TRUST POLICY AND PROCEDURES RELATING TO THE DEATH OF AN ADULT PATIENT FINAL. Version Date Author Reason 1.1 Jan Pam Twine/ 2009 Richard Elliott

TRUST POLICY AND PROCEDURES RELATING TO THE DEATH OF AN ADULT PATIENT Reference Number: POL-CL/1935/09 Version / Amendment History Version: 1.13 Status: FINAL Version Date Author Reason 1.1 Jan Pam Twine/ 2009 Richard Elliott 1.2-1.4 Feb 2009 Pam Twine/ Richard Elliott Author: Lorna Priestman Job Title: Associate Director, Medical Director s Office Review and addition of Death Certification Guidelines and new Cremation Regulations and merging Confirmation of Death Policy Further amendments 1.5 April 2009 Pam Twine/ Richard Elliott Amended following Proc Doc. Group march 2009 1.7 June 2009 Pam Twine/ Richard Elliott Amended following feedback from Medical Referee and MAC 1.8 October 2009 Pam Twine/ Richard Elliott Amended following procedural information from H.M. Coroner 1.9 July 2010 Karen Hill/ Pam Twine Review and addition of Part 2-Care of the Deceased 1.10 April 2011 Pam Twine Merger of adult community services 1.11 May 2011 Pam Twine/ Richard Elliot Amended to include Advanced Practitioner Role 1.12 1.13 January 2016 May 2016 Intended Recipients: All Medical and Clinical staff Lorna Priestman Clare Sutherland Remove community section, Amend LCP to end of life care and DNAR to DNACPR. Clarify role of Doctors in Training in certification Review, clarification and amendments, general check Training and Dissemination: Training will be via Divisional medical staff training, Trust Induction for Doctors in Training and during training of ACPs. Policy and Procedures Relating to the Death of an Adult Hospital Inpatient V1.13 May 2016 Page 1 of 48

To be read in conjunction with: Policy and Procedures for the Care of the Cadaver CL-RM/2009/055 Policy and Procedures for the Handling Patients' property and Valuables CLOP/2010/009 Policy for Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) CL-LP/2008/008 In consultation with and Date: Mortality Committee, Medical Advisory Committee (MAC), Divisional Nursing Director (DND), Head of Midwifery (HOM), Joint Professionals advisory Group (JPAC), Quality Governance Facilitators, Infection Control Group, Mortuary Department, Bereavement Service, Legal Services, H.M. Coroner. EIRA stage One Completed: Yes 2009 Stage Two Completed: No Approving Body and Date Approved ME Date of Issue August 2016 Review Date and Frequency Contact for Review Executive Lead Signature Approving Executive Signature August 2018 (then every 3 years) Head of Governance Executive Medical Director Chief Nurse Section Contents Page 1. Introduction 5 1.1 PART ONE Confirmation of the Death of an Adult Patient 5 1.2 PART TWO Care of the Deceased 5 1.3 PART THREE Completion of the Medical Certificate of Cause Of Death 5 1.4 PART FOUR Notification of Death to H. M. Coroner 5 1.5 PART FIVE Completion of Cremation Forms 5 1.6 PART SIX Procedure for Obtaining Out of Hours Medical Certificates and Removal Of Bodies Out of England And Wales 5 2 Purpose and Outcomes 5 3 Definitions Used 6 4 Key Responsibilities/Duties 6 4.1 Medical Staff 6 4.2 Designated Nurse or Night Nurse Practitioner (NNP), Advanced Clinical 7 Practitioner (ACP) / Trainee ACP 4.3 Registered Nurses 7 4.4 Mortuary Staff 7 4.5 Mortality Committee 7 4.6 Incident Review Group (IRG) 7 4.7 Infection Control Committee 7 Policy and Procedures Relating to the Death of an Adult Hospital Inpatient V1.13 May 2016 Page 2 of 48

4.8 Executive Medical Director 8 4.9 Medical Referee-Crematoria 8 4.10 Consultant Medical Staff 8 4.11 Senior Nurse Accident and Emergency Department 8 4.12 The Bereavement Team 9 5 Implementing the Policy and Procedures Relating to the Death of an Adult Hospital Inpatient 9 PART ONE 9 5.1 The Process for Confirmation of Death 9 5.1.1 General Principles 9 5.1.2 Identification of the Patient 10 5.1.3 Observations to Confirm Death 10 5.1.4 Informing the Doctor 10 5.1.5 Nursing Staff Training 10 PART TWO 11 5.2 Care of the Deceased (Adults) 11 5.2.1 Introduction 11 5.2.2 Purpose and Outcomes 11 5.2.3 Confirmation of Death 11 5.2.4 Informing relatives/carers 11 5.2.5 Last Offices 11 5.2.6 Protection from Infection During Last Offices 12 5.2.7 Washing and Dressing the Deceased 12 5.2.8 Dentures 12 5.2.9 Intravascular Cannulae, Intravenous Infusions and Central Lines 12 5.2.10 Endotracheal Tubes and Catheters 12 5.2.11 Chest Drains, Surgical Drains and Epidural Lines 12 5.2.12 Identification of the Deceased Patient 13 5.2.13 Handling of the Deceased Patient's Property and Valuables 13 5.2.14 Viewing within the Clinical Area 13 5.2.15 Pre Transfer from the Clinical Area 14 5.2.16 Infected Patients/Risk of leakage of Body Fluids 14 5.2.17 Information and Support for Relatives/Carers 14 5.2.18 Transfer to the Mortuary 14 5.2.19 Viewing Arrangements in the Mortuary Department 15 PART THREE 15 5.3 Completion of the Medical Certificate of Cause of Death (MCCD) 15 5.3.1 Legal Responsibility 15 5.3.2 Reporting Death to the Coroner 16 5.3.3 Who Should Certify the Death? 16 5.3.4 Changes Regarding Death Certification 16 5.3.5 Completing the Medical Certificate of Cause of Death (MCCD) 16 5.3.6 Determining the Cause of Death 17 5.3.7 Deaths from Infection 18 5.3.8 Hospital Acquired Infections (HCAI) 18 5.3.9 Types of HCAI 18 Policy and Procedures Relating to the Death of an Adult Hospital Inpatient V1.13 May 2016 Page 3 of 48

5.3.10 Determining the Cause of Death where there is a HCAI 18 5.3.11 Examples 19 PART FOUR 19 5.4 Notification of Death to H. M. Coroner 19 5.4.1 Key Responsibilities 19 5.4.2 Criteria for Deaths that MUST be Reported to H. M. Coroner 20 5.4.3 Contacting the Coroner 21 5.4.4 Hospital Acquired Infections-Discussion with the Coroner 21 5.4.5 Medical Equipment 21 PART FIVE 21 5.5 Completion of Cremation Forms 21 5.5.1 Medical Referee-Crematoria 22 5.5.2 Cremation Forms-Principles 22 5.5.3 Cremation Form 4 Medical (Replaces Form B/Old Certificate Part 1) 23 5.5.4 Cremation Form 5 Confirmatory Medical Certificate (Form C/Old Part 2) 23 5.5.5 Right of Inspection 24 5.5.6 Deaths Involving Ethnic Minorities 24 PART SIX 24 5.6 Procedure for Obtaining Out of Hours Medical Certificates and Removal of 24 Bodies Out of England and Wales 5.6.1 Introduction 24 5.6.2 Procedure for Out of Hours Medical Certificate 25 5.6.3 Procedure when a Death has Occurred and Urgent Permission is Required to Take a Body out of England and Wales (Out of England Certificate) 26 6 Monitoring Compliance and Effectiveness 27 6.1 Notification of Death H. M. Coroner and Completion of Relevant Information 27 7 References 27 Appendices Appendix 1 Confirmation of Death Form 29 Appendix 2 Notice of Death Form 30 Appendix 3 Report of Death Form c 31 Appendix 4 Report of Death to the Coroner Form 32 Appendix 5 Completing a Medical Certificate of Cause of Death Flowchart 35 Appendix 6 Reporting a Death to the Coroner - Flowchart 36 Appendix 7 Cremation Form 4 Medical Certificate 37 Appendix 8 Cremation Form 5 Confirmatory Medical Certificate 43 Appendix 9 Body Donation Following Death 47 Appendix 10 Hyperlink - Ministry of Justice (2012) Medical practitioners: guidance on completing cremation forms. 48 Policy and Procedures Relating to the Death of an Adult Hospital Inpatient V1.13 May 2016 Page 4 of 48

TRUST POLICY AND PROCEDURES RELATING TO THE DEATH OF AN ADULT HOSPITAL INPATIENT 1. Introduction This policy provides a framework for the procedures relating to the death of an adult inpatient within the Trust. The policy includes: 1.1. PART ONE Confirmation of the Death of an Adult Patient Provides a framework to ensure that medical and designated nursing staff work collaboratively to ensure the safe and skilled Confirmation of expected deaths. 1.2. PART TWO Care of the Deceased Patient Provides best practice principles for staff undertaking care of the deceased / last offices. 1.3. PART THREE Completion of a Medical Certificate of Cause of Death (MCCD) Provides guidance for doctors on the completion of a Medical Certificate of Cause of Death (MCCD). 1.4. PART FOUR Notification of Death to H.M.Coroner Provides the criteria for deaths that must be reported to H.M.Coroner and the documentation which must be completed by the reporting doctor prior to contacting the Coroner s Office. 1.5. PART FIVE Completion of Cremation Explains the new Cremation Regulations which were introduced from January 1st 2009 as part of national changed following the Shipman Enquiry. 1.6 PART SIX Procedure for Obtaining Out of Hours Medical Certificates and Removal of Bodies out of England and Wales Explains the procedures relating to out of hours medical certificates and includes relevant contact details for persons from the Muslim community who are prepared to assist staff and families. 2. Purpose and Outcomes This policy will: Clearly identify the responsibilities of medical staff where ward nurses, ACPs and NNPs verify death. Outline the process and procedures for caring for the deceased patient. Ensure that the Trust fulfils all the necessary legal requirements and formal procedures for dealing with deceased patients. Ensure that all relevant documentation is completed. This includes information for use in Cremation forms. Raise awareness amongst medical staff of the criteria for reporting death within the hospital to H.M. Coroner. Ensure that the Trust meets the legal requirements regarding notification of deaths to H.M. Coroner. Policy and Procedures Relating to the Death of an Adult Hospital Inpatient V1.13 May 2016 Page 5 of 48

3. Definitions Used Confirmation of Death: Certification of Death: MCCD: Designated Nurse/ Night Nurse Practitioner (NNP): Advanced Clinical Practitioner (ACP) / Trainee (ACP): Expected Death: Unexpected Death: Last Offices: Viewing: To Confirm Date To Legally Declare Death Medical Certificate of Cause of Death A registered nurse or Night Nurse Practitioner (NNP) with a minimum of 2 years post registration experience who has successfully completed the Framework for Principles of Practice in Confirmation of Expected Death ACP definition as per Derby Teaching Hospitals Professional Accountability & Assurance Framework for Advanced Clinical Practice. ACPs must be competent in advanced clinical examination competencies and have attended local delivery of Confirmation of Death training. The term ACP and trainee ACP is interchangeable with trainee ACP for the purpose of this policy A death following a period of illness that has been defined as terminal and where no active intervention to prolong life is ongoing. The patient must have a valid, completed Decisions Relating to Resuscitation form. A patient who in the event of a cardio-respiratory arrest will have been actively resuscitated. The care given to a deceased patient which demonstrates respect for the dead and is focused on fulfilling religious and cultural beliefs as well as health and safety and legal requirements. Opportunities made available to a relative / carers to see and touch the body of the deceased person. Maternal Death: The death of a woman whilst pregnant or within one year delivery. This includes termination of pregnancy. of Medical Crematoria: Referee- The Medical Referee is appointed by the Ministry of Justice and has the statutory duty to scrutinise all cremation forms prior to the authorisation of a cremation (Cremation Regulations 2008). 4. Key Responsibilities/Duties 4.1 Medical Staff Medical staff are responsible for ensuring that a valid Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR) form is completed and that reviews of resuscitation status are carried out on agreed dates unless an indefinite decision has been made for that admission (see DNA CPR policy) Policy and Procedures Relating to the Death of an Adult Hospital Inpatient V1.13 May 2016 Page 6 of 48

Following Confirmation of Death by a practitioner who is not registered with the GMC, medical staff will be responsible for the completion of the Death Certificate (MCCD) and cremation forms where relevant. The Report of a Death form (Appendix 3) must also be completed and filed in the Health record as this contains essential information for the completion of cremation forms. IT IS THE DOCTOR S LEGAL RESPONSIBILITY TO ISSUE THE DEATH CERTIFICATE. HE/SHE MUST ENSURE THAT THE IDENTITY OF THE PATIENT IS CORRECT ON THE MCCD. 4.2 Designated Nurse, and Night Nurse Practitioner (NNP), ACP Other than a registered and licensed doctor the only practitioners within Derby Teaching Hospitals who may verify death are: designated nurses, ACPs or NNP s who have undertaken relevant training and assessment may verify death. Designated nurses and NNPs may verify an expected death only when a valid Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR) Form has been completed. ACPs may verify expected and unexpected death. Following the Confirmation of Death the designated nurse, NNP or ACP/trainee ACP is responsible for completing the Report of Death form (Appendix 3) which contains essential information for the completion of cremation forms. This must be filed in the patient s Health Record. 4.3 Registered Nurses Registered nurses have a responsibility to be aware of the resuscitation status of all patients in their care Registered nurses also have a responsibility for ensuring that the process of care for the deceased patient is carried out according to this policy and where relevant supporting other members of the ward team to achieve this. 4.4 Mortuary Staff Mortuary staff are responsible for ensuring that the relevant identification of the deceased patient is complete and for liaising with wards, departments, carers and relatives about visiting arrangements and other relevant issues in line with this policy. 4.5 Mortality Committee The purpose of the Mortality Committee is to review all deaths that occur within the Trust. The Committee will liaise with the Coroner to ensure that the Policy and Procedures for Reporting Deaths are agreed, implemented and monitored. 4.6 Incident Review Group (IRG) The Group will review all reports from the Coroner and ensure that any action required in response is implemented at Divisional / Business Unit level and that the actions are implemented within agreed timescales and monitored. 4.7 Infection Control Committee This Committee will advise and monitor issues relating to the care of deceased patients who die of an infection or who have an infection when they die. Policy and Procedures Relating to the Death of an Adult Hospital Inpatient V1.13 May 2016 Page 7 of 48

4.8 Executive Medical Director The Executive Medical Director is responsible for ensuring that all medical staff and clinicians adhere to this Policy in order to fulfil legislative requirements and comply with the process for reporting relevant deaths to the Coroner. 4.9 Medical Referee-Crematoria The Medical Referee is appointed by the Ministry of Justice and must have been a registered Medical Practitioner for at least 5 years. He/she has the statutory duty to scrutinise all cremation forms prior to the authorisation of a cremation (Ministry of Justice 2009). 4.10 Consultant Medical Staff Consultant Medical Staff have the overall responsibility for ensuring that referrals to the Coroner are made appropriately by members of their team. They must take a lead role to ensure that their teams raise all relevant issues with the Coroner who will then advise appropriately. The relevant Consultant must be informed by the reporting doctor or ACP of every death that is reported to the Coroner within a reasonable timeframe. 4.11 Senior Nurse Emergency Department In the Emergency Department most deaths are sudden and unexpected therefore almost all deaths are reported to H. M. Coroner. Sudden Unexpected Death In the case of sudden unexpected death the Senior Nurse in charge of the Emergency Department must inform the Coroner's Office using the standard Trust form for reporting to the Coroner (see Appendices 2 and 3). It is no longer acceptable to fax information to the coroner, instead complete the death of an adult form (appendix 2 & 3) and email to: Derby.coroner@derbyshire.gcsx.gov.uk and a follow up telephone call made during the next office hours to allow discussion of any queries. The Coroner s Office will then decide whether to accept the case or may give permission for the doctor to sign the Death Certificate (MCCD). Discussions with the Coroner In some extreme cases the senior doctor (middle grade or above) may wish to ask the Coroner for permission to sign the Death Certificate. In this case the doctor must speak directly to the Coroner. The Coroner's Office will then decide whether to accept the case or may give permission for the doctor to sign the death certificate. GPs Signing Death Certificates If the GP has not seen the patient within the 14 days preceding death and has not seen the body after death, the registrar is obliged to refer the death to the coroner before it can be registered (Office for National Statistics, 2010). The nurse in charge of the Emergency Department must ring the GP at the next available opportunity and ask the GP if he is prepared to sign the death certificate. If the GP is not prepared to sign the death certificate then the Coroner's Office must be notified. Policy and Procedures Relating to the Death of an Adult Hospital Inpatient V1.13 May 2016 Page 8 of 48

4.12 The Bereavement Team The Bereavement Team have delegated authority to refuse to accept the wording on a MCCD or Cremation form issued by a trainee doctor if it is not in line with this Policy. They will also ensure that a Report of Death form has been completed (appendix 2&3) PART ONE 5. Implementing the Policy and Procedures Relating to the Death an Adult Hospital Inpatient 5.1 The Process for Confirmation of Death This process will ensure that: The Trust fulfils all the legal requirements and formal procedures necessary when dealing with deceased patients whose death may be verified by a nurse. The requirements of the Coroner are met. Clear identification of the responsibilities of clinical staff where it is not a doctor who verifies death 5.1.1 General Principles Medical staff or appropriately trained ACPs are responsible for completion of the Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR) form for those patients with whom a discussion has taken place or where a medical decision has been made not to resuscitate. This decision should be ratified by the responsible consultant at the earliest opportunity. Only a registered and licensed doctor can legally certify death. The GMC state verbally that: this includes Foundation 1 doctors as long as it is agreed as part of their duties within the area they work and they are supervised / competent Designated nurses / NNP s and ACPs who have undertaken relevant training and assessment can verify death. NNPs and designated nurses however may only verify expected deaths i.e those patients in whom a valid DNACPR form is present. Where the nurse has any concerns, or where there are untoward circumstances, the death must be verified by a doctor. Medical staff and appropriately qualified ACPs are also responsible for ensuring that reviews of resuscitation status are carried out and documented on the agreed dates and times unless an indefinite decision has been made for that admission. See Trust DNACPR Policy. Following a death verified by a non-medical practitioner a doctor must certify the death as soon as is practicable and will view the patient in the Mortuary before completion of the health record and the Death Certificate (MMCD) and cremation forms where relevant. The time and date of the Confirmation of Death must be recorded on the Death Certificate. Where there is no NNP, designated nurse or ACP on duty, the time and date of death will be recorded as when the doctor views and certifies the body. The doctor is also responsible for speaking to the patient s relatives at an agreed time where relevant. Policy and Procedures Relating to the Death of an Adult Hospital Inpatient V1.13 May 2016 Page 9 of 48

The doctor must also complete the Report of Death form (Appendix 3) which will contain essential information for completion of cremation forms. This must be filed in the patient s Health Record. IT IS THE DOCTOR S LEGAL RESPONSIBILITY TO ISSUE THE DEATH CERTIFICATE AND HE/SHE MUST ENSURE THAT THE IDENTITY OF THE PATIENT IS CORRECT ON THE MCCD. THIS RESPONSIBILITY CANNOT BE DELEGATED TO ANYONE ELSE. Following the Confirmation of Death the designated nurse, ACP or NNP is responsible for completion of the Report of Death form which contains essential information for the completion of Cremation forms. This must be filed in the patient's Health Record. The nurse / NNP may not verify death in the following circumstances: There is no valid Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR) form. Any paediatric death including Sudden Death Syndrome Any unexpected death Any maternal death (counted as 1 year post delivery) Any patient whose death may be reportable to the Coroner 5.1.2 Identification of the Patient The patient must be clearly identified and their name, age, date of birth and hospital number must be checked with the health record and patient identity bracelet. 5.1.3 Observations to Confirm Death Death will be verified using agreed criteria. Details of observations undertaken to confirm death, plus the date and time of the confirmation of death must be entered into the patient s health record by the practitioner verifying death. Practitioners confirming death are also responsible for completing the Confirmation of Death Form (Appendix 1). In order to verify death the practitioner must check for at least one minute: Absence of carotid pulse Absence of heart sounds Absence of signs of spontaneous respiration Absence of reaction to painful stimuli Fixed dilated pupils which do not react to light determined by shining torchlight into both eyes and observing for any change in shape or size. 5.1.4 Informing the Doctor Where a designated nurse or NNP has verified a death an appropriate doctor or ACP on duty must be informed of the patient s death as soon as possible. The patient s consultant should also be made aware at the earliest opportunity by the doctor / ACP/trainee ACP who has been informed. 5.1.5 Non-medical Staff Training In order for designated nurses, NNPs and ACPs to verify expected adult death a recognised training programme must be undertaken and the practitioner assessed as competent in line with Trust policy. ACPs may continue with medical model of assessment utilised throughout their training. Nurses / NNPs should refer to Verification of Death Scope of Professional Practice. The need to have a certain standard of expertise is common to all health professionals and is important to protect the public and to ensure quality care. Policy and Procedures Relating to the Death of an Adult Hospital Inpatient V1.13 May 2016 Page 10 of 48

PART TWO The Trust has developed its own training programme relating to confirmation of death however if any member of staff has evidence of a previous course from outside the Trust, evidence should be reviewed by the practitioners line manager and the practitioner made aware of both this and DNACPR policies. Staff should be identified by their managers as in a role where there is both necessity to support the patients pathway and are suitably experienced. 5.2 Care of the Deceased Patient (Adults) 5.2.1 Introduction The care of a patient and family/carers following death is one of the most significant and sensitive aspects of care. A consistent approach to help and support employees involved in the care of the deceased patient s last offices is essential to ensure a compassionate, respectful and dignified process which reflects best practice principles, and ensures that relatives/carers receive appropriate and timely information and support following their bereavement. 5.2.2 Purpose and Outcomes To provide best practice principles for staff undertaking care of the deceased / last offices. To ensure that staff provide relevant and timely information following bereavement. To empower staff to feel confident when applying this process. 5.2.3 Confirmation of Death A deceased patient s unexpected death must be confirmed by a doctor or ACP or in the case of an expected death; a designated nurse, Night Nurse Practitioner (NNP) who is appropriately qualified may also confirm death The Confirmation of Death Form must be accurately completed (Appendix 1). 5.2.4 Informing Relative/Carer The relative / carer of the deceased patient should be notified as soon as possible after confirmation of death if they are not present at the time of death. This notification should be performed by the member of staff deemed most suitable by the nurse in charge at the time. Professional discretion should be used when deciding at what time to inform a relative / carer of the patient s death. 5.2.5 Last Offices Last Offices should be performed in accordance with the Last Offices procedure in the Royal Marsden Manual, accessible via the intranet. Prior to undertaking Last Offices please refer to the spiritual, cultural and religious, needs of the deceased person. Two people should participate in Last Offices, one of whom should be an experienced member of the clinical care team. Invite the relative/carer to spend time with the deceased prior to undertaking Last Offices. It is best practice to ask a relative/carer of the deceased if they wish to assist in Last Offices or be present during the procedure. Whenever possible the deceased patient should be left to rest before commencing this procedure. 5.2.6 Protection from Infection During Last Offices Policy and Procedures Relating to the Death of an Adult Hospital Inpatient V1.13 May 2016 Page 11 of 48

It is important that staff or a relative/carer who may have to care for a deceased patient s body are protected from risk of infections due to exposure of pathogenic organisms. Refer to the Trust Policy & Procedures for the Care of the Cadaver for any patient who dies from, or with, an infectious disease. 5.2.7 Washing and Dressing the Deceased Patient The deceased patient should be washed (unless requested not to do so for religious /cultural reasons) and dressed in a shroud. These should be available on each ward however more stock can be requested from the Sewing Room in Kings Treatment Centre at the RDH or through Synergy for wards at LRCH (housekeepers can order). If the relative / carer wishes the deceased person to wear their personal clothing during transfer to the Mortuary it is acceptable EXCEPT if the deceased patient will require a post mortem,. The ward staff need not pre-arrange this with the Mortuary staff, but a note must be made in the 'comments' section of the Notice of Death form. If the deceased patient is to have a post mortem examination, for manual handling purposes they must be placed in a shroud. It must also be noted that there is a risk of the clothing becoming soiled from leakage of body fluids following death. The relative/carer should be advised that this may occur. Additional clothing must not be sent to the Mortuary with the patient as the Mortuary staff do not dress the deceased patient. Relatives/carers should be advised to take all clothing to the Funeral Service and their staff will dress the deceased patient. 5.2.8 Dentures Dentures must be put in place as soon as possible after death as this is difficult for the Mortuary staff to do once rigor mortis has set in. If it is not possible for dentures to be left in place (i.e. an endotracheal tube is insitu), these should be placed in a denture pot labelled with a hospital identification label and sent to the mortuary with the deceased patient. This should be recorded on the Notice of Death Form in the comments box (See Appendix 2). 5.2.9 Intravascular Cannulae, Intravenous Infusions and Central Lines In all deaths in hospital, whether natural or otherwise, intravascular cannulae and lines must remain in situ. Removal of these lines may result in post mortem leakage of blood which can contaminate clothing / body coverings and generates unnecessary health risk for the Mortuary staff who then have to clean the body before viewing by relatives. Any Intravenous Infusion should be disconnected and the cannula capped. Long central lines should be capped and folded over and covered with an occlusive dressing. 5.2.10 Endotracheal Tubes and Catheters In natural deaths, where cardio-pulmonary resuscitation has not been performed and a death certificate can be issued, then it is acceptable to remove endotracheal tubes and urinary catheters. In all other circumstances when a post-mortem examination will usually take place: All endotracheal tubes and catheters must remain insitu. Endotracheal tubes must not be removed, but may be cut short to rest within the mouth, with the cuff remaining inflated. A catheter bag may be removed and the catheter spigotted. Policy and Procedures Relating to the Death of an Adult Hospital Inpatient V1.13 May 2016 Page 12 of 48

5.2.11 Chest Drains, Surgical Drains, Epidural Lines Chest drains, surgical drains, epidural lines etc must remain insitu. They may be disconnected, capped and then folded back and covered with an occlusive dressing. All tubes, drains, venous access lines left in place must be documented on the comments section of the notice of death form (See Appendix 2). If the patient has a pacemaker or external prosthesis this must also be recorded on the Notice of Death Form in the comments section 5.2.12 Identification of the Deceased Patient The deceased patient must be positively identified and their name, age, date of birth and hospital number must be checked with the health record and patient identity bracelet. Following Last Offices the patient must be identified with two identification bracelets, one attached to each wrist. On the rare occasion that the deceased patient has an upper limb amputation, one identity bracelet should be applied to one wrist and the other to an ankle. If the deceased patient s limbs are excessively swollen two identification bracelets can be attached to make one large band. The following information must be written in block capitals: The deceased patient s full name, ward, hospital number and date of birth must be clearly recorded on each identification bracelet. Both bracelets must be clearly visible (i.e. not under the sleeve of the shroud). 5.2.13 Handling of the Deceased Patient s Property and Valuables In accordance with the Trust Policy for handling of patient s property and valuables, all jewellery must be removed (in the presence of a colleague) unless requested by the patient's relative / carer to do otherwise. Jewellery (including rings) must be lightly taped to secure them in place. Jewellery remaining on the deceased patient should be clearly documented on the Notice of Death Form (Appendix 2). A record of the jewellery and other valuables must be recorded in the patient's property book and the items stored according to the Trust s Policy for handling of patient s property and valuables. 5.2.14 Viewing within the Clinical Area The deceased patient should be made presentable for relatives / carers to view should they wish, including ensuring the eyes and mouth are closed, limbs should be straightened if possible, but not bandaged. Explanations should be offered to relatives/carers if this cannot be completed. The relative / carer should be offered the opportunity to spend time with the deceased patient before they are transferred out of the clinical area. The environment should be made as suitable and dignified as possible. 5.2.15 Pre Transfer from the Clinical Area The deceased person must be prepared for transfer to the Mortuary, respecting the spiritual, cultural and religious, wishes of the patient and relatives / carers. Policy and Procedures Relating to the Death of an Adult Hospital Inpatient V1.13 May 2016 Page 13 of 48

The deceased patient must be placed in a non-zipped cadaver body bag that is closed with tape. Staples must NOT be used to secure the bag. The deceased patient should then be wrapped in a sheet ensuring that the face is fully covered. The non-zipped cadaver body bags are available from the Sewing Room (KTC) The white copy of the Notice of Death Form (Appendix 2) should be attached with tape to the outside of the sheet; the green copy should be filed in the patients health records. 5.2.16 Infected Patients/ Risk of Infection due to Leaking of Body Fluids Deceased patients who pose, or potentially pose an infection control risk, should be placed in a cadaver zipped body bag, in accordance with the Policy & Procedures for the Care of the Cadaver. Cadaver zipped body bags are available from the Sewing Room [Kings Treatment Centre - KTC]. Deceased patients who leak body fluids must also be placed in a zipped body bag. Wound dressings should be left in place. An occlusive dressing must be applied to leaking line insertion points. If there is an excessive quantity of exudate an incontinence pad can also be used over the top of the occlusive dressing. Sleek must not be used, as it will cause damage to the skin on removal. Identity bracelets and any jewellery must be clearly visible through the bag. 5.2.17 Information and Support for Relative/Carers The Practical Guide about What to Do When Someone Has Died must be offered to relatives/carers and explanations should be offered. Copies of the guide must be available within all wards and departments. Additional supplies can be obtained from the Faith Centre and the Bereavement Office. It may be appropriate to ask relatives / carers if they would like to talk to someone for initial bereavement support. The hospital chaplains can provide spiritual and religious support, and can be contacted 24 hours per day. The on-call chaplain can be contacted via Switchboard. 5.2.18 Transfer to the Mortuary After completion of all care and documentation the porters must be contacted to take the deceased patient to the Mortuary. It is advisable to remove the deceased from the ward within 4 hours. If the relative/carer wishes to remain with the deceased patient during the transfer from bed to concealment trolley, the porters should be notified as soon as they arrive on the ward. Whilst the deceased patient is being taken from the ward the curtains around adjacent patient s beds should be closed. Patients in adjacent beds should be given an explanation and offered support as needed. The hospital chaplain is available to provide support to these patients if required. Bariatric Patients Nursing staff must inform the portering services at the earliest opportunity in the event of a bariatric deceased patient transfer. The bariatric concealment trolley will be brought to the ward for ease of lateral transfer. If the relative/carer wishes to remain with the deceased during the transfer from bed to the concealment trolley, the porters should be notified as soon as they arrive on the ward. Policy and Procedures Relating to the Death of an Adult Hospital Inpatient V1.13 May 2016 Page 14 of 48

5.2.19 Viewing Arrangements in the Mortuary Department During Working Hours: Viewings normally take place between 10.00am 3.45pm, Monday to Thursday and 10.00am 3.30pm Fridays and always by prior arrangement with the Mortuary technical staff. Any relatives/carers wishing to view can make arrangements through the Patient Support Services. Emergency Department staff may contact the Mortuary staff directly. PART THREE Outside working hours: The mortuary services operate an on-call system and a member of staff is available to conduct any viewings required out of hours. Any viewings outside normal working hours will only be carried out at the discretion of the on-call technician. No viewings will be conducted after 9.00pm unless under exceptional circumstances, i.e. in the case of sudden death when identification is required this will be arranged via Switchboard. The on-call technician can be contacted via the Hospital Switchboard. Contact details of the on-call technician must not be passed on to relatives. External Viewing Arrangements for Patients who have died at LRCH If the relative/carer wish to view the deceased person they will need to make an appointment by contacting: G. Wathall & Son Ltd, 101 Macklin Street, Derby, DE1 1LG. Telephone: 01332 345268 Viewings can take place between 08.30am 16.30pm Monday to Friday by prior arrangement with Wathalls. The viewing of the deceased person can also be made with their chosen Funeral Director, once the funeral arrangements have been made and the relevant documentation completed. 5.3 Completion of a Medical Certificate of Cause of Death (MCCD) 5.3.1 Legal Responsibility It is a legal responsibility of attending doctors to complete a Medical Certificate of the Cause of Death (MCCD) to the best of his/her knowledge and belief (see Appendix 4). This must be carried out promptly and efficiently as delays and errors may result in the funeral arrangements being delayed and can increase anxiety and distress for a family. Certificates should ideally be completed with 24 hours of death or as soon as possible. Data from death certificates is used to code the cause of death using the International Classification of Diseases. Mortality statistics are based on a single cause of death. The underlying cause of death is defined by the World Health Organisation (WHO) as: The disease or injury which started the events directly leading to death The accident or the violence that produced the fatal injury Mortality data is used for monitoring the health of the population, planning and evaluating health services and research (National Statistics Death Certification Advisory Group 2010) 5.3.2 Reporting Death to the Coroner Policy and Procedures Relating to the Death of an Adult Hospital Inpatient V1.13 May 2016 Page 15 of 48

There are certain categories of death which must be reported to the Coroner before the death can be registered. A full list is available in Section 5.4.1 of this Policy and in the Bereavement Offices on each site. A doctor reporting a death to the coroner must be fully registered and licensed (F2 or above). It should not be necessary for an ACP to report a death to the coroner as they are not permitted to sign the MCCD. The Coroner will advise if the doctor may issue an MCCD. The Coroner may tell the reporting doctor not to complete an MCCD which will then be issued by the Coroner following his investigation or autopsy. The NCEPOD Report on the Coronial Autopsy (2006) stated that approximately 55% of deaths are certified by doctors and 45% referred to the Coroner. However the report also states that at least a third of all deaths certificates are likely to be incorrect. There is currently an additional certification process for cremation, which involves professional opinions from two doctors one of whom must be at least 5 years qualified. This process is a private arrangement between the doctors and the funeral director (see Completion of Cremation Forms Section 5.4). 5.3.3 Who Should Certify the Death? This must be an individual doctor who is competent in certifying death and who has cared for the deceased in their last illness. For deaths in hospital this could be an individual doctor from a team, however the Consultant has the final responsibility for ensuring that the MCCD is completed appropriately and should be informed of each death as soon as reasonably possible. If a doctor is uncertain about the cause of death he/she should discuss the case with the Consultant. If doubt about the cause of death still remains the case should be discussed with the Coroner before issuing an MCCD. A doctor reporting a death with the coroner should be fully registered (F2 or above). 5.3.4 Changes Regarding Death Certification Changes to death certification processes were made following a review of Coroners Services and Certification of Death (Luce, T. et al 2003) and due to increasing public scrutiny of the service due to: The Shipman Enquiry The Allitt Enquiry The Bristol Enquiry following children s deaths after Surgery The Alder Hay Enquiry following inappropriate retention of tissue and organs This review has recommended changes regarding the certification of death, particularly for cremation and for increased monitoring of the process(refer to section 5.5). 5.3.5 Completing the Medical Certificate of Cause of Death (MCCD) Cause of death the disease or condition thought to be the underlying cause should appear in the lowest completed line of part 1 1 (a) disease or condition leading directly to death (b) other disease or condition, if any, leading to 1(a) (c) other disease or condition leading to 1(b) 2 Other significant conditions contributing to death but not Related to the disease or Condition causing it Policy and Procedures Relating to the Death of an Adult Hospital Inpatient V1.13 May 2016 Page 16 of 48

5.3.6 Determining the Cause of Death The cause of death should be stated to the best of the doctor s knowledge and belief. The determination of the cause of death is often difficult and advice may be necessary and should be discussed with the Consultant in charge of the case or the relevant covering Consultant. It is a matter of clinical judgement to decide whether a condition present at, or just before, death contributed to the patient s death. There are 2 parts to the MCCD: Part 1 1a Start with the immediate cause of death then go back through the events that led up to the death. If a single disease led to the death this should be entered in 1a and no other cause is necessary. 1b Any other condition that led to the direct cause of death in 1a. 1c Will have caused the conditions recorded in 1a and 1b. This is the section that shows the underlying cause of death and is the data that is used in Mortality statistics. This could be a chronic condition that predisposed to the fatal complications. If necessary more than one condition can be added to one line. If the patient had more than one disease and it is not clear which condition caused the death then all should be added on the certificate. Deaths from infections must be included utilising the guidance at: 5.3.7 on page 18. If there is no evidence of any specific disease which caused the death then the case should be referred to the Coroner. Part 2 Any other disease, injury or condition that contributed to the death but was not the direct cause should be stated in this section. Guidance Notes If the cause of death is known but results of investigations are expected circle 2 on the front of the MCCD for autopsy information, or tick Box B on the back of the certificate that investigations were initiated ante mortem. Do not use terminal events e.g. cardiac arrest, frailty or debility as they are not causes of death. Do not use vague statements such as, organ failure, natural causes Do not use abbreviations e.g. NSTEMI Do not use inappropriate English e.g. use haemorrhage not bleed. Do not use CVA or cerebro-vascular accident Do not use old age as the direct cause of death in 1a - be specific and give relevant details if known Add the histological type and site of any cancer Specify insulin dependent or non-insulin dependent diabetes 5.3.7 Deaths from Infections In deaths from infectious disease include: Policy and Procedures Relating to the Death of an Adult Hospital Inpatient V1.13 May 2016 Page 17 of 48

The organism Antibiotic resistance if relevant The source and route of infection Pneumonia should include if lobar or bronchopneumonia, hypostatic or related to aspiration Add hospital or community acquired if known If associated with ventilation or invasive treatment 5.3.8 Hospital Acquired Infections (HCAI) Recent guidance for certifiers has clarified their responsibility under current legislation; in particular when patients have had an HCAI during their terminal illness (Office for National Statistics 2002). Doctors must include HCAIs on MCCDs where relevant. There is considerable evidence that MCCDs have previously not accurately reflected the contribution of HCAIs to many deaths (NCEPOD 2006). 5.3.9 Types of HCAI The commonest HCAIs potentially related to the cause of death are Methicillin Resistant Staphylococcus Aureus (MRSA), Clostridium difficile (C. difficile) and Extended Spectrum Beta Lactamase positive (ESBL) Escherichia Coli (E coli). In some cases, there may not be documentation of microbiology test results within the clinical records and all relevant outstanding test results should be sought before issuing an MCCD. If the doctor believes that Clostridium Difficile/MRSA or any other hospital acquired infection was the cause of death then this should be entered into Part 1 of the death certificate. If the patient s death was due to a different disease but the doctor believes that Clostridium Difficile/MRSA or any other hospital acquired infection was a contributing factor this should be entered into Part 2 of the death certificate. However if the doctor believes that although Clostridium Difficile/MRSA or any other hospital acquired infection was present neither caused the death nor was a contributing factor, then there is no requirement to include it on the death certificate. If however, the family are unhappy with this, the case should be referred to the Coroner for a decision. 5.3.10 Determining the Cause of Death where there is a HCAI Where HCAIs follow treatment, including surgery, radiotherapy, anti- neoplastic, immunosuppressive, antibiotic or other drug treatment for another disease, then it is important to specify the treatment and disease for which treatment was given. Similarly, the sites or manifestation of any HCAI (eg wound, blood stream or gastro-intestinal infection) should be included together with the source or route of infection (eg healthcare or community acquired, device associated, water or food born). 5.3.11 Examples It should be remembered that there is a high carriage of some infective agents associated with HCAIs in the community and it is important to clearly identify the external source of these infections. HCAIs contracted in hospital should be clearly identified as such by the use of appropriate terminology, e.g. hospital acquired, before the specified type of infection. Policy and Procedures Relating to the Death of an Adult Hospital Inpatient V1.13 May 2016 Page 18 of 48

If a HCAI was part of the clinical sequence of events leading to death, then it should feature in Part 1 of the MCCD and all conditions in the sequence of events back to the original disease being treated should feature in Part 1. PART FOUR Example 1 Clostridium difficile pseudomembranous colitis due to: Multiple antibiotic therapy due to Community acquired pneumonia with severe sepsis. Immobility, polymyalgia rheumatica, osteoporosis. Example 2 Bronchopneumonia (hospital acquired Methicillin Resistant Staphylococcus Aureus due to: Multiple Myeloma Chronic Obstructive airways disease. If the HCAI was not part of the direct sequence leading to death but is believed to have contributed in some way to the death then it should be included in Part 2 of the MCCD. Example 3 Carcinomatosis and Renal failure due to Adenocarcinoma of the prostate Chronic obstructive airways disease and catheter associated Escherichia coli urinary tract infection. 5.4 Notification of Death to H.M. Coroner The Coroner is an independent judicial officer appointed by the Local Authority and has a duty to investigate any death that was violent, sudden or with an unknown cause (Medical Protection Society, 2009). It is the responsibility of the attending doctor to report any death that meets the criteria. In circumstances where the criteria are not clearly met advice should be sought from the Coroner s Office. The Coroner will seek to establish the medical cause of death and may request a post mortem. If following this, the cause of death remains in doubt an inquest will be held. 5.4.1 Key Responsibilities/Duties Consultant Medical Staff Consultant Medical staff have the overall responsibility for ensuring that referrals to the Coroner are made appropriately by members of their team. They must take a lead role to ensure that their teams raise all relevant issues with the Coroner who will then advise appropriately. The relevant Consultant must be informed by the reporting doctor of every death reported to the Coroner within a reasonable timeframe. Medical Staff The doctor reporting the death to the Coroner must be a fully registered doctor (F2 or above) with experience in the specialty, and must either have known the patient or have Policy and Procedures Relating to the Death of an Adult Hospital Inpatient V1.13 May 2016 Page 19 of 48

familiarised themselves with the case. They must then advise the relevant Consultant of the referral within a reasonable time. Doctors must ensure that the information given to the Coroner is complete and that the relevant forms are completed and also documented within the patient s health record. They are also responsible for informing the patient s relatives that a referral to the Coroner has been made when they are present at the death or at an agreed time. Senior Nurse Emergency Department In Accident and Emergency most deaths are sudden and unexpected therefore all deaths are reported to the Coroner. The Senior Nurse in charge of Accident and Emergency may inform the Coroner s Office of these deaths. The Coroner s Office will then decide whether to accept the case or may give permission for the doctor to sign the MCCD. 5.4.2 Criteria for Deaths that MUST be reported to H.M. Coroner All unexpected deaths. Where the death may be linked to an accident (whenever it occurred) or trauma of any kind. Death, which cannot be attributed to natural causes. Where the deceased was not seen by a doctor within the fourteen days prior to their death. If the death is as a result of violence, or there is a history of violence, neglect or suspicious circumstances. The death has occurred during, or shortly after, detention in prison or police custody, including voluntary attendance at a Police Station. The deceased was detained under the Mental Health Act. Any death where the patient was the subject of a Deprivation of Liberty (DOLS) safeguarding procedure under the Mental Capacity Act. The Coroner takes the view that this means that the patient was detained by the state and the death must be reported. The death is linked to an abortion. Patients with any industrial disease e.g. mesothelioma, asbestos related, or where the deceased was pursuing a claim for damages or compensation for an industrial disease or accident even if only a contributory factor. The actions of the deceased person might have contributed to the death, e.g. selfharm, overdose and history of drug addiction, excessive alcohol (see below) or solvent abuse and also self-neglect or neglect by others. The deceased was receiving any form of war pension or industrial disability pension. The death may be related to a medical procedure whether invasive or not. Where there is an allegation of a lack of medical or clinical care. The deceased has been in hospital less than 24 hours. The death occurred within 24 hours of an operation. Death whilst in the operating theatre. Death related to an operation or anaesthesia. All deaths related to alcoholic liver disease. Please Note: Any death where alcohol is mentioned on the death certificate, or is a contributory factor in the death, e.g. cirrhosis of the liver, must be reported to the Coroner. H. M. Coroner has indicated that he is very unlikely to take such a case and will only inquest if alcohol was a major contributory factor (e.g. following a fall whilst intoxicated or aspiration pneumonia due to decreased level of consciousness due to alcohol). However many Crematoria Referees will require the Coroner to have been informed to protect the Policy and Procedures Relating to the Death of an Adult Hospital Inpatient V1.13 May 2016 Page 20 of 48

Referee from any future developments. Therefore the Coroner must be informed in all cases where alcohol is a factor and the Cremation form noted to this effect. Unidentified persons. Deaths from hypothermia. Deaths from food poisoning. Unexpected stillbirths if there is any doubt about the child being born alive. If in any doubt always contact the Coroner to discuss the matter. 5.4.3 Contacting the Coroner When contacting the Coroner faxing information is NO LONGER PERMITTED A secure email address is to be used: Derby.coroner@derbyshire.gcsx.gov.uk. These forms must also all be filed in the patient s health record (See Appendices 2 & 3) 5.4.4 Hospital Acquired Infections Discussion with the Coroner If the family are unhappy with the absence of an infection recorded on the MCCD the case should be referred to the Coroner for a decision. 5.4.5 Medical Equipment Coroner s cases may have received active treatment whilst in hospital and may therefore have items of medical equipment attached to the body. PART FIVE Any such item of medical equipment that has been inserted into the body either percutaneously, e.g. a drain or intravenous line, or subcutaneous cannula or endotracheal tube, must be left in place. The Mortuary Attendant must be informed of any item of medical equipment that is left attached to the body so that it is not accidentally removed nor causes any injury during handling of the body. This will be documented in the patient s health record with a reference note entered on the Report of Death Form which the Nursing staff complete. Mortuary Staff must also be informed if a patient has an implant of any kind including PACEMAKERS & ICDs as this can be a serious Health and Safety risk if the body is for cremation. Relatives must be informed in advance of any medical devices that are left attached to the body. Tubes and lines around the head and neck may be concealed or disguised by tape or bandages if this is felt to be appropriate. 5.5 Completion of Cremation Forms New Cremation Regulations were introduced from January 1st 2009 as part of national changes following the Shipman Enquiry. The new regulations replaced legislation from 1930 which was widely seen as old fashioned and confusing. The main change is that bereaved families now have the legal right to inspect the completed Cremation forms before a cremation takes place. Families can then draw the Medical Referee s attention to any unexpected symptoms and discrepancies in the case. Policy and Procedures Relating to the Death of an Adult Hospital Inpatient V1.13 May 2016 Page 21 of 48

Cremation forms must be completed as soon as possible to minimise delays to funerals and further distress to bereaved relatives. 5.5.1 The Medical Referee Crematoria The Medical Referee is appointed by the Secretary of State for each Cremation Authority and must have been a registered Medical Practitioner for at least 5 years. He/she has the statutory power to authorise cremations following scrutiny of the Cremation forms. The Medical Referee has the power under the Cremation Regulations (2008) to: Expect that evidence offered on the Cremation forms shows sound clinical grounds for the Cause of Death. Reject incomplete forms and may refuse to authorise a cremation until the forms are completed to his/her satisfaction. Make any enquiry they consider necessary about the forms. Refer a case to the Coroner where inspection of the cremation forms raises a possibility that the Cause of Death was not natural Order a post mortem Ensure that the doctors who complete Cremation forms 4 and 5 are sufficiently independent of one another. 5.5.2 Cremation Forms Principles Completion of cremation forms is not part of a doctor s NHS contract, nor is it a statutory duty. Doctors are paid a fee by the relevant funeral director and in doing so this becomes a private arrangement between the doctor and funeral director. Legal Framework and Ministry of Justice Guidance for Medical Practitioners Regulation 16 of the Cremation (England and Wales) Regulations 2008 makes it clear that no cremation of the remains of a deceased person may take place unless A medical certificate and, subject to regulation 17(3), a confirmatory medical certificate are given in accordance with regulation 17(1) and (2) and respectively a certificate is given that the body of the deceased person has undergone an anatomical examination. Every doctor completing cremation forms must be fully registered with the General Medical Council (GMC) and as such F1 doctors are not permitted. All sections of the forms must be completed and the Medical Referee may reject illegible forms. The Bereavement Team are authorised to reject incomplete or illegible forms. A hospital inpatient should have a diagnosis that enables a specific cause of death to be written. Modes of death e.g. multi organ failure or heart attack are not acceptable as a cause of death and the Medical Referee is likely to reject the forms. Old age as a cause of death for the over 80s out of hospital is acceptable but the Medical Referee may ask for more information regardless of age. Abbreviations must not be used and the forms must be completed legibly and signed. The cremation forms make it clear that it is a criminal offence under the Cremation Act (1902) to wilfully make a false statement in order to procure a cremation. Policy and Procedures Relating to the Death of an Adult Hospital Inpatient V1.13 May 2016 Page 22 of 48

Criminal and General Medical Council proceedings have been successfully brought against doctors who have falsely completed cremation forms. A copy of The cremation (England and Wales) regulations 2008- guidance for medical practitioners completing forms 4 and 5 (Ministry of Justice 2012) is available both within the bereavement office and as appendix (10) to this policy 5.5.3 Cremation Form 4 - Medical Certificate ( Replaces Form B / Old Part 1) See Appendix 7 In order to complete Form 4 the doctor should have attended the patient at some time during their last illness and must have seen them within 14 days of their death. Where the deceased has been an in- patient for less than 24 hours the Coroner must be informed. It is acceptable for an F1 or F2 doctor or above to complete the Statement of Truth (Part 3) but the doctor s GMC Number is vitally important and must be added. The Doctor completing Form 4 must view and examine the body after death. The doctor must not allow anyone to complete the form on their behalf. The Medical Referee will expect that evidence of sound clinical grounds for the cause of death are given. All questions must be answered and should include detailed information about the circumstances surrounding the death. If there is any doubt as to the cause, sequence or mechanism of death the consultant in charge of the case MUST be informed and will advise prior to completion of the form. The symptoms and other conditions section should be completed with the doctors observations in the period prior to death. The cause of death should normally be the same as on the death certificate used to register the death and should show whether this was informed by the patient history, operations carried out or witness reports. Any operation which may have shortened the patient s life must be reported to the Coroner. The name and address of all those present at the death must be recorded as the doctor completing Cremation Form 5 must be able to contact them. This includes relatives/carers and nursing staff. Any suspicious circumstances must be reported to the Coroner and the details recorded in the Health Records. Any implants must be recorded on the form as they can cause a serious Health and Safety risk at the Crematorium. The doctor signing part 4 has a duty to confirm whether there are any hazardous implants within the body and confirm whether or not they have been removed. The doctor signing PART 5 is responsible for ensuring the doctor signing part 4 is correct. 5.5.4 Cremation Form 5 Confirmatory Medical Certificate (Form C/Old Part 2) See Appendix 8. The doctor that completes Cremation Form 5 cannot be a colleague of the doctor who completed Cremation Form 4. They must be completely independent of one another and not be on the same team. Where a junior doctor has signed Form 4 it is not acceptable for the doctor in charge of the patient s case or directly involved in the patient s treatment to complete Form 5. The doctor completing this form must have been fully registered with the GMC for at least 5 years. All questions must be answered. The doctor must check the completed Cremation form 4 for any discrepancies and query any inconsistencies. It is expected that at least one of the questions 2-5 will be answered in the affirmative. Policy and Procedures Relating to the Death of an Adult Hospital Inpatient V1.13 May 2016 Page 23 of 48

5.5.5 Right of Inspection Under the new regulations the applicant for cremation now has the right to request to inspect the cremation forms once the forms have been submitted to the Medical Referee. Some of the information on the forms may have been given in confidence (particularly questions 9 and 10 on Cremation Form 4). If this would be a breach of confidence the information can be given to the Medical Referee on a separate sheet of paper attached to the form. This must include reasons for the omissions and that the information should not be disclosed to the applicant. It is essential that the cremation forms are completed as soon as possible to facilitate any request for inspection in order to prevent any delay to the funeral. It is not expected that there will be many applications as difficult cases will already have been referred to the Coroner and most applicants do not have concerns about the circumstances concerning death. 5.5.6 Deaths Involving Ethnic Minorities Certain religious faiths specify specific timeframes for burial and/or cremation. The United Kingdom laws must be upheld even in such difficult circumstances. It is good practice that if a death is anticipated in a patient whose religious belief may require a rapid funeral process or removal of the body from the United Kingdom then this should be discussed with the family and Bereavement Office in advance. PART SIX If it is known that the death will require referral to the Coroner advance discussions should again take place. The Coroner has indicated that provided a post mortem is not required that he may give permission for the body to leave the United Kingdom. 5.6 Procedure for Obtaining Out of Hours Medical Certificates and Removal of Bodies out of England and Wales Multi-Agency Agreement January 2009 5.6.1 Introduction At present a medical certificate of cause of death can be issued when the deceased has died from natural disease, the cause of death is known and the deceased was in regular medical attendance within 14 days prior to death. In such circumstances the death can be registered without notifying the Coroner of the death. In all other circumstances the Coroner needs to be notified of the death. The Coroner has an interest in the death if the death was unnatural, resulted from violence or trauma, is sudden and unexplained or the deceased was not in medical attendance 14 days prior to death. When a death is unnatural or resulted from violence or injury there will be a post mortem examination of the body and an inquest will be held. Where the death is sudden or unexplained the Coroner will discuss the patient with the GP. If there is a strong history of chronic illness or disease such as heart disease, respiratory Policy and Procedures Relating to the Death of an Adult Hospital Inpatient V1.13 May 2016 Page 24 of 48

disease or cancer then if the GP feels that he is in a position to issue a medical certificate of cause of death then with the Coroner s agreement he may do so. In all other cases where the cause of death is unknown a post mortem examination will take place. If the cause of death is found to be natural causes the Coroner will inform the registrar who will then register the death and issue a death certificate and the body can be released to the family. If at post mortem the cause of death is not from natural causes then the Coroner will issue an interim certificate of cause of death and an inquest opened. In these circumstances there may be delay in release of the body to the family as it may be the subject of further examination or more inquiries have to be made by the Coroner. From time to time a death may occur at night, weekends or bank holidays where otherwise the death could be registered and the body released to the family. In certain circumstances arrangements can be made where the death can be registered out of hours and an out of England certificate issued. This will invariably involve certain faith groups or ethnic and cultural groups within the community. These procedures however should be universal and apply to all where the circumstances warrant. To do otherwise may result in discrimination of a section or sections of the community. 5.6.2 Procedure for Out of Hours Medical Certificates Ordinarily if a patient dies after 16:00 hours on a weekday or at any time over a weekend or a Bank Holiday a death certificate will be issued the next working day. These procedures do not apply in a case where a death certificate cannot be issued. 1. If a patient dies Monday to Friday between 09:00 and 16:00 hours and in circumstances where a death certificate can be issued then a certificate may be issued in the usual way. 2. If a patient dies any time from 16:00 hours Friday until 18:00 hours Sunday or on a Bank Holiday and in circumstances where a death certificate can be issued, the doctor must carry out the following procedure. 3. i. Obtain medical certificate box from Hospital out of Hours team in the Operations Centre ii. Complete Medical Certificate. iii. If discussion is needed with H.M. Coroner, the doctor can contact the coroner via the switchboard within the following times: Saturday Sunday 08:00 18:00 hours 08:00 18:00 hours For patients dying after 18:00 hours on Friday night contact can be made Saturday morning. For patients dying after 18:00 hours Sunday night contact can be made Monday morning. For patients dying on a Bank Holiday Monday after 18:00 hours contact can be made on the Tuesday morning. There are a number of funeral committees who are able to assist as liaison with families and the funeral director. Policy and Procedures Relating to the Death of an Adult Hospital Inpatient V1.13 May 2016 Page 25 of 48

5.6.3 Procedure when a Death has Occurred and Urgent Permission is Required to Take a Body out of England and Wales (Out of England Certificate). Introduction 1.1 This procedure has been agreed between H.M. Coroner for Derby and South Derbyshire, the Superintendent Registrar for the City of Derby Registration District and Derby City Council. 1.2 The Procedure shall be used where it is necessary for the Coroner to issue a certificate of Removal, and a Registrar of Births and Deaths to register a death on a Saturday, Sunday or Bank Holiday. 1.3 This procedure shall only be used in an emergency and if certain conditions are met. An emergency arises where the only flights available to carry the body to the required country are on one of the four days following the request for removal. 1.4 In order for this procedure to take effect, the following conditions MUST be met: a. The death must be due to natural causes and give the Coroner no reason to investigate further or require a post mortem examination. The Coroner reserves the right to ask questions concerning the circumstances surrounding the death. If he is not satisfied, he may delay the issue of a certificate of removal. b. A doctor must be able to certify the cause of death. If the deceased had been attended to by a locum doctor, a death certificate will have to be obtained from the deceased s medical practitioner. 1.5 Where it is necessary under this procedure for the Coroner or the Superintendent Registrar of Births and Deaths (or their nominated representatives), to carry out their duties on a Saturday, Sunday or Bank Holiday, the funeral director or Mr M. Azam shall liaise between the Coroner and the Registrar and the family of the deceased. Friends or relatives of the deceased MUST NOT contact the Coroner or Registrar direct. 1.6 By a Memorandum of understanding between the Islamic faith groups and Mr Mohammed Azam (Chairman of the Pakistan Muslim funeral committee), Mr Azam has authority to act on behalf of the Islamic community. Procedure 2.1 Upon a death occurring where the family of the deceased intend to take the body out of England and Wales, a member of the family and / or Mr Azam will contact the funeral director. 2.2 The funeral director will check that a death certificate has been issued and deal with any arrangements associated with removing the body out of England and Wales. 2.3 The funeral director will contact the Coroner by telephone and notify him of the circumstances of the death and whether a death certificate has been issued. 2.4 The Coroner will decide whether he is willing to issue an urgent Certificate of Removal by waiving the prescribed four days notice. 2.5 If the Coroner is willing to issue an urgent certificate, the funeral director will contact the on call Registrar for Births and deaths to arrange for the Registrar to attend the Registrar Office to register the death and issue a certificate for disposal of the body. 2.6 Under the provisions of the Registration Act a registrar who is not satisfied with the circumstances of the death or the certificate contains errors he has the authority not to continue with the registration process and will notify the Coroner of his concerns. 2.7 If the Coroner and the Registrar are willing and able to issue the appropriate certificates, mutually convenient times will be arranged for: Policy and Procedures Relating to the Death of an Adult Hospital Inpatient V1.13 May 2016 Page 26 of 48

a. A Registrar and a member of the family to attend the Register Office and b. The funeral director to attend the Coroner s Office. 2.8 No more than three members of the family will attend the Register Officer with a Registrar for the purpose of registering the death. The Registrar will require the following: Medical Certificate of Cause of Death. Information about the date and place of birth of the deceased. Information regarding the address of the deceased and his / her occupation. 2.9 The exact fee must be paid to the registrar in cash or by cheque. Copy of the Death Certificate, the deceased s passport. From England and Wales. 2.10 When the death has been registered and the Coroner has no issues with the authority to remove the body, the funeral director will be free to complete the arrangement for taking the body out of England and Wales. The funeral director will be supplied with the relevant telephone numbers for the Coroner, Deputy Coroner, Assistant Deputy Coroner and the Registrar, on the strict condition that he will not disclose then to any other person. 6.0 Monitoring Compliance and Effectiveness 6.1 Notification of Death to H.M. Coroner and Completion of Relevant Information Monitoring will be carried out by the Mortality Group which reviews all deaths within the Trust on a monthly basis. The forum will provides assurance and evidence to assist in meeting the Core Healthcare Standard C5d, C6 and D2a. This Group will review all Coroners reports and ensure that any action required is implemented and that Action Plans are developed and monitored where appropriate. The group will also initiate further work to improve outcomes based on any inquests. The Group will liaise with the Coroner s office to agree this policy and procedures and that they are implemented. The Coroner will be invited to attend the Group meeting at least once a year. The Mortality Group will report quarterly to the Clinical Effectiveness Committee which will escalate relevant issues to the Trust board via the report to the Quality Assurance Committee. 7.0 References NMC Code of Professional Conduct (2015) UKCC Scope of Professional Practice (1992) RCN Confirmation of Death and Performance of Last Offices (1981) Derby Hospitals NHS Foundation Trust Manual on Safe Care and Management of Patient with Infection The Royal Marsden Hospital Manual of Clinical Nursing Procedures Edition (6 th Edition). Trust Do Not Attempt Cardio-Pulmonary Resuscitation Policy CL-LP/2008/008 Office for National Statistics Death Certification Advisory Group (2010). Guidance for Doctors Certifying Cause of Death Office for National Statistics (2002). Coding the Underlying Cause of Death NCEPOD Report (2006) Policy and Procedures Relating to the Death of an Adult Hospital Inpatient V1.13 May 2016 Page 27 of 48

Luce, T. et al (2003). Review of Coronial Services, Death Certification and Investigation in England, Wales and Northern Ireland. Office CMNd4810. English Home Office Report of the Committee on Death Certification and Coroners. (1902, 1952 and 2008). The Cremation Acts, and Regulations made thereunder by the Secretary of State for the Home Department Ministry of Justice (2008). Cremation Regulations: Guidance for Doctors. Your right to Inspect the Medical Certificates Policy and Procedures Relating to the Death of an Adult Hospital Inpatient V1.13 May 2016 Page 28 of 48

APPENDIX 1 DERBY TEACHING HOSPITALS NHS FOUNDATION TRUST - CONFIRMATION OF DEATH Patient s Surname: Patient s other names: Patient s Home Address: Date: Time: dd/mm/yyyy Date of Birth (if known) or approximate age Location of death (if different from home address): Contact Telephone: Details of Patient s General Practitioner (GP) Name: Contact Telephone: Contact Telephone: Address: Clinical Findings Please delete as appropriate (please observe each for at least one minute) Baseline Baseline + 10 minutes Carotid pulse Present Absent Present Absent Heart sounds Present Absent Present Absent Signs of spontaneous respiration Present Absent Present Absent Fixed dilated pupils Present Absent Present Absent Reaction to painful stimuli (e.g. trapezium pinch) Present Absent Present Absent Is there any immediate need to refer to the Coroner or Police? Yes No Any Comments: Name & collar number of any Police Officer already in attendance: Prostheses: please specify if known (e.g. internal pacemakers, internal defibrillators, eyes etc.) Confirmation of Death Life verified extinct at: hours minutes date (dd/mm/yyyy) Confirmed by: Name: Signature: Contact Telephone: Witnessed by: (not essential) GP contacted by: Name of GP: Name: Signature: Contact Telephone Time contacted: Date: Contact Telephone: Relative contacted by: Name of relative: Time contacted: Date: Contact Telephone: Funeral Director/Undertaker: Name: Contact Telephone: Body Collected at: Taken to: Policy and Procedures Relating to the Death of an Adult Hospital Inpatient V1.13 May 2016 Page 29 of 48

APPENDIX 2 DERBY TEACHING HOSPITALS NHS FOUNDATION TRUST - NOTICE OF DEATH Details of Deceased Hospital Number: Ward/Department: RDH / LRCH Surname: Date of Birth: Age: Yrs First Name: Religion: Date death verified on: 20 By : Designation: at hrs Details of Medical Staff Consultant Name: Consultant Initials: Name of Doctor (F1/F2): Grade: Bleep Number: Details of Medical Intervention Please record any equipment left in situ. e.g. ET Tubes, CVP lines etc. Identification and Preparation Does the deceased have two identification bracelets in place? YES Please Note: The information on the ID bracelets must include: Full Name, Ward, Hospital Number and Date of Birth. Is the patient dressed in a shroud YES Is the patient placed in a non-zipped bag YES (or) Cadaver zipped bag YES Property: Please list ALL Jewellery left on the patient Does the patient have a pacemaker? Yes / No Please list all external prosthetics: Other Comments: Risk of Infection: Yes / No Please give details of any infection risk: The Trust Infection Control Policy must be adhered to when preparing the deceased for transport to the Mortuary Department. Details of the Person Completing the Above Information Print Name: Designation: Ext No: Date: / / Time: Signature: For Mortuary Use Only: Identification Checked: YES/NO Property Checked: YES/NO Date: / / Signature: Distribution white copy to be attached to the body, Bluer copy to Histopathology, Green copy to remain with notes Policy and Procedures Relating to the Death of an Adult Hospital Inpatient V1.13 May 2016 Page 30 of 48

APPENDIX 3 DERBY TEACHING HOSPITALS NHS FOUNDATION TRUST REPORT OF DEATH Patient Details/Label Hospital: RDH / LRCH / Consultant: Ward/Dept: Date of Death: / / Time of Death: Time Verified: Verified by: hours hours Relatives/ Carers Present: If no have they been notified: Notified By: Title: Time: Date: Yes / No Yes / No Name and Relationship of Relatives/ Carers Notified: Witness at the Death: (Include relatives, doctors, nursing/midwifery staff and other plus contact details and addresses where relevant) Bereavement Support Offered: Relative/ Carers given hospital information booklet A Practical Guide as to What to Do When Someone Has Died Relative/ Carers asked to telephone Bereavement Services after 13:30 hours on next day working to collect Death Certificate and register death if appropriate. YES/NO YES/NO YES/NO Signature: Print Name & Designation: The Section below is to be carried out by the Doctor Reported to the Coroner: Infection Pregnancy in the last 12 months Implants: Doctor s Signature: YES / NO YES / NO YES / NO YES / NO Print Name: Policy and Procedures Relating to the Death of an Adult Hospital Inpatient V1.13 May 2016 Page 31 of 48

APPENDIX 4 DERBY TEACHING HOSPITALS NHS FOUNDATION TRUST REPORT OF DEATH TO THE CORONER FORM Policy and Procedures Relating to the Death of an Adult Hospital Inpatient V1.13 May 2016 Page 32 of 48

Does the patient have any of the following fitted: Patient ID label A Radioactive Device A Pacemaker A Defib Device YES NO Please provide a clinical summary of major events (including procedures and dates) If accepted by the Coroner, I would like to attend the Post Mortem YES NO Reporting Doctor (Signature) Policy and Procedures Relating to the Death of an Adult Hospital Inpatient V1.13 May 2016 Page 33 of 48

DOCUMENT DISCUSSION WITH THE CORONER S OFFICER AND FILE IN PATIENT S NOTES Patient ID label Has this case been accepted by the Coroner? YES NO (File in Patient s Notes) Reason not taken by the Coroner / Cause of Death. Coroner s Comments: Name of Coroner s Officer: Date of Discussion: _ / / Policy and Procedures Relating to the Death of an Adult Hospital Inpatient V1.13 May 2016 Page 34 of 48

APPENDIX 5 DERBY TEACHING HOSPITALS NHS FOUNDATYION TRSUST - COMPLETING A MEDICAL CERTIFICATE OF CAUSE OF DEATH Cause of Death Known? NO Discuss with Consultant YES Category for Report to Coroner Complete MCCD within 24 hours or as soon as possible. 1 (a) Direct of Cause PART 1 1 (b) PART 2 Sequence NO YES Report to Coroner Other significant conditions contributing to death but not part of the direct sequence of events. a 2 a 1 (c) a Underlying Policy and Procedures Relating to the Death of an Adult Hospital Inpatient V1.13 May 2016 Page 35 of 48

DERBY TEACHING HOSPITALS NHS FOUNDATION TRUT REPORT A DEATH TO THE CORONER APPENDIX 6 YES Cause of death known? NO Discuss with consultant who will advise re: the need to contact the Coroner Meet criteria for report to the coroner Inform the Consultant as soon as possible NO YES Complete MCCD and Cremation forms 4&5 where relevant Report to Coroner Coroner may allow MCCD to be issued May need Coroner s Inquest Policy and Procedures Relating to the Death of an Adult Hospital Inpatient V1.13 May 2016 Page 36 of 48