Transfer of deceased patients policy

Contents

1 Introduction

This policy sets out roles and responsibilities of trust staff when arranging for the transfer of the deceased into the care of another service provider. In the case of an expected death this will be the funeral director and in cases of unexpected deaths (which is defined as a death that is not expected, anticipated or presumed) this will be the emergency services.

The policy provides a number of best practice procedures that must be followed by appropriate staff.

2 Purpose

The purpose of this policy is to ensure that deceased patients are treated with the utmost dignity and respect.

3 Scope

The contents of this policy are applicable to all staff involved in the care of the deceased across all clinical areas in the trust. St John’s Hospice has additional guidance (care of the adult patient following death (last offices) standard operating procedure (SOP)).

The procedure for issuing the medical certificate of cause of death (MCCD) by an appropriate medical practitioner and performing last offices is not covered by this policy. Some of the activities associated with care of the deceased overlap with those of other policies, and in the case of an expected death staff are to follow the last offices procedure which can be accessed through the Royal Marsden manual for clinical procedures. For St John’s Hospice staff should refer to the ‘Care of the adult patient following death standard operating procedure.

In the case of an unexpected death staff will be guided by the emergency services as to any action they need to take. Specific regulations and guidance cover the hazards and required precautions of such a death that may need to be taken, and as these will be individual to each case. It is not the intention of this policy to provide details.

4 Responsibilities, accountabilities and duties

4.1 Chief executive

The chief executive is responsible for ensuring that there is a structured approach to policy development and that appropriate management is in place to implement and monitor the effectiveness of policies. Although responsibility for policy development and implementation may be delegated to other officers, accountability remains with the chief executive.

4.2 Care group directors and deputy care group directors

The care group directors and deputy care group directors  are responsible for ensuring that policies and procedures are in place that meets legislation and guidance in order to support best practice, effective management, service delivery and the management of associated risks. This remit includes that a policy is in place to ensure that, as is reasonably practicable, the deceased are treated with the utmost dignity and respect and that staff included in the process are provided with information, instruction, and training.

Arrangements for the effective implementation and monitoring of this policy are the responsibility of care group directors and deputy care group directors.

4.3 Service managers or modern matrons

Service managers and modern matrons are responsible for all the staff they manage being aware of and implementing the contents of this policy and to also monitor the effective implementation of the policy.

4.4 Medical and nursing staff involved in the care of the deceased

Nursing staff have a responsibility for maintaining the privacy and dignity of the deceased at all times. Access to the deceased should be limited to those who need to have direct involvement in the care of the deceased.

Clinical staff have a responsibility to ensure the patient’s death is recorded in the clinical record and where appropriate referred to the Coroner (using the recognised process, using the on-line form) and to communicate this outcome to the nursing staff and patient’s relatives.

All staff must adhere to the procedures outlined in the learning from deaths policy the right thing to do for the reporting of deaths on the report a death page via the Ulysses Safeguard IR1 System within the trust.

4.5 Funeral directors involved in care of the deceased

The appointed funeral director is responsible for assisting nursing staff to place the deceased into a body pouch and to then transfer the deceased to a body storage facility.

4.6 Funeral directors involved in transporting the deceased to body storage facilities

The appointed funeral director is responsible for ensuring that deceased patients are conveyed to a body store facility. It is important to remember that this final image of the persons loved one will remain with them forever. The funeral director shall not approach the deceased relatives or carers in order to try to have the deceased relocated or try and speed up the relatives or carers decision-making process or to offer other services. Respect must be maintained to any relatives or other persons wishing to view the deceased.

5 Procedure or implementation

Expected deaths:

• an expected death is the result of an acute or gradual deterioration in a patient’s health status, usually due to advanced progressive incurable disease. The death is anticipated, expected and predicted

Continued compassionate, sympathetic, dignified and quality care for a patient, once they have died, and supporting their relatives is enormously important and a privilege. Allow relatives to spend time with their loved one immediately after death.

Once a patient has died, it is important that the personal care after death is carried out within two to four hours of the person dying, to preserve their appearance, condition and dignity.

Care after death is the care given to the deceased patient which demonstrates respect for the dead. Nursing staff will check that the deceased has been prepared in accordance with the Royal Marsden Hospital clinical procedure chapter 11 for care after death which is the standard that the trust has adopted.

Once the care after death has been performed the patient may be transferred to the trust appointed local funeral director or funeral director of relative’s choice. Nursing staff are responsible for arranging the collection of the deceased in accordance with procedures outlined in appendix A.

Nursing staff must ensure the deceased patient is properly identifiable by ensuring the admission bracelet remains intact and legible and then add the date and place of death to the information on the bracelet. A second bracelet must be placed around the patient’s left wrist or right ankle with the identical information.

Where the deceased patient has a known or suspected infection or has excessive body fluid leakage the care after death procedure must be followed before releasing the body to the funeral director. This includes the use of appropriate body bag to contain any leakage. These bags can be obtained by ordering from the regional distribution centre (RDC).

The body’s core temperature will take time to lower and therefore transferring the deceased to the family appointed or trust appointed funeral director for refrigeration within four to six hours of death is optimum.

5.1 Transport of the deceased to the appointed funeral director

The procedure is shown in appendix A (not St John’s Hospice).

Nursing staff may inform switchboard or reception that the deceased is awaiting transportation to the appointed funeral directors body store and may advise on the use of a body pouch. White body pouches are for normal use and black body pouches are for use if the deceased had a known infection.

Staff involved in the process of handling the deceased must ensure that any other relevant polices, such as infection prevention and control and safe moving or handling operations are adhered to.

Before handing over the deceased to the appointed funeral director, nursing staff must ensure that the deceased is properly identifiable by checking the identification labels attached to the left wrist or right ankle and also must complete the notification of death form (WZT 030) which states the deceased’s name and details, including patient property. The green copy of the notification of death form (WZT 030) must be handed to the appointed funeral director and must go with the deceased to the body store.

Ward staff will provide relatives or appropriate others with an information leaflet that details the options available to them. (appendix A).

St John’s Hospice only, follow the directions above, except the nurse in charge calls the funeral directors direct.

5.1.1 Viewing of the deceased

If the certifying doctor needs to see the deceased in the body store ( for example, to certify the deceased, complete the cremation form or to remove a pacemaker) he or she must request a visit with the appointed funeral director.

Please note, since March 2020, due to the pandemic, the above need to view the deceased to certify death or complete a cremation for has temporarily changed. The doctor must follow the new guidance that is not covered in this policy.

5.1.2 Releasing a body from the appointed funeral directors body store

The family or relatives or those closest to the deceased will appoint their own funeral director. The family appointed funeral director will arrange collection of the deceased from the trust appointed funeral director body store. Collection will usually be within 2 to 3 working days unless there are exceptional circumstances that have been individually agreed with the trust.

5.2 Unexpected deaths

An unexpected death is a death that is not anticipated or related to a period of illness that has not been identified as terminal. When the death is unexpected there is a requirement to begin resuscitation

The coroner must be informed of the death, the deceased patient will be transferred to hospital mortuary by the trust appointed funeral directors and will remain there until advised by the coroner’s office.

5.2.1 Procedure following unexpected death in an inpatient or residential area

If a member of staff has any doubts that a person is not breathing cardiopulmonary resuscitation (CPR) should be commenced immediately and the emergency services called. In the event of an attempted suicide by ligature, the ligature should be removed and an immediate assessment of breathing must be made. If the patient is not breathing cardiopulmonary resuscitation (CPR) should commence immediately and emergency services called.

If the death of a patient is pronounced in the inpatient setting and the patient has not been moved to accident and emergency (A and E) the body should not be touched, it should be covered, and the room locked. No one should enter the room until given permission by the police or coroner’s office.

5.2.2 Preserving evidence and safeguarding the scene

In the immediate aftermath of a patient safety incident steps need to be taken to secure and preserve evidence. This may be particularly true of busy NHS clinical areas that are in constant use by patients and staff and when people are following routine NHS operational practice.

The availability of physical, scientific and documentary evidence may be critical to understanding what has happened and to the conduct of a satisfactory investigation by any agency. Destruction of evidence may also delay putting safety measures in place. It may also lead to a more protracted and complex investigation than would otherwise have been necessary.

It is especially important where a criminal offence is suspected that evidence is retained, since failure to do so may mean that legal proceedings are undermined.

Some healthcare incidents only come to light sometime after the event(s). In this case, the evidence may be less easy to identify and locate. However, the same approach as outlined below should also be followed.

The following practical steps should be taken by trust staff in their efforts to preserve and safeguard evidence, including long after the event. If in doubt about how to do this, seek the advice of the police and, or health and safety executives (HSE) via your line manager. The practical steps are divided into three distinct phases: assessment, protection and communication.

5.2.3 Assessing the nature of evidence

The nurse in charge or manager in conjunction with a senior manager or clinician should take responsibility for assessing what evidence is to hand. This needs to be done from the point of view of how it might help any future investigation. For example, evidence may include:

• records, for example, notes, letters, drug charts
• equipment, for example, instruments, syringes and devices
• clothing including that of patient and staff
• packaging, for example, from drugs and equipment
• the scene more generally, for example, a treatment room
• personal possessions
• body of a patient
• photographs of the scene, with time and date

Such evidence needs to be safeguarded. However, for example, if equipment needs to be moved for the sake of patient safety then a record should be made of this, including, if necessary, by taking a photograph. This will remain the responsibility of the nurse in charge or manager in conjunction with a senior manager or clinician.

Such an assessment needs to be made even when the original incident(s) took place a long while ago. For example, archived medical records may need to be traced, carefully recovered and stored or batch numbers of drugs traced.

5.2.4 Protecting evidence

Once evidence has been identified, all efforts need to be taken to protect it. Such steps may include placing a clinical area temporarily out of bounds to staff and patients but for no longer than necessary. Support staff, for example, cleaners and engineers need to be notified too. An identified person, usually the senior manager, needs to take responsibility for holding any such evidence and for safeguarding it. For example, this might include packaging the evidence carefully or preserving it in a fridge. Receipts should be obtained, and a record kept where any evidence, including equipment, that is handed to another agency.

5.2.5 Communicating

A senior member of staff needs to take responsibility for briefing the Police and, or the HSE about what evidence is available, where it is, who has had access to it and what efforts have been made to protect it.

It is important that the trust, police and, or health and safety executive work together to keep patients, relatives, injured parties and NHS staff informed and to provide support as appropriate. The trust should therefore, as far as possible, identify, agree and follow a liaison strategy for each incident with the police, HSE or the coroner.

5.2.6 Grounds in which trust deaths will be reported to the coroner

• Every situation where the doctor treating the patient is unable to provide a medical certificate of the cause of death (MCCD).
• Where the death may be due to suicide.
• Where the death occurred during or shortly after detention in police or prison custody.
• When death occurs within 24 hours of admission to an inpatient unit.
• Where the cause of death is unknown or unexpected.
• Where the deceased had not been seen by the medical practitioner within 28 days of the death (the 28-day rule) for the condition from which the patient has died or where the certifying doctor did not see (can be virtual) the deceased after death.
• Where the cause of death may have been unnatural, violent or attended by suspicious circumstances.
• Where the death may have been due to self-neglect or neglect by others.
• Where death may be due to industrial disease or industrial poisoning or related to their employment history.
• Where death is due to an abortion.
• Where the death occurred during surgery or before full recovery from the effects of an anaesthetic that may contribute to the death.
• Where there is any evidence of concern following examination of the body.
• Where relatives express any concerns relating to professional management if related to the cause of death (Births and Deaths Registration Act 1953)

The death of a patient who is detained under a section of the Mental Health Act 1983 (as amended 2007) is treated as a death in custody and should also be reported to the Coroner.

5.2.7 Guidelines for wards and residential settings

• Assess the patient using the danger, response, airway breathing and compressions (DRABC) assessment. If the person is not breathing start CPR and ensure:
  • emergency services have been called
  • grab bag collected (in–patient services only)
  • team leader to co-ordinate staff to locate and secure access for the emergency services
  • observe and monitor other patients
• If found hanging or with a ligature tied, remove the ligature using the ligature cutter if required. Do not cut through the knot and preserve ligature for the police. However, do not delay the removal of the ligature to ensure this process is followed.
• Ensure that the cardiac arrest report form is completed and received by the resuscitation service with 24 hours of the incident.
• Ensure that all equipment used is replaced or reset as required immediately after the incident if possible. If equipment is locked away for short period, ensure a process is communicated to gain access to other equipment if needed in the interim and ensure equipment is replaced or reset when freed.
• If absence of life is declared by the paramedics, do not move the body or disturb the environment unnecessarily as there is need to preserve evidence for police and the coroner. The immediate environment, where the death occurred, will become a crime scene. This is normal police practice and staff are asked to support and cooperate with the police where possible).
• Isolate and close off the environment and give consideration and respect to the place of death.
• Take details and incident number from the paramedic. Contact the on-call manager to inform of incident and request initial guidance.
• Inform your local police contact of the unexpected death and request an incident number. This may have been done automatically by the paramedic in attendance.
• Co-ordinate with the on-call manager in attendance the contact plan for relatives, more senior managers as appropriate.
• Identify who, when and how to contact relatives in conjunction with the police and plan how to support those relatives if they wish to attend immediately. Note, it is important relatives are made aware they may not be able to view the body in situ on the ward nor may they be able to see the place of death due to the requirements of the initial investigation. If the police make contact with the family, they will liaise with trust staff.
• Allocate tasks to available staff including ensuring the safety and containment of service users in the area and ensuring appropriate information is disseminated as required.
• Await the arrival of the police, crime investigation officers will normally attend promptly.
• Begin collecting initial statements of events from staff on the ward as soon as practicable before other issues influence memory.
• Ensure all clinical records are collected together, and a full copy is made of all documents including medication prescribing and recording charts.
• Place the original record in a secure place. The attending police officers will probably require a full copy of the clinical record and all materials (see records below).
• Police officers should request information formally using a section 29 of the Data Protection Act (1998) form. If you are in doubt over the release of information staff should contact a senior manager or the on-call manager for the trust or the director on-call out of hours.
• The police officers however would need to take any equipment or materials that may be required as evidence. Any recent communication from the service user, such as letters, drawings etc., may be classified as evidence and as such may be required by the Police or coroner. All material should be included in the collection of notes or reports or documents as above.
• Once the police arrive, staff in charge should work with them to complete the initial investigation and support staff through the process.
• All staff present will be expected to make statements both for the police and the trust investigation. The police may take statements on the ward or they may request staff to accompany them to the local police facility for taking statements using video recording (this is normal police practice) and staff are asked to support the Police where possible.
• The police may also wish to interview staff from earlier contact with a service user on the ward.

5.2.8 Records

The Police and Criminal Evidence Act (PACE, 1984), sets out the legal position regarding clinical patient records in circumstances where a potential crime is being investigated by the police.

Normally the police will take the copy of the clinical record and other materials or documents that has been made by the ward staff. Under section 22, PACE original documents should not be retained by the police if a copy would be sufficient for their purposes.

The police are however empowered to take original clinical patient records from the trust in the following specific circumstances as set out in the PACE. Any such requests for the original records must be referred to and dealt with by the senior or on-call manager in attendance, who may need to refer to a more senior manager or director on-call.

Under the following conditions, Police are empowered to take original clinical patient records:

1. where a search warrant has been issued by a circuit judge
2. under Section 19, PACE, where the police are on trust premises with the trust’s consent and they have reasonable grounds for believing that the original records:
   • have been obtained illegally (as a result of the commission of an offence)
   • are evidence in relation to an offence and there are reasonable grounds to believe that it is necessary to seize the records to prevent evidence being concealed, lost, altered or destroyed
3. Under section 21, PACE, the police are under a duty to supply a copy of the originals seized to the organisation within a reasonable time unless the police have reasonable grounds for believing that supplying a copy would prejudice the investigation.

5.2.9 Working with the police

• Please request that the police officers do not impound the emergency equipment.
• Please note the police officers will treat an unexpected death as a potential crime and will be very thorough and challenging in their initial investigation. Staff will need to be co-operative but it should be recognised that staff will be feeling vulnerable and distressed by events. The on-call manager may wish to request more senior managers who are on call to attend to provide additional support and assistance with the initial investigation by the police.
• Once the police have released the body, contact the appropriate services for transfer of the body from the clinical area (refer to local protocol or guidance). Consider the religious and cultural beliefs of individual as these may require a variety of practices regarding the body.
• The relatives may have specific wishes regarding the treatment and removal of the body. These should be respected wherever possible.
• When the body is removed from the area by an external funeral or religious service provider their identity should be verified, and a record kept of their receipt of the body, the time of removal and contact details.
• In all cases inform the trust chaplain as soon as practicable during working hours of incident.
• Seek police consent prior to collecting clothing and personal effects. Once this is established and all possessions are itemised keep in safe place for eventual return to next of kin. Consider the impact of the condition of any clothing returned to family or friends, for example, damaged or stained clothing. Always return items in a respectful and suitable manner utilising an appropriate container (for example, new pale, coloured storage box with lid; purchased for purpose)

Note, clothing and personal effects may be retained by the police for evidence purposes and the family will need to be informed.

• Once the body has been removed then procedures need to be initiated for staff support and the process of investigation need to be followed as outlined in the trust Incident Management Policy.
• Whenever a patient who is detained under the MHA 1983 (as amended 2007) dies (including those who are either under Section 17 Leave, absent without leave or subject to a community treatment order) the MHA Office must be notified immediately. The nurse in charge must fully complete the statutory notification form: Death of a person liable to be detained providing all details required. The completed form must then be delivered to the MHA office. These actions must be carried out the same day, or if out of office hours, the next working day.

5.2.10 Mental Health Act office

Immediately on receipt of the statutory notification form, the MHA office will forward the form to the Care Quality Commission (CQC), and this must be received by the CQC within three working days of the death.

5.2.11 Guidelines for non-residential settings

• When making a community visit, if there is clear evidence that an incident has occurred and, or life is in immediate danger assess the person using the DRABC assessment and commence CPR, contact the emergency services
• If unable to enter the area where the patient is situated, consider letting emergency services enter first as their personnel are more used to dealing with this type of incident. However, staff should liaise with them regarding known medical history or risks and next of kin details.
• If absence of life is declared, contact your line manager and community team colleagues, including responsible medical officer.
• Be prepared for the emergency services requesting your contact details. You may also be asked to make a statement.
• Consider contacting colleagues for support and advice.
• Consider impact on carer, family or friend and liaise with relevant agencies for their support.
• If situation regarding risk to you as a worker is less clear refer to recent risk assessment and contact next of kin if necessary. If risk to you as a worker is suspected, consider requesting collegial support and police involvement to conduct a home visit.
• Ensure all clinical records are completed, and IR1 and cardiac arrest report form (must be received by the resuscitation service within 24 hours of the incident) submitted on return to base. See section on records above as a request may be made at a later date for clinical patient records.

5.2.12 Guidelines for the senior staff member co-ordinating the incident of discovery of an unexpected death, attempted suicide or near miss to a fatality

• At all times ensure truthful, clear and effective communication with all involved. The trust is required to maintain a duty of candour to all that use our services.
• At all times on a residential area ensure other service users and staff are managed safely.
• Ensure that a contemporaneous record is maintained of all responses made by people, for example, relatives, additional help and also keep a record of those persons in attendance, for example, staff, emergency teams, police, coroner, managers. Keep a written record of when parts of process have been completed and by whom.
• Involve all staff as much as possible to deal with situation.
• Ensure that the trust is compliant with guidelines and check timescales for specific tasks are met.
• Co-ordinate the need for additional staff support through on-call manager and on-call care group director (out of hours), heads of service, modern matron, community service manager, and locality manager as appropriate.
• Liaise with senior managers arriving at the scene, review progress to date and handover lead co-ordinator role if appropriate.

5.2.13 Guidelines for senior manager arriving at a ward or residential incident

• Check with person co-ordinating incident events to date the progress and what assistance they require. Agree who is to continue as lead manager of the incident and allocate tasks accordingly.
• Check with other staff who are co-ordinating the incident and those continuing to provide care how they are coping with events.
• Offer emotional and practical support in the first instance and continue to review staffs emotional and stress levels offering assistance as required. Begin to co-ordinate activity in liaison with the local lead manager for the incident or agree plan if taken over as lead manager.
• If necessary, move staff from other areas to assist in the provision of care to other patients on the ward.
• Assess and continue to review the need to alert other managers or directors to the incident.
• Once police have given permission, enable individual staff to take leave if necessary, recognising that some staff may not be able to work and others would prefer and are better able to cope at work. Where possible ensure staff has made initial statements before leaving the unit and any information they can provide has been obtained regarding the chronology of events.
• Ensure no member of staff, including support staff, leaves without being made aware of the psychological support available and how to access it. In addition it is important that addresses or phone contacts are checked with staff before they leave duty.
• Follow the ward or residential setting guidance regarding record keeping. You may need to refer to a more senior manager or director on call.
• Follow the media communication guidance as required.
• Consider and plan your own support or supervision needs.

5.2.14 Guidelines for informing relatives or carers about an unexpected death

• It is important that information communicated to relatives or carers needs to be well thought out in relation to who tells who, where, what, when and how with specific reference to relatives and friends’ vulnerability, sources of direct support and expectations.
• The content of information given needs to be agreed with colleagues, police and other agencies involved to ensure accuracy and consistency. Trust staff should also check with police or coroner if any information needs to be withheld for evidential purposes. A full record is to be made of the information provided family or relatives and friends.
• Giving bad news is a serious responsibility and needs to be undertaken by a person who feels the most able from their experience, training and the relationship they have with the deceased and their family or friends.
• The need for support and time to prepare and recover from giving bad news needs to be taken into account. This should always be face to face and if it is an unexpected death, would be the responsibility of the police, who can arrange for the death inform message to be undertaken by local officers or force nationally or internationally if required.
• Health staff need to inform relatives or friends of practical arrangements, for example, who to contact with regard to release of body and death certificate, police or coroner. As they may not retain the verbal information provided staff should also provide written information, and a useful resource is the Royal College of Psychiatrists bereavement information pack.
• Relatives may request to see where the person died and where possible they should be supported to do so. However, this may not always be possible in the immediate period following the death due to investigation or cleaning requirements and if this is the case the relative or friend is to be given a full explanation.
• Ensure relatives, friends have contact details of trust chaplain.
• Offer support or signposting facilities for continuing support.
• Offer a referral to IAPT services, if appropriate and if that person is not already involved.
• A member of staff should be nominated to keep family or friends informed of proceedings and important dates for them to contact to check progress, access support, arrange to visit staff or place of death.

5.2.15 Guidelines for giving statement to the police and other statements

• The police will want to interview and take statements from all staff on duty and staff who may have been on duty at other times prior to a death or serious incident. They may take statements on the ward or request staff to be interviewed in their own interview facilities where audio or video recording is available to ensure accuracy.
• You can ask to take someone into the interview with you for support.
• Your manager can advocate for you if you are too distressed, at that point, to make a statement and the Police may be able to make another arrangement to interview you as soon as possible after the incident.
• Managers should co-ordinate the interviewing of staff, ensuring that they are all adequately supported.
• Your statement should be an official, factual and contemporaneous record of events.
• Police will give guidance regarding required completion date for interviews.
• There will be requests for other statements, for example, from the coroner, trust management. Such requests are normally made to the organisation rather than directly to individual staff and you will be asked by your line manager to provide the statement. In the event that the request is made directly to you, you should immediately inform your line manager.
• Someone can help you put together your statement using your own factual recollection.
• You can ask for, or take a copy of, your internal trust statement and other requested statements but you may not be given a copy of your police statement, although you can request it.
• Your statement needs to be a full, factual but concise, report of the incident and events leading up to it.
• The statement must be written on the trust statement template, which you can get from your line manager.

5.2.16 Guidelines for staff support

Patient safety incidents and the ensuing investigation(s) have a considerable effect on the staff involved. Appropriate and timely support should be made available to staff.

• Managers should consider whether they wish to access formal psychological support for their staff following an unexpected death or near miss. Human resources should be contacted for advice on the current procedure for obtaining group support following a serious incident.
• Informal support should be implemented immediately by the manager in charge of the incident, from the time of the incident, and will include checking of staff’s response and immediate support needs.
• Staff are not to leave the area of the incident (or their work base for community incidents) to go home until the manager in charge is assured, they are fit to travel and have resources for support at home if needed. The manager in charge of the incident must give advice and guidance to staff on how to access the appropriate level of support to meet their needs. This may take the form of individual or group supervision from the team at the site of the incident, or access to occupational health services including the staff counselling service. The manager in charge of the incident will inform staff of the options available to support them, including return to work plans, following the incident, and will ensure that support is available for all staff and that all staff have access to support systems to meet their individual needs.
• The manager in charge of the incident will also ensure that staff do not leave the area of the incident (or their work base for community incidents) until the urgent actions required are completed to manage the incident. This may include, for example, providing statements, completion of clinical records or clinical emergency equipment checks and completion of the cardiac arrest report form.
• The manager should arrange debrief of staff following the incident prior to formal review processes and ensure continued staff support in days or weeks to follow. Staff will need safe space to go and talk, receive support and express feelings.
• The needs of staff coming into work after the incident also need to be considered as individual’s needs will vary depending on circumstances, experiences and coping mechanisms.
• Consideration also needs to be given to how staff respond may be influenced by their experience of having been in previous incidents.
• Recognise the need to deal with the effects of badly managed incidents in the past and that some reactions may be related to incidents or experiences.
• Managers should utilise existing support and supervision structures, ensuring that they consider their own psychological and support needs.
• Managers should endeavour to keep staff up-to-date with the incident review and the coroner’s processes, events and decisions.

6 Training implications

There are no specific training needs in relation to this policy. However, staff should be up-to-date with their moving or handling training including the use of roll boards. General awareness training of this policy will be achieved by team meetings and one to one meetings.

7 Monitoring arrangements

7.1 Non-compliance with the policy

• How: Via incident reports.
• Who by: Modern matrons or service managers or clinical leads.
• Reported to: Care groups leadership and quality groups.
• Frequency: Ongoing as the need arises.

7.2 Any service user feedback, complaints or your opinion counts which relate to non-compliance with the standards in this policy

• How: Investigation feedback review.
• Who by: Modern matrons or service managers or clinical leads.
• Reported to: Care groups leadership and quality groups.
• Frequency: Ongoing as the need arises.

8 Equality impact assessment screening

To access the equality impact assessment for this policy, please email rdash.equalityanddiversity@nhs.net to request the document.

8.1 Privacy, dignity and respect

The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, “not just clinically but in terms of dignity and respect”.

As a consequence the trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided).

8.1.1 How this will be met

The content of this policy emphasises the need throughout that deceased patients and their relatives or carers are treated with the utmost privacy, dignity are respect.

8.2 Mental Capacity Act (2005)

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals’ capacity to participate in the decision-making process. Consequently, no intervention should be carried out without either the individual’s informed consent, or the powers included in a legal framework, or by order of the court.

Therefore, the trust is required to make sure that all staff working with individuals who use our service are familiar with the provisions within the Mental Capacity Act (2005). For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act (2005) to ensure that the rights of individual are protected and they are supported to make their own decisions where possible and that any decisions made on their behalf when they lack capacity are made in their best interests and least restrictive of their rights and freedoms.

8.2.1 How this will be met

Not applicable.

9 Links to any other associated documents

• Care after death (on-line edition) Royal Marsden Hospital manual of clinical procedures
• Care after death (last offices), Royal Marsden Manual (opens in new window)
• Safer manual handling operations policy
• Infection prevention and control manual
• Verification of expected death (adults) COVID-19 interim guidance
• Care of the adult patient following death (last offices) SOP
• Resuscitation manual
• Learning from deaths policy the right thing to do

10 Appendices

10.1 Appendix A Procedure for the removal of a deceased patient from the ward area

10.1.1 Procedure for the removal of a deceased patient from an inpatient setting (except St John’s Hospice, Rotherham and North Lincolnshire)

1. Ward staff to contact switchboard or reception on 03000 213 000 (24-hour number) and inform that a funeral director is required. Ward staff to give information or advice sheet to relatives with contact details for funeral director.
2. Switchboard or reception to call the trust approved funeral director, Steadman’s funeral directors on 01302 344444 (24-hour number).
3. Funeral director to confirm attendance at inpatient setting wit anticipated time of arrival.
4. Switchboard or reception to contact ward staff and confirm time of arrival by funeral director.
5. Funeral director to attend site and directed to the back service door if necessary by switchboard or reception.
6. Funeral director to use doorbell at the back door of ward to inform staff of arrival.
7. Ward to handover body to funeral director after completing handover form (reference WTZ030). Funeral director to sign and retain top copy of the form, copy to be kept by ward area.

10.1.2 Rotherham mental health inpatient services, the Woodlands and Swallownest court

In the unfortunate event that we need to arrange for the dignified removal of the deceased to the main mortuary at the Rotherham Foundation Trust Hospital an agreement has been reached with Pritchard’s Funeral Directors to provide this service for us.

Please contact:

Ann or Grayson Radcliffe

Pritchard’s Funerals Directors
88 to 90 Worksop Road
Swallownest
Sheffield
S26 4WH

• Phone: 0114 2875852

Then follow Doncaster appendix A flow chart steps 5 to 7.

There will be a cost incurred and this will be charged per occasion.

Pritchard’s Funeral Directors will provide the removal function only. Families of the deceased will make their own arrangements with the funeral directors of their choice.

10.1.3 North Lincolnshire mental health inpatient services, Great Oaks

Once last offices have been undertaken the patient may be transferred to the funeral director of relatives’ choice.

Then follow Doncaster appendix A flow chart steps 5 to 7.

If no family or if family are not contactable then staff are to contact:

Ashby Funeral Care on 01724 841112 (24 hr number) for the body to be collected.

10.2 Appendix B Advice for the bereaved

10.2.1 Rotherham Doncaster and South Humber NHS Foundation Trust, advice for the bereaved

The death of a close family member or friend will be emotionally distressing. These feelings are normal.

It can be a confusing time following a death and difficult to know what you need to do first, especially if this is the first time you are experiencing it.

If you are the named next of kin, the trusts nursing staff will inform you and will coordinate the issue of documentation and explain the procedures to you.

Please note that preparing the documents takes time as they can only be completed by medical staff who were directly involved in the care of the patient whilst they were in hospital. In some cases, the hospital medical staff will have to refer the death to the coroner. This means they will not be able to issue the medical certificate and the coroner’s officer will give you further information about when you can register the death.

You will be asked to sign formal documents so the belongings and any documents of the deceased can be given to you.

Rotherham, Doncaster and South Humber NHS Foundation Trust do not have any mortuary facilities and has arranged for a local funeral director (Steadman’s Funeral Directors) to provide this service on its behalf. You do not have to use this funeral director and are free to use a funeral director of your choice. Steadman’s in Doncaster can be contacted 24 hours a day via Rotherham, Doncaster and South Humber NHS Foundation Trust switchboard or on 01302 344444.

There are also many people who will need to be informed of the death. You can find more information about letting people know on the internet or from a number of publications or from your chosen funeral director. One internet website that provides independent advice is given below.

Bereavement advice website (opens in new window).

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Document control

• Version: 3.4.
• Unique reference number: 53.
• Approved by: Clinical policy review and approval group.
• Date approved: 3 December 2024.
• Name of originator or author: Nurse consultant, St John’s Hospice.
• Name of responsible individual: Chief nurse.
• Date issued: 18 December 2024.
• Review date: 30 April 2025.
• Target audience: All staff within in-patient areas across the trust.

Page last reviewed: December 18, 2024
Next review due: December 18, 2025

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