondents), followed by contact with the patient’s GP (23%) and through the coroners office or liaison officer (19%). Seven percent reported that the results of post mortem examinations had been relayed to family members over the telephone.

Ward and hospice managers were also asked to identify any methods they employed to obtain feedback from their service users, with responses summarised in Figure 57.

Figure 56: Means of informing families with the results of post mortem examinations, as reported by ward managers (n=145)

Figure 57 : Methods employed by wards and hospices to secure user feedback, as reported by ward managers (n=143)

By far the most common method employed was through the receipt of complaints and compliments (reported by 87% of the managers audited). Thank you cards and gifts were reported by 39%, with families returning to the ward, charitable donations, and asking family members throughout their relative’s stay in the unit each recorded by fewer than 15% of the managers.

Equally small percentages of the managers reported using more formal means of securing service user feedback, including user questionnaires (10%) or focus groups (4%).

No service within the hospital or hospice sector identified a systematic approach of collecting or using user feedback on their services.

39

Results from this audit identified a wide range of services and information across the NI Health and Social Care Services and within Hospices for the care of dying patients and to support bereaved people. There are, however, variations in the standards and organisation of such services. No overarching system or set of policies were in place to ensure appropriate standards. In consequence the following recommendations are set out to improve the quality and organisation of these important services.

1. A strategy for bereavement care within the Health and Social Care Services should be developed to inform the direction of end of life and bereavement care in Northern Ireland.

2. HSC Trusts should develop an overarching policy which incorporates core policies around care of the dying and the management of death. As a minimum this should include written guidance on the following:

• Last offices (including cultural and religious requirements)

• All aspects of identification, transfer, storage, viewing and release of bodies

• A minimum agreed set of information which complies with health and safety requirements should be noted on a mortuary form which accompanies the body.

• The issue of the Medical Certificate of Cause of Death

• Reporting deaths to the Coroners Service

• The management of sudden, unexpected death and the preservation of evidence in forensic cases

• A clear system for informing other professionals of the death

3. Corporate and local induction should cover issues concerning death and bereavement as relevant to the role of the staff concerned.

4. Trusts must offer training in consent for hospital post mortem examinations to those senior medical staff who may be required to seek consent.

5. Staff should be made aware of support systems available to them.

6. As identified by staff, there should be opportunities for staff development and training in the care of dying patients and bereaved relatives (see Appendix 7).

7. The use of the care of the dying pathway should be promoted as a minimum safe standard.

8. Trusts should have operational policies for chaplains’ services.

9. Governance systems should ensure learning from complaints made by bereaved families.

10. Systems should be developed to obtain feedback from bereaved relatives.

11. Information booklets for bereaved relatives should be audited.

12. New capital builds and refurbishment programmes should include areas to promote privacy and dignity for dying patients and bereaved families.

5. Recommendations

40


Appendices

ContentsNo Audit Criteria Page

1 Organisational Audit Standards 42

2 Mortuary Services Audit Standards 44

3 Chaplaincy Services Audit Standards 46

4 Palliative Care Services Audit Standards 48

5 Porters and Funeral Directors Services Audit Standards

49

6 Ward Managers Questionnaire Results 50

7 Individual Staff Questionnaire Results 52

8 Standards Documents 57

41

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ow

ing

po

lic

ies

/gu

ide

lin

es

co

nc

ern

ing

de

ath

an

d

be

rea

ve

me

nt

are

in

pla

ce

:

a.

Acce

ssin

g in

terp

retin

g s

erv

ice

s

10

0%

9

0.0

%

“Pa

tie

nts

sh

ou

ld b

e a

ble

to

co

mm

un

ica

te w

ith

he

alth

wo

rke

rs in

th

e la

ngu

ag

e t

he

y

fee

l co

mfo

rta

ble

with

.” -

3

b.

A

dva

nce

Dir

ective

10

0%

5

2.5

%

“ In

div

idu

als

m

ay h

ave

a

n a

dva

nce

d

ire

ctive

o

r liv

ing

w

ill sp

ecifyin

g h

ow

th

ey

wo

uld

lik

e t

o b

e t

rea

ted

in

th

e c

ase

of

futu

re i

nca

pa

city.

……

Fa

ilure

to

re

sp

ect

su

ch

an

ad

va

nce

re

fusa

l ca

n r

esu

lt in

le

ga

l a

ctio

n a

ga

inst

the

pra

ctitio

ne

r.”

- 4

c.

Be

rea

ve

me

nt

Ca

re

10

0%

5

0.0

%

“All

NH

S T

rusts

sh

ou

ld p

rovid

e su

pp

ort

a

nd

a

dvic

e to

fa

mili

es a

t th

e tim

e o

f b

ere

ave

me

nt.

” -

5

d.

Bre

akin

g b

ad

ne

ws

10

0%

8

0.0

%

“Im

ple

me

nta

tio

n

of

the

R

eg

ion

al

Gu

ide

line

s

for

Bre

akin

g

Ba

d

Ne

ws

is

the

re

sp

on

sib

ility

of

ea

ch

HP

SS

Tru

st,

HP

SS

an

d V

olu

nta

ry P

rovid

ers

, in

pa

rtn

ers

hip

w

ith

ed

uca

tio

n p

rovid

ers

an

d in

div

idu

al p

rofe

ssio

na

ls”.

- 6

e.

Bu

ria

l b

y h

osp

ita

l (i

f n

o n

ext

of

kin

) *h

osp

ice

s n

ot

inclu

de

d

10

0%

6

2.9

%*

n=

35

“C

hild

ren

Ord

er

(NI)

19

95

, H

ea

lth

an

d P

ers

on

al

So

cia

l S

erv

ice

s (

NI)

Ord

er

19

72

(A

rtic

le2

5&

39

), H

ea

lth

a

nd

P

ers

on

al

So

cia

l S

erv

ice

s (N

I) O

rde

r 1

99

1(A

rtic

le2

5)

an

d W

elfa

re S

erv

ice

s A

ct

(NI)

19

71

(S

ectio

n 2

5).

f.

Ca

re o

f th

e d

yin

g p

ath

wa

y:

10

0%

7

4.4

%

“P

rovid

er

org

an

isa

tio

ns s

ho

uld

en

su

re t

ha

t m

an

ag

ed

syste

ms t

o e

nsu

re b

est

pra

ctice

in

ca

re o

f th

e d

yin

g p

atie

nts

are

im

ple

me

nte

d b

y a

ll m

ultid

iscip

lina

ry

tea

ms.

Th

is m

igh

t in

clu

de

th

e L

ive

rpo

ol C

are

of

the

Dyin

g p

ath

wa

y”

– 8

g.

Ca

re p

lan

fo

r p

reg

na

ncy lo

ss,

stillb

irth

an

d n

eo

na

tal d

ea

th

10

0%

7

5.0

%

(n=

16

) D

HS

SP

S -

9

h.

Ch

ap

lain

cy /

sp

iritu

al ca

re

10

0%

5

2.5

%

“NH

S T

rusts

ma

y w

ish

to

co

nsid

er

ho

w b

est

to p

rovid

e s

pir

itu

al ca

re a

s a

n in

teg

ral

pa

rt o

f th

e o

ve

rall

be

rea

ve

me

nt

ca

re t

he

y p

rovid

e.

Th

is m

ay b

e b

est

led

th

rou

gh

a

he

alth

ca

re c

ha

pla

in o

r sim

ilar

role

an

d T

rusts

ma

y w

ish

to

ta

ke

in

to a

cco

un

t th

e

NH

S

gu

ida

nce

fo

r m

an

ag

ers

a

nd

th

ose

in

vo

lve

d

in

the

p

rovis

ion

o

f ch

ap

lain

cy/s

pir

itu

al ca

re issu

ed

in

20

03

”. –

2

i.

De

ath

ce

rtific

atio

n

10

0%

8

2.5

%

“Mo

st

ho

sp

ita

ls w

ill h

ave

a w

ritt

en

re

co

rd o

f p

roce

du

res t

o b

e u

se

d f

ollo

win

g t

he

d

ea

th o

f a

pa

tie

nt

in o

rde

r to

co

mp

lete

a f

act

of

de

ath

fo

rm (

if u

se

d),

th

e m

ed

ica

l C

au

se

of

De

ath

Ce

rtific

ate

, a

cre

ma

tio

n f

orm

(if n

ee

de

d)

an

d t

he

do

cu

me

nta

tio

n

ne

ce

ssa

ry t

o p

erm

it t

he

re

lea

se

of

the

de

ce

ase

d f

rom

th

e h

osp

ita

l, a

nd

to

pa

ss o

n

the

ne

ce

ssa

ry d

ocu

me

nta

tio

n t

o t

he

ne

xt

of

kin

.” –

1


Au

dit

Cri

teri

a

Sta

nd

ard

A

ch

iev

ed

R

ati

on

ale

j.

Cre

ma

tio

n

10

0%

6

5.0

%

As a

bo

ve

.

k.

Cu

ltu

ral a

nd

re

ligio

us o

bse

rva

nce

s

10

0%

8

7.5

%

“Ad

eq

ua

te a

rra

ng

em

en

ts a

re m

ad

e f

or

the

sp

iritu

al, r

elig

iou

s,

sa

cra

me

nta

l, r

itu

al

an

d c

ultu

ral re

qu

ire

me

nts

ap

pro

pri

ate

to

th

e n

ee

ds,

ba

ckg

rou

nd

an

d t

rad

itio

n o

f a

ll p

atie

nts

an

d s

taff

, in

clu

din

g t

ho

se

of

no

sp

ecifie

d f

aith

.” –

2

l.

Do

no

t a

tte

mp

t re

su

scita

tio

n

10

0%

9

5.0

%

“NH

S

Tru

sts

ch

ief

exe

cu

tive

s

are

a

ske

d

to

en

su

re

tha

t th

e

ap

pro

pri

ate

re

su

scita

tio

n p

olic

ies w

hic

h r

esp

ect

pa

tie

nts

rig

hts

are

in

pla

ce

, u

nd

ers

too

d b

y a

ll re

leva

nt

sta

ff,

an

d a

cce

ssib

le t

o t

ho

se

wh

o n

ee

d t

he

m,

an

d t

ha

t su

ch

po

licie

s a

re

su

bje

ct

to a

pp

rop

ria

te a

ud

it a

nd

mo

nito

rin

g a

rra

ng

em

en

ts”

– 1

0

m.

Id

en

tifica

tio

n o

f th

e d

ece

ase

d

10

0%

4

7.5

%

“Mo

rtu

ary

se

rvic

es f

ollo

win

g g

oo

d p

ractice

will

ha

ve

a p

olic

y in

pla

ce

wh

ich

co

ve

rs

the

pro

ce

du

res n

ece

ssa

ry f

or

the

id

en

tifica

tio

n o

f

de

ce

ase

d p

eo

ple

s b

od

ies a

nd

th

eir

po

sse

ssio

ns”

– 1

2

n.

In

form

atio

n f

or

rela

tive

s

10

0%

6

5.0

%

“Th

e p

rovis

ion

of

wri

tte

n i

nfo

rma

tio

n (

listin

g a

nd

de

scri

bin

g s

ou

rce

s o

f su

pp

ort

, h

elp

line

s

an

d

we

b-b

ase

d

info

rma

tio

n,

for

exa

mp

le)

is

reco

mm

en

de

d

to

he

lp

pe

op

le w

ho

are

bere

ave

d m

an

ag

e t

he

pra

ctica

l a

rra

ng

em

en

ts n

ece

ssa

ry a

fte

r a

d

ea

th.”

– 1

o.

La

st

off

ice

s w

ith

r

eg

ard

to

: i.

M

an

ua

l

ha

nd

ling

ii.

I

nfe

ctio

n c

on

tro

l iii

. C

ultu

ral &

re

ligio

us p

ractice

s

iv.

Tra

nsfe

r o

f th

e d

ece

ase

d

v.

Id

en

tifica

tio

n

vi.

No

tifica

tio

n t

o o

the

r d

ep

art

me

nts

vii.

R

em

ova

l o

f im

pla

nts

viii

. R

etu

rn o

f p

rop

ert

y a

nd

va

lua

ble

s

ix.

V

iew

ing

th

e d

ece

ase

d

10

0%

1

00

%

10

0%

1

00

%

10

0%

1

00

%

10

0%

1

00

%

10

0%

82

.5%

8

7.5

%

89

.7%

6

2.5

%

80

.0%

8

2.5

%

45

.0%

8

2.5

%

55

.0%

“It

is re

co

mm

en

de

d th

at

NH

S T

rusts

co

nsid

er

pu

ttin

g in

p

lace

a

w

ritt

en

p

olic

y

ratifie

d b

y t

he

Tru

st

Bo

ard

, co

ve

rin

g a

ll se

rvic

es r

ela

tin

g t

o d

ea

th &

be

rea

ve

me

nt.

” -

1

- 2

1

p.

Po

st

mo

rte

m p

roce

sse

s

10

0%

6

7.5

%

11

an

d 1

9

q.

Re

po

rtin

g c

ase

s t

o t

he

Co

ron

er

10

0%

9

2.5

%

13

, 2

2

r.

Su

dd

en

de

ath

pro

toco

ls

10

0%

3

7.5

%

“Su

ch

po

licie

s s

ho

uld

id

en

tify

be

rea

ve

me

nt

ca

re p

ath

wa

ys f

or

bo

th e

xp

ecte

d a

nd

u

ne

xp

ecte

d d

ea

ths”

- 1

s.

Ava

ilab

ility

of

Me

mo

ran

du

m o

f u

nd

ers

tan

din

g f

or

inve

stig

atin

g

pa

tie

nt/

clie

nt

sa

fety

in

cid

en

ts…

10

0%

6

5.0

%

“Th

e

me

mo

ran

du

m

will

ta

ke

e

ffe

ct

in

cir

cu

msta

nce

s

of

un

exp

ecte

d

de

ath

o

r se

rio

us u

nto

wa

rd h

arm

re

qu

irin

g i

nve

stig

atio

n b

y t

he

po

lice

, co

ron

ers

or

HS

EN

I se

pa

rate

ly o

r jo

intly.”

-

14

2.

Mo

rtu

ary

Ser

vice

s A

ud

it S

tan

dar

ds

44

Au

dit

Cri

teri

a

Sta

nd

ard

A

ch

iev

ed

R

ati

on

ale

1.

Th

e f

oll

ow

ing

vie

win

g a

rra

ng

em

en

ts a

re i

n p

lac

e:

a)

Re

lative

s c

an

vie

w t

he

de

ce

ase

d in

th

e m

ort

ua

ry

b)

Mo

rtu

ary

is c

lea

rly s

ign-p

oste

d f

rom

th

e h

osp

ita

l e

ntr

an

ce

c)

Do

orb

ell

or

inte

rco

m t

o g

ain

acce

ss

d)

Acce

ss t

o s

an

ita

ry f

acili

tie

s

e)

Acce

ss t

o d

rin

kin

g w

ate

r f)

W

aitin

g a

rea

with

co

mfo

rta

ble

ch

air

s

g)

De

sig

na

ted

vie

win

g a

rea

h)

Sp

ecia

l a

rra

ng

em

en

ts f

or

vie

win

g b

ab

ies/c

hild

ren

i)

Ca

pa

city t

o a

cco

mm

od

ate

re

ligio

us/c

ultu

ral ri

tua

ls

j)

Ca

pa

city t

o h

old

re

ligio

us s

erv

ice

s

k)

All

are

as a

re w

he

elc

ha

ir a

cce

ssib

le

10

0%

1

00

%

10

0%

1

00

%

10

0%

1

00

%

10

0%

1

00

%

10

0%

1

00

%

10

0%

(n=

12

)

1

00

.0%

8

3.3

%

66

.7%

8

3.3

%

50

.0%

8

3.3

%

91

.7%

5

0.0

%

10

0.0

%

75

.0%

9

3.8

%

“…

mo

rtu

ary

fa

cili

tie

s w

ou

ld id

ea

lly n

ee

d t

o in

clu

de

at

lea

st

on

e p

riva

te,

co

mfo

rta

ble

ro

om

w

he

re a

bo

dy c

an

be

se

en

by r

ela

tive

s a

nd

oth

ers

. F

acili

tie

s s

ho

uld

be

de

sig

ne

d t

o c

ate

r fo

r a

ll a

ge

gro

up

s”

- 1

“

Co

nsid

era

tio

n sh

ou

ld b

e g

ive

n to

a

ll a

pp

roa

ch

es,

ad

jace

ncie

s a

nd

ro

ute

s (e

ntr

an

ce

s a

nd

d

ep

art

ure

s),

eg

th

e jo

urn

ey f

or

the

be

rea

ve

d f

rom

th

e p

lace

of

de

ath

to

th

e m

ort

ua

ry”

– 1

an

d

20

“A v

iew

ing

ro

om

will

usu

ally

be

de

co

rate

d a

nd

fu

rnis

he

d in

a w

ay w

hic

h w

ill h

elp

pe

op

le f

ee

l ca

lm a

nd

ca

red

fo

r…a

nd

ea

sy c

ha

irs s

o t

ha

t if t

he

y w

ish

, re

lative

s c

an

sta

y w

ith

th

e d

ece

ase

d

pe

rso

n f

or

a w

hile

in

co

mfo

rt”-

12

“D

ea

th a

nd

be

rea

ve

me

nt

aff

ect

ind

ivid

ua

ls in

diffe

ren

t w

ays.

Th

eir

re

sp

on

se

is a

lso

in

flu

en

ce

d

by t

he

ir b

elie

fs,

cu

ltu

re,

relig

ion

, va

lue

s,

se

xu

al o

rie

nta

tio

n,

life-s

tyle

or

so

cia

l d

ive

rsity.

Mo

rtu

ary

se

rvic

e s

taff

will

be

ale

rt t

o in

div

idu

al n

ee

ds,

an

d b

e f

lexib

le in

att

em

ptin

g t

o m

ee

t th

em

.” -

12

2.

Th

e f

oll

ow

ing

do

cu

me

nta

tio

n a

cc

om

pa

nie

s p

ati

en

t’s

re

ma

ins

fro

m t

he

wa

rd/d

ep

art

me

nt

to t

he

mo

rtu

ary

: a

) P

atie

nt

ID la

be

l b

) W

rist/

an

kle

ID

ba

nd

c)

Mo

rtu

ary

fo

rm

10

0%

1

00

%

10

0%

(n=

12

) 7

5.0

%

10

0.0

%

75

.0%

“It

is r

eco

mm

en

de

d t

ha

t N

HS

Tru

sts

ha

ve

in

pla

ce

: se

cu

re s

yste

ms f

or

the

id

en

tifica

tio

n o

f b

od

ies,

in o

rde

r to

en

su

re t

ha

t th

e c

orr

ect

bo

dy is p

rep

are

d f

or

vie

win

g a

nd

/or

rele

ase

fo

r cre

ma

tio

n o

r b

uri

al”

- 1

3.

Mo

rtu

ary

sta

ff a

re i

nfo

rme

d o

f th

e f

oll

ow

ing

: a

) C

ultu

ral/re

ligio

us r

eq

uir

em

en

ts

b)

He

alth

an

d s

afe

ty r

isks

c)

Pro

pe

rty o

n b

od

y

d)

Pa

ce

ma

ke

r in

situ

e)

Tu

be

s/d

rain

s e

tc in

situ

f)

If d

ea

th c

ert

ific

ate

issu

ed

g)

If b

od

y is f

or

cre

ma

tio

n

h)

If r

em

ain

s c

an

be

re

lea

se

d

i)

If b

od

y n

ee

ds t

o b

e h

eld

: I.

F

or

ho

sp

ita

l p

ost

mo

rte

m

II.

Fo

r d

ecis

ion

of

Co

ron

er

j)

If C

oro

ne

r in

vo

lve

d

10

0%

1

00

%

10

0%

1

00

%

10

0%

1

00

%

10

0%

1

00

%

10

0%

1

00

%

10

0%

(n=

12

) 9

1.7

%

10

0.0

%

83

.3%

6

6.7

%

75

.0%

7

5.0

%

66

.7%

7

5.0

%

10

0.0

%

10

0.0

%

75

.0%

“M

ort

ua

ry a

nd

be

rea

ve

me

nt

se

rvic

es w

ill n

ee

d t

o h

ave

in

pla

ce

ro

bu

st

me

ch

an

ism

s f

or

co

mm

un

ica

tin

g in

form

atio

n a

bo

ut

the

de

ce

ase

d p

atie

nt…

this

will

en

su

re t

ha

t a

ny r

ele

va

nt

info

rma

tio

n f

rom

th

e f

am

ily is p

asse

d t

o m

ort

ua

ry s

taff

.” -

12

“M

ort

ua

ry s

erv

ice

s w

ill h

ave

in

pla

ce

fa

cili

tie

s,

pro

toco

ls a

nd

pro

ce

du

res w

hic

h e

na

ble

sta

ff t

o

pro

vid

e t

he

re

qu

ire

d s

erv

ice

eff

icie

ntly,

eff

ective

ly a

nd

to

ap

pro

pri

ate

clin

ica

l sta

nd

ard

s”

- 1

2

“Ca

re n

ee

ds t

o b

e t

ake

n t

o id

en

tify

im

pla

nte

d d

evic

es,

wh

ere

ap

pro

pri

ate

, a

s t

he

se

will

pre

se

nt

a h

aza

rd a

t cre

ma

tio

n”

- 1

“

Be

fore

a d

ece

ase

d p

ers

on

s b

od

y is r

ele

ase

d,

mo

rtu

ary

sta

ff s

ho

uld

ch

eck t

ha

t a

ll n

ece

ssa

ry

do

cu

me

nta

tio

n is c

om

ple

te a

nd

th

e d

ece

ase

d p

ers

on

’s id

en

tity

is c

on

firm

ed

bo

th b

y t

he

m

ort

ua

ry s

taff

an

d t

he

pe

rso

n t

o w

ho

m t

he

bo

dy is r

ele

ase

d”

– 1

2

“All

po

st-

mo

rte

ms m

ust

be

ca

rrie

d o

ut

in a

pre

mis

es lic

en

ce

d b

y t

he

HT

A in

acco

rda

nce

with

th

e c

on

ditio

ns o

f th

e lic

en

ce

”- 2

4

“In

Co

ron

er’

s c

ase

s,

it is im

po

rta

nt

tha

t th

ere

is a

n a

gre

ed

pro

toco

l in

pla

ce

to

en

su

re t

ha

t th

ere

is n

o

co

nfu

sio

n a

bo

ut

wh

o is r

esp

on

sib

le f

or

the

cu

sto

dy a

nd

re

lea

se

of

the

bo

die

s o

f th

e d

ece

ase

d”

– 1

2

4.

Th

e f

oll

ow

ing

po

lic

ies

are

in

pla

ce

: a

) R

eco

rd k

ee

pin

g

b)

Re

ce

ivin

g,

ide

ntify

ing

, se

cu

rin

g,

sto

rin

g a

nd

re

lea

sin

g

bo

die

s,

org

an

s a

nd

tis

su

es

c)

Lo

ne

wo

rke

r d

) P

rep

ara

tio

n f

or

vie

win

g

e)

Su

pp

ort

ing

re

lative

s

f)

Lia

iso

n p

roto

co

ls w

ith

Co

ron

er

Se

rvic

e a

nd

PS

NI

g)

Co

ron

er’

s p

ost

mo

rte

ms –

acce

ss t

o m

ort

ua

ry o

ut o

f h

ou

rs

h)

Infe

ctio

n c

on

tro

l

10

0%

1

00

%

10

0%

1

00

%

10

0%

1

00

%

10

0%

1

00

%

66

.7%

7

5.0

%

58

.3%

6

6.7

%

33

.3%

5

8.3

%

66

.7%

1

00

.0%

“Mo

rtu

ary

se

rvic

es w

ill h

ave

in

pla

ce

fa

cili

tie

s,

pro

toco

ls a

nd

pro

ce

du

res w

hic

h e

na

ble

sta

ff t

o

pro

vid

e t

he

re

qu

ire

d s

erv

ice

eff

icie

ntly,

eff

ective

ly a

nd

to

ap

pro

pri

ate

clin

ica

l sta

nd

ard

s”

- 1

2

“M

ort

ua

ry s

erv

ice

s s

ho

uld

ha

ve

in

pla

ce

a p

olic

y o

n d

ocu

me

nta

tio

n p

roce

du

res”

- 1

2

“M

ort

ua

ry s

erv

ice

s…

will

ha

ve

a p

olic

y in

pla

ce

wh

ich

co

ve

rs t

he

pro

ce

du

res n

ece

ssa

ry f

or

the

id

en

tifica

tio

n o

f d

ece

ase

d p

eo

ple

’s b

od

ies a

nd

th

eir

po

sse

ssio

ns”

- 1

2

“W

he

re f

am

ilie

s h

ave

in

div

idu

al, c

ultu

ral o

r re

ligio

us p

refe

ren

ce

s c

on

ce

rnin

g t

he

sto

rage

, h

an

dlin

g,

tra

nsp

ort

atio

n o

r p

rese

nta

tio

n o

f th

e d

ece

ase

d p

ers

on

, th

ese

ne

ed

to

be

ca

refu

lly

do

cu

me

nte

d a

nd

acco

mm

od

ate

d w

he

reve

r p

ossib

le.”

-1

2

“As a

re

su

lt o

f th

e iso

late

d lo

ca

tio

n o

f m

ost

mo

rtu

ari

es a

nd

th

e s

hift

pa

tte

rns m

ain

tain

ed

by

sta

ff,

a r

isk a

sse

ssm

en

t w

ill u

su

ally

be

un

de

rta

ke

n a

nd

ad

he

ren

ce

to

a L

on

e W

ork

er

po

licy

en

co

ura

ge

d a

mo

ng

all

mo

rtu

ary

sta

ff. -

12


i)

Mo

vin

g a

nd

ha

nd

ling

j)

Re

mo

va

l o

f th

e d

ece

ase

d o

uts

ide

wo

rkin

g h

ou

rs

k)

Dis

aste

r p

lan

nin

g

l)

Ma

na

ge

me

nt

of

ma

ss f

ata

litie

s

m)

Su

pp

ort

ing

ch

ildre

n t

o v

iew

de

ce

ase

d r

ela

tive

s

n)

Sta

ff s

up

po

rt

o)

Co

mp

lain

ts p

roce

du

re

p)

Acce

ssin

g in

terp

rete

rs

q)

Ma

na

ge

me

nt o

f p

ers

on

al p

rop

ert

y o

f th

e d

ece

ase

d

10

0%

1

00

%

10

0%

1

00

%

10

0%

1

00

%

10

0%

1

00

%

10

0%

10

0.0

%

66

.7%

7

5.0

%

66

.7%

3

7.5

%

58

.3%

8

3.3

%

66

.7%

6

6.7

%

“It

is im

po

rta

nt

tha

t th

e d

ece

ase

d is p

rese

nte

d in

th

e b

est

po

ssib

le w

ay.

Mo

rtu

ary

se

rvic

es

sh

ou

ld h

ave

in

pla

ce

a p

olic

y o

n t

his

issu

e”

- 1

2

“It

ma

y b

e im

po

rta

nt

for

be

rea

ve

d f

am

ilie

s t

o s

ee

an

d s

pe

nd

tim

e w

ith

th

e p

ers

on

wh

o h

as d

ied

d

uri

ng

th

e t

ime

th

ey a

re in

th

e m

ort

ua

ry.

Mo

rtu

ari

es n

ee

d t

o h

ave

in

pla

ce

po

licie

s t

o s

up

po

rt

go

od

pra

ctice

lo

ca

lly”

- 1

2

“M

ort

ua

ry s

erv

ice

s s

ho

uld

ha

ve

in p

lace

a p

olic

y o

n c

om

mu

nic

atin

g w

ith

be

rea

ve

d f

am

ilie

s”

- 1

2

“If

a d

ea

th h

as b

ee

n r

efe

rre

d t

o t

he

co

ron

er…

co

nsid

era

tio

n s

ho

uld

be

giv

en

as t

o h

ow

be

st

arr

an

ge

me

nts

ca

n b

e m

ad

e f

or

the

fa

mily

to

dis

cu

ss (

or

rece

ive

) in

form

atio

n f

rom

th

e c

oro

ne

r o

r co

ron

er’s o

ffic

er;

clo

se

lia

iso

n w

ith

th

ose

ag

en

cie

s is t

he

refo

re im

po

rta

nt

in t

his

re

sp

ect”

- 1

H

ea

lth

& S

afe

ty a

t W

ork

Act,

19

74

- 1

8

“A

ll sta

ff in

vo

lve

d,

in w

ha

teve

r ro

le…

sh

ou

ld h

ave

acce

ss t

o a

ra

ng

e o

f fo

rma

l a

nd

in

form

al

su

pp

ort

” -

1

“T

he

org

an

isa

tio

n h

as a

n e

ffe

ctive

co

mp

lain

ts a

nd

re

pre

se

nta

tio

n p

roce

du

re…

” -

15

“

Mo

rtu

ary

se

rvic

es s

ho

uld

ha

ve

a s

yste

m in

pla

ce

to

im

ple

me

nt

se

cu

rity

of

pe

rso

na

l p

osse

ssio

ns o

n t

he

de

ce

ase

d’s

bo

dy,

or

de

live

ry t

o t

he

mo

rtu

ary

with

th

e d

ece

ase

d.”

– 1

2

5.

Sta

ff r

ec

eiv

e t

rain

ing

on

th

e f

oll

ow

ing

po

lic

ies

: a

) R

eco

rd k

ee

pin

g

b)

Re

ce

ivin

g,

ide

ntify

ing

, se

cu

rin

g,

sto

rin

g a

nd

re

lea

sin

g

bo

die

s,

org

an

s a

nd

tis

su

es

c)

Lo

ne

wo

rke

r d

) P

rep

ara

tio

n f

or

vie

win

g

e)

Su

pp

ort

ing

re

lative

s

f)

Lia

iso

n p

roto

co

ls w

ith

Co

ron

er

Se

rvic

e a

nd

PS

NI

g)

Co

ron

er’

s p

ost

mo

rtem

s –

acce

ss t

o m

ort

ua

ry o

ut

of

ho

urs

h

) In

fectio

n c

on

tro

l i)

M

ovin

g a

nd

ha

nd

ling

j)

Re

mo

va

l o

f th

e d

ece

ase

d o

uts

ide

wo

rkin

g h

ou

rs

k)

Dis

aste

r p

lan

nin

g

l)

Ma

na

ge

me

nt

of

ma

ss f

ata

litie

s

m)

Su

pp

ort

ing

ch

ildre

n t

o v

iew

de

ce

ase

d r

ela

tive

s

n)

Sta

ff s

up

po

rt

o)

Co

mp

lain

ts p

roce

du

re

p)

Acce

ssin

g in

terp

rete

rs

q)

Ma

na

ge

me

nt

of

pe

rso

na

l p

rop

ert

y o

f th

e d

ece

ase

d

10

0%

1

00

%

10

0%

1

00

%

10

0%

1

00

%

10

0%

1

00

%

10

0%

1

00

%

10

0%

1

00

%

10

0%

1

00

%

10

0%

1

00

%

10

0%

41

.7%

5

0.0

%

25

.0%

4

1.6

%

41

.6%

5

0.0

%

50

.0%

5

8.3

%

66

.7%

5

0.0

%

41

.6%

4

1.6

%

41

.6%

2

5.0

%

33

.3%

2

5.0

%

41

.7%

“All

sta

ff in

vo

lve

d in

de

live

rin

g m

ort

ua

ry s

erv

ice

s s

ho

uld

pa

rtic

ipa

te in

ed

uca

tio

n a

nd

tra

inin

g

tha

t is

ap

pro

pri

ate

to

th

eir

ro

le.

Tru

sts

sh

ou

ld,

the

refo

re,

ma

ke

tra

inin

g a

nd

le

arn

ing

o

pp

ort

un

itie

s a

va

ilab

le t

o m

ort

ua

ry s

taff

at

all

leve

ls t

o e

na

ble

th

em

to

de

ve

lop

: a

ccu

rate

, p

ractica

l kn

ow

led

ge

of

ho

sp

ita

l p

olic

y a

nd

pro

ce

du

res,

an

d r

ele

va

nt

leg

isla

tio

n”

- 1

2

“W

he

re r

isk a

sse

ssm

en

ts in

dic

ate

a n

ee

d,

syste

ms s

uch

as p

an

ic a

larm

s a

nd

lo

ne

wo

rke

r d

evic

es s

ho

uld

be

in

pla

ce

an

d u

nd

erp

inn

ed

by s

uita

ble

an

d s

uff

icie

nt

su

pp

ort

pro

ce

du

res t

o

pro

tect

sta

ff”

– 1

2

“S

taff

wh

o w

ork

in

mo

rtu

ari

es s

ho

uld

be

tra

ine

d in

th

e r

isks o

f th

eir

wo

rk a

nd

en

vir

on

me

nt

an

d

sh

ou

ld k

no

w h

ow

to

avo

id o

r m

inim

ise

th

ese

ris

ks”

– 1

2

6.

Th

e f

oll

ow

ing

su

pp

ort

sy

ste

ms

are

av

ail

ab

le f

or

sta

ff:

a)

Pe

er

su

pp

ort

b

) C

ase

re

vie

w

c)

Su

pp

ort

an

d c

ou

nse

llin

g

d)

Re

fle

ctive

pra

ctice

e)

Re

ferr

al to

Occu

pa

tio

na

l H

ea

lth

f)

Co

nfid

en

tia

l co

un

se

llin

g

10

0%

1

00

%

10

0%

1

00

%

10

0%

1

00

%

10

0.0

%

50

.0%

5

0.0

%

25

.0%

1

00

.0%

6

6.7

%

“T

his

are

a o

f w

ork

ca

n b

e p

art

icu

larl

y d

em

an

din

g,

an

d it

is im

po

rta

nt

tha

t sta

ff s

ho

uld

ha

ve

a

cce

ss t

o a

ra

ng

e o

f fo

rma

l a

nd

in

form

al su

pp

ort

. T

ime

sh

ou

ld b

e a

lloca

ted

to

en

su

re t

ha

t sta

ff

are

ab

le t

o a

cce

ss t

he

su

pp

ort

th

ey n

ee

d”

- 1

2

“All

sta

ff s

ho

uld

als

o h

ave

op

po

rtu

nitie

s t

o d

eve

lop

th

eir

un

ders

tan

din

g a

nd

pra

ctice

th

rou

gh

m

ech

an

ism

s s

uch

as c

linic

al su

pe

rvis

ion

, ca

se

re

vie

w,

cri

tica

l in

cid

en

t a

na

lysis

an

d r

isk

ma

na

ge

me

nt

me

etin

gs”-

1

3.

Ch

apla

incy

Ser

vice

s A

ud

it S

tan

dar

ds

46

Au

dit

Cri

teri

a

Sta

nd

ard

A

ch

iev

ed

R

ati

on

ale

1.

Na

me

d c

o-c

oo

rdin

ato

r/le

ad

ch

ap

lain

of

the

ch

ap

lain

cy

s

erv

ice

10

0%

6

3.6

%

(n=

33

) “

Th

e c

ha

pla

incy s

erv

ice

is h

ea

de

d b

y a

de

dic

ate

d m

em

be

r o

f th

e c

ha

pla

incy t

ea

m”

- 2

2.

Po

lic

y f

or

the

ch

ap

lain

cy

se

rvic

e

10

0%

42

.4%

(n

=3

0)

"Cle

ar

line

s o

f a

cco

un

tab

ility

/ma

na

ge

me

nt

are

esta

blis

he

d t

o e

na

ble

a c

on

sis

ten

t sta

nd

ard

a

nd

qu

alit

y o

f se

rvic

e f

or

all

pa

tie

nts

an

d s

taff

" -2

3.

Jo

b d

es

cri

pti

on

fo

r c

ha

pla

ins

10

0%

84

.8%

(n

=3

3)

“A

pp

oin

tme

nts

to

ch

ap

lain

cy-

Ho

sp

ita

l ch

ap

lain

cy a

pp

oin

tme

nts

are

NH

S t

rust

ap

po

intm

en

ts.

HR

de

pa

rtm

en

ts w

ith

in t

rusts

will

ad

vis

e o

n t

rust

ap

po

intm

en

t p

roce

du

res…

Pa

ne

l o

f a

sse

sso

rs…

sh

ou

ld b

e id

en

tifie

d t

o p

rovid

e a

dvic

e o

n s

uch

issu

es a

s jo

b d

escri

ptio

ns…

” -

2

HS

S (

TC

7)

8/2

00

4 C

od

e O

f C

on

du

ct

Fo

r N

HS

He

alth

ca

re C

ha

pla

ins s

tate

s t

ha

t N

HS

e

mp

loye

rs in

co

rpo

rate

th

e c

ode

in

to c

on

tra

cts

of

em

plo

ym

en

t -

23

4.

Wri

tte

n i

nfo

rma

tio

n i

s a

va

ila

ble

ab

ou

t th

e c

ha

pla

inc

y

se

rvic

e

10

0%

6

6.7

%

(n=

33

) S

ee

ab

ove

re

fere

nce

“Tru

sts

ma

y in

form

pa

tie

nts

ab

ou

t th

e a

va

ilab

ility

of

ch

ap

lain

cy s

erv

ice

s f

or

exa

mp

le t

hro

ug

h

info

rma

tio

n le

afle

ts a

nd

we

lco

me

pa

cks”

- 2

5.

Th

e f

oll

ow

ing

ve

rba

l/w

ritt

en

in

form

ati

on

is

pro

vid

ed

by

th

e

ch

ap

lain

cy

se

rvic

e:

a)

Sp

iritu

al su

pp

ort

bo

okle

t fo

r p

atie

nts

b

) R

eco

rd o

f vis

it in

pa

tie

nt

no

tes

c)

Re

co

rd o

f a

dm

inis

tra

tio

n o

f sa

cra

me

nts

in

pa

tie

nt

no

tes

d)

Re

co

rd o

f vis

it in

ch

ap

lain

s n

ote

s

e)

Re

co

rd o

f a

dm

inis

tra

tio

n o

f sa

cra

me

nt

in c

ha

pla

ins n

ote

s

f)

Vis

itin

g c

ard

le

ft if

ap

pro

pri

ate

g

) N

otifica

tio

n o

f a

dm

issio

n t

o p

atie

nts

’ o

wn

fa

ith

le

ad

er

10

0%

1

00

%

10

0%

1

00

%

10

0%

1

00

%

10

0%

(n=

33

) 6

3.6

%

30

.3%

6

3.6

%

54

.5%

4

2.4

%

93

.9%

9

7.0

%

“Ad

eq

ua

te a

rra

ng

em

en

ts a

re m

ad

e f

or

the

sp

iritu

al, r

elig

iou

s,

sa

cra

me

nta

l, r

itu

al a

nd

cu

ltu

ral

req

uir

em

en

ts a

pp

rop

ria

te t

o t

he

ne

ed

s,

ba

ckg

rou

nd

an

d t

rad

itio

n o

f a

ll p

atie

nts

an

d s

taff

in

clu

din

g t

ho

se

of

no

sp

ecifie

d f

aith

” -

2

6.

Th

e f

oll

ow

ing

se

rvic

es

are

pro

vid

ed

by

ch

ap

lain

s:

a)

Ro

utin

e w

ard

vis

its

b)

Vis

its t

o ill

pa

tie

nts

c)

Vis

its t

o b

ere

ave

d r

ela

tive

s

d)

Pro

vis

ion

of

sa

cra

me

nts

e

) N

am

ing

se

rvic

e f

or

ba

bie

s

f)

Su

nd

ay s

erv

ice

s

g)

Mid

-we

ek s

erv

ice

s

h)

Re

me

mb

ran

ce

se

rvic

es f

or

ch

ildre

n

i)

Re

me

mb

ran

ce

se

rvic

es f

or

infa

nts

j)

R

em

em

bra

nce

se

rvic

es f

or

sta

ff

k)

Fu

ne

ral se

rvic

es f

or

pa

tie

nts

with

no

re

lative

s

l)

Inp

ut

to m

ultid

iscip

lina

ry t

ea

m m

ee

tin

gs

m)

Inp

ut

to d

isa

ste

r p

lan

n)

Inp

ut

to c

linic

al d

eb

rie

fin

g s

essio

ns

o)

Sta

ff s

up

po

rt

p)

Sta

ff t

rain

ing

10

0%

1

00

%

10

0%

1

00

%

10

0%

1

00

%

10

0%

1

00

%

10

0%

1

00

%

10

0%

1

00

%

10

0%

1

00

%

10

0%

1

00

%

(n=

33

) 1

00

.0%

1

00

.0%

7

5.8

%

97

.0%

3

9.4

%

72

.7%

4

5.5

%

36

.4%

3

3.3

%

30

.3%

9

0.9

%

42

.4%

4

8.5

%

27

.3%

6

9.7

%

51

.5%

“T

rusts

sh

ou

ld e

nsu

re t

ha

t th

e D

yin

g a

nd

re

ce

ntly b

ere

ave

d a

re a

ble

to

acce

ss c

ha

pla

incy

se

rvic

es a

t th

e a

pp

rop

ria

te tim

e”

- 2

“

Ch

ap

lain

s a

re t

he

tru

st

exp

ert

s o

n a

rra

ng

ing

an

d p

rovid

ing

litu

rgie

s a

nd

ce

rem

on

ies t

o m

ee

t th

e n

ee

ds o

f th

e b

ere

ave

d,

esp

ecia

lly in

th

e c

ase

of

ne

on

ata

l, c

hild

de

ath

an

d in

an

nu

al

se

rvic

es f

or

the

be

rea

ve

d”

- 2

“

Ch

ap

lain

cy t

ea

ms s

ho

uld

be

in

vo

lve

d in

Tru

st

em

erg

en

cy p

lan

s…

. a

nd

th

eir

ro

les c

lea

rly

de

fin

ed

” U

se

ful co

ntr

ibu

tors

to

de

bri

ef.

- 2


Au

dit

Cri

teri

a

Sta

nd

ard

A

ch

iev

ed

R

ati

on

ale

7.

Fu

ne

ral

se

rvic

es

ca

n b

e p

rov

ide

d o

n s

ite

10

0%

5

0.0

%

8.

Th

e f

oll

ow

ing

tra

inin

g i

s p

rov

ide

d f

or

ch

ap

lain

s b

y t

he

T

rus

t:

a)

Ch

ild p

rote

ctio

n

b)

Ma

nu

al h

an

dlin

g

c)

Infe

ctio

n c

on

tro

l d

) F

ire

pre

ve

ntio

n

e)

Tru

st

ind

uctio

n

f)

D

ata

pro

tectio

n

10

0%

1

00

%

10

0%

1

00

%

10

0%

1

00

%

51

.5%

2

7.6

%

72

.4%

4

4.8

%

62

.1%

4

8.3

%

“T

rusts

are

re

sp

on

sib

le f

or

tra

inin

g a

nd

de

ve

lop

me

nt…

ap

pro

pri

ate

tra

inin

g a

nd

de

ve

lop

me

nt

inve

stm

en

t sh

ou

ld b

e m

ad

e t

o a

va

ilab

le t

o a

ll m

em

be

rs o

f th

e c

ha

pla

incy t

ea

m. -

2

9.T

he

ch

ap

lain

cy

se

rvic

e h

as

ac

ce

ss

to

th

e f

oll

ow

ing

su

pp

ort

: a

) A

lloca

ted

tim

e f

or

ch

ap

lain

s t

o m

ee

t to

ge

the

r b

) M

ee

tin

gs w

ith

Dir

ecto

r c)

Inte

rpre

tin

g s

erv

ice

s

d)

Ad

min

istr

ative

sta

ff

e)

Ap

pra

isa

l/d

eve

lop

me

nt

revie

w

f)

Co

rpo

rate

in

form

atio

n v

ia c

ircu

latio

n lis

ts

10

0%

1

00

%

10

0%

1

00

%

10

0%

1

00

%

85

.7%

7

8.6

%

67

.9%

5

3.6

%

32

.1%

9

2.9

%

“Th

e a

nn

ua

l a

pp

rais

al p

roce

ss s

ho

uld

id

en

tify

tra

inin

g n

ee

ds a

nd

wa

ys t

o m

ee

t th

em

” -2

10

. T

he

fo

llo

win

g f

ac

ilit

ies

are

av

ail

ab

le t

o c

ha

pla

ins

: a

) C

ha

pla

incy o

ffic

e

b)

Te

lep

ho

ne

c)

An

sw

er

ma

ch

ine

d)

Co

mp

ute

r e

) P

ag

er/

ble

ep

f)

Mu

lti-fa

ith

wo

rsh

ip r

oo

m

g)

Ch

ap

el

h)

Qu

iet

roo

m f

or

co

nfid

en

tia

l su

pp

ort

of

clie

nts

i)

D

ed

ica

ted

ca

r p

ark

ing

fo

r e

me

rge

ncy c

alls

1

00

%

10

0%

1

00

%

10

0%

1

00

%

10

0%

1

00

%

10

0%

1

00

%

90

.6%

8

1.3

%

21

.9%

5

0.0

%

59

.4%

4

3.8

%

65

.6%

7

1.9

%

37

.5%

“T

rusts

sh

ou

ld p

rovid

e a

cce

ssib

le a

nd

su

ita

ble

sp

ace

s f

or

pra

ye

r, r

efle

ctio

n a

nd

re

ligio

us

se

rvic

es w

hic

h a

re o

pe

n t

o p

atie

nts

an

d s

taff

24

ho

urs

a d

ay. -

2

4.

Pal

liat

ive

Car

e S

ervi

ces

Au

dit

Sta

nd

ard

s

48

Au

dit

Cri

teri

a

Sta

nd

ard

A

ch

iev

ed

R

ati

on

ale

1.

Po

lic

y f

or

sp

ec

iali

st

pa

llia

tiv

e c

are

se

rvic

e i

n p

lac

e

1

00

%

63

.6%

“

Cle

ar

refe

rra

l p

ath

wa

ys t

o s

pe

cia

list

pa

llia

tive

ca

re s

erv

ice

s w

ill b

e in

pla

ce

w

ith

in e

ach

tru

st/

pro

vid

er”

- 1

6

“T

ho

se

pro

vid

ing

ge

ne

ralis

t m

ed

ica

l a

nd

nu

rsin

g s

erv

ice

s s

ho

uld

ha

ve

acce

ss t

o

sp

ecia

list

ad

vic

e a

t a

ll tim

es”

- 8

“

Sp

ecia

list

pa

llia

tive

Ca

re s

erv

ice

s m

ust

be

pro

vid

ed

by a

n a

pp

rop

ria

tely

qu

alif

ied

a

nd

exp

eri

en

ce

d m

ultip

rofe

ssio

na

l te

am

, n

orm

ally

le

ad

by a

co

nsu

lta

nt

in

pa

llia

tive

me

dic

ine

” -

16

“Ea

ch

mu

ltid

iscip

lina

ry t

ea

m o

r se

rvic

e s

ho

uld

im

ple

me

nt

pro

ce

sse

s t

o e

nsu

re

eff

ective

in

ter-

pro

fessio

na

l co

mm

un

ica

tio

n w

ith

in t

ea

ms a

nd

be

twe

en

th

em

an

d

oth

er

se

rvic

e p

rovid

ers

…”

- 8

2.

Wri

tte

n i

nfo

rma

tio

n i

s p

rov

ide

d a

bo

ut

the

sp

ec

iali

st

pa

llia

tiv

e c

are

se

rvic

es

10

0%

8

1.8

%

“Co

mm

issio

ne

rs a

nd

pro

vid

er

org

an

isa

tio

ns s

ho

uld

en

su

re t

ha

t p

atie

nts

an

d

ca

rers

ha

ve

ea

sy a

cce

ss t

o a

ra

ng

e o

f h

igh

qu

alit

y in

form

atio

n m

ate

ria

ls.”

– 8

3.

Pa

llia

tive

ca

re t

ea

m h

as

ac

ce

ss

to

th

e f

oll

ow

ing

su

pp

ort

: (a

) A

lloca

ted

tim

e f

or

tea

m t

o m

ee

t to

ge

the

r (b

) A

dm

inis

tra

tive

su

pp

ort

(c

) A

pp

rais

al/d

eve

lop

me

nt

revie

w

10

0%

1

00

%

10

0%

(n=

11

) 8

1.8

%

90

.9%

1

00

.0%

“All

pro

vid

ers

of

pa

llia

tive

ca

re s

ho

uld

ha

ve

me

ch

an

ism

s in

pla

ce

to

en

su

re s

taff

h

ave

acce

ss t

o r

eg

ula

r su

pp

ort

, e

.g.

mu

ltip

rofe

ssio

na

l ca

se

dis

cu

ssio

ns,

clin

ica

l su

pe

rvis

ion

an

d a

ra

ng

e o

f syste

ms f

or

pe

rso

na

l su

pp

ort

” -

16

4.

Ad

dit

ion

al

Tra

inin

g

(a)

Ind

ica

te if

tea

m m

em

be

rs h

ave

un

de

rta

ke

n a

dd

itio

na

l tr

ain

ing

a

nd

de

ve

lop

me

nt

in b

ere

ave

me

nt

ca

re (

fre

e t

ext

listin

g)

10

0%

10

0%

( fr

ee

te

xt

resp

on

se

s

ind

ica

ted

all

tea

ms h

ad

a

dd

itio

na

l tr

ain

ing

)

“Pro

vid

er

org

an

isa

tio

ns s

ho

uld

id

en

tify

sta

ff w

ho

ma

y b

en

efit

fro

m t

rain

ing

an

d

sh

ou

ld f

acili

tate

th

eir

pa

rtic

ipa

tio

n in t

rain

ing

an

d o

ng

oin

g d

eve

lop

me

nt.

In

div

idu

al

pra

ctitio

ne

rs s

ho

uld

en

su

re t

he

y h

ave

th

e k

no

wle

dg

e a

nd

skill

s r

eq

uir

ed

fo

r th

e

role

s t

he

y u

nd

ert

ake

” 8

“ S

pe

cia

list

pa

llia

tive

ca

re:

All

sta

ff s

ho

uld

ha

ve

exp

eri

en

ce

in

th

e p

alli

ative

ca

re

en

vir

on

me

nt

an

d h

ave a

n a

ccre

dite

d,

reco

gn

ise

d o

r sp

ecia

list

qu

alif

ica

tio

n,

ap

pro

pri

ate

to

th

eir

sp

ecia

list

gro

up

in

pa

llia

tive

ca

re/m

ed

icin

e”

– 1

6

5.

Pa

llia

tiv

e c

are

te

am

co

ntr

ibu

te t

o b

ere

av

em

en

t c

are

(a

) In

dic

ate

wa

y(s

) in

wh

ich

te

am

co

ntr

ibu

te t

o

be

rea

ve

me

nt

ca

re (

fre

e te

xt

listin

g)

10

0%

1

00

%

( fr

ee

te

xt

resp

on

se

s

ind

ica

ted

all

tea

ms m

ad

e

va

rio

us

co

ntr

ibu

tio

ns

to

be

rea

ve

me

nt

ca

re)

“Asse

ssm

en

t a

nd

dis

cu

ssio

n o

f p

atie

nts

’ n

ee

ds f

or

ph

ysic

al, p

sych

olo

gic

al, s

ocia

l,

sp

iritu

al a

nd

fin

an

cia

l su

pp

ort

sh

ou

ld b

e u

nd

ert

ake

n a

t ke

y p

oin

ts (

su

ch

as a

t d

iag

no

sis

, a

t co

mm

en

ce

me

nt,

du

rin

g,

an

d a

t th

e e

nd

of

tre

atm

en

t; a

t re

lap

se

; a

nd

w

he

n d

ea

th is a

pp

roa

ch

ing

). -

8

“Th

is c

an

be

dis

tre

ssin

g t

ime

fo

r fa

mili

es a

nd

fri

en

ds a

nd

re

tain

ing

ve

rba

l in

form

atio

n m

ay b

e d

ifficu

lt.

It is im

po

rta

nt th

at

the

y a

re m

ad

e a

wa

re o

f b

ere

ave

me

nt

issu

es,

bo

th a

bo

ut

the

gri

evin

g p

roce

ss a

nd

ab

ou

t h

ow

to

acce

ss

he

lp a

nd

su

pp

ort

lo

ca

lly”

– 1

7


5.

Po

rter

s an

d F

un

eral

Dir

ecto

rs S

ervi

ces

Au

dit

Sta

nd

ard

s

49

^ T

ota

l o

ut

of

15

as t

he 5

SL

A s

erv

ice

s r

esp

on

de

d t

ha

t 1

(c)

wa

s n

ot

ap

plica

ble

. ^^ T

ota

l o

ut

of

18

as 2

se

rvic

es r

esp

on

de

d t

ha

t 1

(d

) w

as n

ot

ap

plica

ble

. ^^^T

ota

l o

ut

of

14

as 4

SL

A s

erv

ice

s a

nd

2 p

ort

eri

ng

se

rvic

es s

tate

d t

ha

t 1

(f)

wa

s n

ot

ap

plica

ble

. ^^^^T

ota

l o

ut

of

13

as 5

SL

A s

erv

ice

s a

nd

2 p

ort

eri

ng

se

rvic

es s

tate

d t

ha

t 1

(g

) w

as n

ot

ap

plica

ble

.

Au

dit

Cri

teri

a

Sta

nd

ard

A

ch

iev

ed

R

ati

on

ale

1.

Th

e f

oll

ow

ing

in

form

ati

on

if

giv

en

wh

en

po

rte

rin

g t

ea

m i

s

co

nta

cte

d t

o r

em

ov

e a

bo

dy

fro

m t

he

wa

rd:

a)

Na

me

of

the

de

ce

ase

d

b)

He

alth

an

d s

afe

ty issu

es:

(i)

Infe

ctio

n c

on

tro

l (i

i)

We

igh

t c)

Cu

ltu

ral/re

lig

iou

s r

eq

uir

em

en

ts

d)

Pro

pe

rty o

n b

od

y

e)

Tu

be

s/d

rain

s in

situ

f)

If D

ea

th C

ert

ific

ate

issue

d

g)

If r

em

ain

s c

an

be

re

lea

se

d

h)

If C

oro

ne

r in

vo

lve

d

10

0%

1

00

%

10

0%

1

00

%

10

0%

1

00

%

10

0%

1

00

%

10

0%

70

.0%

7

0.0

%

70

.0%

7

3.3

%^

44

.4%

^^

55

.0%

5

7.1

%^^^

61

.5%

^^^^

50

.0%

Ma

na

gin

g t

he

re

ce

ipt,

sto

rag

e a

nd

re

lea

se

of

de

ce

ase

d p

eo

ple

an

d t

he

ir p

rop

ert

y

sa

fely

, se

cu

rely

, e

ffic

ien

tly,

eff

ective

ly a

nd

ap

pro

pri

ate

ly is t

he

co

re b

usin

ess o

f m

ort

ua

ry s

erv

ice

s. -

12

A

ud

it C

rite

ria

S

tan

da

rd

Ac

hie

ve

d

Ra

tio

na

le

SL

A

(n=

5)

Po

rte

rs

(n=

15

)

2.

P

ort

eri

ng

te

am

ha

ve

re

ce

ive

d t

he

fo

llo

win

g

tra

inin

g t

o

he

lp i

nc

rea

se

sk

ills

an

d c

on

fid

en

ce

:

a)

De

ath

, g

rie

f a

nd

be

rea

ve

me

nt

(to

th

e a

pp

rop

ria

te le

ve

l)

b)

Inte

rpe

rso

na

l a

nd

co

mm

un

ica

tio

n s

kills

c)

Ro

les a

nd

se

rvic

es p

rovid

ed

by o

the

r m

em

be

rs o

f th

e m

ulti-

dis

cip

lin

ary

te

am

e.g

. m

ort

ua

ry s

erv

ice

s,

ch

ap

lain

s

d)

Mu

lti-cu

ltu

ral a

nd

re

lig

iou

s p

ractice

s

e)

Ma

nu

al h

an

dlin

g

f)

Infe

ctio

n c

on

tro

l

10

0%

1

00

%

10

0%

1

00

%

10

0%

1

00

%

10

0%

1

00

%

10

0%

1

00

%

10

0%

1

00

%

0.0

%^

0.0

%^

0.0

%^

7.1

%^

86

.7%

8

0.0

%

All m

ort

ua

ry s

taff

will n

ee

d t

o b

e a

wa

re o

f cu

rre

nt

he

alth

an

d s

afe

ty

leg

isla

tio

n a

nd

gu

ida

nce

an

d w

ill re

ce

ive

tra

inin

g t

o e

na

ble

th

em

to

w

ork

sa

fely

. T

rusts

sh

ou

ld m

ake

tra

inin

g a

nd

le

arn

ing

op

po

rtu

nitie

s

ava

ila

ble

to

mo

rtu

ary

sta

ff a

t a

ll le

ve

ls t

o e

na

ble

th

em

to

de

ve

lop

.-

12

Au

dit

Cri

teri

a

Sta

nd

ard

A

ch

iev

ed

R

ati

on

ale

3.

T

he

fo

llo

win

g m

ec

ha

nis

ms

are

cu

rre

ntl

y i

n p

lac

e o

r w

ou

ld

lik

e t

o b

e s

ee

n d

ev

elo

pe

d t

o s

up

po

rt t

he

po

rte

rin

g t

ea

m t

o

ca

re f

or

dy

ing

pa

tie

nts

an

d t

he

ir r

ela

tiv

es

: a

) In

form

al su

pp

ort

fro

m p

ee

rs

b)

Co

nfid

en

tia

l o

ne

to

on

e s

up

po

rt f

rom

ma

na

ge

r/d

esig

na

ted

co

lle

ag

ue

/me

nto

r to

ta

lk t

hro

ug

h t

he

exp

eri

en

ce

c)

De

dic

ate

d ‘d

e-b

rie

fin

g’ tim

e w

ith

pe

ers

fo

llo

win

g

pa

rtic

ula

rly t

rau

ma

tic s

itu

atio

ns (

as d

ete

rmin

ed

by t

he

sta

ff)

d)

De

dic

ate

d ‘d

e-b

rie

fin

g’ tim

e w

ith

th

e m

ulti-p

rofe

ssio

na

l te

am

fo

llo

win

g p

art

icu

larl

y t

rau

ma

tic s

itu

atio

ns (

as

de

term

ine

d b

y t

he

sta

ff)

e)

Co

nfid

en

tia

l o

ne

to

on

e s

up

po

rt f

rom

me

mb

er

of

sta

ff

exte

rna

l to

th

e w

ard

/de

pa

rtm

en

t f)

A

cce

ss t

o e

xte

rna

l su

pp

ort

or

co

un

se

llin

g s

erv

ice

s

10

0%

1

00

%

10

0%

1

00

%

10

0%

1

00

%

10

0%

9

0.0

%

55

.0%

4

5.0

%

55

.0%

6

5.0

%

Th

is a

rea

of

wo

rk c

an

be

pa

rtic

ula

rly d

em

an

din

g a

nd

it

is im

po

rta

nt

tha

t sta

ff

sh

ou

ld h

ave

acce

ss t

o a

ra

ng

e o

f fo

rma

l a

nd

in

form

al su

pp

ort

. –

12

6.

War

d M

anag

er Q

ues

tio

nn

aire

Res

ult

s

50

Au

dit

Cri

teri

a

Ex

pe

cte

d %

A

ch

iev

ed

%

Nu

mb

er

of

res

po

ns

es

T

ota

l n

=1

45

1.

Re

sp

on

de

nts

ra

ted

th

e f

oll

ow

ing

as

pe

cts

of

the

wa

rd e

nv

iro

nm

en

t e

xc

ell

en

t/g

oo

d:

a.

Sp

ace

b

. P

riva

cy

c.

No

ise

le

ve

ls

d.

Te

lep

ho

ne

acce

ss

e.

Ava

ilab

ility

of

foo

d

f.

Re

st

facili

tie

s

g.

Ba

thro

om

fa

cili

tie

s

h.

Qu

iet

sp

ace

s f

or

pra

ye

r o

r co

nte

mp

latio

n

i.

Pa

rkin

g f

acili

tie

s

j.

Mo

rtu

ary

fa

cili

tie

s*

*Exce

ptio

n:

No

mo

rtu

ary

on

site

10

0%

(o

ve

rall)

1

00

%

10

0%

1

00

%

10

0%

1

00

%

10

0%

1

00

%

10

0%

1

00

%

10

0%

53

.7%

4

5.5

%

56

.5%

4

0.4

%

82

.5%

5

7.2

%

48

.9%

4

3.8

%

51

.0%

4

7.5

%

64

.8%

n=

14

19

a

n=

14

5

n=

14

5

n=

14

1b

n=

14

3c

n=

14

5

n=

14

1b

n=

14

4d

n=

14

5

n=

14

5

n=

12

5e

,f

2.

Re

sp

on

de

nt

ind

ica

ted

th

at

are

as

de

tail

ed

in

qu

ali

ty m

ea

su

re 1

ne

ed

ed

im

pro

ve

d

0%

8

0.6

%

n

=1

39

a

3.

Re

sp

on

de

nt

ind

ica

ted

th

at

the

fo

llo

win

g i

nfo

rma

tio

n i

s p

rov

ide

d t

o p

ati

en

ts a

nd

re

lati

ve

s i

n e

ith

er

wri

tte

n o

r v

erb

al

form

: a.

Lo

ca

tio

n o

f p

ub

lic p

ho

ne

s

b.

Lo

ca

tio

n o

f to

ilets

c.

Ca

r p

ark

ing

arr

an

ge

me

nts

d

. C

ha

pla

incy s

erv

ice

e.

Acce

ss t

o f

oo

d/b

eve

rag

es

10

0%

1

00

%

10

0%

1

00

%

10

0%

92

.3%

9

5.8

%

71

.0%

9

3.6

%

97

.6%

n=

14

3

n=

14

3

n=

13

8

n=

14

1

n=

14

0

4.

Re

sp

on

de

nt

ind

ica

ted

th

at

the

re i

s 2

4 h

r a

cc

es

s t

o f

oo

d /

be

ve

rag

es

1

00

%

70

.6%

n

=1

43

5.

Re

sp

on

de

nt

ind

ica

ted

th

at

foo

d a

nd

be

ve

rag

es

are

lo

ca

ted

wit

hin

a f

ive

min

ute

wa

lk f

rom

th

e w

ard

10

0%

9

3.0

%

n=

10

0

6.

Re

sp

on

de

nt

ind

ica

ted

th

at

the

re i

s a

pri

va

te a

rea

de

sig

na

ted

fo

r re

lati

ve

s o

n t

he

wa

rd

1

00

%

66

.9%

n

=1

42

7.

Re

sp

on

de

nt

ind

ica

ted

th

at

sin

gle

ro

om

s a

re a

lwa

ys

pri

ori

tis

ed

fo

r d

yin

g p

ati

en

ts

10

0%

6

3.4

%

n=

13

4

8.

Re

sp

on

de

nt

ind

ica

ted

th

at

dy

ing

pa

tie

nts

are

ca

red

fo

r in

a s

ing

le r

oo

m 5

1 –

10

0%

of

tim

es

10

0%

7

9.9

%

n=

13

4

9.

Re

sp

on

de

nt

ind

ica

ted

th

at

pa

tie

nts

are

alw

ay

s a

sk

ed

if

the

ir r

eli

gio

us

aff

ilia

tio

n c

an

be

do

cu

me

nte

d

1

00

%

86

.6%

n

=1

42

10

. R

es

po

nd

en

ts i

nd

ica

ted

th

at

pa

tie

nts

are

as

ke

d i

f th

is i

nfo

rma

tio

n c

an

be

pa

ss

ed

to

th

e c

ha

pla

inc

y s

erv

ice

1

00

%

79

.4%

n

=1

41

11

. R

es

po

nd

en

t in

dic

ate

d t

ha

t th

e p

ati

en

ts i

nit

ial

de

cis

ion

ab

ou

t c

on

tac

t w

ith

th

e c

ha

pla

inc

y s

erv

ice

is

re

vis

ite

d

1

00

%

95

.7%

n

=9

2

12

. R

es

po

nd

en

t in

dic

ate

d t

ha

t th

e c

are

of

the

dy

ing

pa

thw

ay

is

op

era

tio

na

l w

ith

in t

he

de

pa

rtm

en

t *E

xc

ep

tio

n:

pa

ed

iatr

ic w

ard

s (

8)

10

0%

5

8.1

%

n=

13

1


13

. R

es

po

nd

en

t in

dic

ate

d t

ha

t s

taff

me

mb

ers

ro

uti

ne

ly e

xp

lore

th

e w

ish

es

an

d f

ee

lin

gs

of

dy

ing

pa

tie

nts

re

ga

rdin

g

the

ir d

ea

th

10

0%

7

6.6

%

n=

13

7

14

. P

are

nts

are

off

ere

d t

he

op

po

rtu

nit

y t

o t

ak

e t

he

ir d

ec

ea

se

d c

hil

d o

r b

ab

y f

rom

th

e w

ard

to

ho

me

in

th

eir

ow

n c

ar

*Ex

ce

pti

on

: a

du

lt w

ard

s (

10

7)

10

0%

6

8.4

%

n=

38

15

. R

es

po

nd

en

t in

dic

ate

d t

ha

t e

lem

en

ts o

f th

e r

em

ov

al

pro

ce

ss

co

uld

be

im

pro

ve

d

0%

4

2.2

%

n=

90

16

. R

es

po

nd

en

t in

dic

ate

d t

ha

t th

e f

oll

ow

ing

do

cu

men

tati

on

/id

en

tifi

ca

tio

n r

ou

tin

ely

ac

co

mp

an

ies

th

e p

ati

en

ts’

rem

ain

s

fro

m t

he

wa

rd/d

ep

t:

a.

Pa

tie

nt

ID L

ab

el

b.

Wri

st/

an

kle

ID

ba

nd

c.

Mo

rtu

ary

/ID

fo

rm

d.

De

ath

Ce

rtific

ate

e

.

C

rem

atio

n f

orm

10

0%

a

. 8

5.0

%

b.

97

.9%

c.

85

.3%

d

. 5

7.8

%

e.

41

.3%

a.

n=

12

7

b.

n=

14

0

c.

n=

13

6

d.

n=

13

5

e.

n=

12

6

17

. T

he

fo

llo

win

g i

nfo

rma

tio

n i

s p

rov

ide

d t

o f

am

ilie

s o

f th

e d

ec

ea

se

d w

he

n a

po

st

mo

rte

m i

s r

eq

uir

ed

: a

. D

iscu

ssio

n c

ove

rin

g p

urp

ose

, p

roce

du

res a

nd

th

eir

ch

oic

es

b.

Re

leva

nt

bo

okle

t c.

Co

py o

f co

nse

nt

form

10

0%

1

00

%

10

0%

a.

99

.2%

b

. 9

9.2

%

c.

97

.2%

n=

12

9

n=

12

2

n=

10

9

18

. R

es

po

nd

en

ts i

nd

ica

ted

th

at

rela

tiv

es

are

giv

en

th

e o

pp

ort

un

ity

to

sp

ea

k t

o t

he

fo

llo

win

g p

rofe

ss

ion

als

pri

or

to

the

ir r

ela

tiv

e’s

de

ath

: a

. C

on

su

lta

nt/

Re

g/S

taff

Gra

de

b.

Do

cto

r o

n d

uty

c.

Nu

rse

d

.

H

osp

ita

l C

ha

pla

in

10

0%

1

00

%

10

0%

1

00

%

a.

99

.3%

b

. 9

7.8

%

c.

10

0%

d

. 9

7.1

%

n=

13

8

n=

13

7

n=

14

0

n=

13

9

19

. R

es

po

nd

en

ts i

nd

ica

ted

th

at

rela

tiv

es

are

giv

en

th

e D

ea

th C

ert

ific

ate

at

the

tim

e o

f th

eir

re

lati

ve

s d

ea

th a

t le

as

t a

pp

rox

ima

tely

51

% o

f th

e t

ime

10

0%

5

6.8

%

n=

13

9

20

. R

es

po

nd

en

ts i

nd

ica

ted

th

at

a f

oll

ow

-up

me

eti

ng

is

alw

ay

s o

ffe

red

to

th

e f

am

ily

to

dis

cu

ss

th

e p

ati

en

t’s

de

ath

1

00

%

30

.1%

n

=1

43

21

. R

es

po

nd

en

t in

dic

ate

d t

ha

t th

ey

re

ce

ive

th

e f

oll

ow

ing

fe

ed

ba

ck

fro

m f

am

ilie

s r

eg

ard

ing

th

e c

are

pro

vid

ed

be

fore

, a

t th

e t

ime

an

d a

fte

r th

e r

ela

tiv

e’s

de

ath

: a

. U

se

r q

ue

stio

nn

air

es

b.

Fo

cu

s g

rou

ps

c.

Co

mp

lain

ts/c

om

plim

en

ts

d.

No

fe

ed

ba

ck

e.

Oth

er

10

0%

1

00

%

10

0%

1

00

%

10

0%

a.

9.7

%

b.

4.1

%

c.

85

.5%

d

. 1

4.5

%

e.

37

.9%

n=

14

5

n=

14

5

n=

14

5

n=

14

5

n=

14

5

22

. R

es

po

nd

en

ts i

nd

ica

ted

th

at

the

y c

an

re

fer

rela

tiv

es

dir

ec

tly

to

an

oth

er

se

rvic

e (

sta

tuto

ry o

r v

olu

nta

ry)

for

info

rma

tio

n o

r s

up

po

rt

10

0%

7

9.4

%

n=

14

1

7.

Ind

ivid

ual

Sta

ff Q

ues

tio

nn

aire

Res

ult

s

52

G

EN

ER

AL

IN

FO

RM

AT

ION

T

ota

l n

um

be

r o

f re

sp

on

se

s =

16

32

Re

sp

on

se

ra

te 4

0%

1

. C

urr

en

t o

rga

nis

ati

on

of

em

plo

ym

en

t

Be

lfa

st

HS

C T

rust

24

.0%

(3

88

)

No

rth

ern

HS

C T

rust

21

.2%

(3

42

)

So

uth

Ea

ste

rn H

SC

Tru

st

16

.4%

(2

65

)

So

uth

ern

HS

C T

rust

18

.2%

(2

94

)

We

ste

rn H

SC

Tru

st

1

6.5

% (

26

6)

Ho

sp

ice

3

.7%

(5

9)

(To

tal n

um

be

r o

f re

sp

on

de

nts

= 1

61

4)

2.

Sp

ec

ific

sp

ec

iali

ty/r

ole

wit

hin

cu

rre

nt

ho

sp

ita

l/h

os

pic

e?

Me

dic

al

8

.4%

(1

36

)

Re

gis

tere

d N

urs

e

61

.5%

(9

97

)

Re

gis

tere

d M

idw

ife

0.7

% (

11

)

So

cia

l W

ork

er

(Acu

te)

3.1

% (

50

)

Allie

d H

ea

lth

Pro

fessio

na

l 9

.3%

(1

51

)

He

alth

ca

re A

ssis

tan

t 9

.8%

(1

59

)

Ad

min

istr

ative

2.8

% (

45

)

Do

me

stic/H

ote

l S

erv

ice

s

4.4

% (

72

)

(To

tal n

um

be

r o

f re

sp

on

de

nts

= 1

62

1)

3.

Le

ng

th o

f ti

me

em

plo

ye

d w

ith

in t

he

he

alt

h a

nd

so

cia

l c

are

se

cto

r:

Le

ss t

ha

n 1

ye

ar

4.5

% (

73

)

1 –

5 y

ea

rs

30

.2%

(4

90

)

6 –

10

ye

ars

1

4.0

% (

22

8)

Mo

re t

ha

n 1

0 y

ea

rs

51

.3%

(8

34

)

(To

tal n

um

be

r o

f re

sp

on

de

nts

= 1

62

5)

4.

Ho

w o

fte

n i

n y

ou

r d

ay

to

da

y w

ork

do

yo

u h

av

e c

on

tac

t (e

.g.

fac

e t

o f

ac

e o

ve

r th

e t

ele

ph

on

e o

r w

ritt

en

co

rre

sp

on

de

nc

e)

wit

h t

he

fo

llo

win

g:-

a)

Pa

tie

nts

wh

o a

re d

yin

g

Ne

ve

r 7

.6%

(1

21

)

Le

ss t

ha

n o

nce

a m

on

th

31

.7%

(5

05

)

1-3

tim

es a

mo

nth

3

1.0

% (

47

2)

Mo

re t

ha

n 4

tim

es a

mo

nth

2

9.6

% (

83

4)

(To

tal n

um

be

r o

f re

sp

on

de

nts

= 1

59

2)


b)

Re

ce

ntl

y b

ere

av

ed

fa

mil

y m

em

be

rs

Ne

ve

r 6

.2%

(9

7)

Le

ss t

ha

n o

nce

a m

on

th

41

.7%

(6

49

)

1-3

tim

es a

mo

nth

2

9.3

% (

45

6)

Mo

re t

ha

n 4

tim

es a

mo

nth

2

2.7

% (

35

3)

(To

tal n

um

be

r o

f re

sp

on

de

nts

= 1

55

5)

c

) S

taff

wh

o h

av

e c

are

d f

or

dy

ing

pa

tie

nts

Ne

ve

r 4

.4%

(6

8)

Le

ss t

ha

n o

nce

a m

on

th

27

.0%

(4

21

)

1-3

tim

es a

mo

nth

2

3.3

% (

36

4)

Mo

re t

ha

n 4

tim

es a

mo

nth

4

5.3

% (

70

7)

(To

tal n

um

be

r o

f re

sp

on

de

nts

= 1

56

0)

EN

VIR

ON

ME

NT

AN

D F

AC

ILIT

IES

A

ud

it C

rite

ria

Exp

ecte

d P

erc

en

tag

e

Actu

al P

erc

en

tag

e A

ch

ieve

d

5a

.Th

e f

oll

ow

ing

as

pe

cts

of

the

ho

sp

ita

l e

nv

iro

nm

en

t/fa

cil

itie

s p

rov

ide

d f

or

dy

ing

pa

tie

nts

a

nd

th

eir

fa

mil

ies

are

ex

ce

lle

nt/

go

od

:-

a)

Sp

ace

1

00

%

33

.6%

(5

42

)

b)

Pri

va

cy

10

0%

3

5.9

% (

58

2)

c)

No

ise

le

ve

ls

10

0%

1

9.1

% (

30

9)

d)

Te

lep

ho

ne

acce

ss f

or

fam

ilie

s 1

00

%

47

.5%

(7

20

)

e)

Ava

ilab

ility

of

foo

d f

or

fam

ilie

s 1

00

%

30

.2%

(4

88

)

f)

Re

st

facili

tie

s f

or

fam

ilie

s 1

00

%

21

.0%

(3

38

)

g)

Ba

thro

om

fa

cili

tie

s f

or

fam

ilie

s 1

00

%

20

.5%

(3

30

)

h)

Pa

rkin

g f

acili

tie

s 1

00

%

33

.7%

(5

45

)

i)

Mo

rtu

ary

fa

cili

tie

s 1

00

%

32

.9%

(5

27

)

j)

Qu

iet

pla

ce

s f

or

co

nte

mp

latio

n a

nd

pra

ye

r 1

00

%

42

.5%

(6

86

)

k)

Wri

tte

n g

uid

an

ce

/ in

form

atio

n

10

0%

4

1.9

% (

67

6)

5b

. H

os

pit

al

en

vir

on

me

nt/

fac

ilit

ies

pro

vid

ed

re

qu

ire

s i

mp

rov

em

en

ts

0%

9

1.8

% (

11

33

)

TR

EA

TM

EN

T A

ND

CA

RE

A

ud

it C

rite

ria

E

xp

ec

ted

Pe

rce

nta

ge

Ac

tua

l P

erc

en

tag

e A

ch

iev

ed

6a

. C

are

giv

en

be

fore

de

ath

co

uld

be

im

pro

ve

d f

or:

-

i) P

atie

nts

0

%

42

.9%

(6

82

)

ii) F

am

ilie

s 0

%

54

.4%

(8

55

)

b.

Ca

re g

ive

n a

t ti

me

of

de

ath

, c

ou

ld b

e im

pro

ve

d f

or:

-

i) P

atie

nts

0

%

32

.6%

(5

11

)

ii) F

am

ilie

s 0

%

41

.8%

(6

48

)

c.

Ca

re g

ive

n a

fte

r d

ea

th,

co

uld

be

im

pro

ve

d f

or:

-

i) P

atie

nts

0

%

29

.4%

(4

50

)

ii) F

am

ilie

s 0

%

43

.0%

(6

59

)

54

ST

AF

F S

KIL

LS

, T

RA

ININ

G &

SU

PP

OR

T

Au

dit

Cri

teri

a

Ex

pe

cte

d P

erc

en

tag

e

Ac

tua

l P

erc

en

tag

e A

ch

iev

ed

7.

Re

sp

on

de

nts

sta

ted

th

ey

are

co

mfo

rta

ble

wit

h t

he

fo

llo

win

g;-

a)

Bre

akin

g,

or

be

ing

pre

se

nt

at

the

de

live

ry o

f b

ad

ne

ws

10

0%

2

4.1

% (

33

9)

b)

Me

etin

g t

he

fo

llow

ing

ne

ed

s o

f p

atie

nts

wh

o a

re d

yin

g a

nd

th

eir

fa

mily

: i)

P

hysic

al n

ee

ds

10

0%

4

5.6

% (

66

3)

ii)

Em

otio

na

l n

ee

ds

10

0%

2

9.9

% (

44

1)

iii)

Sp

iritu

al n

ee

ds

10

0%

2

7.7

% (

38

5)

iv)

So

cia

l n

ee

ds

10

0%

3

0.6

% (

42

7)

c)

Dis

cu

ssin

g d

ea

th a

nd

dyin

g

10

0%

2

2.2

% (

32

5)

d)

Ta

lkin

g t

o p

eo

ple

wh

o h

ave

be

en

re

ce

ntly b

ere

ave

d

10

0%

2

4.0

% (

36

9)

e)

Su

pp

ort

ing

a c

hild

wh

ose

re

lative

is d

yin

g

10

0%

1

1.8

% (

14

3)

f)

Su

pp

ort

ing

pe

op

le f

rom

diffe

ren

t cu

ltu

res

10

0%

9

.5%

(1

39

)

g)

Pa

rtic

ipa

tin

g in

fo

llow

-up

me

etin

gs s

ho

uld

re

lative

s w

ish

to

re

turn

to

th

e h

osp

ita

l o

r d

iscu

ss

asp

ects

of

the

pa

tie

nt’s c

are

1

00

%

20

.3%

(2

38

)

8.

Th

e f

oll

ow

ing

ad

dit

ion

al

ed

uc

ati

on

/tra

inin

g t

o i

nc

rea

se

sk

ills

an

d c

on

fid

en

ce

in

ca

rin

g f

or

the

dy

ing

an

d t

he

ir r

ela

tiv

es

ha

s b

ee

n p

rev

iou

sly

re

ce

ive

d:

a)

De

ath

, g

rie

f a

nd

be

rea

ve

me

nt

(to

th

e a

pp

rop

ria

te le

ve

l)

10

0%

1

9.5

% (

29

5)

b)

Inte

rpe

rso

na

l a

nd

co

mm

un

ica

tio

n s

kill

s

10

0%

2

8.2

% (

42

7)

c)

Th

e r

ole

s a

nd

se

rvic

es p

rovid

ed

by o

the

r m

em

be

rs o

f th

e m

ulti-d

iscip

lina

ry t

ea

m e

.g.

mo

rtu

ary

se

rvic

es,

ch

ap

lain

s

10

0%

1

1.0

% (

16

3)

d)

Mu

lti-cu

ltu

ral a

nd

re

ligio

us p

ractice

s

10

0%

4

.7%

(7

1)

e)

Eth

ica

l is

su

es r

ela

tin

g t

o e

nd

of

life

ca

re f

or

exa

mp

le a

dva

nce

dir

ective

s,

do

no

t re

su

scita

te

ord

ers

, p

atie

nt

au

ton

om

y v

ers

us r

ela

tive

s w

ish

es a

nd

with

ho

ldin

g/w

ith

dra

wa

l o

f tr

ea

tme

nt

10

0%

1

3.1

% (

19

2)

f)

Sp

iritu

al su

pp

ort

at

the

en

d o

f lif

e

10

0%

1

1.0

% (

15

7)

g)

De

live

rin

g b

ad

ne

ws t

o p

atie

nts

an

d t

he

ir r

ela

tive

s

10

0%

2

3.1

% (

31

8)

h)

Eq

ua

lity a

nd

hu

ma

n r

igh

ts

10

0%

1

4.6

% (

22

0)

i)

Oth

er

10

0%

1

2.7

% (

13

)


Bre

ak

do

wn

of

qu

es

tio

n 8

T

he

fo

llow

ing

ta

ble

is a

bre

akd

ow

n o

f tr

ain

ing

re

ce

ive

d,

tra

inin

g r

eq

uir

ed

/no

t re

qu

ire

d a

s in

dic

ate

d b

y r

esp

on

de

nts

(in

re

latio

n t

o a

dd

itio

na

l e

du

ca

tio

n/t

rain

ing

to

in

cre

ase

skill

s a

nd

co

nfid

en

ce

in

ca

rin

g f

or

the

dyin

g a

nd

th

eir r

ela

tive

s):

Ha

ve

re

ce

ive

d t

rain

ing

W

ou

ld b

e h

elp

ful

Wo

uld

no

t b

e h

elp

ful

a)

De

ath

, g

rie

f a

nd

be

rea

ve

me

nt

(to

th

e a

pp

rop

ria

te le

ve

l)

19

.5%

(2

95

) 7

0.1

% (

11

44

) 2

.9%

(4

4)

b)

Inte

rpe

rso

na

l a

nd

co

mm

un

ica

tio

n s

kill

s

28

.2%

(4

27

) 6

0.9

% (

92

3)

7.1

% (

10

7)

c)

Th

e r

ole

s a

nd

se

rvic

es p

rovid

ed

by o

the

r m

em

be

rs o

f th

e m

ulti-d

iscip

lina

ry

tea

m e

.g.

mo

rtu

ary

se

rvic

es,

ch

ap

lain

s

11

.0%

(1

63

) 7

7.4

% (

11

45

) 7

.0%

(1

04

)

d)

Mu

lti-cu

ltu

ral a

nd

re

ligio

us p

ractice

s

4.7

% (

71

) 8

7.2

% (

13

16

) 3

.9%

(5

9)

e)

Eth

ica

l is

su

es r

ela

tin

g t

o e

nd

of

life

ca

re f

or

exa

mp

le a

dva

nce

dir

ective

s,

do

no

t re

su

scita

te o

rde

rs,

pa

tie

nt

au

ton

om

y v

ers

us r

ela

tive

s w

ish

es a

nd

w

ith

ho

ldin

g/w

ith

dra

wa

l o

f tr

ea

tme

nt

13

.1%

(1

92

) 7

9.8

% (

11

67

) 3

.1%

(4

5)

f)

Sp

iritu

al su

pp

ort

at

the

en

d o

f lif

e

11

.0%

(1

57

) 7

5.0

% (

10

75

) 7

.4%

(1

06

)

g)

De

live

rin

g b

ad

ne

ws t

o p

atie

nts

an

d t

he

ir r

ela

tive

s

23

.1%

(3

18

) 6

9.4

% (

95

4)

4.1

% (

57

)

h)

Eq

ua

lity a

nd

hu

ma

n r

igh

ts

14

.6%

(2

20

) 7

2.7

% (

10

96

) 6

.8%

(1

03

)

i)

Oth

er

12

.7%

(1

3)

44

.1%

(4

5)

3.9

% (

4)

Au

dit

Cri

teri

a

Ex

pe

cte

d P

erc

en

tag

e

Ac

tua

l P

erc

en

tag

e A

ch

iev

ed

9.

Th

e f

oll

ow

ing

as

pe

cts

of

su

pp

ort

wh

en

pa

rtic

ipa

tin

g i

n t

he

ca

re o

f d

yin

g p

ati

en

ts a

nd

th

eir

fa

mil

ies

are

c

urr

en

tly

in

pla

ce

g)

Info

rma

l su

pp

ort

fro

m y

ou

r p

ee

rs

10

0%

6

7.6

% (

10

64

)

h)

Co

nfid

en

tia

l o

ne

to

on

e s

up

po

rt f

rom

ma

na

ge

r/d

esig

na

ted

co

llea

gu

e/m

en

tor

to t

alk

thro

ug

h t

he

exp

eri

en

ce

10

0%

3

8.1

% (

58

8)

i)

Clin

ica

l S

up

erv

isio

n

10

0%

4

1.6

% (

64

5)

j)

Ca

se

re

vie

w/c

ritica

l in

cid

en

t a

na

lysis

1

00

%

26

.5%

(4

03

)

k)

De

dic

ate

d “

de-b

rie

fin

g”

tim

e w

ith

yo

ur

pe

ers

fo

llow

ing

pa

rtic

ula

rly t

rau

ma

tic s

itu

atio

ns (

as d

ete

rmin

ed

by t

he

sta

ff)

10

0%

2

1.2

% (

33

1)

l)

De

dic

ate

d “

de-b

rie

fin

g”

tim

e w

ith

th

e m

ulti-p

rofe

ssio

na

l te

am

fo

llow

ing

pa

rtic

ula

rly t

rau

ma

tic s

itu

atio

ns (

as

de

term

ine

d b

y t

he

sta

ff)

10

0%

1

4.0

% (

22

0)

m)

Co

nfid

en

tia

l o

ne

to

on

e s

up

po

rt f

rom

me

mb

er

of

sta

ff e

xte

rna

l to

th

e w

ard

/de

pa

rtm

en

t to

ta

lk t

hro

ug

h t

he

e

xp

eri

en

ce

1

00

%

17

.2%

(2

68

)

n)

Acce

ss t

o e

xte

rna

l su

pp

ort

or

co

un

se

llin

g s

erv

ice

s

10

0%

2

4.7

% (

38

6)

56

Bre

ak

do

wn

of

Qu

es

tio

n 9

Th

e t

ab

le b

elo

w is a

bre

akd

ow

n o

f th

at

wh

ich

is c

urr

en

tly in

pla

ce

or

wo

uld

be

he

lpfu

l, w

he

n p

art

icip

atin

g in

th

e c

are

of

dyin

g p

atie

nts

an

d t

he

ir r

ela

tive

s a

s in

dic

ate

d b

y r

esp

on

de

nts

:

Au

dit

Cri

teri

a

Cu

rre

ntl

y i

n p

lac

e

Wo

uld

be

he

lpfu

l D

on

’t k

no

w

a)

Info

rma

l su

pp

ort

fro

m y

ou

r p

ee

rs

67

.6%

(1

06

4)

26

.7%

(4

21

) 5

.7%

(9

0)

b)

Co

nfid

en

tia

l o

ne

to

on

e s

up

po

rt f

rom

ma

na

ge

r/d

esig

na

ted

co

llea

gu

e/m

en

tor

to t

alk

th

rou

gh

th

e e

xp

eri

en

ce

38

.1%

(5

88

) 4

6.0

% (

71

0)

16

.0%

(2

47

)

c)

Clin

ica

l S

up

erv

isio

n

41

.6%

(6

45

) 3

4.3

% (

53

2)

2

4.1

% (

37

4)

d)

Ca

se

re

vie

w/c

ritica

l in

cid

en

t a

na

lysis

2

6.5

% (

40

3)

50

.1%

(7

61

) 2

3.4

% (

35

6)

e)

De

dic

ate

d “

de-b

rie

fin

g”

tim

e w

ith

yo

ur

pe

ers

fo

llow

ing

pa

rtic

ula

rly t

rau

ma

tic

situ

atio

ns (

as d

ete

rmin

ed

by t

he

sta

ff)

21

.2%

(3

31

) 6

5.6

% (

10

25

) 1

3.2

% (

20

6)

f)

De

dic

ate

d “

de-b

rie

fin

g”

tim

e w

ith

th

e m

ulti-p

rofe

ssio

na

l te

am

fo

llow

ing

p

art

icu

larl

y t

rau

ma

tic s

itu

atio

ns (

as d

ete

rmin

ed

by t

he

sta

ff)

14

.0%

(2

20

) 6

7.7

% (

10

65

) 1

8.3

% (

28

7)

g)

Co

nfid

en

tia

l o

ne

to

on

e s

up

po

rt f

rom

me

mb

er

of

sta

ff e

xte

rna

l to

th

e

wa

rd/d

ep

art

me

nt

to t

alk

th

rou

gh

th

e e

xp

eri

en

ce

1

7.2

% (

26

8)

50

.7%

(7

90

) 3

2.1

% (

50

1)

h)

Acce

ss t

o e

xte

rna

l su

pp

ort

or

co

un

se

llin

g s

erv

ice

s

24

.7%

(38

6)

50

.8%

(7

92

) 2

4.5

% (

38

2)


8.

Sta

nd

ard

s D

ocu

men

ts

57

No

.

Do

cu

me

nt

1

De

pa

rtm

en

t o

f H

ea

lth

(2

00

5)

Wh

en

a P

atie

nt

Die

s;

Ad

vic

e o

n D

eve

lop

ing

Be

rea

ve

me

nt

Se

rvic

es in

th

e N

HS

. D

OH

2

De

pa

rtm

en

t o

f H

ea

lth

(2

00

3)

NH

S C

ha

pla

incy:

Me

etin

g t

he

Re

ligio

us a

nd

Sp

iritu

al N

ee

ds o

f P

atie

nts

an

d S

taff

. D

OH

3

De

pa

rtm

en

t o

f H

ea

lth

(2

00

3).

So

cia

l S

erv

ice

s a

nd

Pu

blic

Sa

fety

Ra

cia

l E

qu

alit

y in

He

alth

an

d S

ocia

l C

are

Go

od

Pra

ctice

Gu

ide

. D

OH

4

De

pa

rtm

en

t o

f H

ea

lth

, S

ocia

l S

erv

ice

s a

nd

Pu

blic

Sa

fety

(2

00

3)

Re

fere

nce

Gu

ide

to

Co

nse

ntin

g f

or

Exam

ina

tio

n,

Tre

atm

en

t o

r C

are

. D

HS

SP

SN

I

5

De

pa

rtm

en

t o

f H

ea

lth

(2

00

1)

Th

e R

em

ova

l R

ete

ntio

n a

nd

Use

of

Hu

ma

n O

rga

ns a

nd

Tis

su

e f

rom

Po

st

Mo

rte

m E

xa

min

atio

ns.

Ad

vic

e f

rom

th

e C

hie

f M

ed

ica

l O

ffic

er

D.O

.H.

6

De

pa

rtm

en

t o

f H

ea

lth

, S

ocia

l S

erv

ice

s a

nd

Pu

blic

Sa

fety

(2

00

3)

Bre

akin

g B

ad

Ne

ws G

uid

elin

es.

DH

SS

PS

NI

7

He

alth

an

d P

ers

on

al S

ocia

l S

erv

ice

s (

NI)

Ord

er

19

91

(A

rtic

le 2

5)

an

d W

elfa

re S

erv

ice

s A

ct

(NI)

19

71

(S

ectio

n 2

5).

B

uri

al o

r C

rem

atio

n o

f th

e D

ea

d.

Th

e C

hild

ren

(N

ort

he

rn I

rela

nd

) O

rde

r 1

99

5,

Art

icle

34

. C

hild

ren

Lo

oke

d A

fte

r b

y a

n A

uth

ori

ty.

8

Na

tio

na

l In

stitu

te f

or

Clin

ica

l E

xce

llen

ce

(2

00

4)

Imp

rovin

g S

up

po

rtiv

e a

nd

Pa

llia

tive

Ca

re f

or

Ad

ults w

ith

Ca

nce

r. N

ICE

9

De

pa

rtm

en

t o

f H

ea

lth

, S

ocia

l S

erv

ice

s a

nd

Pu

blic

Sa

fety

(2

00

5)

Ca

re p

lan

fo

r W

om

en

Who

Exp

eri

en

ce

a M

isca

rria

ge

, S

tillb

irth

or

Ne

on

ata

l D

ea

th.

DH

SS

PS

NI

10

R

esu

scita

tio

n G

uid

elin

es 2

00

5. R

esu

scita

tio

n C

ou

ncil

(UK

), L

on

do

n

11

D

ep

art

me

nt

of

He

alth

, S

ocia

l S

erv

ice

s a

nd

Pu

blic

Sa

fety

(2

00

5)

Po

st

Mo

rte

m E

xa

min

atio

ns -

A C

od

e o

f G

oo

d P

ractice

: R

igh

ts o

f P

atie

nts

an

d R

ela

tive

s:

Re

sp

on

sib

ilitie

s o

f P

rofe

ssio

na

ls.

DH

SS

PS

NI

12

D

ep

art

me

nt

of

He

alth

(2

00

6)

Ca

re a

nd

Re

sp

ect

in D

ea

th:

Go

od

Pra

ctice

Gu

ida

nce

fo

r N

HS

Mo

rtu

ary

Sta

ff.

DO

H

13

C

oro

ne

rs A

ct

(19

59

) N

ort

he

rn I

rela

nd

Se

ctio

n 7

Th

e C

oro

ne

rs S

erv

ice

No

rth

ern

Ire

lan

d:

Info

rma

tio

n le

afle

ts (

20

06

)

1)

Co

ron

ers

Se

rvic

e

2)

Co

ron

ers

In

qu

est

3)

Co

ron

ers

po

st

mo

rte

m E

xa

min

atio

n:

Info

rma

tio

n f

or

Re

lative

s

4)

Th

e C

oro

ne

rs L

iais

on

Off

ice

r

14

D

ep

art

me

nt

of

He

alth

, S

ocia

l S

erv

ice

s a

nd

Pu

blic

Sa

fety

, P

olic

e S

erv

ice

(N

I), C

ou

rt S

erv

ice

NI,

He

alth

an

d S

afe

ty E

xe

cu

tive

(N

I) (

20

06

) M

em

ora

nd

um

of

Un

de

rsta

nd

ing

: In

ve

stig

atin

g

Pa

tie

nt

or

Clie

nt

Sa

fety

In

cid

en

ts (

Un

exp

ecte

d D

ea

th o

r S

eri

ou

s U

nto

wa

rd H

arm

) (D

HS

SP

SN

I)

15

D

ep

art

me

nt

of

He

alth

, S

ocia

l se

rvic

es a

nd

Pu

blic

Sa

fety

(2

00

6)

Th

e Q

ua

lity S

tan

da

rds f

or

He

alth

an

d S

ocia

l C

are

. D

HS

SP

SN

I

16

D

ep

art

me

nt

of

He

alth

, S

ocia

l S

erv

ice

s a

nd

Pu

blic

Sa

fety

(2

00

0)

Pa

rtn

ers

hip

s in

Ca

rin

g:

Sta

nd

ard

s f

or

Se

rvic

e.

A R

evie

w o

f P

alli

ative

Ca

re.

DH

SS

SN

I

17

L

ive

rpo

ol C

are

Pa

thw

ay –

Go

al 1

8 B

ere

avem

en

t L

ea

fle

t, D

ata

Dic

tio

na

ry 2

00

6 –

Ma

rie

Cu

rie

Pa

llia

tive

Ca

re I

nstitu

te,

Liv

erp

oo

l

18

H

ea

lth

an

d S

afe

ty A

t W

ork

Act

19

74

19

D

ep

art

me

nt

of

He

alth

an

d S

ocia

l S

erv

ice

s a

nd

Pu

blic

Sa

fety

(2

00

5)

Ca

re p

lan

s,

Co

nse

nt

Fo

rms a

nd

In

form

atio

n f

or

Re

lative

s f

or

a H

osp

ita

l P

ost

Mo

rte

m E

xa

min

atio

n o

f

I.

A b

ab

y

II.

A

ch

ild

II.

An

ad

ult

IV

. H

isto

pa

tho

log

ica

l e

xa

min

atio

n a

nd

dis

po

sa

l o

f e

arl

y m

isca

rria

ge

s (

DH

SS

PS

NI)

20

N

HS

Esta

tes 2

00

5:

A p

lace

to

die

with

dig

nity:

Cre

atin

g a

Su

pp

ort

ive

En

vir

on

me

nt.

DO

H

21

R

oya

l M

ars

de

n H

osp

ita

l M

an

ua

l o

f C

linic

al N

urs

ing

Pro

ce

du

res (

20

04

) 6

tth

ed

. L

ast

Off

ice

s P

roce

du

re.

Bla

ckw

ell

Pu

blis

hin

g L

td.

Oxfo

rd

22

B

irth

s a

nd

De

ath

s R

eg

istr

atio

n (

No

rth

ern

Ire

lan

d)

Ord

er

19

76

23

D

ep

art

me

nt

of

He

alth

, S

ocia

l S

erv

ice

s a

nd

Pu

blic

Sa

fety

(2

00

4)

Cir

cu

lar

HS

S (

TC

7)

8/2

00

4 C

od

e O

f C

on

du

ct

Fo

r N

HS

He

alth

ca

re C

ha

pla

ins

24

H

um

an

Tis

su

e A

uth

ori

ty (

20

06

) C

od

e o

f P

ractice

3:

Po

st

Mo

rte

m E

xa

min

atio

n.

HT

A

Births and Deaths Registration (Northern Ireland) Order. 1976. http://www.opsi.gov.uk/RevisedStatutes/Acts/nisi/1976/cnisi_19761041_en_3

Coroners Act (1959) Northern Ireland Section 7. http://www.opsi.gov.uk/RevisedStatutes/Acts/apni/1959/capni_19590015_en_1

Coroners Service Northern Ireland (2006) Information leaflets

1) Coroners Inquest2) Coroners Post Mortem Examination: Information for Relatives3) Coroners Service4) The Coroners Liaison Officer http://www.coronersni.gov.uk/publications.htm

Department of Health (2000) NHS Executive Resuscitation Policy. HSC 2000/028. DOH. http://www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/Healthservicecirculars/DH_4004244

Department of Health (2001) The Removal Retention and Use of Human Organs and Tissue from Post Mortem Examinations. Advice from the Chief Medical Officer D.O.H. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4064942

Department of Health (2003) NHS Chaplaincy: Meeting the Religious and Spiritual Needs of Patients and Staff. DOH. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4073108

Department of Health (2005) When a Patient Dies; Advice on Developing Bereavement Services in the NHS. DOH. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4122191

Department of Health (2006) Care and Respect in Death: Good Practice Guidance for NHS Mortuary Staff. DOH. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4137969

Department of Health and Social Services and Public Safety (2005) Care plans, Consent Forms and Information for Relatives for a Hospital Post Mortem Examination. DHSSPSNI. http://www.dhsspsni.gov.uk/index/hss/hoi-home/hoi-postmortem.htm

Department of Health Social Services and Public Safety (2003). Racial Equality in Health and Social Care: Good Practice Guide. DHSSPSNI. http://www.dhsspsni.gov.uk/raceeqhealth_contents.pdf

Department of Health, Social Services and Public Safety (2000) Partnerships in Caring: Standards for Service. A Review of Palliative Care. DHSSSNI. http://www.dhsspsni.gov.uk/pallcare.pdf

References

58


Department of Health, Social Services and Public Safety (2003) Breaking Bad News Guidelines. DHSSPSNI. http://www.dhsspsni.gov.uk/breaking_bad_news.pdf

Department of Health, Social Services and Public Safety (2003) Reference Guide to Consenting for Examination, Treatment or Care. DHSSPSNI. http://www.dhsspsni.gov.uk/consent_referenceguide.pdf

Department of Health, Social Services and Public Safety (2004) Circular HSS (TC7) 8/2004 Code of Conduct for NHS Healthcare Chaplains. DHSSPSNI.

Department of Health, Social Services and Public Safety (2005) Care plan for Women Who Experience a Miscarriage, Stillbirth or Neonatal Death. DHSSPSNI. http://www/dhsspsni.gov.uk/hoi-careplan.pdf

Department of Health, Social Services and Public Safety (2005) Post Mortem Examinations - A Code of Good Practice: Rights of Patients and Relatives: Responsibilities of Professionals. DHSSPSNI. http://www.dhsspsni.gov.uk/postmotrem.pdf

Department of Health, Social Services and Public Safety (2006) The Quality Standards for Health and Social Care. DHSSPSNI. http://www.dhsspsni.gov.uk/qpi_quality_standards_for_health_social_care.pdf

Department of Health, Social Services and Public Safety, Police Service NI, Court Service NI, Health and Safety Executive NI (2006) Memorandum of Understanding: Investigating Patient or Client Safety Incidents (Unexpected Death or Serious Untoward Harm). DHSSPSNI. http://www.dhsspsni.gov.uk/mou_investigating_patient_or_client_safety_incidents.pdf

Department of Health, Social Services and Public Safety. (2002). Human Organs Inquiry: Report from Inquiry Chair; John O’Hara QC. DHSSPSNI. http://www.dhsspsni.gov.uk/hoi-mainreport.pdf

Health and Personal Social Services (NI) Order 1991 (Article 25) Provision of Accommodation. http://www.opsi.gov.uk/si/si1991/Uksi_19910194_en_9.htm#mdiv25

Health and Safety At Work Act 1974.http://www.opsi.gov.uk/RevisedStatutes/Acts/ukpga/1974/cukpga_19740037_en_1

Human Tissue Act (2004) http://www.opsi.gov.uk/acts/acts2004/ukpga_20040030_en_1

Human Tissue Authority (2006) Code of Practice 3: Post Mortem Examination. HTA. http://www.hta.gov.uk/guidance/codes_of_practice.cfm

Liverpool Care Pathway – Goal 18 Bereavement Leaflet, Data Dictionary 2006 – Marie Curie Palliative Care Institute, Liverpool. http://www.mcpcil.org.uk/liverpool_care_pathway/view_the_lcp_and_associated_documentation/goal_definitions

59

National Institute for Clinical Excellence (2006) Clinical Guideline 43: Obesity; guidance on prevention, identification, assessment and management of overweight and obesity in adults and children. NICE. http://www.nice.org.uk/nicemedia/pdf/word/CG43NICEGuideline.doc

National Institute for Clinical Excellence (2004) Improving Supportive and Palliative Care for Adults with Cancer. NICE. http://www.nice.org.uk/nicemedia/pdf/csgspmanual.pdf

NHS Estates 2005: Improving the Patient Experience series; A place to die with dignity: Creating a Supportive Environment. Design Brief Working Group. http://195.92.246.148/nhsestates/knowledge/knowledge_content/home/home.asp

Northern Ireland Statistics and Research Agency (2006) Registrar General Northern Ireland 2005 Annual Report. NISRA. http://www.nisra.gov.uk/archive/dempgraphy/publications/annual_reports/2005/chpt1.pdf

Resuscitation Guidelines (2005) Resuscitation Council (UK) http://resus.org.uk/pages/bls.pdf

Royal Marsden Hospital Manual of Clinical Nursing Procedures (2004) 6th ed. Last Offices Procedure. Blackwell Publishing Ltd. Oxford

The Children (Northern Ireland) Order 1995, Article 34. Children Looked After by an Authority. http://www.opsi.gov.uk/si/si1995/uksi_19950755_en_1

Welfare Services Act (NI) 1971 (Section 25). Burial or Cremation of the Dead. http://www.opsi.gov.uk/RevisedStatutes/Acts/apni/1971/capni_19710002_en_1

60


The Northern Ireland Health and Social Care Bereavement Network would like to acknowledge the work of the Audit Department South Eastern Health and Social Care Trust who provided the lead for this regional audit and in particular Debbie Schofield in her role as audit lead, whose patience direction and support has greatly enhanced the quality of this audit.

We would like to thank the members of the steering group at the Department of Health, Social Services and Public Safety NI, chaired by Mr Martin Bradley Chief Nursing Officer, who provided the network with invaluable support and direction.

We would also like to thank former members of the network who inspired us in the early stages of the project. Sharon McCloskey, Area Bereavement Coordinator, Southern Trust, Ruth Smith, Assistant Director Surgery, South Eastern Trust, John Mone, Director of Nursing And Quality, Craigavon Area Hospital Group Trust, Ann McVey, Assistant Director of Nursing, Craigavon Area Hospital Group Trust, Irene Duddy, Director of Nursing, Altnagelvin Hospital Trust and Alice McParland, Interim Deputy Director of Nursing, United Hospitals Trust.

This audit was undertaken at a time of great change within health and social care in Northern Ireland. The co-operation of staff at all levels throughout the legacy trusts during this time was greatly appreciated.

Finally the Network would like to acknowledge the leadership, inspiration and commitment of Dr Patricia Donnelly, Divisional Director Clinical Services, Belfast Trust, to this project.

Acknowledgements

61

Name Address Telephone Numbers

E-mail

Barbara BankheadPhyllis Tweed (secretary)

Northern HSC Trust

Bush HouseBush Road AntrimBT41 2QB

Work (028) 9442 4992Trust mobile: 07841 468 824Phyllis (028) 9442 4000 Ext 2191Fax No: (028) 9442 4675

[email protected]

Carole McKeemanCathy McCartney (secretary)

Western HSC Trust

Medical DirectorateRoom 2Centrepoint BuildingAltnagelvin Area HospitalGlenshane RoadDerryBT47 6SB

Work (028) 7134 5171 Ext 5545Work mobile 07841 970 715Cathy (028) 7134 5171 Ext 5548

[email protected]@westerntrust.hscni.net

Paul McCloskeyLucille Crossley (secretary)

South Eastern HSC Trust

Home 3The Ulster HospitalUpper Newtownards RoadDundonaldBelfast BT16 1RH

Work (028) 9048 4511 Ext 2398Work mobile 07841 103 955Lucille (028) 9048 4511 Ext 3674

[email protected]@setrust.hscni.net

Anne CoyleMarina Hamilton (secretary)

Southern HSC Trust

The RowansCraigavon Area Hospital68 Lurgan RoadPortadownBT63 5QQ

Work (028) 3861 3861Work mobile 07702 923 161Marina (028) 3861 3862

[email protected]@southerntrust.hscni.net

Heather RussellJulie McQuillan (secretary)

Belfast HSC Trust

Clinical Services Division1st Floor, Bostock HouseRoom 104Royal Victoria HospitalGrosvenor RoadBelfast BT12 6BA

Work (028) 9063 3904Work mobile 07920 186 935Julie (028) 9063 3193

[email protected]@belfasttrust.hscni.net

For further information regarding this Audit, please contact the relevant Bereavement Coordinator for your Trust.

NI Area Bereavement Coordinators Contact Details

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Northern Ireland Audit: Dying, Death and Bereavement€¦ · bereavement care standards and...

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Transcript of Northern Ireland Audit: Dying, Death and Bereavement€¦ · bereavement care standards and...