3.1 Death of an Adult Service User Policy Title State previous title where relevant. State if Policy New or Revised Policy Strand Org, HR, Clinical, H&S, Infection Control, Finance For clinical policies only - state index category Links to National Regulatory Standards: Care Quality Commission(CQC) NHS Litigation Authority (NHSLA) National Institute for Health & Clinical Excellence (NICE) Policy Lead/Author Job titles only Consultation State year and the individuals, groups, committees, service users, working partners etc. you have consulted with Ratification State ratified by whom - Policy Ratification Group, Executive Committee or Director Equality Impact Assessment Implementation Plan Death of an Adult Service User New Clinical Practice Development Nurse Physical Health Matron Divisional Managers and Teams. Clinical Policy Alignment Group August 2013 Policy Ratification Group Yes Yes Month/year policy first developed October 2013 Months/years policy reviewed Keep review dates in chronological order New Policy Next review due October 2016 Review details Revisions made, changes etc include page numbers and paragraphs For Corporate Executive Support use New Policy Date Policy First Uploaded to Intranet January 2014 Date Policy Revised & Reloaded to Intranet Version 1.0 January 2014
Death of an Adult Service User Ref. Contents Page 1.0 Introduction 3 2.0 Purpose 3 3.0 Objectives 3 4.0 Definitions 3 5.0 Duties 4 6.0 Committee/Group Responsible for Approval of this Policy 5 7.0 Process 5 8.0 Monitoring Compliance 6 9.0 Standards/Key Performance Indicators 6 10.0 Equality Impact Assessment 6 11.0 Data Protection Act and Freedom of Information Act 6 12.0 Links to other Policies and Procedures 7 13.0 References 7 Appendices Appendix 1 Flowchart following the Death of an Adult Service User 8 Appendix 2 Infection Control Precautions 9 Appendix 3 Last Offices Equipment and Procedure 13 Appendix 4 Guidelines for the Verification of Death 4a - Clinical signs of death 4b - Flowchart for verification/confirmation of expected death by nursing staff 4c - Certificate of verification of death competency 4d - Recommendations from HM Coroner Robin J Balmain 17 Review and Amendment Log Version Reason Status Date V1.0 New Policy Ratified Jan 2014 Description of Change Newly aligned Policy for BCPFT Version 1.0 January 2014 2
1.0 Introduction Within any NHS setting it is inevitable that there will be instances when the death of an adult service user occurs and nursing care should not stop when the patient dies. Every patient has the right to die with dignity, without pain and in their own familiar surroundings with people they know and trust nearby. The quality of care a patient receives after death is as important as the quality of life they experienced prior to this time. 2.0 Purpose The purpose of this policy and procedure is to ensure that staff from the Black Country Partnership Foundation Trust (hereafter called the Trust) handle the death of an adult service user in an appropriate manner including verification/confirmation of expected death by registered nurses. This policy and procedure applies to the death of all adult service users in Trust premises. It also applies to the death of adult service users in the community who are discovered by staff employed by the Trust. 3.0 Objectives To establish a framework to ensure that: relatives and carers are informed as soon as possible death certificates are appropriately issued any suspicious deaths are investigated any necessary arrangements are made with the coroner and appropriate funeral directors This policy and procedure is based on the belief that all deaths should be managed in a dignified manner. 4.0 Definitions Expected death a patient who has been identified formally by the medical team as expecting to die and relevant documentation completed. This will be communicated to nursing staff and relatives and whenever possible all known religious and cultural requests should be ascertained and any advance directive/statement referred to and documented. Sudden unexpected death this is defined as unforeseen death. As well as the collapse and death of an apparently healthy person, it also applies to death as a result of an overdose, self-harm, homicide or other suspicious circumstances. Sudden death is a traumatic event for the family, friends and professionals involved. Staff involved have a vital role to play in ensuring that the situation is managed in a dignified and professional manner and the families assisted sensitively. Verification of death sometimes referred to as pronouncing death or confirming death is the procedure of determining whether a person is actually deceased. All deaths should be subject to verification that life has ended. Version 1.0 January 2014 3
The verification of death must be recorded. Death can be verified by all doctors and, in situations where there is an explicit organisational policy, associated protocols and appropriate training and assessment, it can also be undertaken by registered nurses. Verification of death is separate to the certification process. Certification of Death is the process of completing a Medical Certificate of Cause of Death and can only be carried out by a Medical Practitioner. This certificate details the cause of death and enables the family of the deceased to register the death and make funeral arrangements. A nurse cannot legally certify death since this is one of the few activities that the law requires to be performed by registered medical practitioners. Last offices is the term for nursing care given to the deceased patient which demonstrates continued respect for the patient as an individual and also focuses on attending to health, safety and legal requirements, making the body safe to handle and pleasant for others to see, whilst also respecting religious beliefs and cultural norms. 5.0 Duties Chief Executive (Accountable) The Chief Executive is responsible for assuring that this policy is implemented within the Trust. Operational responsibility has been delegated. Trust Board (Strategic) The role of the Trust Board is to have a strategic overview and final responsibility for safe and high quality care within service areas across the Trust in accordance with its Assurance Framework and strategic priorities. Executive Committee (Accountable) A sub-committee of the Trust Board has delegated responsibility for ensuring that this policy is efficient and effective in accordance with the Board s Assurance Framework and Strategic priorities. Care Governance (Responsible) The Care Governance Committee is responsible for overseeing the implementation of a systematic and consistent approach to this policy. The group is chaired by the medical Director and provides exception and progress reports to the Executive Committee. Service Managers, Modern Matrons, Ward Managers and Lead Nurses The above named are responsible for ensuring that:- They are familiar with this policy and are responsible for adhering to the procedures. Staff attend training applicable to their role and for implementing the guidance across their areas of responsibility. Staff work to the standards set out in this policy. Version 1.0 January 2014 4
Medical Staff Medical staff should be familiar with this policy and adhere to the procedures referred to within the policies. Ward Staff All clinical staff are responsible for ensuring that they are familiar with the policy and for adhering to the procedures referred to within the policy. 6.0 Committee/Group Responsible for Approval of this Policy The Clinical Policy Alignment Group is responsible for the approval of this policy. 7.0 Process Patient deaths fall into three categories - expected death, sudden unexpected death and suspicious death. In the case of all deaths, the patient s nearest relative and person with whom they had the closest relationship should be informed as soon as possible following verification of death. (See also appendix 4 guidelines for the Verification of Death). For expected deaths, the appropriate doctor should certify the death. Wherever possible, a patient s last wishes and preferences would have been determined in advance e.g. advance directive, end of life books. If an end of life care plan is in place, which incorporates an advance directive, it should be referred to at this stage. Nurses need to take into account the different religious and cultural rituals that may accompany the death of a patient. Following the Last Offices, (see Appendix 3) arrangements should be made with the Funeral Director for removal of the body. If the deceased has no next of kin and dies intestate (no will) the cremation/funeral is arranged by the Trust and paid from the patient s estate. If there are insufficient funds, the Trust bears the cost. No property/monies should be handed back to the next of kin by ward staff. All patients property, except those items which would be appropriately left with the deceased patient (e.g. wedding ring) must be checked in the presence of another nurse and taken into safekeeping. For sudden unexpected deaths, the coroner should be contacted by the doctor (police out-of-hours) who will decide what further action is necessary. For all suspicious deaths, the coroner and police should be contacted. For suspicious deaths and sudden unexpected deaths where the coroner and/or police need to attend the scene, the body should not be moved once death has been verified and the area should be vacated and left undisturbed. Following certification of death and approval by the police and/or Coroner, the Last Offices should be carried out (see appendix 3). Version 1.0 January 2014 5
All suspicious deaths and sudden unexpected deaths should be reported as serious incidents and an incident form completed (Datix). The appropriate Trust staff should be informed of the death (see Appendix 1). A record must be made when the body is removed indicating the date of death, any property left on the body, whose body the details refer to, where the body is being removed from (ward area), who released and received the body and when this occurred. Support should be provided for relatives, staff and other patients affected by the death by nursing staff who knew the patient or the chaplaincy team (0121 612 8067). Information can be provided for Bereavement Groups. 8.0 Monitoring Compliance The Trust Care Governance Group is responsible for monitoring of compliance with this policy. 9.0 Standards / key performance indicators This section needs to contain auditable standards and/or key performance indicators which may assist the trust in the process for monitoring compliance. Key Performance indicators Staff compliance with policy guidelines and processes. Incidents, complaints and concerns. Feedback from staff following the death of a patient. Methods of Assessment Audit of documentation - medical and nursing notes. Monitoring of all incidents concerning the death of a patient. Audit of documentation medical and nursing notes. 10.0 Equality Impact Assessment The Black Country Partnership NHS Foundation Trust is committed to ensuring that the way we provide services and the way we recruit and treat staff reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group. The Equality Impact Assessment for this policy has been completed and is readily available on the Intranet. If you require this in a different format e.g. larger print, Braille, different languages or audio tape, please contact the Equality & Diversity Team on 0121-612-8067 or email EqualityImpact.assessment@bcpft.nhs.uk. 11.0 Data Protection Act and Freedom of Information Act All staff have a responsibility to ensure that they do not disclose information concerning the Trust s activities or about service users in its care to unauthorised individuals. This responsibility applies whether you are currently employed or after your employment ends and in certain aspects of your personal life e.g. use of social networking sites etc. The Trust seeks to ensure a high level of transparency in all its business activities but reserves the right not to disclose information where relevant legislation applies. Version 1.0 January 2014 6
12.0 Links to other policies and procedures Resuscitation Policy Incident Reporting Policy Policy for Patient Monies Respect and Dignity Policy guidelines for advanced decisions and advanced statements. 13.0 References The Royal Marsden Hospital Manual of Clinical Procedures Seventh Edition 2008, Blackwell Publishing, Oxford. The Code: Standards of Performance and Ethics for Nurses and Midwives- Nursing and Midwifery Council May 2008 Report of the Committee of Death Certification English Office CMND 4810 November 1971 Royal College of Nursing (2013) Confirmation (Verification) of Expected Deaths by Registered Nurses Confirmation of Death Nursing and Midwifery Council 2012 http://www.nmc-org/nmc/main/advice/conformationofdeath.html NMC (2008) NMC Advice Verification of Death Version 1.0 January 2014 7
Appendix 1 This is a corporate procedure for the Black Country Partnership Foundation Trust. It is intended to provide a framework for services to meet the policy statements. 3.1 Flow chart illustrating the corporate procedure following the death of an adult service user Member of staff discovering death 1. Inform member of staff responsible for team. Member of staff responsible for team 1. Informs the doctor, the person in charge of the hospital and the relatives. Person In charge of the ward/unit 1. Inform Service Manager (Manager on-call) 2. Agree category of death referring to verification of death policy. Expected death Sudden unexpected death Suspicious death 1. Ensure arrangements made for appropriate doctor to certify death. 2. Ensure appropriate arrangements made for Last Offices (in line with patient s preferences and following discussion with carers and relatives- refer to Royal Marsden Procedures). 3. Ensure arrangements made with funeral directors for removal of the body (following discussion with relatives and carers). 4. Consider use of local funeral directors if no relatives or the mortuary (Edward Street Hospital). 5. Inform and offer support to relatives and/or next of kin. 6. Offer support of hospital chaplain or other religious leader or other appropriate person. 1. Inform Director Responsible for Service (or Director oncall), carers and relatives. 2. The Doctor must inform the coroner. 3. Complete an Incident Report. 4. Ensure site undisturbed and await further advice from coroner. 5. Coroner will decide what action to take usually an autopsy. 6. Inform and offer support to relatives and/or next of kin. 7. Offer support of hospital chaplain or other religious leader or other appropriate person. Spiritual Care Team/ Bereavement Support Services 0121 612 8067 07972732748 1. Follow the sudden unexpected death procedure. 2. The Doctor or a delegated person must inform the police. Version 1.0 January 2014 8
Appendix 2 Infection control precautions are necessary for the safe handling of the bodies of patients who have died with known or presumed infection. Standard Infection Control Precautions should be used in the care of all deceased patients. This will include the use of plastic aprons and disposable gloves. Any additional transmission based infection control precautions taken during life should be continued after death, during hygienic preparation of the body, embalming or post mortem examination. The Advisory Committee on Dangerous Pathogens (ACDP) has grouped infectious diseases into four categories depending on how infectious they are and the seriousness of the disease they cause. Categories 1 and 2 are mild diseases, which, although some can be transmitted quite easily, rarely cause serious or life threatening infections. Category 3 and 4 pathogens are those requiring the deceased to be handled with additional care to minimise the likelihood of cross-infections to staff and undertakers. Category 3 pathogens These organisms can cause significant disease to HCW s and other additional precautions need to be taken when handling an infected body. Category 4 pathogens These are organisms that are extremely hazardous and may cause serious epidemic disease. Definition of Hazard Category Group 4 - A biological agent that causes severe human disease and is a serious hazard to employees; it is likely to spread to the community and there is usually no effective prophylaxis or treatment available. There are a number of rare infections which are caused by Category 4 pathogens. Examples of these diseases are: Rabies, Viral haemorrhagic fevers, Lassa fever, Marburg virus, Ebola virus and Pulmonary anthrax. Patients suffering from these and other dangerous diseases should be strictly isolated and transferred to the Regional Infectious Diseases Unit. Although there are no appropriate isolation facilities for these patients in most hospitals, a patient may be admitted and die before transfer. If the patient is suspected to be infected with a Category 4 pathogen, special precautions must be taken with the body. Advice must be sought as a matter of urgency from the Infection Prevention & Control Team or the Consultant in Communicable Disease Control if any of these diseases are suspected. Mortuary staff, funeral directors or embalmers must be informed of any infection risk, particularly tuberculosis. Patients who present a particular infection hazard should be identified to the mortuary staff or funeral directors to ensure that the appropriate precautions are taken in the on-going care of the body. Version 1.0 January 2014 9
Cadaver bags (body bags) should be used where the containment of blood and body fluids is difficult or where there is a particular infection hazard (See table for specific infections in Guidance Table 1). Tuberculosis (Open Pulmonary Only) Patients with clinically suspected or diagnosed open pulmonary tuberculosis who have NOT completed two weeks of Chemotherapy are considered infectious. When movement of the body is essential a disposable face mask should be placed over the mouth and nose of the deceased to prevent release of aerosols of infectious materials. Staff must also wear appropriate respiratory protection when performing any procedures or moving the patient, this is especially important in the case of MDR-TB. Viewing the Body If relatives become distressed because they cannot view a body, the medical staff that cared for the deceased should be asked to discuss the matter with them. In the case where relatives or religious representatives wish to be involved in the performance of last offices including hygienic preparation of the body or religious rites, on a patient who presents an infection hazard, advice may be obtained on an individual patient basis from the Infection Prevention & Control Team. Mortuary Staff and Funeral Directors The clinical team looking after a patient have a duty to inform mortuary staff, funeral directors or embalmers about patients who present a particular infection hazard, particularly tuberculosis. Nursing Staff All relevant information is made available to persons handling/viewing the body so that they may take appropriate action to avoid acquiring an infection themselves. This includes ensuring that mortuary staff are aware of any known or suspected infection risk prior to transfer to the mortuary. If a patient dies before a clinical diagnosis has been confirmed e.g. tuberculosis, meningitis, mortuary staff should be informed of the likely diagnosis. While observing universal precautions, the body should be laid out and washed in the normal manner according to religious and cultural needs. Nurses/staff should wear disposable gloves and plastic aprons. All drains, catheters, etc, should be removed unless the case has been referred to the Coroner or medical staff request the lines to be left in. All vascular access e.g. drains and line sites, or wound sites should be totally occluded using the minimum padding required and waterproof tape (e.g. Sleek) to prevent leakage. Inco-pad sheets must be placed in the bag if leakage is anticipated. Version 1.0 January 2014 10
The body should be placed in a body bag (head placed at zip end) which must then be sealed. This is to enable viewing of the face only if necessary. The patient identity information should be completed. This information MUST be inserted in the body bag pocket (not on the body). A number of mortuaries and undertakers provide service for inpatient sites. Each Ward/Unit should have the contact for this. These local services may expect their local forms to accompany the body for transportation and contact would need to be made directly for this information. Those transporting the body must be informed when requesting that the body is moved: Whether the bag is being used for infection control purposes or leakage of fluids. SERVICE USER DIAGNOSIS MUST NOT BE DISCLOSED. Medical Staff Medical Staff must: Advise relatives who may wish to view the body before it is placed in the body bag of the potential risk of infection to themselves and the appropriate measures to be taken when viewing the body. When seeking permission for a hospital post-mortem examination on a body known or suspected of having an infectious condition, discuss with pathologists whether the post-mortem is necessary or practical. Should it only subsequently become known that a service user was suffering from an infectious disease, the pathologist and senior mortuary staff should be informed by the clinical team caring for the service user in life as soon as possible. If there is doubt as to whether or not the patient was suffering with an infectious disease, seek further advice from the Microbiologist. Universal infection control precautions should be applied. Staff transporting the body: Should wear a plastic apron and gloves when moving a body from the bed to the trolley if it is in a body bag. The gloves and apron should be discarded into the ward orange clinical waste bag. Hands should be washed before leaving the ward. It is not necessary for staff to wear gloves and aprons when transporting a body. If the body is removed to a mortuary, the body should be placed in the refrigerated body store, the body should be placed on the lowest available shelf. Any equipment associated with infected bodies must be cleaned and disinfected irrespective of whether or not they are soiled. Gloves and apron must be removed and placed into the clinical waste bag provided. Hands should be washed with soap and water before returning to other duties. Specific Infections Guidance: Table 1 Version 1.0 January 2014 11
Degree of risk Infection Body Bag Viewing Embalming Hygienic Preparation Low Acute encephalitis No Yes Yes Yes Low Chickenpox/shingles No Yes Yes Yes Low Cryptosporidiosis No Yes Yes Yes Low Dermatophytosis No Yes Yes Yes Low Legionellosis No Yes Yes Yes Low Lyme disease No Yes Yes Yes Low Measles No Yes Yes Yes Low Meningitis (except meningococcal) No Yes Yes Yes Low Mumps No Yes Yes Yes Low Meticillin-resistant Staphylococcus No Yes Yes Yes aureus (MRSA) Low Ophthalmia neonatorum No Yes Yes Yes Low Psittacosis No Yes Yes Yes Low Rubella No Yes Yes Yes Low Tetanus No Yes Yes Yes Low Whooping cough No Yes Yes Yes Medium Acute poliomyelitis No Yes Yes Yes Medium Cholera No Yes Yes Yes Medium Diphtheria Adv* Yes Yes Yes Medium Dysentery Adv* Yes Yes Yes Medium Food poisoning No Yes Yes Yes Medium Hepatitis A No Yes Yes Yes Medium HIV/AIDS No Yes No Yes Medium Leptospirosis (Weil s disease) No Yes Yes Yes Medium Malaria No Yes Yes Yes Medium Paratyphoid fever Adv* Yes Yes Yes Medium Q fever No Yes Yes Yes Medium Relapsing fever Adv* Yes Yes Yes Medium Meningococcal septicaemia Adv* Yes Yes Yes Medium Scarlet fever Adv* Yes Yes Yes Medium Tuberculosis Adv* Yes Yes Yes Medium Typhoid fever Adv* Yes Yes Yes Medium Typhus Adv* No No No High Anthrax Adv* No No No High CJD and TSE No Yes No Yes High Group A streptococcal infection No Yes Yes Yes (invasive) High Hepatitis B and C Yes Yes No Yes High Plague Yes No No No High Rabies Yes No No No High Smallpox Yes No No No High Viral haemorrhagic fever Yes No No No High Yellow fever Yes No No No *ADV advisable. Version 1.0 January 2014 12
Appendix 3 LAST OFFICES. Equipment Disposable plastic aprons Disposable plastic gloves Bowl of warm water, soap, the deceased s own toiletries and face cloths or disposable wash cloths and two towels Disposable razor or the patient s own electric razor, comb and equipment for nail care Equipment for oral care including equipment for cleaning dentures Identification labels x 2 Documents required by law and organisation policy Shroud or patient s personal clothing Body bag if required ( in the event of actual or potential leakage of bodily fluids and/or infectious disease) and labels for the body defining the nature of the infection/disease (see Appendix 2) Gauze, waterproof tape, dressings and bandages if wounds are present Plastic bags for clinical and household waste Sharps bin if appropriate Laundry skip and appropriate bags for soiled linen Clean bed linen Record books for property and valuables Bags for patient s personal possessions. Version 1.0 January 2014 13
PROCEDURE (Appendix 3) Action Inform the nurse in charge of the ward/unit and medical staff of the patient s death. Confirmation/verification of death must be given and recorded in the patient s medical and nursing notes.(see Verification of Death guidelines) Inform and offer support to relatives and/or next of kin. Offer support of hospital chaplain or other religious leader or other appropriate person. If relative or next of kin not contactable by telephone, it may be necessary to inform the police Ascertain if the patient had an infectious disease and whether this is notifiable or not. (Patient may need to be placed in a body bag) (See appendix 2) Last offices should be carried out within 2-4 hours of death If possible, determine from the family or carers the patient s wishes for care after death or whether an end of life care plan incorporates an advance directive Wash hands and put on disposable gloves and disposable plastic apron.(personal Protective equipment - PPE) If the patient is on a pressure relieving mattress or device, consult the manufacturers instructions before switching off or changing settings. Lay the patient on his/her back remove all but one pillow. Support the jaw by placing a pillow or rolled-up towel on the chest or underneath the patient s jaw (do not bind the patient s jaw with bandages can leave pressure marks). Straighten the patient s limbs. Close the patient s eyes by applying light pressure to the eyelids for 30 seconds. If this is unsuccessful then a little sticky tape such as micropore can be used and leaves no mark. Drain the bladder by applying firm pressure over the lower abdomen. Rationale A registered medical practitioner who has attended the deceased during their last illness is required to give a medical certificate of the cause of death. The certificate requires the doctor to state on which date he/she last saw the deceased alive and whether or not he/she has seen the body after death. To ensure relevant individuals are aware of patient s death and to provide sensitive care. Extra precautions required when patient has died from an infectious disease. Rigor mortis can occur relatively soon after death and this time is shortened in warmer environments. Consideration must be given to requirements for people of different religious faiths, any cultural rituals that may accompany the death of a patient, and any patient wishes or preferences for care after death PPE must be worn when performing last offices and is used to both protect yourself and all of your patients from the risk of cross infection. Nurses must act at all times to maintain the patient s safety when using a pressure relieving mattress or device. To maintain the patient s privacy and dignity and for future nursing care of the body. To maintain the patient s dignity and for aesthetic reasons. Closure of the eyelids will also provide tissue protection in case of corneal donation. Because the body can continue to excrete fluids after death. Version 1.0 January 2014 14
Leakages from the vagina and bowel can be contained by the use of incontinence pads respectively. Patients who do continue to have leakages after death should be placed in a body bag following last offices. Exuding wounds should be covered with a clean absorbent dressing and secured with an occlusive dressing. Wash the patient unless requested not to do so for religious/cultural reason s or carer s preference. Male patients should be shaved unless they chose to wear a beard in life. If shaving a man apply water-based emollient cream to the face. It may be important to family and carers to assist with washing thereby continuing to provide the care given in the period before death. Clean the patient s mouth to remove debris and secretions. Clean dentures and replace them in the mouth if possible. Remove all jewellery (in the presence of another nurse) unless requested by the family to do otherwise. Jewellery remaining on the patient should be documented on the notification of death form. Rings left on the body should be secured with tape if loose. Dress the person in a shroud or personal clothing depending on organisational policy or relatives wishes. Ensure a correct hospital or organisational patient identification label is attached to the patient s wrist and attach a further identification label to one ankle. Complete any documents such as notification of death cards tape one securely to shroud or clothing. Wrap the body in a sheet ensuring that the face and feet are covered and that all limbs are held securely in position. Secure the sheet with tape. If leakage of body fluids is a problem or is anticipated, place the body in a sheet and then a body bag. Leaking orifices pose a health hazard to staff coming into contact with the body. Ensuring that the body is clean will demonstrate a continued respect for the patient s dignity. The packing of orifices is considered unnecessary as it increases the rate of bacterial growth and therefore increases odour when these areas of the body are not allowed to drain naturally. The dressing will absorb any leakage from the wound site. Open wounds and stomas pose a health hazard to staff coming into contact with the body. For hygienic and aesthetic reasons. As a mark of respect and point of closure in the relationship between nurse and patient. To prevent brown streaks on the skin. It is an expression of respect and affection and part of the process of adjusting to loss and experiencing grief. For hygienic and aesthetic reasons. To meet with legal requirements, cultural practices and relatives wishes. To maintain the security of the deceased s possessions. For aesthetics for family and carers viewing the body or religious or cultural reasons and to meet family or carer s wishes. To ensure correct and easy identification of the body in the mortuary. To avoid possible damage to the body during transfer and to prevent distress to colleagues. Pins must not be used as they are a health and safety hazard to staff. Actual or potential leakage of fluid whether infection is present or not, poses a health hazard. The sheet will absorb excess fluid. Version 1.0 January 2014 15
Action Tape the second notification of death card to the outside of the sheet. All areas contact local funeral directors for the removal of the body. Screen off the area where removal of the body will occur. Remove gloves and apron. Dispose of equipment according to local policy and wash hands. Record all details and actions within the nursing documentation. Transfer property, patient records etc. to the appropriate administrative department. Rationale For ease of identification of the body. Decomposition occurs rapidly particularly in hot weather and in overheated rooms. Many pathogenic organisms survive for some time after death and so decomposition of the body may cause a health and safety hazard for those handling the body. Autolysis and growth of bacteria are delayed if the body is cooled. To avoid causing unnecessary distress to other patients, relatives and staff. To minimise the risk of cross-infection and contamination. To record the time of death, names of those present and names of those informed. The administrative department cannot begin to process the formalities such as the death certificate or the collection of property by the next of kin until the required documents are in its possession. Version 1.0 January 2014 16
APPENDIX 4 Guidelines for the verification of death. A nurse cannot legally certify death, since this is one of the few activities that the law requires to be performed by registered medical practitioners. S/he may, however, confirm that death has occurred, providing there is explicit local policy or protocol to allow such an action. The protocol should, however, only be used in situations where death is expected. These guidelines will not apply to the following In cases of sudden and unexpected death In cases of death within twenty-four hours of admission, or in the community setting, within 24 hours of the commencement community nurse visits, if no firm clinical diagnosis has been made. Within seven days of surgical intervention. Within 24 hours of a fall In cases of expected death when death occurs in an unexpected manner or unexpected circumstances Following an untoward incident e.g. drug error In cases of expected death where no note indicating death is expected has been entered into the patients notes. Paediatric deaths of any sort. Any violent or unnatural death including any involving industrial disease. Any death where medical involvement (or non-involvement) may be a factor MEDICAL RESPONSIBILITIES Patient whose death is expected will be identified formally by the Medical Officer. The discussions will include the views if appropriate, of the patient, relatives and nursing staff responsible for the patient Any decision will be communicated to the nursing staff. The decision that death is expected will be documented in the clinical notes/patient held records. Carers should also be made aware that as a consequence of the terminal condition, cardiopulmonary resuscitation would not be appropriate and a record of this conversation should be documented in the clinical notes. The doctor will communicate verbally with the nursing staff regarding those patients identified as an expected death. The doctor should document in the patient records that he has discussed this with the nursing team and has authorised them to verify death. If the relatives of a deceased patient wish to speak with a doctor, this request should be honoured at a reasonably practical time. The doctor of the deceased patient will complete the death certificate as soon as practical in readiness for collection by relatives/ Funeral Director. A member of the medical/nursing team should always be prepared to speak to relatives when they collect the certificate. Version 1.0 January 2014 17
NURSING RESPONSIBILITIES All nurses should adhere to the NMC Code of Professional Conduct (2008) Nurses should ensure that documentation in the patients clinical notes/patient held records reflect the patients current condition/diagnosis and expected death (appendix ii) Verification of death must only be carried out by those nurses, who have read and understood these guidelines, have received training and are confident and competent in recognizing the clinical signs of death. (appendix i and iii) The nurse will record in the clinical notes/patient held records, the date and time of verification of death including documentation of clinical signs of death. The nurse will record in the clinical notes/patient held records, the date and time the medical officer was informed of the patients death. The nurse will arrange transfer of the deceased patient to local Funeral Directors following the wishes of the patients family. PROCESS Registered nurses have an individual responsibility to ensure they feel confident and competent in the knowledge and skills of practice (NMC, 2008). All new nursing staff will be made aware of the content of these guidelines and will be required to confirm/demonstrate they are competent in recognising the clinical signs of death. If they are not confident in this area of clinical practice, this should be discussed with their line manager who will be responsible for organising training in carrying out the verification of death procedure. If the nurse has any doubt regarding verification of a death, they should not feel pressured to carry out the verification but encouraged to seek assistance/advice from the line manager and should not make the verification. All new medical staff will be aware of the roles and responsibilities relating to verification of expected death by receiving a copy of these guidelines. The Guidelines for the Verification of Expected Death will be available and understood by medical and nursing staff. TRAINING Registered nurses will have received guidance and instruction on recognizing clinical signs of death prior to verifying the death of patients (see Appendix i and iii) Where training is required, registered nurses will be made aware of the content of the guidelines and the process of verifying death. Version 1.0 January 2014 18
Appendix 4a CLINICAL SIGNS OF DEATH The following are commonly recognized clinical signs used when verifying death: 1. Absence of a carotid pulse over one minute. 2. Absence of heart sounds over one minute using a stethoscope. 3. Absence of respiratory movements and breath sounds over one minute. 4. Fixed, dilated pupils (unresponsive to lights). 5. No motor (withdrawal) response or facial grimace in response to painful stimuli. If there is any doubt, wait ten minutes and repeat the procedure. Version 1.0 January 2014 19
Appendix 4b Flow Chart for Verification/Confirmation of Expected Death by Nursing Staff. Doctor formally identifies a patient whose death is expected. Doctor discussed with nursing staff and where appropriate the patient and relatives. Doctor to document that death is expected in patient s notes. Doctor to communicate to nursing staff that he/she is happy for them to verify death and document in medical notes. Doctors of deceased patient to complete death certificate ASAP for collection by relatives. Version 1.0 January 2014 20
Appendix 4c Black Country Partnership Foundation Trust Certificate of Verification of Death Competency Name of Registered Nurse.. Designation Absence of heart sounds over one minute using a stethoscope Absence of respiratory movements and breath sounds over one minute Fixed, dilated pupils (unresponsive to lights) No motor (withdrawal) response or facial grimace in response to painful stimuli. I certify that.. is competent to verify expected deaths based on the above criteria. Authorised by.. Designation Version 1.0 January 2014 21
Appendix 4d Recommendations from H.M. Coroner Robin J Balmain The coroner is content for appropriately trained nursing staff from Black Country Partnership Foundation Trust to verify expected deaths. Any deaths, which are not expected, are to be verified by Medical Staff and referred to the Coroner. It is then permissible for the deceased to be transferred to local Funeral Directors whilst awaiting the Coroners investigations unless the Coroner gives instructions to the contrary. Not all cases referred to the Corner have Post Mortem examinations. All Post Mortem examinations are carried out by the Coroner. In cases of expected death which must be reported to the Coroner e.g. mesothelioma, the deceased may, subject to the coroner s agreement, be transferred to local funeral directors. Version 1.0 January 2014 22