NHS Trust

					Care of the Deceased Patient (“Last Offices”)




Trust Reference          B28/2010
Approved By              Policy & Guideline Committee
Date Approved            13 August 2010
Version                  2
Supersedes               Last Offices Policy (2006)
Author / Originator(s)
                         Hannah Jarvis, Specialist Midwife Quality and Safety
                         Michelle Scowen, Education and Practice Development
                         Sister, Medicine

Name of Responsible      Last Offices Policy Group / End of Life Group
Committee / Individual
Review Date              February 2012
                                                        CONTENTS PAGE


 Section                                                                                                                        Page

 1. Introduction .........................................................................................................      3
 2. Scope ...................................................................................................................   3
 3. Roles and Responsibilities ...............................................................................                  3
 4. Care of the deceased patient ………...................................................................                         4
 5. Process for Monitoring Compliance ................................................................                          4
 6. References and Useful Contacts ........................................................................                     4
 7. Development, Consultation and Review .........................................................                              5
 8. Dissemination, Implementation and Access ..................................................                                 6
 9. Legal Liability ......................................................................................................      6



 Appendix One                     Declaring life extinct                                                                            7
 Appendix Two                     Review referral to and contact with HM Coroner                                                    9
 Appendix Three                   Communication with the family                                                                 12
 Appendix Four                    Postmortem examination / taking tissue samples after                                          14
                                  death
 Appendix Five                    Preparation of the deceased adult (“Last Offices”)                                            17
 Appendix Six                     Preparation of the deceased child (“Last Offices”)                                            22
 Appendix Seven                   Transfer to the mortuary                                                                      29
 Appendix Eight                   Risk of infection and use of body bags                                                        33
 Appendix Nine                    Brought in deceased                                                                           36
 Appendix Ten                     Cultural and religious requirements                                                           37
 Appendix Eleven                  Organ and tissue donation                                                                     40




Care of the Deceased Patient (“Last Offices”) Trust ref B28/2010
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1        INTRODUCTION
1.1   This document sets out the University Hospitals of Leicester (UHL) NHS Trust Policy
      for care of the patient who has died (deceased patient) from the point of death until
      arrival in the Mortuary.
1.2   The Policy also outlines the procedures that enable respectful and dignified care
      compliant with regulatory guidance and statutory legislation.
2        SCOPE
2.1   The policy covers all three hospital sites within University Hospitals of Leicester NHS
      Trust (UHL), applies to all staff groups and applies to all deceased patients (adult and
      children).
2.2   This policy does not apply to St Mary’s Birth Centre. Any death at the Birth Centre
      would be classified as an outside case, and the procedures for ‘Brought in Deceased’
      would apply, and the local ‘Maternal Death’ guidelines would be used by the Maternity
      Unit (see related documents) in relation to care of the family and investigations.
2.3   This policy does not cover the care of the non-viable fetus, stillborn baby or neonatal
      death within Maternity or Neonatal Services. The process for managing these cases is
      different and will be contained within a separate policy currently in development.
3        ROLES AND RESPONSIBILITIES
3.1 Chief Nursing Officer
Is responsible for informing the Trust Board of changes in practice and relevant information.
3.2 Registered Medical Staff
Are responsible for examining the deceased patient, declaring and documenting that life is
extinct and assessing whether referral to HM Coroner is required.
Are responsible for completing the appropriate Medical Cause of Death Certificate for non-
Coronial cases.
3.3 Registered Nursing and Midwifery Staff
Are responsible for preparation of the deceased patient, completion of the Death Notification
Form, ensuring availability of personal protective clothing on the ward, initiating transfer to
the mortuary, recording the date and time of release from the ward, informing portering and
mortuary staff of manual handling / infection / other known risks, and providing support for
the bereaved.
3.4 Care Assistants
Under the care of a registered nurse or midwife may prepare the deceased patient for
transfer to the Mortuary; management of the deceased’s property in accordance with the
“Management of Patient Property Policy and Procedures”.
3.5 Portering Staff
Sole responsibility for the transfer of the deceased, maintaining the safety, dignity and care
of the deceased whilst in transit, as well as cleaning and disinfecting equipment after use.
3.6 Ward Clerks
Responsible for transferring the deceased patient’s case notes to the Bereavement Services
office; management of the deceased’s property in accordance with the “Management of
Patient Property Policy and Procedures”.
3.7 Duty Managers
Identification and administration at the point of release out of hours.




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3.8 Mortuary department staff
Provision of personal protective equipment in the mortuary, disinfectant and spill kits for their
use.
3.9 Premises department
Provision of manual handling training for portering staff, provision and maintenance of
equipment.
3.10 Funeral directors
Loading and unloading of their vehicles, completion of Mortuary Reception Register.


4        CARE OF THE DECEASED PATIENT
Staff must follow the following procedures for the care of the deceased patient.
 Appendix One             Declaring life extinct
 Appendix Two             Review referral to and contact with HM Coroner
 Appendix Three           Communication with the family
 Appendix Four            Postmortem examination / taking tissue samples after death
 Appendix Five            Preparation of the deceased adult (“Last Offices”)
 Appendix Six             Preparation of the deceased child (“Last Offices”)
 Appendix Seven           Transfer to the mortuary
 Appendix Eight           Risk of infection and use of body bags
 Appendix Nine            Brought in deceased
 Appendix Ten             Cultural and religious requirements
 Appendix Eleven          Organ and tissue donation


5        PROCESS FOR MONITORING COMPLIANCE
5.1      Key performance indicators / audit standards
The deceased patient will be identified correctly; the Death Notification completed accurately
and transfer to the Mortuary will be appropriate and timely.
5.2      Process and timescales for monitoring compliance
To audit compliance with this Policy the Mortuary Manager will undertake a monthly audit of
the reception and identification of the deceased patient.
Audit results will be presented on a regular basis to the Mortuary Management Team and
escalated through the Divisional Management Team as appropriate.


6.       REFERENCES AND USEFUL CONTACTS
6.1      Related Documents
Death of a Patient:                                                            DMS Document: 26526
Policy for the handling and release of the                                     DMS Document: 57132
deceased and products of conception outside of normal hours.
Guidelines Following a Death of a Child:                                       DMS Document: 31010
Management of Maternal Death:                                                  DMS Document: 16691
Sudden Unexpected Death in Infancy / Childhood                                 DMS Document: 10142
Management of Patient Property                                                 DMS Document: 38753

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Consent to Post Mortem Examination Policy                            DMS Document: 56600
Verification of expected death of adult patients by                  DMS Document: 32477
by Registered Nurses

6.2      Links
Muslim Burial Council of Leicestershire
http://www.mbcol.org.uk/

Undertakers of Leicestershire
http://www.uk-funerals.co.uk/funeral directors/leicestershire.html



6.3      Contact telephone numbers
*HM Coroner for Leicester and South Leicestershire:            0116 225 2535
*HM Coroner for North Leicestershire and Rutland:              01509 268 748
(*normal working hours only)
Muslim Burial Council of Leicester (MBCoL)
Adam Sabat:                07801101786
Mohamed Omarji:            07855931911
Zubeir Hassam:             078779610649
Salim Mangera:             07833533490

Jewish Community
Rabbi Shmuel Pink          Contact via hospital switchboard

7        DEVELOPMENT, CONSULTATION AND REVIEW
The Policy was first approved in 2006 and has been reviewed by a multi-professional group
consisting of representatives from the UHL Nursing and Midwifery, Head of Chaplaincy,
Bereavement Services, Mortuary, Pathology and Portering.

The ‘Last Offices’ review group will be responsible for reviewing the policy at regular
intervals, six months after approval initially and then no more than two years apart (or earlier
in response to changes in national guidelines). Progress will be reported through the UHL
End of Life Board. The contributors to the Last Offices Review Group include, in alphabetical
order, the following:
Andrew Bootles, Senior Deputy Head Porter
Mark Burleigh, Head of Chaplaincy and Bereavement Services
Steve Cramphorn, Site Services Manager SERCO
Alison Emmerson, Senior Bereavement Services Officer
David Gorrod, Patient Advisor
David Halford, Premises Support Manager
Jill Hardman-Smith, ICP Facilitator / Palliative Care Nurse
Nicholas Howlett, Manual Handling Service Leader
Diane Jarvis, Patient Safety Advisor
Hannah Jarvis, Specialist Midwife Quality and Safety
Emma Johns, Ward Sister
Euan Johnson, Premises Support Manager

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Islwyn Jones, Senior Nurse Infection Control
Lucy Joyce, ICP Facilitator
Peter Juby, Laboratory Manager
Jane Lee, UHL Palliative Care Team Manager
Paul Leete, Midland Co-op Funeral Services
Sharon Maughan, Senior Bereavement Services Officer
Eleanor Meldrum, Assistant Director of Nursing
Keith Osborn, Head Porter
Fiona Pimm, Senior Nurse Infection Control
Matthew Rogers, Mortuary Manager
Michelle Scowen, Education and Practice Development Sister
Sue Stephenson, Senior Specialist Nurse
Lynn Stokoe, Education and Practice Development Lead
Frances Wood, Patient Safety Manager


8         DISSEMINATION, IMPLEMENTATION AND ACCESS
The Document will be available on the UHL Document Management System (DMS) and will
be circulated to all staff with responsibilities for the care of the deceased patient.

9         LEGAL LIABILITY
The Trust as an employer will assume vicarious liability for the acts of its staff, including
those on honorary contracts, providing that:
      •    Staff have undergone any suitable training identified as necessary under the terms
           of this policy or otherwise.
      •    Staff have been fully authorised by their Line Manager and their Directorate to
           undertake the activity.
      •    Staff fully comply with the terms of any relevant policies and/or procedures at all
           times.
      •    Only depart from any relevant Trust Guidelines providing that such departure is
           confined to the specific needs of individual circumstances. In healthcare delivery,
           such departure shall only be undertaken where, in the judgement of the responsible
           clinician it is fully appropriate and justifiable – such decision to be fully recorded in
           the patient’s notes.
Staff are recommended to have Professional Indemnity Insurance cover in place for their
own protection in respect of those circumstances where the Trust does not automatically
assume vicarious liability and where Trust support is not generally available.
These circumstances will include, but are not limited to, those situations where the above
criteria do not apply or are not observed, private treatment (which may include Samaritan
Acts) and criminal investigations. Suitable Professional Indemnity Insurance Cover is
generally available from the various Royal Colleges and Professional Institutions and Bodies.
For further information contact Assistant Director (Head of Legal Services) on ext 8960.




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       DECLARING LIFE EXTINCT
                                                                                              Appendix One
                                                                         Care of the Deceased Patient (“Last Offices”)




1. Declaring Life Extinct:
1.1   It is essential that all deaths are verified prior to transfer to the mortuary.
1.2   Declaring Life Extinct is a clinical process sometimes known as ‘verifying death’
      rather than a legal one. Any member of medical or nursing staff who has been
      trained to verify death may assess the patient for signs of life and declare that
      the patient has died, in accordance with the “Verification of Expected Death of
      Adult Patients by Registered Nurses Policy”.
1.3   Procedure:
      a) Systematically assess the patient for signs of life:
                -    Check the patient does not respond to painful stimuli
                -    Check there is no cardiac output
                             palpate carotid or femoral pulse for a minimum of 1 minute
                             use a stethoscope for a minimum of 1 minute to ensure there are no
                             heart sounds present)
                -    Check the absence of respiratory effort
                             Looking and feeling for the rise and fall of the chest, at the same time
                             listening for any signs of respiration for a minimum of one minute
                             Checking there are no breath sounds present by listening with a
                             stethoscope for a minimum of one minute
                -    Check both pupils are fixed, dilated and unresponsive
                -    Check both pupils for no reaction to light with a torch
      b) Document time of death in patient’s case notes.
  1.4 Verification of death should ideally take place in the ward prior to the transfer
  of the deceased patient to the mortuary. If this is not possible, medical or specially
  trained nursing staff should:
         a)         During working hours: contact bereavement services / mortuary staff and
                    attend the mortuary
         b)         Out of hours: Medical staff to contact Duty Manager via switchboard.


2. Assess whether death is suspicious:
2.1      Death is considered to be suspicious where a person’s death is not anticipated or
         when a body is found and it is immediately apparent that something untoward has
         occurred to bring about that person’s demise, whether accidental, self-inflicted,
         inflicted by others, or medically unaccountable.
2.2      In these cases, the scene must be managed carefully to preserve evidence and
         senior Trust staff informed immediately (Line Manager and Duty Manager).
         Detailed procedures are listed below.




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3. Actions to be taken for suspicious death:
3.1      What should be done?
         a) Immediately call the Crash Team and commence resuscitation. If resuscitation is
            not successful:
         b) DO NOT TOUCH ANYTHING
         c) Do not touch anything on the body, the surrounding area or personal effects. If the
            is any evidence of drug abuse do not touch or move the evidence. If the Crash
            Trolley is not implicated, in the incident it may be removed and restocked.
         d) Screen off the area, wherever possible, to maintain the dignity of the deceased
            patient.
         e) Inform Line Manager / Duty Manager immediately and follow their instructions.
         f)   ALL equipment must be kept in situ. This includes intravenous lines, central lines,
              arterial lines, catheters, chest drains and any disposable equipment. A list of all
              equipment present at the time of death must be completed and filed in the case
              notes.
         g) DO NOT PERFORM LAST OFFICES; do not wash the deceased, change their
            clothes or bed linen.
         h) The deceased patient may be collected by HM Coroner’s removal service. If this
            does not happen the Line Manager / Duty Manager will authorise transfer to the
            Mortuary; place the deceased patient in a body bag and document clearly on
            Death Notification Form.
         i)   Preserve the scene of death until authorised to clear it by the Line Manager / Duty
              Manager or Police even after the deceased patient has been transferred to the
              Mortuary.
3.2      Who should be informed?
         a) Inform patient’s Consultant immediately, if deceased was an in-patient.
         b) Appropriate manager(s) within the department.
         c) Next of Kin / Relatives should be informed and supported (see “Communication
            with the Family”). Communication with the next of kin / relatives should be (in
            hours) via the Clinical Business Unit Lead Nurse or Medical Lead, or (out of
            hours) via the on-call Third Tier manager. It is important to be clear about the
            procedures and further investigations that are conducted in suspicious
            circumstances.
         d) Immediate reporting to the Divisional Quality and Safety Manager, Corporate
            Safety Team and Duty Manager within normal working hours. They will in turn
            inform relevant members of the Corporate Team.
         e) Outside of normal working hours the Duty Manager will cascade this information
            as appropriate to the on-call Managers and Director on call, who will ensure that
            the Coroner is informed by the clinicians at the appropriate time.
         f)   It is not the remit of frontline staff to report such incidents to external agencies
              (including but not limited to the police); this responsibility shall be reserved to
              senior management dependent on the nature of the incident.
         g) The Corporate Safety Team will ensure that other interested parties external to
            the Trust are informed, as appropriate, such as the Strategic Health Authority,
            Health and Safety Executive, National Patient Safety Agency and, if appropriate,
            the relevant PCT.
         h) If the deceased patient is below the age of 18 years, the Safeguarding Team must
              be informed via Switchboard immediately.

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       REVIEW REFERRAL TO AND
      CONTACT WITH HM CORONER                                                                Appendix Two
                                                                      Care of the Deceased Patient (“Last Offices”)




1. Referral to H.M. Coroner
If the patient dies out of hours but there is no need for urgent release, the Coroner should be
contacted the next working day as normal.

2. Reporting Deaths
Registered Medical Practitioners are required by law to report deaths to H.M. Coroner if any
of the following apply:-

2.1   The deceased was not attended by a Registered Medical Practitioner during his last
      illness.
2.2   The deceased was not attended by a Registered Medical Practitioner immediately after
      death or within 14 days preceding death.
2.3   The death is sudden, unexplained, violent and unnatural or attended by suspicious
      circumstances.
2.4   The cause of death is unknown, or if there is any doubt regarding the cause of death.
2.5   The deceased is a child in foster care.
2.6   The death occurred in the following circumstances:
           a) After an operation or invasive procedure necessitated by injury or disease within
              the preceding 12 months.
           b) During an operation.
           c) Before recovery from the effects of any anaesthetic.
           d) The death may be related to a medical procedure or treatment whether invasive
              or not
2.7   When it is believed there is a possibility the death was due to neglect, ill-treatment self
      neglect or abortion.
2.8   Still birth where there was any possibility of the child being born alive.
2.9   The deceased was detained under the Mental Health Act.
2.10 Where it is believed the death is due to any kind of poisoning including alcohol, and
     drugs either taken in therapy, in addiction, in suicide or accidentally.
2.11 When death occurs either directly or indirectly, following an injury or accident, including
     those associated with road traffic accidents of any date. Injuries may include burns,
     scalds, choking or other effects of foreign bodies, suffocation, concussion, wounds
     drowning and effects of heat or cold, sunstroke, lightning, fractures, electricity, electric
     shock.
2.12 The deceased is a person detained in prison or in any other place of detention, or is a
     person who has recently been in police custody (release within 24 hours of death).
2.13 The deceased was in receipt of a disability pension/ war pension.
2.14 When the death is believed to be due to an industrial injury, conditions associated with
     service in H.M forces, or due to actual or suspected industrial diseases or industrial
     poisonings as detailed below:-
         a) Diseases of the Lungs:-


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             •    Any form of Pneumoconiosis, Asbestosis and Mesothelioma, Berylliosis.
             •    Any Lung Disease qualified by an occupational term (e.g. Farmers Lung)
         b) Other Diseases if Occupationally Related e.g.
             •    Any form of barotrauma, Weils disease, hepatitis B or C, Anthrax
             •    Malignancy related to any form of industrial exposure
             •    Any form of industrial toxicity or poisoning.

2.15 At the request of the H. M. Coroner for Leicester and South Leicestershire, certain
     treatment-related infections which are considered to have caused or contributed to
     death must be referred to her office. In most cases, there will be no requirement for an
     autopsy, but the final decision rests with the Coroner.
      The following types of cases should be referred:
         •   Within 24 hours of admission to hospital
         •   Deaths due to hospital acquired Clostridium difficile infection
         •   Deaths due to hospital acquired MRSA infection
         •   Deaths due to infection following iatrogenic neutropenia
         •   Deaths due to infection following immunosuppressive therapy for transplantation,
             autoimmune or other disease.
         •   Deaths due to infection of in-dwelling medical equipment.
         •   Any other case where medical treatment may have contributed to the
             development of a fatal infection
         •   Signs of life before 24 weeks of pregnancy - discussion of these cases with the
             UHL legal team and coroner is advised.

2.16 Any maternal death should also be referred to the Coroner, but in many cases a death
     certificate may be written and no post mortem will be requested.

The Coroners Office can be contacted by telephone on 0116 2252534 or 0116 2252535.

3. Out of Hours contact with the Coroner
HM Coroner has provided guidance for medical staff on Out of Hours contact with the
Coroner that has been agreed with the Medical Director (August 2010).
Certification and Release of Deceased Out of Hours
Medical Staff should NOT attempt to make contact with the coroner in respect of body
release. Medical staff should contact the Duty Manager for advice and where appropriate
any initial contact MUST be made by the Duty Manager. Where a Duty Manager is busy this
does not mean that medical staff are thereby at liberty to contact the coroner.
Only the Duty Manager may contact the Coroner and in deciding whether to make contact
the Duty Manager shall consider the following stipulations laid down by the Coroner:-
1. If the urgent release of the body of a deceased patient is required out of normal working
   hours where the doctor believes that the death requires referral to the Coroner, contact
   with the Coroner can be made via the UHL Duty Manager ONLY. The Coroner can be
   contacted by the Duty Manager at the following times only:-
      a. Out of Hours Weekdays between the hours of 4pm and 9pm.
      b. Weekends and Bank Holidays between the hours of 8am and 9pm.
There are no exceptions to this rule irrespective of the personal beliefs or age of the
deceased.

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2. If, following an out-of-hours consultation with the Duty Manager, the Coroner agrees that
   the Medical Cause of Death Certificate can be issued by a doctor, the doctor will be
   asked to provide contact details of the deceased’s next of kin. This is so that the Coroner
   can confirm with the next-of-kin that they are satisfied with the cause of death before the
   paperwork is issued (Pink A) to the Leicester Registrar. A death can not be registered
   until the Coroner’s form has been received by the Leicester Registrar.

3. If the patient dies out of hours but there is no need for urgent release, the Coroner should
   be contacted the next working day as normal.

4. If the deceased was in custody or was detained under the Mental Health Act, or DoLS the
   body cannot be released and the police must be informed via the Duty Manager.

It is accepted that medical staff may come under pressure to contact the coroner from the
families of deceased. However the coroner has clearly stated what she requires of us and
we need to be very clear with families that we will adhere to the coroner’s requirements.

Child Death

If a child dies in hospital and Medical Staff want to seek advice on how to proceed on matters
other than body release (eg removal of tubes etc) then contact can be made with the coroner
at the same times as stipulated for Certification and Release of Deceased Out of Hours
i.e.
     a) Out of Hours Weekdays between the hours of 4pm and 9pm.
     b) Weekends and Bank Holidays between the hours of 8am and 9pm.

Medical Staff should contact the Duty Manager to obtain the coroner’s contact details.

Organ Donation

The Coroner takes a different approach where the deceased is a potential organ donor and
under these circumstances the Coroner can be contacted direct 24hrs a day, 7 days a week
to discuss the donation of the deceased’s organs. The Coroner has provided the following
guidance:

1. Approval for donation must be obtained from the Coroner if the donor’s death needs
referral to the Coroner.

2. There is no requirement for medical staff to contact a Duty Manager in cases of organ
donation.

3. Contact with the Coroner is not to be left solely to the Donor Coordinator Team.

4. Unless the death has been reported to the Coroner, it will not be possible for the Coroner
to give consent and donation cannot occur. Accordingly the treating Doctor is to also contact
the Coroner in the first instance

Anyone requiring further information on this should contact the Assistant Director – Head of
Legal Services on extension 8960.




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 COMMUNICATION WITH THE FAMILY
                                                                                                   Appendix Three
                                                                              Care of the Deceased Patient (“Last Offices”)



1. Introduction
1.1      Relatives always remember the way in which the news of the death of a loved one
         was broken to them. The way that the news was given and subsequent actions may
         influence the bereavement process.
1.2      Breaking bad news over the telephone is never easy but sometimes it is unavoidable.
         It is important to tell the truth when giving such sensitive information over the phone,
         and try and support that person as much as possible.

2. Breaking bad news
2.1   Prior to informing the next of kin that a patient has died, it is essential to confirm the
      correct information i.e. that the correct patient and their relatives are identified.
2.2   For those patients on ‘The End of Life Care Pathway’ it should already be established
      how the next of kin wish to be contacted during the night. Therefore breaking bad news
      should be expected.
2.3   In circumstances of sudden death, informing the next of kin that an accident or sudden
      illness has occurred and requesting their presence at the hospital can be justified. The
      intention is to prevent harm and maximise benefit by imparting news in a supportive
      environment. It may be more appropriate to involve the Police, if not already involved,
      and ask them to visit the next of kin.

3. Breaking bad news over the telephone

3.1   Consider the following before making the decision to break bad news over the
      telephone:
                -   Whether it is appropriate to break bad news over the telephone
                -   Whether you are the most appropriate person to deliver this news
                -   What knowledge the next of kin / bereaved may have about the patient’s condition
                    prior to death
                -   When that person last saw the patient
                -   The age and health of the person
                -   How far the next of kin may have to travel to reach the hospital
                -   Language barriers; speech, hearing or language
                -   Whether they wanted to be contacted over the telephone or during the night / have
                    any previous discussions taken place?
3.2   Once the decision has been made to break the bad news over the telephone:
                -   It is essential to confirm the correct information, i.e. that the correct patient and their
                    relatives are identified.
                -   Do not imply or state that the patient is alive at the time of the call if they are not, as
                    omitting truth or facts may later appear suspicious.
                -   Make sure you will not be disturbed or interrupted when making the call
                -   Check their location and whether they are alone
                -   State who you are when calling and whether you have met or spoken to them
                    previously

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                -   Acknowledge the difficulty of having this conversation over the phone as this will
                    reduce the negative impact and serve as a warning shot
                -   Be direct and clear with the information you give. Confirm that death has occurred –
                    use the words ‘is dead’ or ‘has died’
                -   Be honest if they ask if the patient has died and give a brief description of what
                    happened
                -   Make sure you have time to listen and answer any question that the next of kin may
                    have
                -   Offer that they can phone back later with any questions or queries
                -   Do they want to see the deceased patient? Not all people do. Are other relatives /
                    friends / important others likely to want to visit?
4. Care of the deceased patient’s family

The experiences of those grieving can very much affect the grieving process in the short and
long term. The response of relatives and important others are not always going to be the
same and may vary significantly. It is important that staff respect and are sensitive to the
grief response of relatives and important others.
4.1   It is essential that a lead is taken from the family with regards to their needs. They may
      have religious or cultural needs that they wish to demonstrate, even if the patient does
      not have a preferred religion. They may ask to see a member of the chaplaincy or ask
      to contact a specific person. It is appropriate to ask if they wish anyone else to be
      contacted.
4.2   In each circumstance, where possible privacy should be offered.
4.3   Family and important others may not wish to see the deceased.
4.4   Family may wish to speak to a Doctor or ask questions regarding the time before the
      patient’s death e.g. ‘who was with them’ and ‘were they in pain’.
4.5   Do not use medical language. At such times a lot of information is not absorbed by
      relatives and it may be necessary to reiterate the information or give them written
      information.
4.6   Family members should not be rushed to leave the ward and refreshments should be
      offered.
4.7   The appropriate UHL bereavement booklet should be given to the family, copies of
      which are available from Bereavement Services.
5. Viewings
5.1      Following the death of a loved one the relatives will be required to make an
         appointment with Bereavement Services the next working day. During the visit they
         will be given the opportunity to view the deceased patient.
5.2      Requests for viewings outside of normal working hours must be referred to the
         Hospital / Duty Manager. Preparation of the deceased patient for viewings is not part
         of the porter’s duties and nursing staff must arrange viewings through the porters.
5.3      The use of the mortuaries viewing facilities will be dependant on availability.
         Bereavement Services or the hospital/duty manager will establish availability with
         mortuary staff before confirming the viewing to the relatives.
5.5      All viewings must take place in the mortuaries and not on the ward. The only
         exception to this is the Maternity Unit(s) where the condition of the mother may
         prevent her from attending the mortuary. In this situation, a midwife or nurse may
         accompany the porter to the mortuary to transport the baby back to the Maternity Unit
         for viewing. Please refer to Appendix Seven Transfer to the Mortuary.
__________________________________________________________________________

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    POSTMORTEM EXAMINATION /
   TAKING TISSUE SAMPLES AFTER
                                                                                          Appendix Four
              DEATH                                                 Care of the Deceased Patient (“Last Offices”)



Please see “Taking Samples After Death / Removal of ET Tubes” B51/2009.

TAKING SAMPLES AFTER DEATH WHEN NOT PART OF A POST MORTEM
EXAMINATION

1.1      The Human Tissue Act (2004 - HT Act) governs post mortem activity, including any
         tissue samples that are taken after death.

1.2      The HT Act defines this as any sample which may contain cells (including urine), and
         therefore includes every possible sample which may be taken. Locks of hair are not
         covered by the HT Act.

1.3      The HT Act is enforced by the Human Tissue Authority (HTA) and failure to comply
         can result in withdrawal of HTA licence, a fine or up to three years imprisonment.

1.4      At UHL, the situation is that:

         1.4.1    NO sample can be taken after death without explicit consent from a close
                  relative, usually the next of kin.
         1.4.2    Samples can only be taken on premises with HTA Pathology Licence
         1.4.3    Individuals taking such samples must be trained to do so: this would usually
                  be medical staff but could include nurses and midwives.
         1.4.4    Samples can only be used for the purpose specified (usually diagnosis of
                  disease or identification of genetic abnormalities)

1.5      Such tissue samples will almost always be taken as part of a formal post mortem
         examination (see UHL Policy for Post Mortems). However, on rare occasions such
         samples may be required out with a post mortem examination. This would usually
         occur when a patient dies unexpectedly, or dies before important diagnostic samples
         can be taken, and where delaying the taking of the sample until a post mortem can be
         organised may reduce the chance of a useful result (e.g. cytogenetics). This would
         almost exclusively occur in child deaths in the context of sudden unexpected death in
         infancy / childhood.

1.6      Samples can only be taken in areas specified on the HTA Pathology Licence, which
         are as follows:

         1.6.1    The mortuaries at LRI, LGH and GH
         1.6.2    Emergency Department LRI
         1.6.3    CICU LRI
         1.6.4    PICU GH
         1.6.5    Labour Wards LRI and LGH
         1.6.6    Neonatal Units LRI and LGH

1.7      No samples are to be taken after death in areas that are not specified on the HTA
         Pathology Licence, as listed in 4.6.

         1.7.1    If samples may be required to be taken in patients who die in other areas, the
                  body must be moved to the mortuary before any sample can be taken and the
                  duty mortuary technician should be called.



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1.8      The Procedure for taking samples after death out with post mortem examination is
         listed on the next page.

Procedure for taking samples after death out with post mortem examination.

1) Wherever possible important diagnostic samples to be taken before death.

2) If the deceased patient is likely to require a post mortem, then samples should be taken
   during the post mortem.

3) If the clinical team believes that a sample should be taken immediately after death, and
   post mortem is not required or it is believed that waiting for a post mortem may
   jeopardise the value of a sample (e.g. cytogenetics), then samples can be taken after
   death.

      3.1. As a general rule, the value of cytogenetic testing reduces with time after death, but
           a short delay will have little impact on the result.

4) Samples can only be taken in areas specified on the HTA Pathology Licence, which are
   as follows:

      4.1. The mortuaries at LRI, LGH and GH
      4.2. Emergency Department LRI
      4.3. CICU LRI
      4.4. PICU GH
      4.5. Labour Wards LRI and LGH
      4.6. Neonatal Units LRI and LGH

5) If there is any doubt over the need for a sample then the advice should be sought from a
   senior member of the clinical team or one of the individuals named under ‘responsibility’
   on the next page.

Consent:

1) Consent must be fully informed.

2) Consent will usually be given by the parent or guardian and should be documented on
   either:

      2.1. Post mortem consent form
      2.2. Treatment consent form

3) In the context of a coronial post mortem, consent is given by the coroner.

4) The HT Act provides a detailed hierarchy on who can give valid consent:

      4.1. Spouse or partner (including civil or same sex partner) The HT Act states that, for
           these purposes, a person is another person's partner if the two of them (whether of
           different sexes or the same sex) live as partners in an enduring family relationship.
      4.2. Parent or child (in this context a child may be of any age and means a biological or
           adopted child)
      4.3. Brother or sister
      4.4. Grandparent or grandchild
      4.5. Niece or nephew
      4.6. Stepfather or stepmother
      4.7. Half-brother or half-sister
      4.8. Friend of long standing

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5) An individual lower in the hierarchy cannot over-rule consent of someone higher on it, but
   if there is disagreement in a family over whether or not a sample should be taken, then
   clinicians are advised to carefully consider the situation before proceeding in taking a
   sample.

6) The reason for taking the sample and exactly what samples have been taken must be
   documented fully in the medical case notes.

7) Consent must also include the wishes of the family with regard to disposal of any residual
   tissue that may remain after analysis has taken place. The family may wish surplus tissue
   to be re-united with the body (which may delay a funeral), to be cremated or disposed of
   by incineration.

8) Tissue samples should be no larger than required for the appropriate test to be carried
   out.

Sudden Unexpected Death in Infancy / Childhood (SUDIC):

1) For child deaths on any ward, PICU, NICU, the Postnatal Wards and ED: See detailed
   procedures for taking samples in the SUDIC protocol (DMS number 10142).

Responsibility:

1) The HT Act requires that named individuals have responsibility to ensure that this
   process complies with the HT Act.

    1.1. The Designated Individual for UHL, with legal responsibility for compliance with the
         HT Act, is Dr Angus McGregor, Head of Service Histopathology.

    1.2. Designated Persons, who manage services in line with the requirements of the HT
         Act, are:

         1.2.1.   Dr C Read                   Head of Service Emergency Department
         1.2.2.   Dr A Currie                 Consultant Neonatologist
         1.2.3.   Mrs C Oppenheimer           Consultant Obstetrician
         1.2.4.   Dr J Whitelaw               Consultant Paediatric Intensivist (GH)
         1.2.5.   Dr M Green                  Clinical Director Children’s


2) ANY member of staff seeking consent or taking a sample is personally responsible for
   ensuring compliance with this policy.




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  PREPARATION OF THE DECEASED
      ADULT (“Last Offices”)                                                                  Appendix Five
                                                                       Care of the Deceased Patient (“Last Offices”)




 Action                                                                    Rational


 Do not follow this procedure if the death is considered                   Evidence must be
 suspicious or has been referred to HM Coroner.                            preserved for a forensic
                                                                           investigation into the
 The deceased patient may be collected from the place of death
                                                                           cause of death for the
 by HM Coroner’s removal service. If this is not required
                                                                           Policy and / or HM
 authority for removal must be given by the Line Manager or
                                                                           Coroner.
 Duty Manager and the deceased patient placed directly into a
 body bag and transferred to the Mortuary.
 The only other action that should be taken is to ensure correct
 identification bands are on the deceased patient and document
 any equipment in use (including batch numbers if available).


 1.         Equipment list:                                                Not applicable
            -   Disposable plastic aprons and gloves
            -   Mouth care equipment
            -   Identification bands (x2)
            -   Disposable gown or patient’s own cloths or nightwear
            -   Bowl, soap, towel and disposable cloths, comb
            -   Micropore tape
            -   Clinical waste bag
            -   Valuable property bag and green property bag
            -   Clean sheets
            -   Sharps box
            -   Clean sheet

            Extra equipment may include:

            -   Dressings, bandages, gauze, wicks
            -   Cannula bungs
            -   Body bag



 2.         Put on gloves and apron.                                       Standard (universal)
                                                                           precautions must be
                                                                           followed for any contact
                                                                           with bodily fluids.
                                                                           To reduce risk of
                                                                           contamination and
                                                                           cross-infection.

            Lay the patient on his/her back with assistance of other       To maintain the patient’s
 3.                                                                        dignity and for future
            member/s of staff (adhering to UHL Manual Handling             management of the body, as
            Procedures and Safer Handling Policy).                         rigor mortis occurs 2-6 hours
                                                                           after death, with full intensity
                                                                           within 48 hours and then
                                                                           disappearing within another
                                                                           48 hours.

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            Ensure a pillow is placed underneath the head                     To assist with drainage
                                                                              from the head and
            Support the jaw by placing a pillow or rolled-up towel on         promote jaw closure
            the deceased’s chest underneath the jaw.

                        Do not tie jaw unless otherwise guided by
                     family members.

            Remove only mechanical aids such as syringe drivers, etc,         Lines removed after
            and secure the sites with gauze and tape to syringe driver        death leak profusely.
            sites and document actions in nursing documentation. All
            lines must be left in situ and capped off with a blind end
            cannula bung.

            ET tubes must not be removed where death is sudden,               Instruction received from
            suspicious or referred to the Coroner.                            HM Coroner regarding
                                                                              the removal of lines and
            ET tubes may be removed if it is clear when death is              tubes.
            verified that referral to the Coroner is not required. If there
            is any doubt the ET tube must be left in place until referral
            is clarified.

            Ensure family are aware ET tube has been left in situ, and
            reassure them they will be able to view deceased without
            ET tube when Coroner’s investigations have been
            completed, either in the Mortuary viewing room or at the
            Funeral Directors.


            Ensure that relatives are fully prepared prior to viewing of      To alleviate distress
            the deceased’s body as to what they will observe in               caused by medical
            relation to lines etc.                                            devices left in situ.

            Straighten the lower limbs. Raise the hands up onto the           To prevent haemostasis
            chest / abdomen.                                                  in the hands which can
                                                                              cause permanent and
                                                                              unsightly mottling.


            Close the patient’s eyes by applying light pressure to the        To maintain the patient's
 4.
            eyelids for 30 seconds.                                           dignity and for aesthetic
                                                                              reasons. Closure of eyes
                                                                              will also provide tissue
                                                                              protection in case of
                                                                              corneal donation.


            If a catheter is in-situ, gently drain the bladder by pressing    Because the body can
 5.
            on the lower abdomen. Leave catheter bag insitu.                  continue to excrete fluids
                                                                              after death.

            Pack orifices with gauze if fluid secretion continues or is       Leaking orifices pose a
 6.         anticipated. If excessive leaking of bodily fluids occurs,        health hazard to staff
            consider suctioning.                                              coming into contact with
                                                                              the body.
            Consider body bag if there is excessive body fluid
            leakage.




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 7.         Exuding wounds should be covered with a clean                 Open wounds pose a
            absorbent dressing and secured with an occlusive              health hazard to staff
            dressing.                                                     coming into contact with
                                                                          the body.
            If a post mortem is required, existing dressings should be
            left in situ and covered with an additional dressing.


            Open drainage sites may need to be sealed with an             Open drainage sites
 8.
            occlusive dressing                                            pose a health hazard to
                                                                          staff coming into contact
                                                                          with the body. If a post
                                                                          mortem is required
                                                                          drainage tubes, etc,
                                                                          should be left in situ.


            Wash the patient, unless requested not to do so for           For hygienic and
 9.
            religious / cultural reasons (please refer to sections on     aesthetic reasons. As a
            individual faiths). Family members must not perform last      mark of respect and a
            offices without a member of staff being present.              point of closure in the
                                                                          relationship between
            It may be important to family and carers to assist with       nurse / midwife and
            washing, thereby continuing to provide the care given in      patient.
            the period before death
                                                                          Post-death shaving
            Do not shave the deceased. If shaving is necessary, it        causes severe burn
            should be performed prior to death using an electric razor    marks that cannot be
            if possible.                                                  disguised by the funeral
                                                                          director, causing
                                                                          disfigurement.


            Clean the patient’s mouth using a foam stick to remove        For hygienic and
 10.
            any debris and secretions.                                    aesthetic reasons.

            Clean dentures and replace them in the mouth if possible.
            If not, ensure they accompany the body.                       To maintain the integrity
                                                                          of the face shape.
            Suction may be necessary to clear fluids from the patient’s
            mouth.


            Remove all jewellery (in the presence of another member       To meet with legal
 11.
            of staff) unless requested by the patient’s family to do      requirements and
            otherwise.                                                    relatives wishes.
                        Sikh’s may have a bangle on that should not be
                     removed.

            If jewellery does not come off easily leave it on, and
            document it’s presence on the Death Notification Form.

            Refer to UHL Management of Patient Property – Policy
            and Procedure for full details.


            Ensure the patient is clothed during transfer to the          To maintain dignity.
 12.
            mortuary, e.g. night clothes, hospital gown or shroud.
            Patients should NOT be sent to the mortuary without being
            appropriately and decently attired.

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            Ensure two identification bracelets with the following             To ensure the legal,
            information are present:                                           correct and easy
 13.                                                                           identification of the body
                    -   Patient’s S number                                     in the mortuary.
                    -   Date of Birth
                    -   Address
                    -   Name

                Place one label on the deceased’s right wrist, and one
                label on their right ankle. It is acceptable for this to be
                their current identification bracelet, and one other. If the
                right limbs are missing, place identification label on the
                left limbs.


            Complete Death Notification Form (including                        To ensure legal, correct
 14.
            addressograph label) and hand to porter when deceased              and easy identification of
            patient is transferred to mortuary.                                the body in the mortuary.


            Sensitivity should be used when preparing the transsexual          To comply with the
 15.
            deceased patient to maintain strict confidentiality of             Gender Recognition Act
            previous gender including discussion with the family.              2004


            Non-infectious / non-leaking bodies should be wrapped in           To maintain the
 16.
            a clean white sheet.                                               deceased patient’s
                                                                               dignity.


            Body bags should be used for the following cases:                  Minimize the risk of
 17.
                                                                               transmission of
            -      Hepatitis B&C, HIV, TSE (including CJD) and active          infectious diseases.
                   tuberculosis where the patient has not successfully
                   completed a course of antibiotics
            -      Known or suspected intra-venous drug abuse
            -      Forensic and suspicious death including death in
                   custody (place deceased patient in body bag with
                   minimal intervention from nursing staff)
            -      Recently administered active unsealed source
                   radioactive material for cancer treatment
            -      Where leakage and discharge of body fluids or faeces
                   is likely (this includes patients from ITU,HDU, Renal
                   Wards, immediate post-operative patients, patients
                   with large pressure sores, trauma, burns, gangrenous
                   limbs and infected amputation sites)


            Dispose of equipment according to infection control                To minimize risk of
 19.
            principles. Remove gloves and apron and wash hands                 cross-infection and
            with soap and water.                                               contamination.


            Request transfer of deceased patient to mortuary by                Decomposition occurs
 20.
            contacting porters. Inform porters of any relevant factors:        rapidly, particularly in hot
            - Deceased patient weighing more than 200Kg (may                   weather and overheated
               need to contact Manual Handling Team or Duty                    rooms and safe transfer
               Manager out of hours for advice)                                to the mortuary should
            - If body bag has been used, including reason why                  take place within a
               (leaking fluids, risk of infection, radiopharmaceuticals,       reasonable time.
               other)
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            -   Other ward factors such as ward rounds, catering
                rounds, drug rounds and visiting times
            -   Potential threat of any aggression or conflict (transfer
                may be delayed until area secure)

            Transfer to mortuary should be within 4 hours of death,
            although sensitivity to family needs must be exercised.


            Prepare ward area for arrival of porters with concealment      To ensure the safe, legal
 21.
            trolley by drawing curtains and remove unnecessary             and dignified transfer of
            equipment to allow concealment trolley to be placed next       the deceased patient to
            to the bed.                                                    the mortuary.


            Greet porters on their arrival, confirm identity of deceased
 22.
            patient (S number on ID bands) and assist with transfer by
            ensuring bed brakes are locked, bed and trolley are at the
            same height and patslide used for lateral transfer.


            Inform Bereavement Services office of patient’s death          To ensure Bereavement
 23.
            within 3 hours during office hours by hand delivering a        Services Officers can
            copy of the Death Notification Form.                           deal appropriately with
                                                                           relative’s enquiries.


            Provide appropriate support and reassurance to other           Other patients and
 24.
            patients and visitors to the ward.                             visitors may be aware
                                                                           that a death has
                                                                           occurred.


            Record all details and actions within the nursing              To record the time of
 25.
            documentation.                                                 death, names of those
                                                                           present, and names of
                                                                           those informed.


            Transfer property, completed patient records to                Documentation / case
 26.
            Bereavement Services. Soiled property should be stored         notes etc needed to
            in individual bags, and properly identified in accordance      process the death
            with “Management of Patient Property Policy and                certificate or property
            Procedures”.                                                   collection.

            If deceased is under 19 years of age – copy case notes for
            Child Death Overview Panel




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  PREPARATION OF THE DECEASED
       CHILD (“Last Offices”)                                                                  Appendix Six
                                                                      Care of the Deceased Patient (“Last Offices”)




                                    Action                                   Rationale



 Do not follow this procedure if the death is                  Evidence must be preserved for a
 considered suspicious or has been referred to HM              forensic investigation into the
 Coroner.                                                      cause of death for the Policy and /
                                                               or HM Coroner.
 The deceased patient may be collected from the
 place of death by HM Coroner’s removal service. If
 this is not required authority for removal must be
 given by the Line Manager or Duty Manager and the
 deceased patient placed directly into a body bag and
 transferred to the Mortuary.
 The only other action that should be taken is to
 ensure correct identification bands are on the
 deceased patient and document any equipment in
 use (including batch numbers if available).



   1      Equipment list:                                      N/A
          - Mouth care equipment
          - Identification bands (x2)
          - Disposable gown or Child’s own clothes /
              nightwear
          - Bowl, soap, towel & disposable cloths, comb
          - Micropore tape
          - Clinical waste bag
          - Valuable property bag and green property
              bag
          - Clean sheets


          Extra equipment may include:
          - Dressings, bandages, gauze, wicks
          - Cannula bungs
          - Body bag


          Extra equipment for Infants / Children or Young
          People:
          - Child’s clothes (or whatever family want the
               child dressed in)
          - Children’s Hospital Bereavement Pack
          - Nappies if the deceased is a baby
          - Toothbrush and toothpaste




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   2      Approach child’s family to explain the last offices   Family Orientated Care and gives
          procedure and gain verbal consent to undertake        the family an opportunity for
          the procedure whilst encouraging participation if     closure whilst recognising that
          appropriate (Not appropriate if coroners case,        child is still part of their family.
          death under suspicious circumstances or child
          protection issues are a query).

          Discuss the option of taking a lock of hair,          These keepsakes will act as a
          photograph, hand or footprint with the parents        memory of the child for the family
          before last offices are performed.

          There is also an option to have the child’s name      To allow the family ongoing
          entered into the Children’s Hospital Book of          support
          Remembrance kept within CICU Children’s
          Hospital LRI.

   3.     Some families may request to take the child’s         To ensure that all legal issues
          body home before last offices are performed. This     have been considered.
          can be arranged if appropriate but must be
          arranged via the hospital mortuary.

          Please refer to the procedure in the Children’s
          Hospital Bereavement Pack and contact the Duty
          Hospital Manager for advice

          Discuss with the family the option of transfer to     To provide the family with
          Rainbows Children’s Hospice, for use of the           additional time and support up
          “quiet room” facility. Refer to hospice for further   until the time of burial / cremation
          support/information as needed.


   4.     Put on gloves and apron.                              Standard (universal) precautions
                                                                must be followed for any contact
                                                                with bodily fluids. To reduce risk
                                                                of contamination and cross-
                                                                infection.

   5.     Lay the infant or child on their back with            To maintain the patient’s dignity
          assistance of another member of staff if the          and for future management of the
          patient is an older child (adhering to the manual     body, as rigor mortis occurs 2-6
          handling policy).                                     hours after death, with full
                                                                intensity within 48 hours and then
          If possible lay limbs out straight, close mouth and   disappearing within another 48
          shut eyes by applying light pressure to the eyelids   hours. Closure of eyes will also
          for 30 seconds but do not force.                      provide tissue protection in case
                                                                of corneal donation.
          Remove excess bedding and pillows leaving a
          sheet underneath and covering the child and a
          single pillow if appropriate.

          In older children consider supporting the jaw by
          placing a pillow or rolled-up towel on the child’s
          chest underneath the jaw.

              Do not tie jaw unless otherwise guided by
             family members.




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          Remove only mechanical aids such as syringe
          drivers, etc, and secure the sites with gauze and
          tape to syringe driver sites and document actions
          in nursing documentation. Lines must be left in
          situ and capped off with a blind end cannula
          bung.

          ET tubes must not be removed where death is
          sudden, suspicious or referred to the Coroner.

          ET tubes may be removed if it is clear when
          death is verified that referral to the Coroner is not
          required. If there is any doubt the ET tube must
          be left in place until referral is clarified.

          Ensure family are aware ET tube has been left in
          situ, and reassure them they will be able to view
          deceased without ET tube when Coroner’s
          investigations have been completed, either in the
          Mortuary viewing room or at the Funeral
          Directors.


  6.      If a catheter is in-situ gently drain the bladder by    Because the body can continue to
          pressing on the lower abdomen. Leave catheter           excrete fluids after death.
          bag insitu. In infants/younger children use a
          nappy to retain urinary secretions


   7.     Pack orifices with gauze if fluid secretion             Leaking orifices pose a health
          continues or is anticipated. If excessive leaking of    hazard to staff coming into contact
          bodily fluids occurs, consider suctioning.              with the body.


   8.     In older children / young people you may need to        The dressing will absorb any
          pack orifices with gauze if fluid secretion             leakage from the wound site.
          continues or is anticipated.                            Open wounds pose a health
                                                                  hazard to staff coming into contact
          In younger children and babies use a nappy to           with the body.
          retain secretions. If excessive leaking of bodily
          fluids occurs, consider suctioning.                     If a post mortem is required,
                                                                  existing dressings should be left in
                                                                  situ and covered.


   9.     Open drainage sites may need to be sealed with          Open drainage sites pose a health
          an occlusive dressing                                   hazard to staff coming into contact
                                                                  with the body. If a post mortem is
                                                                  required drainage tubes, etc,
                                                                  should be left in situ.


  10.     Wash the infant or child, (allowing family to           For hygienic and aesthetic
          participate as appropriate) unless requested not        reasons. As a mark of respect and
          to do so for religious / cultural reasons (please       a point of closure in the
          refer to sections on individual faiths). Family         relationship between nurse /
          members must not perform last offices without a         midwife and patient.
          member of staff being present (continued
          overleaf).

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          It may be important to family and carers to assist
          with washing, thereby continuing to provide the
          care given in the period before death.


  11.     If necessary clean the Infant/child’s mouth using           For hygienic and aesthetic
          a foam stick to remove any debris and secretions.           reasons.

          Otherwise clean the child’s teeth using their own
          toothbrush and toothpaste.


  12.     If family want jewellery to be removed then do so           To meet with legal requirements
          and give to the family (in the presence of another          and relatives wishes.
          nurse) and record on the Death Notification form.

                Sikh’s may have a bangle on that should not be
                removed.

          If jewellery does not come off easily or parents want
          to leave it on the child document it’s presence on
          the Death Notification form.

          Jewellery remaining on the patient should be
          documented on the ‘notification of death’ form.

          Record the jewellery and other valuables in the
          patient’s property book and store the items
          according to UHL policy.


  13.     Dress the child in parents choice of clothing or            To maintain dignity and include
          nightclothes as appropriate                                 family in the procedure

  14.     Ensure two identification bracelets with the                To ensure correct and easy
          following information are present:                          identification of the body in the
                                                                      mortuary.
          -     Patient’s S number
          -     Date of Birth
          -     Address
          -     Name
              Place one label on the infant or child’s right wrist,
              and one label on their right ankle. It is acceptable
              for this to be their current identification bracelet,
              and one other. If the right limbs are missing, place
              identification label on the left limbs.


  15.     Complete Death Notification Form (including                 To ensure correct and easy
          addressograph label) and hand to porter when                identification of the body in the
          deceased patient is transferred to mortuary.                mortuary.


  16.     Support family to say goodbye to infant or child            Family Orientated Care and to
          on ward before transfer to the Mortuary. Ensure             ensure that the family has an
          they are aware of visiting arrangements in the              opportunity for closure whilst
          Mortuary and with the Funeral Director.                     recognising that child is still part of
                                                                      their family.
          Family to leave ward area prior to transfer.



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  17.     Non-infectious / non-leaking bodies should be           Actual or potential leakage of
          wrapped in a clean white sheet.                         fluid, whether infection is present
                                                                  or not, poses a health hazard to
                                                                  all those who come into contact
                                                                  with the deceased patient. The
                                                                  sheet will absorb excess fluid.


  19.     Body bags should be used for the following              Minimize the risk of transmission
          cases:                                                  of infectious diseases.

          -    Hepatitis B&C, HIV, TSE (including CJD) and
               active tuberculosis where the patient has not
               successfully completed a course of antibiotics
          -    Known or suspected intra-venous drug abuse
          -    Forensic and suspicious death including
               death in custody (place deceased patient in
               body bag with minimal intervention from
               nursing staff)
          -    Recently administered active unsealed source
               radioactive material for cancer treatment
          -    Where leakage and discharge of body fluids
               or faeces is likely (this includes patients from
               ITU,HDU, Renal Wards, immediate post-
               operative patients, patients with large
               pressure sores, trauma, burns, gangrenous
               limbs and infected amputation sites)


  21.     Dispose of equipment according to infection             To minimize risk of cross-infection
          control principles. Remove gloves and apron.            and contamination.
          Wash hands with soap and water.


  22.     Request transfer of deceased patient to mortuary        Decomposition occurs rapidly,
          by contacting porters. Inform porters of any            particularly in hot weather and in
          relevant factors:                                       overheated rooms.

          -    Deceased patient weighing more than 200Kg          Transfer to the mortuary must
               (may need to contact Manual Handling Team          occur in a respectful and dignified
               or Duty Manager out of hours for advice)           manner, ensuring that members
          -    If body bag has been used, including reason        of the public are not exposed to
               why (leaking fluids, risk of infection,            the sight of a deceased child
               radiopharmaceuticals, other)                       during transfer and that staff are
          -    Other ward factors such as ward rounds,            not placed under unnecessary
               catering rounds, drug rounds and visiting          risk.
               times
          -    Potential threat of any aggression or conflict
               (transfer may be delayed until area secure)

          Concealment container or trolley to be used for all
          transfers to the mortuary. Give porters estimate
          as to the length / size of child so the appropriate
          concealment trolley is brought to ward:

          -    Neonatal transport container
          -    Half-size “child” concealment trolley
          -    Full-size “adult” concealment trolley


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          Document time porter requested.
          Family members must not accompany porters
          during transfer to the mortuary.


          Prepare ward area for arrival of porters with          To ensure the safe, legal and
 23.
          concealment trolley by drawing curtains and            dignified transfer of the deceased
          remove unnecessary equipment to allow                  patient to the mortuary.
          concealment trolley to be placed next to the bed.


          Greet porters on their arrival, confirm identity of
 24.
          deceased patient (S number on ID bands) and
          assist with transfer by ensuring bed brakes are
          locked, bed and trolley are at the same height
          and patslide used for lateral transfer.


          Inform Bereavement Services office of patient’s        To ensure Bereavement Services
 25.
          death within 3 hours during office hours by hand       Officers can deal appropriately
          delivering a copy of the Death Notification Form.      with relative’s enquiries.


  26.     Provide appropriate support and reassurance to         Other patients and visitors may be
          other children and visitors to the ward.               aware that a death has occurred.



  27.     Record all details and actions within the nursing      To record the time of death,
          documentation.                                         names of those present, and
                                                                 names of those informed.


  28.     Allow the family to take the child’s belongings with   The administrative department
          them and offer the appropriate information to allow    cannot begin to process the
          them to contact Bereavement Services on the next       formalities such as the death
          working day.                                           certificate or the collection of
                                                                 property by the next of kin until the
                                                                 required documents are in its
                                                                 possession.

          Relevant Information on support groups should also     To ensure the family receive
          be offered to the family before they leave the ward    ongoing support
          area.

          Transfer the patient records, etc, to Bereavement      To ensure that the family do not
          Services with the second copy of the Death Notice      receive any appointments or letters
          Form.                                                  regarding the child and to allow
                                                                 those staff who have been involved
                                                                 with the child to visit the family


          You must ensure that there is a system in place        To provide ongoing support
 29.
          for other professionals involved in the child’s care
          to be informed (such as GP, community nurses,
          Health Visitor, Rainbows Children’s Hospice, or
          Service Coordination Scheme)

          You must ensure that the family have a follow-up
          appointment in place with the child’s consultant
          before they leave the hospital.

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          Transfer property, patient records (we need to be    Documentation / case notes etc
 30.
          explicit on the paperwork to be completed and        needed to process the death
          what to send where), etc, to Bereavement             certificate or property collection.
          Services. Soiled property should be stored in
          individual bags, and properly identified.

          If deceased is under 19 years of age – copy case
          notes for Child Death Overview Panel




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      TRANSFER TO THE MORTUARY
                                                                                            Appendix Seven
                                                                        Care of the Deceased Patient (“Last Offices”)




1. Introduction
1.1      The Portering Department is responsible for undertaking the transfer of the deceased
         patient from the ward / place of death to the Mortuary.
1.2      All transfers will be undertaken in a safe, dignified and timely manner.
1.3      Family and friends are not able to accompany the porters whilst they collect or
         transfer the deceased patient to the mortuary.

2. Equipment
2.1      In order to maintain the privacy and dignity of the deceased patient and visitors and
         staff in any surrounding area an appropriate concealment trolley will be used for all
         transfers:

         -   Neonatal transport container (held on Delivery Suite)
         -   Half-size “child” concealment trolley
         -   Full-size “adult” concealment trolley
         -   Bariatric concealment trolley or bariatric trolley cover

2.2      Concealment trolleys will be stored out of public view when not in use, and will be
         used in a dignified and professional manner at all times (even when empty).

2.3      The concealment trolley and it’s cover should be checked to make sure it is in good
         working order prior to use, and cleaned and disinfected with a 10% dilution of
         TriGene (available in the Mortuary) after every transfer. Appropriate Personal
         Protective clothing must be worn when disinfecting and cleaning the trolley.

3. Procedure for transfer to the Mortuary
3.1      Request for transfer:
         -   Ward staff to request transfer of deceased patient to the mortuary by contacting
             UHL Porters (LGH and GGH) or SERCO Porters (LRI)
         -   Ward staff to inform porters of any relevant factors, including which concealment
             trolley to be used, whether patient is more than 200Kg and as well as whether
             body bag has been used and if so reason why.
                       o   The use of a body bag and Personal Protective Equipment is sufficient
                           to protect those handling the deceased patient from leaking fluids,
                           infections or radiopharmaceuticals.
         -   Ward staff to inform porter of any other factors that may affect transfer, including
             ward rounds, catering rounds, drug rounds and visiting times.
         -   If there are any potential threat of aggression or conflict. Portering staff will decide
             whether to delay transfer until an escort from security is available.
3.2      Collection of deceased patient from ward:
         -   Ward staff are responsible for ensuring the deceased patient is prepared and
             death notification form completed prior to portering staff arriving to collect the
             patient.



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         -   Ward staff are responsible for preparing the ward area prior to the arrival of
             portering staff, ensuring that curtains are drawn to maintain privacy (unless
             deceased patient is in a single room) and any unnecessary equipment has been
             removed to allow placement of the concealment trolley next to the deceased
             patient’s bed.
         -   A minimum of 2 porters are required for the transfer of all deceased patients, and
             more for bariatric patients.
         -   Porters will collect the correct concealment trolley, ensure it is in good working
             order and proceed to the ward in a professional and dignified manner, reporting to
             the Nurses Station on arrival to the ward.
         -   Ward staff must be available to assist the porters, and confirm the identification of
             the deceased patient.
         -   Nursing staff and porters will use appropriate Personal Protective Equipment
             during the transfer of the deceased patient from their bed to the concealment
             trolley.
         -   Once privacy has been ensured (closing single room door or curtains around the
             bed space) the frame and cover of the concealment trolley can be removed and
             the trolley positioned laterally to the bed. It is essential that the castors of the bed
             and trolley are locked, and both are at the same height.
         -   A patslide should be used to transfer the deceased patient from the bed to the
             trolley.
         -   Once the deceased patient is on the concealment trolley the framework and cover
             should be replaced, maintaining the privacy and dignity during transfer to the
             mortuary.

3.3      Death Notification Form:

         -   Ward staff are responsible for ensuring the correct identification labels are on the
             deceased patient, and that the Death Notification Form has been completed.
         -   Portering staff will take one copy of the Death Notification Form with the deceased
             patient to the mortuary.
         -   Out of hours portering staff will also deliver an additional copy of the Death
             Notification Form to Bereavement Services.

3.4      Transfer of deceased patient to the mortuary:

         -   Personal Protective Equipment should not be used during transfer to the mortuary
         -   The route from wards to all three mortuaries at UHL is through public areas.
             Maintaining privacy and dignity of the deceased patient and minimising distress to
             visitors / contractors / staff members will be by the use of the concealment trolley
             with frame and cover insitu at all times as well as ensuring family members do not
             accompany the deceased patient during transfer to the mortuary. Transfer will be
             in a professional and dignified manner.

3.5      Reception of deceased patient into the mortuary:

         -   On arrival into the mortuary porters will make sure the mortuary is secure, transfer the
             deceased patient into the fridge room and adopt appropriate Personal Protective
             Equipment. See section 6 below for details of accommodation of the deceased.
         -   The Hydraulic Hoist should be used to remove an empty tray from the temperature
             controlled accommodation, and the frame and cover removed from the concealment
             trolley. The height of the hoist and concealment trolley should be the same and the
             castors locked for safe transfer.
         -   A patslide should be used to transfer the deceased patient from the trolley to the tray.
         -   The deceased patient should remain securely wrapped at all times, to protect their
             privacy and dignity.
         -   The tray should be returned to its original position and the door secured. Portering
             staff should document the first initial of the forename and the name of the deceased

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             patient on the name plate on the exterior of the door, and the Mortuary Register
             completed.
         -   The concealment trolley can then be disinfected and cleaned, the framework and
             cover replaced and Personal Protective Equipment removed and disposed of.
         -   On leaving the mortuary portering staff will ensure the department is secure.

4. Transfer of babies from the Maternity or Neonatal Unit
4.1      The transfer of the deceased baby (including the non-viable fetus, stillborn baby and
         neonatal deaths) from the Maternity or Neonatal Unit will follow the procedure as outlined
         above.
4.2      A Midwife or Nurse may accompany portering staff during the transfer but must not
         transfer the deceased baby on their own.
4.3      The Death Notification Form is not completed in these cases. Instead and Infant
         Bereavement Notification Form will be completed by ward staff, and a clinical summary
         and post-mortem request form (if necessary). Ward staff are responsible for the accuracy
         and completion of this paperwork and portering staff will deliver the forms as outlined in
         section 3 above.
4.4      Ward staff may occasionally request that the deceased baby is brought back to the
         Maternity or Neonatal Unit for viewing, if the condition of the mother is such that she is
         unable to attend the mortuary. This is the only time it is acceptable for any deceased
         patient to return to the ward area and must be carefully managed:
         -   Ward staff should accompany portering staff to the mortuary to confirm the identity of
             the deceased baby and complete the Temporary Release and Return Register in the
             Mortuary. If ward staff are not available to accompany portering staff to the mortuary
             viewing on the ward will not be possible.
         -   Ward staff are responsible for:
             -    Attending the mortuary with portering staff.
             -    Confirming the identity and ensuring the deceased baby is presentable before
                  viewing takes place.
             -    Maintaining the privacy, dignity and security of the deceased baby on the ward.
             -    Ensuring there is minimal impact on any other patients, visitors or staff.
             -    Supporting the mother and any visitors during the viewing.
             -    Preparing the deceased baby for transfer back to the mortuary.

Please note: the deceased baby cannot be released to the family direct from the wards. All
releases must be through the mortuary, even out of hours (refer to UHL ‘Policy for the Handling
and Release of the Deceased and Products of Conception Outside Normal Hours’ for full
procedure).

5. Bariatric patients
5.1      Ward staff must inform portering staff if the transfer of the deceased patient is likely to
         pose a manual handling risk and / or weighs more than 200Kg.
5.2      Portering staff may decide to visit the ward to visually assess the deceased patient in
         order to use the most appropriate and respectful method of transport.
5.3      In certain circumstances, transfer to the mortuary may be delayed whilst additional staff
         and / or equipment is located. The method of transport will be adapted to suit each of the
         three hospital sites dependant on availability of equipment.
5.4      In circumstances where such equipment is not adequate, it may be necessary for the
         deceased patient to be transferred direct from the ward to the funeral home by UHL
         contract funeral directors. Transfer is authorised and arranged by either the Mortuary
         Manager or on-call mortuary staff.
5.5      Once appropriate staff and equipment are available transfer should follow the procedure
         outlined in section 3 above.


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6. Accommodation of the Deceased
                                         Leicester Royal Infirmary
1) Deceased from the Emergency Department (ED) and the community are placed in designated fridges –
   refer to poster in each Mortuary for details.
2) Deceased that are forensic cases are to be placed into P & Q. These are locked and access limited to
   technical staff. If technical staff are unavailable, forensic cases can be placed In D to L then transferred
   at an appropriate time.
3) Paediatric and neonatal cases are to be place in A on level 5.
4) Internal hospital deaths except ED are to be placed in R to X inclusive.
5) Bariatric patients are to be placed in C; patients that arrive in the department on a bed are to remain on
   a bed at the far end of the fridge room until assessed by Mortuary staff.
Contingency for LRI
Stage 1
The storage facility in the loading area of the LRI Mortuary will be used to accommodate deceased when all
other spaces are occupied at LRI.
Stage 2
If the implementation of stage 1 fails to resolve accommodation issues then the Senior Porter will contact the
Duty Manager who will contact the On-call Technician via switch board, The On-call Technician will confirm
availability of spaces at the other two UHL Mortuaries will be established. The On-call Technician will
relocate deceased to other sites.
                                             Leicester General Hospital

Deceased to be placed in spaces (to the right when accessing the department) A-G inclusive.
Babies will be placed in B.

Contingency for LGH

Stage 1
Spaces (to the left when accessing the department) 1-40 inclusive will be used to accommodate deceased
when all other spaces at LGH are occupied.
Stage 2
If the implementation of stage 1 fails to resolve accommodation issues then the Senior Porter will contact the
Duty Manager who will contact the On-call Technician via switch board, The On-call Technician will confirm
availability of spaces at the other two UHL Mortuaries will be established. The On-call Technician will
relocate deceased to other sites.

                                             Glenfield General Hospital

Spaces 1-30 inclusive are to be used at accommodate deceased.
The spaces in the Neonate & Paediatric room are to be used to accommodate babies.

Contingency for GGH

Stage 1
Vacant spaces in the neonate room will be used to accommodate deceased when all other spaces at GGH
are occupied.
Stage 2
If the implementation of stage 1 fails to resolve accommodation issues then the Senior Porter will contact the
Duty Manager who will contact the On-call Technician via switch board, The On-call Technician will confirm
availability of spaces at the other two UHL Mortuaries will be established. The On-call Technician will
relocate deceased to other sites.




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      RISK OF INFECTION AND USE OF
                BODY BAGS                                                                      Appendix Eight
                                                                          Care of the Deceased Patient (“Last Offices”)



1. Spread of infection
1.1      The risks of infection from a patient do not increase after death and can be prevented
         by the use of standard precautions including the use of appropriate Personal
         Protective Equipment.

2. Performing last offices
2.1      Because it is not possible to rule out an underlying infection in every case, it is
         advisable that Nursing staff perform last offices with the same protective precautions
         as when the patient was alive; this includes disposable gloves and apron when
         handling the deceased.
2.2   Overt use of protective measures can cause distress. Protective clothing should be
      removed after handling the deceased and hands washed thoroughly before meeting
      the family.
3. Communication
3.1      If a patient has died with a known or suspected infection, it is the legal responsibility
         of those performing last offices to ensure those who care for the deceased after death
         are informed of the potential risk of infection.
3.2      The persons who need to know include next of kin, portering staff, mortuary staff and
         funeral director.
3.3      Ward staff should use the Death Notification Form to communicate the nature of
         infection and the precautions required. This will ensure the specific diagnosis remains
         confidential, even after death.
3.4      Relatives may be unaware of the true nature of the infection and an individual’s right
         to confidentiality continues after death but, the bereaved relatives must be advised on
         how to avoid risk of infection to themselves.
3.5      Specific questions about the nature of the infection from the next of kin should be
         referred to the doctor who confirmed that the patient had died.
4. Body bags
4.1      Body bags are used for deceased patients that are likely to leak or are thought to be
         infective to handlers. They can occasionally be used to contain a patient whose death
         was suspicious.
4.2      Body bags are to be used for the following cases:
         -   Hepatitis B & C, HIV, TSE (including CJD) and active tuberculosis where the patient has
             not successfully completed a course of antibiotics
         -   Known or suspected intra-venous drug abuse
         -   Forensic and suspicious death including death in custody (place in bag with minimal
             intervention from nursing staff)
         -   Recently administered active unsealed source radioactive material for cancer treatment
         -   Where leakage and discharge of body fluids or faeces is likely (this includes patients from
             ITU, HDU, Renal Wards, immediate post-operative patients, patients with large pressure
             sores, trauma, burns, gangrenous limbs and infected amputation sites.

4.3      Detailed advice about the use of body bags and specific infections (not covered in
         this document) should be sought from the Pathology Consultant Clinical
         Microbiologist (ext. 6507).

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4.4      The deceased patient must be clothed (e.g. night clothes, hospital gown or shroud)
         even when contained in a body bag, irrespective of the reason why, in order to
         maintain their privacy and dignity.
4.5      The inappropriate use of body bags can cause unnecessary distress to relatives.
         Where a body bag is used and is necessary and the actual use is unidentifiable (not
         recorded on the Death Notification Form) unnecessary distress can also occur.
4.6      If the exterior of the bag inadvertently comes into contact with potential sources of
         infection, clean and disinfect the exterior with a Chlorclean solution.
4.7      The deceased can remain unwrapped (i.e. clothed but not wrapped in a sheet) within
         the bag but, a sheet must be wrapped around the exterior of the bag, allowing the
         deceased patient to be transferred with minimal risk of tears to the bag.
5. Death Notification Form
5.1      The body bag section of the Death Notification Form has a check list with a table of
         some frequently encountered conditions that require a body bag:




5.2      The Infection section on the checklist lists the boxes to be ticked on the
         corresponding section of the notification form and records the precautions for those
         caring for the patient after
         death.




5.3      A more comprehensive list of infections and conditions are listed in the tables below:
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                                             Known or Suspected Infections that
                                                Do Not Require a Body bag
                              Infection                  View      Embalm       Wash &    Degree of Risk
                                                                                 dress
          Acute encephalitis
          Chickenpox/shingles
          Cryptosporidiosis                                                                      Low
          Clostridium Difficile (C. diff)
          Dysentery                                                                             Medium
          Leprosy
          Legionelliosis
          Measles
          Meningitis (except meningococcal)
          Mumps
          Methicillin-resistant Staphylococcus                                                   Low
          aureus (MRSA)
          Rubella
          Tetanus
          Whooping cough
          Food poisoning
          Hepatitis A
          Acute poliomyelitis (Polio) No                                                        Medium
          Leptospirosis (Weil's disease)
          Malaria
           Yes with caution
           Not advised

         Note:    The Level of risk to those caring for the deceased after death is assed with the
                  assumption that Standard Personal Protective clothing is worn. Table summarised
                  from advice published by the Health Protection Agency.

                                             Known or Suspected Infections that
                                                    Require a Body bag
                  Infection                  Transmitted       Embalm      Wash &        View        Degree
                                                                            dress                    of risk
                Diphtheria
              Meningococcal                   Air-borne
            septicaemia with or
            without meningitis)
             Paratyphoid fever                Ingestion                                              Medium
               Tuberculosis                   Air-borne
               Typhoid fever                  Ingestion
             Hepatitis B, C and              Blood-borne
                    HIV
                  Anthrax                 Air-borne & contact
                                           with broken skin                                            High
              Transmissible
               spongiform
            encephalopathies           Neurological
             e.g. Creutzfeldt-
              Jakob disease
            Yes with caution
            Not advised
            Yes but not after Post-mortem

         Note:    The Level of risk to those caring for the deceased after death is assed with the
                  assumption that Standard Personal Protective clothing is worn. Table summarised
                  from advice published by the Health Protection Agency.



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          BROUGHT IN DECEASED
                                                                                     Appendix Nine
                                                               Care of the Deceased Patient (“Last Offices”)




Guidance in development




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               CULTURAL AND RELIGIOUS
                 REQUIREMENTS                                                                       Appendix Ten
                                                                            Care of the Deceased Patient (“Last Offices”)




The following are only suggestions and can be used in conjunction with the Green “Diversity
in Healthcare” folder produced by the University Hospital of Leicester (April 2003). Folders
are available within the clinical area.
-     Primarily it is essential that any religious beliefs held by the patient are identified on
      admission, or prior to death, so that nursing staff can adhere to the needs of the patient,
      relatives and important others.
-     Individual requirements will vary even among members of the same faith. Varying
      degrees of adherence and orthodoxy exist within all the world’s faiths. The identified
      religion may occasionally be offered to indicate an association with particular cultural and
      national roots, rather than to indicate a significant degree of adherence to a particular
      faith.
-     It is essential where a specific need is identified, a lead should be taken from the family.
-     All guidance should be utilized in conjunction with the procedure guidelines, which
      applies to all faiths unless otherwise stated.
-     When requesting a member of the Chaplaincy to visit a patient, contact switchboard and
      ensure you clearly state the patient’s faith.
Requirements for people of different religious faiths
All guidance should be utilized in conjunction with the procedure guidelines, which applies to
all faiths unless otherwise stated. Therefore the following only incorporates specific issues
which would not be covered from the general policy.


       Bahai       Bahai relatives may wish to say prayers for the deceased person, but normal last
                   offices performed by nursing staff are quite acceptable.

                   If a special ring is placed on the finger of the patient it should not be removed.




    Buddhism       A request may be made for a Buddhist monk or nun to be present.

                   As there are a number of different schools of Buddhism, relatives should be
                   contacted for advice on how the body should be treated.

                   The relatives may request, for the body to be left for a period of time, while prayers
                   are said.



    Christianity   Relatives may request a hospital chaplain or priest from their own church to offer
                   prayers.

                   Roman Catholic families may request the presence of a Roman Catholic Priest.




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  Hinduism         A Hindu patient or relative may request the services of a priest during the last
                   stages of life.

                   Where possible the body should not be handled before consulting the relatives.
                   Hindu’s often prefer nursing staff of the same sex as the patient to handle the body.
                   The deceased should always be covered by a plain white sheet.

                   Where possible preparation for this eventually should be made by moving the dying
                   person to a single room so that other patients or visitors are not disturbed by these
                   expressions of grief at the time of death.

                   Support the jaw.

                   Do not remove threads or jewellery.

                   Cremation frequently occurs soon after death, and speedy completion of the death
                   certificate will aid this process.


     Islam         Many Muslims would prefer to be touched by someone of the same faith and of the
                   same sex.

                   The body should not be washed

                   The family may request that the body is turned to face towards Mecca (head first).
                   Mecca is South East of Leicester.

                   Muslim patients are usually buried as soon as possible after death.


   Jainism         No special requirements



   Judaism         Many Jews would prefer someone from the Jewish faith to touch the body.

                   Traditionally the body is left for about 8 minutes before being moved while a
                   white feather is placed across the lips and nose to detect any signs of
                   breathing.

                   The body should be handled as little as possible.

                   The patient should not be washed and should remain in the clothes in which they
                   died.

                   The family may request the jaw is tied up.
                   It is often seen as a religious duty for Jewish people to stay with the body until
                   burial.


Mormon             Relatives may advise staff if the patient wears a one or two piece sacred
(Church of         undergarment. If this is the case, relatives may dress the patients in these items.
Jesus Christ
of the Latter
Day Saints)




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    Muslim         See Islam




 Rastafarian       No special requirements




   Sikhism         The eldest son may wish to take a lead for the Last Offices.

                   Do not remove the ‘5 Ks’ which are personal sacred objects:

                            Kesh:              Do not remove head covering -
                                               turban (men) / duppata (women)
                            Kanga:             Do not remove semi-circular comb which fixes hair
                            Kara:              Do not remove any bracelets
                            Kaccha:            Do not remove special shorts worn as underwear.
                                               Seek advice from family if soiled.
                            Kirpan:            Do not remove miniature sword if worn.



Zoroastrian        The family may wish to be present during, or participate in, the preparation of the
(Parsee)           body.

                   Orthodox Parsees are likely to require a priest to be present.

                   The family may provide specific clothing to be worn, called the Sadra.




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    ORGAN AND TISSUE DONATION
                                                                                     Appendix Eleven
                                                                  Care of the Deceased Patient (“Last Offices”)




The vast majority of people, upon certification of death, can be considered for tissue donation
in some form. Families should be approached about organ and tissue donation when they
have acknowledged that death has or will occur. Families may also approach staff about
organ or tissue donation.

Tissue donation (donation of bone, heart valves, skin, tendons and corneas) is the only
available option for bereaved families in the Emergency Department (ED) and on the Wards.
Currently this service is handled by the National Blood Service (NBS) Tissue Co-ordinators,
who will take consent from families and organise the retrieval operations for any tissues.
The Donor Co-ordinator is a specialist nurse who is an expert in the field of organ donation
and breaking bad news. The role of the Donor Co-ordinator is to provide advice, support,
guidance and impart knowledge to ITU practitioners and bereaved families, as well as to all
other areas of the Trust. If bereaved families wish to consider organ or tissue donation, it is
the Donor Co-ordinator’s responsibility to facilitate this process.

All patients admitted to the ITU with complete or partial absence of brain stem reflexes
should be discussed with the Donor Co-ordinator. If recovery is not expected, discussion /
advice will be given on the possibility of organ or tissue donation.

Currently organ donation only happens on ITU following the declaration of death through
brain stem testing. It is the responsibility of all health care professionals to consider the
option of organ donation. The approach to the family should be made by those deemed most
suitable following discussion with all members of the multi-disciplinary team.

Last offices should be carried out before tissue donation occurs. In circumstances where the
patient is brain stem dead and multi-organ donation has occurred, the last offices will be
performed in theatre by the Donor Co-ordinator and the theatre team.

Organ / Tissue Donation on ITU:

1. All patients in Intensive Care Units in whom brain-stem death is suspected should be
   discussed with the Donor Coordinator. They will advise whether organ or tissue donation
   is appropriate and can be facilitated. The on call Donor Coordinator is available for
   advice, discussion and referrals on a 24-hour basis via group pager: 07659 185 183 or
   via the hospital switchboard.
2. The Donor Co-ordinator will advise on patient suitability for donation. However, HIV and
   CJD are the only two absolute contraindications to organ donation.
3. If brain-stem death is suspected and plans are made to perform brain-stem tests, then
   patients should be referred to the Donor Coordinator at the earliest opportunity.
4. Diagnosis of brain-stem death should be made by at least two medical practitioners (one
   of which should be a consultant) who have been registered for five years and are
   competent in the conduct and interpretation of brain-stem death testing. Guidance for
   brain-stem death testing is available in the Code of Practice for the Diagnosis and
   Confirmation of Death published by the Academy of the Royal Colleges.
5. The Donor Coordinator will give advice and guidance to the healthcare team and speak
   to the bereaved family about their options for organ donation.


Care of the Deceased Patient (“Last Offices”)
                                                th
Approved by Policy and Guideline Committee on 13 August 2010
                                                                                             Page 40 of 41
6. The Donor Coordinator will discuss organ donation in detail with the family. They will be
   informed if the patient was on the organ donor register if this is not already known by the
   family. If the patient had expressed a wish in life to donate or the family consent to organ
   donation, then the Donor Coordinator will complete the necessary consent and
   assessment documentation.
7. All cases where a family have agreed to donation will be discussed with the coroner by
   the Donor Coordinator, even if the consultant caring for the patient is prepared to issue a
   death certificate.
8. The Donor Coordinator will make the necessary arrangements to facilitate the organ
   donation. The patient will be transferred to theatre for the retrieval operation to take
   place.
9. Last offices (see Appendices 5 and 6) will be performed in theatre by the Donor
   Coordinator and the theatre staff. Paediatric cases will return to PICU for last offices to
   be completed. This will be agreed with PICU before the retrieval operation takes place.
10. The donor family will also be given the option of performing last offices and may also
    come and see their loved one after the retrieval operation if they wish to. This will be
    facilitated by the Donor Coordinator and organised with the theatre coordinator.
    Discussion will take place as to the most appropriate place for this to be facilitated.
11. The deceased will be then taken to the mortuary after completion of the relevant
    paperwork.

Tissue donation in the Emergency Department / Wards:
1. Once death has been verified, a large percentage of the population could be considered
   for tissue donation in some form. If in any doubt, please contact the National Blood
   Authority (NBS) Tissue Co-ordinator or the on call Donor Transplant Co-ordinator for
   advice. Absolute contraindications to all tissue donations are:

                       •   Positive Virology (Hepatitis B and C, HIV, Syphilis, Human T-cell
                           Lympthotropic Viruses {HTLV])
                       •   CJD risk factors
                       •   Blood and bone marrow malignancies (leukaemia, myeloma,
                           lymphoma)
                       •   Diseases of unknown aetiology
                       •   Behavioural risk activities

2. Every family should be given the option of tissue donation, as long as the patient meets
   the criteria. Some families may approach health care professionals about the option of
   donation. Once a family have agreed in principle to consider the option of tissue donation
   then please refer to NBS Tissue Co-ordinator.
3. To refer to the NBS Tissue Co-ordinator to facilitate the donation process via:

                       •   Pager on 07659 180 773
                       •   Or 0800 432 0559

4. Upon referral to the Tissue Co-ordinator details regarding the potential donor and their
   family will be required. Families are then free to go home and NBS will contact them by
   telephone to gain consent.




Care of the Deceased Patient (“Last Offices”)
                                                th
Approved by Policy and Guideline Committee on 13 August 2010
                                                                                      Page 41 of 41

				
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