Guidelines for the verification of life extinct and the protocol for actions to be taken following the death of a patient/client (in hospital) Title Guidelines for the verification of life extinct and the protocol for actions to be taken following the death of a patient/client (in hospital) Authors/Reviewers Version 6 Speciality/Division Directorate Date Uploaded 31 July 2017 Review Date July 2019 Clinical Guideline (ID) CG0110 Dr Richard Wright, Medical Director Simon Gibson, Assistant Director, Medical Directorate Karen Wasson, Acting Litigation Manager, Human Resources and Organisational Development Margaret Marshall, Assistant Director of Clinical and Social Care Governance (Acting) Mrs Anne Coyle, Bereavement Coordinator Trustwide Medical Directorate following death of a patient/client July 2017 (V6)
CONTENTS PAGE NO(S). 1 Introduction 1 2. Purpose of Guidance 2 3. Verification of Life Extinct 2-3 4 Issuing a Medical Certificate of Cause of Death (MCCD) 4-5 5 Reporting Death to the Coroner 5-7 6 Reporting death using the Trust incident reporting system 8 7 Recording actions taken after death for review purposes 8 8 Useful Contact Numbers 9 Appendix 1 Appendix 2 Appendix 3 Life Extinct Record Sheet Protocol for Actions to be Taken after a Death Checklist after the death of a patient/client following death of a patient/client July 2017 (V6)
1 1 Introduction A number of staff employed by the Southern Health and Social Care Trust may be involved in coordinating the supportive, statutory and legal processes and procedures at the time of death 1 and into bereavement. The performance of these duties will at times require inter-agency liaison and cooperation and should always be carried out with sensitivity and compassion. A range of legislation and Department of Health (formerly known as Department of Health, Social Services and Public Safety), Health and Social Care Board, Public Health Agency standards for practice as well as guidance from professional bodies informs actions to be taken following the death of a patient, such as; In March 2008 the DHSSPS requested that Health and Social Care Trusts in Northern Ireland develop guidance with regard to verifying life extinct 2. The guidance contained in this document is based upon the content of the Departmental protocol issued at that time. In September 2008 the DHSSPS issued Guidance on Death, Stillbirth and Cremation Certification 3 which included guidance on reporting deaths to the Coroner under section 7 of the Coroners Act (NI) 1959. Further information on actions to be taken by HSC Trusts and medical staff when reporting a death that occurs in hospital to the Coroners Service is outlined in the publication titled Working with The Coroners Service 4 In October 2013 the Health and Social Care Board published their Procedure for the reporting and follow up of Serious Adverse Incidents 5 (SAIs). Some deaths will meet the definition that requires they are reported to the HSCB as SAI. By March 2017, it is proposed that all hospital deaths will be recorded onto the new Regional Morbidity and Mortality Review System which has been incorporated into Northern Ireland Health and Care Record (NIECR). This new system allows for completion of Medical Certificates of Cause or Death (MCCDs) which are then printed from NIECR and signed by the doctor completing it. When a patient dies the feelings and wishes of the family should be explored and respected. They must be communicated with at all times throughout the process of dealing with the death. 1 Examples include completing the Medical Certificate of Cause of Death, reporting deaths to the Coroner etc. 2 DHSSPS (March 2008) HSS (MD)8/2008. Verifying and Recording Life Extinct by Appropriate Professionals 3 Guidance on Death, Stillbirth and Cremation Certification (2008) DHSSPS 4 Working with the Coroners Service for Northern Ireland Best Practice Guide (2009) 5 Procedure for the Reporting and Follow up of Serious Adverse Incidents (2013) HSCB
2 2 Purpose of guidance The purpose of this guidance is to assist best practice in applying the regulations, recommendations and procedural advice in DoH, HSCB, PHA and Coroners Service publications and outlines the protocol for actions to be taken after death by all staff in the Southern Trust with a responsibility for: Verification of life extinct Completing Medical Certificates of Cause of Death (MCCD) Reporting death to the Coroner Reporting death using the Trust incident reporting system Recording information on actions taken after death in the deceased patients records and for clinical review purposes 3. Verification of Life Extinct All deaths must be formally verified and the fact of death recorded in the patients medical record This task can be undertaken by all doctors and, in situations where there is an organisational policy, associated protocols and appropriate training and assessment, it can also be undertaken by nurses and ambulance clinicians. In the SHSCT verification of death is carried out by Hospital Medical Staff and those Nursing Staff who have attended Verification of Death Training and follow the procedure for Verification of Death by a Registered Nurse i.e. Hospital at Night Coordinators in Daisy Hill and Craigavon Area Hospitals Procedure for the Verification of Death by a Registered Nurse.pdf In order to verify life extinct, cessation of circulatory and respiratory systems and cerebral function must be confirmed and documented in the patient s notes. N.B. this applies in all cases whether it is a doctor, nurse or ambulance clinician who undertakes the task. Formally recording that the patient has died should take place as soon as practicable after death as the date and time death has been verified is important information for the Doctor responsible for either completing the MCCD or reporting the death to the Coroner. There are some special circumstances, including brain-stem death in ventilated patients, where medical consultants will be involved in verifying life extinct under more detailed protocols. Where such protocols are in place, the documentation recording the examination to test for the cessation of brainstem function and verify death should be based on appropriate guidelines, such as the Academy of Royal Colleges (2008) Code of Practice for the Diagnosis and Confirmation of Death 6. 6 www.aomrc.org.uk
3 Life extinct must always be verified by examining all of the following systems: i) Cessation of circulatory system e.g. No pulses on palpation. No heart sounds (verified by listening for heart sounds or asystole on an ECG tracing for a minimum of one full minute). ii). Cessation of respiratory system e.g. No respiratory effort observed. No breath sounds (verified by listening for at least one full minute). iii) Cessation of cerebral function e.g. Pupils dilated and not reacting to light. No reaction to painful stimuli. Documentation recording the examination undertaken to verifying life extinct should be completed and placed in the patient s notes. Appendix 1, the Life Extinct Record Sheet (LERS) can be used for this purpose. Copies of this form can be printed from the Southern Trust Intranet site: Policies and Procedures/Bereavement/Life Extinct Record Sheet and Bereavement SharePoint. When death has been formally verified, the doctor to whom the death is reported needs to determine the next step, which will depend on the circumstances of the death. In all circumstances, the doctor to whom the death has been reported must; Issue a MCCD without delay or, Hand that responsibility directly to a named colleague who can legally complete the MCCD, before he/she goes off duty or, Report the death to the Coroner
4 4. Issuing a Medical Certificate of Cause of Death (MCCD) Certification of death is important for the deceased s family to enable them to register the death. They will receive from the registrar a death certificate which is required to settle the deceased s estate and the necessary documentation to arrange burial or cremation Statistical information from registration of deaths also has an important function for society e.g. monitoring causes of death of the population Registered Medical Practitioners have a legal duty to provide, without delay, a certificate of cause of death if to the best of their knowledge that person died of natural causes for which they had treated that person in the last 28 days In hospital there may be several doctors in a team caring for the patient who will be able to certify the cause of death Foundation level doctors should not complete MCCDs unless they have received training All doctors completing MCCDs should ensure they are competent by updating their knowledge and skills relating to certification 4.1 Guidance for good practice Incorrectly completed MCCDs can cause difficulties for the doctor, registrar and in particular cause distress for families By March 2017, it is proposed all hospital deaths will be recorded onto the new Regional Morbidity and Mortality Review System which has been incorporated into Northern Ireland Electronic Health and Care Record (NIECR). This new system will generate a Medical Certificate of Cause or Death (MCCD) on completion of the Initial Record of Death form (IRD). The MCCD is then printed and signed by the doctor completing it. Abbreviations are not to be used. It is a requirement of the General Registrar Office that doctors include their GMC License Number on the death certificate. Should the Registrar of Death need to contact the doctor who completed the MCCD to clarify issues before registering the death a telephone number for the doctor should be provided on the MCCD Doctors should ensure that relatives of the deceased patient are aware of what is written on the MCCD i.e. the cause of death and any contributory factors; and that relatives are given the opportunity to discuss the patient s illness, its treatment and any other questions and concerns 7. 7 Public inquiry into the outbreak of Clostridium Difficile infection in the Northern Trust Hospitals, Northern Ireland. http://www.cdiffinquiry.org/index/inquiry-report.htm
5 When the MCCD is completed on NIECR, it is to be printed and then signed (legibly) by the doctor. See section 4.2 for information about ensuring the Mortuary receive the MCCD to complete their records 4.2 Completion of MCCDs and release of deceased patients from the mortuary The remains of a deceased patient will not be released from the mortuaries in Trust hospitals unless a MCCD has been completed (or the Coroner gives permission - see section 5.) The MCCD should be sent to the mortuary when complete, either with the deceased or delivered by a porter at a later time. It should be placed in an envelope addressed e.g. Mortuary Technician contains MCCD. The mortuary staff will then give the MCCD to the family or their funeral director when they collect the body. For more information and guidance on completing the MCCD and referring deaths to the Coroner, please read Department of Health, Social Services and Public Safety (2008) Guidance on Death, Stillbirth and Cremation Certification http://vsrintranet.southerntrust.local/shsct/html/documents/guidancedeath-stillbirth-and-cremation-certificationdhssps.pdf 5. Reporting Death to the Coroner If the circumstances or cause of death require that it be reported to the Coroner, a foundation level doctor should consult a more senior colleague before reporting the death Medical staff should follow the advice in the protocol flow chart (appendix 2) and in the Coroners Investigations/Inquests presentation available at the SharePoint link; http://sharepoint/med/home/litigation/forms/allitems.aspx The duty to report arises if a medical practitioner has reason to believe that the deceased died directly or indirectly: As a result of violence, misadventure or by unfair means; As a result of negligence, misconduct or malpractice (e.g. deaths from the effects of hypothermia or where a medical mishap is alleged); From any cause other than natural illness or disease e.g.: homicidal deaths or deaths following assault; road traffic accidents or accidents at work; deaths associated with the misuse of drugs (whether accidental or deliberate); any apparently suicidal death; all deaths from industrial diseases (e.g. asbestosis) From natural illness or disease where the deceased had not been seen and treated by a registered medical practitioner within 28 days of death
6 Death as the result of the administration of an anaesthetic (there is no statutory requirement to report a death occurring within 24 hours of an operation though it may be prudent to do so) In any circumstances that require investigation; the death, although apparently natural, was unexpected; Sudden Unexpected Death in Infancy. 8 Doctors should refer to the Registrars General s extra statutory list of causes of death that require to be referred to the Coroner Medical practitioners must now also consider that all cases of fetal demise, capable of being born alive, will require to be reported to the Coroner. If there are doubts about the demise of the fetus or the mother has concerns, the circumstances should be reported to the Coroner. The Chief Medical Officer for Northern Ireland has issued interim advice for reporting such cases to the Coroner pending a review of the 2008 guidance 9 The doctor who assumes responsibility for dealing with the death should always view the body before reporting the death Contact/discussion with the Coroner should be documented in the medical record. He/she will direct one of three courses i.e. advise the doctor to complete an MCCD; allow death to be processed under the pro-forma system; direct a post mortem examination to establish cause of death When the Coroner directs that the death can be processed using the pro-forma system, a clinical summary, along with an unsigned MCCD, should be printed and faxed/ e-mailed to the Coroner s Service as soon as possible and the hard copy of both documents posted to them (see contact details in section 8) The new Regional Mortality and Morbidity Review System will generate a Coroners Clinical Summary when the Coroner notified Coroner Requested Proforma option is selected along with a MCCD for this purpose. NB. In this situation the MCCD is not given to the family. They should be given an explanation about this process and that the Coroner, on receipt of the clinical summary and unsigned MCCD, will notify the Registrar about the death who will then issue a death certificate to the family. 8 Guidance on Death, Stillbirth and Cremation Certification (2008) DHSSPS 9 HSS (MD) 38/2014 Guidance on death, stillbirth and cremation certification following the court of appeal decision on the death of a fetus in utero. 01/12/2014
7 In the event of the Coroner directing a post mortem, the doctor who has reported the death to the Coroner is required to complete a detailed relevant Clinical Summary to assist the Pathologist carrying out the post mortem. This Summary should accompany the body of the deceased to the mortuary The deceased patient s family should be advised if the death is being referred to the coroner and the reason why. Booklets for relatives that explain the Coroner s role are available on all wards and can be printed from the Trust Clinical Guidelines website (www.southernguidelines.hscni.net) Medical staff should ensure that the Nursing and Mortuary Teams are made aware if the Coroner has directed a post mortem. This is important as the performance of Last Offices, i.e. the preparation of the deceased for viewing by relatives and subsequent transfer to mortuary, will be affected. The Pathologist may need to see exactly what state the patient was in at the time of death, therefore invasive devices such as endotracheal tubes and central lines etc. must remain insitu unless their removal has been discussed and directed otherwise by the Coroner When the Coroner directs a post mortem, he/she will authorize a police officer to act on their behalf in making the necessary arrangements and investigations, which may include securing evidence if circumstances of the death are suspect In certain circumstances the Coroner may request to see the patient s medical records or may require statements from staff who were involved in the treatment of the patient. If the PSNI is requesting disclosure of the patient s medical records or statements on behalf of the Coroner, please direct these requests to the Litigation Department who will liaise with the Coroner s Office directly If an Inquest is to be held into a patient s death, the Coroner s Office will liaise with the Trust via the Litigation Team who in turn will contact and guide those staff who may be required to provide statements etc. as part of the investigation into the death. Further and more in-depth information in relation to reporting deaths to the Coroner and the Inquest process can be accessed in the Coroner s e-learning presentation on SharePoint; http://sharepoint/med/home/litigation/forms/allitems.aspx
8 6. Reporting death using the incident reporting system On some occasions it will be appropriate to report a death using the Trust s incident reporting system i.e. DatixWeb. Incidents are reported on an electronic incident reporting form (IR1) which is available as an icon on many desktops and from the useful links section on the intranet Relevant to death, such incidents may include: If any member of the multi-disciplinary team had concerns about the management or care provided to the deceased patient. If there is an opportunity to learn from the case Any unexpected/unexplained death in which you are involved in the treatment and care of the patient/service user. A case in which suicide is suspected. If you are unsure about the appropriateness of reporting a death using the incident reporting system please discuss with your clinical manager and/or Directorate Governance lead 7. Recording actions taken after death and review processes It is important that all staff involved in providing care when a patient dies record their actions and events after death in a timely way in the patients case notes The Trust s Checklist following the death of a patient is placed in the front of a deceased patients notes for the attention of the clinical coding staff and records the steps taken after death by a range of staff. Medical staff should complete those sections relevant to their responsibility (appendix 3) Deaths are recorded on the Morbidity and Mortality Review System and discussed at monthly morbidity and mortality meetings
9 8. Useful Contact Numbers Coroners Office: Telephone: 03002007811 Fax: 028 90446801 E-mail: coronersoffice@courtsni.gov.uk Website: www.coronersni.gov.uk The office is staffed weekdays 9.00 am - 5.00 pm Weekends and Public holidays 9.30 am - 12.30 pm (except Christmas day when the office is closed) Outside normal office hours a recorded message will provide contact details for the duty coroner or messages may be left on the telephone answering machine Coroners Service for Northern Ireland information leaflets for relatives and staff are available from the website (click on link above) Mortuary Services The mortuary technicians are a valuable source of advice on matters concerning post-mortem arrangements, release of deceased patients, transportation of bodies and funeral arrangements Craigavon Area Hospital and Daisy Hill Hospital Mortuaries are open 9.00 am- 5 pm Mortuary technician on call can be contacted via hospital switchboard or on 07801 458710 If above number is not available contact the Senior Mortuary Technician, SHSCT on 07742 452394 Litigation Department: Further advice in relation to providing information to PSNI/Coroners Service can be obtained from the Litigation Department: 1 st Floor, Nurses Home Daisy Hill Hospital Newry E-Mail: litigation.department@southerntrust.hscni.net
Appendix 1 10 LIFE EXTINCT RECORD SHEET (To be completed by the Registered Health Professional Verifying Death and filed in the Patient s Medical Record) Patient s Name: Record Number: I have checked for cessation of: Circulatory Respiratory Cerebral No pulse felt No respiratory effort Pupils dilated and not responding to light No heart sounds or asystole on ECG for 1 minute No chest sounds for 1 minute No reaction to painful stimuli I have confirmed the death of the patient named above following the Guidelines for Verifying Life Extinct on: Date: Time: Signature: Designation: Print Name: Contact details: For a Death Verified by Nursing Staff: This patient s death was expected. I will report the death to the doctor on duty at the time of the patient s death, following the Protocol for Actions to be Taken after a Death. Name of Doctor informed: Date: Time: How have you made contact? (Please state) For a Death Verified by a Doctor: I will complete/have completed a Death Certificate (MCCD), following the Protocol for Actions to be Taken after a Death. I am unable to complete a Death Certificate (MCCD), but I have followed the Protocol for Actions to be Taken after a Death, so that the appropriate discussions/contacts have been made. Name of other Professionals/Agencies informed: Name: Date: Time: Name: Date: Time: How have you made contact? (Please state) following death of a patient/client July 2017 (V6)
Appendix 2 Protocol for Actions to be Taken after a Death 11 Ward staff should have death verified by a Doctor or Nurse trained in Verification of Death Record the examination and time of death in patient s notes eg using Life Extinct Record Sheet Inform other Hospital or Community HSC Services of death All of the following decisions will be made by medical staff to determine if the Medical Certificate of Cause of Death (MCCD) can be completed immediately or if further consideration is needed including possible contact with the Coroners Service for Northern Ireland. Do the circumstances of death allow a Medical Certificate of Cause of Death to be completed? See Note 1 NO Does death need reported to Coroner? YES Inform Doctor who meets the legal requirements for completing the MCCD. Log onto NIECR, enrol deceased on Mortality Pathway, complete Initial Record of Death, generate MCCD, print and sign Provide advice to family as necessary regarding the certification/registration of death Body may be transferred to mortuary. MCCD to accompany body or be delivered by a Porter to Mortuary when completed Body released to Funeral Director when MCCD complete. See Note 5 Was death sudden or unexpected? See Note 2. Was death related to a specific cause notifiable to Coroner or on Registrar General s extra-statutory list? See Note 3. Inform the Doctor on duty at the time of death. Doctor will discuss death with senior medical staff to decide if circumstances of death require discussion with Coroner. Record outcome of discussions in case notes/niecr. If the Coroner directs a post mortem to take place, the doctor must complete a Clinical Summary and send to the Mortuary with the deceased. Provide relatives with information about Coroners process and next steps Body may be moved to mortuary to await Coroner s instructions. Mortuary staff will forward Clinical Summary with body to Pathologist in Belfast Was death suspicious? See Note 4. Inform Doctor on duty at time of death to direct next steps e.g. informing Coroner/PSNI The body must not be moved. Do not disturb the scene
Appendix 2 Protocol for Actions to be Taken after a Death 12 Note 1: Who can complete the Medical Certificate of Cause of Death (MCCD)? Note 2: Sudden/unexpected death without suspicious circumstances e.g. person found dead, or initial resuscitation is unsuccessful but circumstances do not raise concerns. Note 3: Death related to specific conditions which need referred to the Coroners Service Note 4: Death involving suspicious circumstances e.g. injuries, apparent suicide, scene of death raises concerns etc. Note 5: Death occurring Out of Hours: Registered Medical Practitioners have a legal duty to provide without delay, a certificate of cause of death if, to the best of their knowledge, that person died of natural causes for which they had treated that person in the last 28 days. In hospital, there may be several doctors in a team caring for a patient who will be able to certify the cause of death. Foundation level doctors should not complete MCCDs unless they have received training. Discussion of a case with a senior colleague may help clarify issues about completion of a MCCD or referral to a Coroner. (DHSSPS, GRO, Coroners Service NI (2008) Guidance on Death, Stillbirth and Cremation Certification) Contact the appropriate medical practitioner who must contact the Coroner. The coroner may direct a post mortem examination by State Pathology. If the coroner is content that post mortem examination is not required a pro-forma letter to the coroner can be completed by the doctor, and the body released to the family s funeral director. If the medical practitioner and coroner cannot immediately deal with the death (e.g. if the coroner needs to wait until the persons normal GP is available to discuss the case) the body should be taken to the designated hospital mortuary. In addition to suspicious and unexpected deaths there is a statutory requirement to refer to the coroner any death due to: Industrial disease such as asbestosis or mesothelioma, during or shortly after an anaesthetic, any injury, including fractures, neglect. Contact the appropriate medical practitioner who must contact the Coroner. The coroner may direct a post mortem examination either by a hospital pathologist or by State Pathology. If the coroner is content that post mortem examination is not required a pro-forma letter to the coroner can be completed by the doctor and the body released to the family s funeral director. If the medical practitioner and coroner cannot immediately deal with the death (e.g. if the coroner needs to wait until the persons normal GP is available to discuss the case) the body should be taken to the designated hospital mortuary. The body must not be moved. Do not disturb the scene. There must be immediate contact with Coroner. When the Coroner directs a post mortem examination, a Police Officer will act on behalf of the Coroner to make the necessary arrangements and investigations. There are a number of arrangements in place to provide medical cover across the Trust out-of-hours and at weekends. When a death occurs during this period, the MCCD should be completed as soon as possible the following morning. At weekends, the doctor who can legally complete the MCCD may not be able to do so until Monday. In these circumstances the Doctor-on-call to whom the death has been reported, having followed this protocol, may authorise the body to be released from the Mortuary to the nominated family Funeral Director using a standard Trust Letter of Release see Doctors authorisation pending MCCD. On call mortuary staff can be contacted to assist this process. This authorisation must be recorded in the deceased s medical record. The MCCD must then be completed at the earliest opportunity and given to the family
Appendix 3 13 following death of a patient/client July 2017 (V6)