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Verification of Death by Registered Nurses

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					                                                               North Somerset




           Verification of Death by
             Registered Nurses
                                                                 Susan Hinchley; Locality Manager
                                                                 Rurals/Professional Lead District
                                    Author(s):
                                                                 Nursing

                                    Lead Clinician (if
                                                                 Thelma Howell
                                    appropriate):
                                                                 Clare-Louise Nicholls
                                    In consultation with:
                                                                 Pam Thomas, Hannah Braine,
                                                                 Lesley Taylor, Sue Jack
                                                                 Management of cadaver policy
                                    To be read in
                                    association with:
                                                                 NMC code of conduct

                                    Ratified by:             Professional Executive Committee
                                    Issue/Ratification date: February 2010
                                    Review date:             February 2012




If you require this document in a different format, please
telephone the Corporate Manager on 01275 546717




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                                               Contents
1. Purpose of Guidelines                                                                3
2. Key Principles                                                                       3
3. Aim                                                                                  3
4. Legal Position                                                                       4
       4.1. Certification of death                                                      4
       4.2. Report to coroner                                                           4
       4.3. Verification of death                                                       4
5. Scope                                                                                4
6. Competencies                                                                         6
7. Definitions for purposes of these guidelines                                         6
       7.1. Expected death                                                              6
       7.2. Verification of death                                                       6
       7.3. Certification of death                                                      6
8. Verification of inevitable expected death                                            7
9. Verification of unexpected death                                                     7
10. Conditions unequivocally associated with death                                      8
       10.1. Hypostasis                                                                 8
       10.2. Rigor Mortis                                                               8
11. Reporting to the Coroner
12. Criteria for informing the coroner of death.                                        9
13. Declaring “death has occurred” guidelines                                           10
14. Monitoring                                                                          12
15. References                                                                          12

Appendices
1. Clinical procedure for verifying an expected death                                   13
2. Document for recording Verified Death                                                15
3. Verification of death competency workbook                                            17
4. Flowchart for verification of expected death by nurse                                21
5. Action to be taken in case of unexpected death or collapse                           22
6. Action to be taken after verification of unexpected death by nurse                   23




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 1.            Purpose of the guidelines

          These guidelines and procedures provide a framework for the verification of death,
          by Registered Nurses across NHS North Somerset.

          This document outlines how registered nurses scope of professional practice can
          be extended to verify both expected and unexpected death.


 2.        Key Principles

           District nursing teams provide palliative and end of life care on a regular basis. The
           ability of the community nurse to confirm the inevitable expected death of a patient
           and provide appropriate aftercare to relatives and carers will provide continuity at a
           time of stress and anxiety.

           Confirming that death has occurred is an important stage in the grieving process,
           and therefore should be undertaken by the most appropriate person at the time,
           avoiding unnecessary stress and anxiety for the family or relatives. Respect and
           compassion for the dying, the deceased and the bereaved is a universal concept.
           When caring for the dying person, a nurse should be aware of the cultural and
           religious/faith aspects of what is expected and preferred by the individual, their
           family and their ethnic/cultural/religious community.

           The role of a nurse is paramount in ensuring patients, carers and their relatives are
           able to access the most appropriate palliative/end of life care. The ability for
           registered nurses to confirm the death of a patient will provide continuity of care.


3.         Aim

           The expected aims of this policy are:

           •     That the death of the patient is dealt with in a timely, sensitive and caring
                 manner respecting the dignity of the patient, relatives and carers;

           •     The death of a patient is dealt in accordance with the law;

           •     The appropriate use of registered nurse/professional’s skills and competencies;

           •     The reduction of delays that can lead to difficulties, in particular when patients
                 may have parenteral medication sited for pain relief. The disconnection of such
                 devices;

           •     Prevention of unnecessary emergency ambulance call outs where resuscitation
                 would be inappropriate.



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4.         Legal Position

 4.1       Certification of death is the process of completing the “Medical Certificate of
           Cause of Death” and must be completed by a medical practitioner.
           The legal position regarding certification of death is determined by the Births and
           Deaths Registration Act 1953. A registered medical practitioner who has attended a
           deceased person during his last illness is required to give a medical certificate of
           the cause of death, “to the best of his knowledge and belief” and to deliver that
           certificate forthwith to the Registrar. The certificate requires the doctor to state the
           last date on which he saw the deceased person alive and whether or not he has
           seen the body after death. He is not obliged to view the body but good practice
           requires that if he has any doubt about the fact of death he should satisfy himself in
           this way. (Para 5.01 Report of the Committee on Death Certification and Coroners
           English Home Office CMND 4810 November 1971).

           A certifying doctor is required only to certify the cause of death and not the fact of
           death and does not need to have examined the body in order to sign the death
           certificate.

 4.2       Reporting to the coroner.

           All sudden or unexpected deaths must be reported to the coroner.

           In summary English Law:

           •         Does not require a doctor to confirm that death has occurred.
           •         Does not require a doctor to view the body of a deceased person
           •         Does not require a doctor to report the fact that a death has occurred
           •         Does require the doctor who attended the deceased during the last
                     illness to issue a certificate detailing the cause of death
                                                                          (Kent LMC 2001)

 4.3       Verification of death.

           Verification of the fact of death is defined as deciding whether a patient is actually
           deceased and does not require a medically registered practitioner to undertake
           verification. Traditionally, a medical practitioner had always been called upon to
           pronounce life extinct although a certifying doctor is required only to certify the
           cause of death and not the fact of death and does not need to have examined the
           body in order to sign the death certificate.

 5.        Scope

           This policy will apply to all registered clinical nursing staff working within adult care
           areas for Provider Services of North Somerset.



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          Registered Nurses with the necessary competencies working within these
          guidelines have the authority to verify ‘life extinct’, notify the relatives and arrange
          for the removal of the body.

          A nurse cannot legally certify death. S/he may, however, verify that death has
          occurred, providing there is a local policy or protocol to allow such an action.

          Where the death meets the criteria listed in section 11, it must be reported to the
          coroner. It is the responsibility of the attending doctor or nurse to report the death to
          the Coroner’s Office.


6.        Competencies.

6.1       The NMC Code of Professional Conduct and Scope of Professional Practice 2002,
          places specific responsibilities on registered nurse practitioners to maintain
          professional knowledge and competence. To practice competently within these
          guidelines, nurses must possess the knowledge, skills and abilities required for
          lawful, safe and effective practice without direct supervision. Nurses will
          acknowledge the limits of their professional competence and only undertake
          practice and accept responsibilities for those activities in which they are competent.

6.2       All Registered Nurses verifying death must have the competencies, skills and
          knowledge to enable them to determine the physiological aspects of death. If the
          nurse requires training to achieve these competencies, there will be a commitment
          to training to support this practice. Additionally s/he should be aware of the legal
          issues and related accountability that relate to this extended scope of professional
          practice (RCN 2004).

6.3 Training for registered nursing staff who may be called upon, as part of their role, to
    verify an expected death will be available and repeated periodically to ensure skills
    are developed, maintained and updated as required. The training should
    incorporate professional and legal considerations, policy and procedure details, the
    role of the Coroner’s office, documentation, communication skills, clinical
    examination required to verify that life is extinct, bereavement support/advice for
    family/carers.

7.        Definitions for the purpose of these guidelines

          Nurse
          For the Purpose of these guidelines a ‘nurse’ is a person who holds current nursing
          registration with the United Kingdom regulatory authority for nursing and midwifery,
          the Nursing and Midwifery Council (NMC).

          Expected Death
          Death following on from a period of illness which has been identified as terminal,
          where registered nurses and doctors have been involved in providing palliative care
          and where there is agreement between patient, relatives, medical and nursing
          teams that no active intervention to prolong life is ongoing and/or a Do Not Attempt
          Resuscitation (DNAR) decision has been made and the decision is recorded in the

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          patient record on appropriate DNAR form (see resuscitation policy) and has been
          communicated to the whole team.

         Unexpected Death

          A death where there was no expectation that the patient was terminally ill or likely
          to die. This should include suspicious death, where there is suspicion or signs of
          violence, accident, poisoning or suicide or unexplained death where there is
          insufficient evidence available to assist in determining the likely cause of death.

          Verification of Death/Confirmation of Death

          Physical examination to confirm death has taken place. This does not require a
          medically registered practitioner to undertake verification.

          Certification of Death

          The process of completing the “Medical Certificate of Cause of Death” and this
          must be completed by a medical practitioner.
          “A nurse cannot legally certify death, since this is one of the few activities that the
          law requires to be performed by registered medical practitioners. S/he may,
          however, confirm that death has occurred provided there is an explicit local policy
          or protocol to allow such an action”.

8.        Verification of inevitable expected death.
8.1       Within any setting there will always be those patients whose death becomes
          inevitable. For the purposes of this policy, death can be defined as death following
          on from a period of illness that has been identified as terminal, and where no active
          intervention to prolong life is ongoing. The patient’s GP/hospital doctor will have
          been attending regularly to provide medical support.

8.2       Discussion, and documentation of this discussion, should have taken place
          between the medical practitioners and nursing staff, it should be clearly agreed that
          further intervention would be inappropriate, and death is expected to be imminent.
          A Do Not Attempt Resuscitation (DNAR) decision has been made and the decision
          is recorded in the patient record on appropriate DNAR form (see resuscitation
          policy) and has been communicated to the whole team. Wherever possible the
          relative should be made aware of the patient’s deteriorating condition and of the
          patient’s care plan.

8.3       Verification can be undertaken where:

            •     Death will be expected and not accompanied by any suspicious
                  circumstances. See section 11 for deaths that need to be reported to the
                  coroner.
            •     The patient will have seen a doctor within the last 14 days.
            •     The nurse has received identified Verification of Death training and
                  demonstrates competence. S/he is accountable for his/her own professional
                  practice in accordance with NMC guidelines (2006).

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9.        Verification of unexpected death.
9.1       Where the death is unexpected and where no explicit advance decision has been
          made about the appropriateness or otherwise of attempting resuscitation prior to a
          patient suffering cardiac or respiratory arrest, and the express wishes of the patient
          are unknown and cannot be ascertained, there should be a presumption that health
          professionals will make all reasonable effort to attempt to revive the patient unless
          the fact of death is unmistakable (see 10 below).
9.2       The Emergency Ambulance Service must be called whenever there is a
          chance of survival, however remote. Nevertheless, it is possible to identify
          patients in whom there is absolutely no chance of survival, and the patient is
          irrefutably dead where resuscitation would be both futile and distressing for
          relatives, friends and healthcare personnel.
9.3       The conditions, listed (see point 10 below) are unequivocally associated with death
          in all age groups and resuscitation should not be attempted. If a third party
          (relative or close friend) insists on resuscitation, careful explanation of the
          circumstances and the reason for not carrying out resuscitation should be given.
9.4       In the following conditions resuscitation can be discontinued:
          The presence of a DNAR (Do Not Attempt Resuscitation) order or a Living Will or
          an Advance Directive that states the wish of the subject not to undergo attempted
          resuscitation.

9.5       In situations when ALL the following exist together:

                  • 15 minutes since the onset of collapse;

                  • no bystander Cardio Pulmonary Resuscitation (CPR) prior to arrival of the
                     ambulance;

                  • the absence of any of the exclusion factors.

          Unless all the above conditions apply or there is irrefutable evidence as to
          the fact of death, resuscitation should be continued until the emergency
          ambulance team arrives.

10.       Conditions unequivocally associated with death.
10.1 Hypostasis: the pooling of blood in congested vessels in the dependant part of the
     body in the position in which it lies after death. Initially hypostatic staining may
     appear as small round patches looking rather like bruises but later these coalesce
     to merge as the familiar pattern. Above the hypostatic engorgement there is
     obvious pallor of the skin. The presence of hypostasis is a diagnosis of death – the
     appearance is not present in a live subject. In extremely cold conditions hypostasis
     may be bright red in colour, and in carbon monoxide poisoning it is
     characteristically ‘cherry red’ in appearance.
10.2 Rigor mortis: the stiffness occurring after death from the post mortem breakdown
     of enzymes in the muscle fibres. Rigor mortis occurs first in the small muscles of
     the face, next in the arms, then in the legs (30 minutes to 3 hours). It is stated that
     the diagnosis of rigor mortis can be verified by firmly pressing on a joint such as the
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          knee, when the rigor mortis will be abolished and the joint becomes flaccid. In
          some the rigidity never develops (infants, cachectic and the aged) and in some it
          may become more apparent more rapidly (in conditions in which muscle glycogen
          is depleted): exertion (that includes struggling), strychnine poisoning, local heat
          (from a fire, hot room or direct sunlight). Rigor should not be confused with
          cadaveric spasm (sometimes referred to as instant rigor mortis) which develops
          immediately after death without preceding flaccidity following intense physical
          and/or emotional activity. Examples are: following death by drowning and falls from
          heights where in contrast with true rigor mortis only one group of muscles is
          affected and NOT the whole body. Rigor mortis will develop subsequently.
          (JRCALC 2003).

11.       Reporting to the coroner.

          The Coroner’s Officers on 0117 952602 or 0117995603 between 8.30am and
          5.00pm after consultation with the senior member staff.

          After this time the Police Control Room, on 0845 4567000, acts as the Coroner’s
          Officer and will advise whether they need to attend before removal of the
          deceased. This is the Police Communications at Portishead. Ask to speak to the
          on-call Coroners officer.

          If reporting the death to the coroner, take advice before removal of any devices or
          equipment.

          Advice and support after a death has been reported to the Coroner can be obtained
                          s
          from HM Coroner' Team Avon based at Froomsgate House in Bristol.

            Their objectives are:
               • To manage all bereavements in the HM coroners Avon effectively and in a
                   timely manner.
               • To provide a quality, professional service.
               • To offer information and help in processes associated with bereavement.

            They are employed by the Constabulary and are specialists in their field, providing
            a vital community contact role with bereaved families and are the link between
            police officers, hospitals and HM Coroner Avon who is based at Flax Bourton.

            The Coroner
            The Courthouse, Old Weston Road
            Flax Bourton
            North Somerset
            BS48 1UL
            Telephone: 01275 461920

            They manage, on behalf of HM Coroner, all sudden, unexpected or unnatural
            deaths to which a doctor cannot issue certification. They also manage all deaths
            that result from trauma and all hospital-related deaths.


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            Any one of the team will be able to assist the nurse.

            The team are there to help and can be contacted by calling the family line on:
            0117 952 9685 or,

            Facsimile – 0117 952 9601 or,

            Email: avoncoronersofficers@avonandsomerset.police.uk


12.       Criteria for informing the coroner of a death.
          If in doubt please contact the Coroner’s Office.
          It is the responsibility of the attending doctor or senior nurse to report a death
          where;
          12.1     The deceased was not seen by a doctor within 14 days prior to death.

          12.2          The cause of death is unknown or an underlying cause of death is
                        uncertain.

          12.3          Where Clostridium Difficile Colitis, Diarrhoea is written on any part of the
                        death certificate.

          12.4          There is death due to injury or if injury is suspected to have contributed or
                        accelerated death. This would include;
                           • All forms of violence whether deliberate, accidental or self inflicted;
                           • Deaths due to septicaemia, gangrene, tetanus, or other infection
                              resulting from an injury;
                           • Death by poisoning in all forms including poisoning by drugs,
                              alcohol, food poisoning, solvent abuse or other causes.

         12.5           The death occurs during medical treatment/health care. These would
                        include:
                            • All deaths within 24 hours of admission to hospital;
                            • All deaths within 48 hours of an operation or procedure;
                            • All maternal deaths within 21 days of delivery;
                            • Any death where prescribed drugs or other complications are
                               thought to be responsible;
                            • Any death due to a medical, surgical or anaesthetic mishap;
                            • Any death where the relatives complain regarding the medical
                               treatment: this includes administration of drugs and after any
                               therapy, transfusion or any other clinical undertaking, any
                               anaesthetic procedure, whether general or local;
                            • Death of unidentified person if the cause is unnatural or unknown;
                            • Death within 30 days of an operation or invasive procedure;
                            • Any unclear or suspicious death;
                            • Deaths which may be attributable to a fracture, septicaemia
            12.6        Deaths related to industrial diseases i.e. Pneumoconiosis, Silicosis,
                        Anthracosis, Asbestosis or poisoning from whatever cause, deaths from
                        any such cause, where the deceased’s employment or former employment
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                        is thought to be connected must be reported to the Health and Safety
                        Executive (HSE) which is the Government’s regulatory body for monitoring
                        health and safety performance. The HSE requires certain incidents to be
                        reported under the Reporting of Injuries, Diseases and Dangerous
                        Occurrences Regulations (1995) or RIDDOR.

            12.7        Pensioners – receiving disability or war pensions. Where death might be
                        connected with the pensionable disability.

            12.8        Poisoning - From any cause, occupational, therapeutic, accidental, suicidal,
                        homicidal and also food poisoning.

            12.9        Deaths constituting a threat to the health of the community – food
                        poisoning, psittacosis, etc,
            12.10 Any case where the deceased was a prisoner, in Youth Custody, at an
                  Approved School, or under arrest, or was deprived of their liberty when first
                  admitted to hospital;
            12.11 The death of a person with a serious mental health condition; *
            12.12 Deaths due to want, exposure or neglect, either by the deceased or others
                  i.e. hypothermia, lack of food or general care;
            12.13 Death where Sepsis or fracture will appear as the cause of death on the
                  death certificate. *
                        *        The Coroner may not normally be required to be informed, but this
                                 has been recognised as good practice guidelines.
            12.14 Where death is unexpected from which the cause is not yet known or
                  deaths which may be due to, or contributed by, accident, suicide, injury,
                  poisoning, violence, neglect, industrial disease (even if the contributory
                  event occurred a long time ago e.g. patient in hospital for several months
                  after near-fatal episode of trauma, who subsequently dies of an infection or
                  patient who dies from a complication of quadriplegia from a motorcycle
                  accident 20 years ago and deaths occurring during an operation or before
                  full recovery from anaesthesia).

13.       Declaring ‘Death has Occurred’ Guidelines.
            The nurse should:
                  •     Ensure that the patient’s records reflect that the death is expected.
                  •     Note the exact time of death where possible. In the case of nurses being
                        contacted as soon as possible after death, the time of death should be
                        established as closely as possible from the relatives.
                  •     Check for clinical signs of death, using a stethoscope and penlight or
                        ophthalmoscope.
                  •     Repeat the check for clinical signs of death after 10 minutes
                  •     The following are the recognised clinical signs used when verifying death.
                        All signs should be present before death is verified:
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                           o Absence of a carotid pulse over one minute
                           o Absence of heart sounds over one minute
                           o Absence of respiratory movements and breath sounds over one
                             minute
                           o Fixed pupils. (unresponsive to bright lights)
                           o No response to painful stimuli (e.g. Sternal rub)
                           o If there is any uncertainty, the situation is likely to become clearer in
                             15- 30 minutes. Go through the checklist again then.
            Do not feel pressurised to declare ‘death has occurred’ instantly. Gurgling noises
            etc may occur immediately after death which may make verification more difficult.
            When verifying death the nurse must record in the patient’s notes:
                  •     The date and time of death;
                  •     Name, age and date of birth of the deceased;
                  •     When deceased was last seen alive;
                  •     Identity of any persons present at the death, or if the deceased were alone,
                        of the person who found the body.
                  •     Whether the body has been moved and if so by whom
                  •     Time of verification
                  •     Circumstances of death (e.g. place of death)
                  •     Clinical signs of death (including signs additional to those listed above such
                        as post-mortem changes on the skin (waxy appearance, mottling,
                        dependent markings), or Rigor mortis.
                  •     Name of the doctor informed and the time and date this took place (also
                        any others informed such as other nurse teams involved)
                  •     Name of the coroner informed (where relevant) and the time and date this
                        took place;
                  •     Name of undertaker if contacted and any details relating to this contact
            Once the death has been verified (or certified by a doctor) the patient may be
            transferred to the funeral directors.
            The record of the nurse’s visit should be formally communicated to the patients
            GP as soon as possible. If the death occurred out of working hours this should be
            the next working day.

            Parenteral drug administration equipment or any life prolonging equipment should
            not be removed prior to verification of death.

            The nurse should contact all professionals involved in the care of the patient so
            that they are aware of the death.

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            Having undertaken the above, the nurse will inform the Next of Kin
            (relatives/carers) of the death and advise that they can arrange for the transfer of
            the deceased patient to the undertakers.
            If the nurse has any concerns that the death may not be from natural causes the
            police must be informed.
            The nurse should advise the deceased’s relative that they will be able to obtain
            the death certificate from the patients own doctor.

14.       Monitoring.

            The implementation of this Policy and associated guidance will be monitored
            through the following processes:

                  •     Patient Complaints

                  •     Patient Advice and Liaison Services (PALS)

                  •     Adverse Incident Reporting procedure

                  •     Number of staff trained to undertake verification of death

                  •     The percentage of expected deaths occurring that are verified by a
                        registered nurse

15.       References.

          Skills for Health (2008) Accessed May 2009 Regarding Verification of Unexpected Death.
          Medical Protection Society Factsheet (2007) Reporting Deaths to the Coroner.
          Secretary of State for the Home Department (June 2003) Death Certification and
          Investigation in England, Wales and Northern Ireland. Report of a Fundamental Review.
          Home Office (2001) Report of the Home Office Review of Death Certification. Executive
          Summary and Recommendation.
          Royal College of Nursing (2004) Confirmation (Verification) of Expected Deaths by
          Registered Nurses.




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16.       Appendices.

APPENDIX 1

CLINICAL PROCEDURE FOR VERIFYING AN EXPECTED DEATH

The registered nurse will need to:

1.          Identify, access and evaluate all relevant information and consult with colleagues to that
            you clearly understand the care pathway and the current circumstances.

2.          Accurately identify the patient in line with NS PCT policy.

3.          Identify and greet any key persons present and determine their preferences with regard to
            their role in the procedure and any cultural or religious requirements.

4.          Arrange for a professional translator/interpreter if you have reason to believe this will
            assist the understanding of the key person.

5.          Ensure the environment provides for the maximum possible privacy and dignity for the
            deceased and key person present throughout the procedure, including religious rites
            where possible.

6.          Take action to pre-empt interruptions from communication devices and visitors.

7.          Undertake the assessment involving the key person if appropriate.

8.          Assess the patient’s vital signs and check the patient for the following clinical signs:
               • Check the patient is unresponsive and there are no signs of life.
               • Check for one minute that carotid pulse is absent.
               • Using a stethoscope, check for one minute that heart sounds are absent.
               • Using a stethoscope check for one minute that breath sounds are absent.
               • Check pupils are fixed or unresponsive.
               • Check no response to painful stimuli.
            Wait 10 minutes and repeat checks for vital signs.

9.          Record and complete the Verification of Death by a Registered Nurse documentation.
            (Appendix 2).

10.         Assess the emotional state of the key person and respond accordingly throughout the
            process.

11.         Use visual clues to add to your understanding of the needs, circumstances, choices and
            preferences of the key persons.

12.         Inform the key persons of the death at a pace and level which is appropriate to:
                • Their needs, circumstances, choices and preferences;
                • Their emotional state;
                • Their level of understanding;
                • Their culture and background;
                • Their preferred way of communicating.
                • Be clear about removal from the deceased or keeping in place of items such
                    jewelry and religious items such as threads, amulets.

13.         Provide opportunities for the key persons to ask any questions and respond appropriately.
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14.         Inform the key person of the next steps in the process and of the range of options
            available to them, taking account of their preferences and any cultural or religious
            requirements without making assumptions.

15.         Provide and/or signpost the key person with supporting and appropriate information,
            including how to obtain further information and/or support.

16.         Inform appropriate professional colleagues of the death and relevant circumstances.

17.         Seek advice and support from an appropriate source when you recognize the complexity
            of the case is beyond your competence and capability.

18.         See flow diagram for quick reference. (Appendix 4).




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Appendix 2




                               Verification of Death by a Registered Nurse

Patient’s Name                                                                     DOB
Address

Postcode                                                                           NHS No.
GP                                                                                 Hosp No.


This patient’s death is expected (a case where discussions have taken place between the medical and nursing
team and the patient/family and a decision has been made and documented that no further intervention is appropriate.
Completion of this section will ensure fewer deaths in the community are notified to the Coroner’s office because the patient
hadn’t been seen by their GP within the previous 14 days. )
Doctor’s Name                                                                                     Date
Doctor’s Signature


Date of Death                Time of Death        (use 24hr clock,     Time Verified            Place of death (i.e.
                             not 24.00 – 1 min before or after)                                 hospital, home, hospice)




Clinical observation of absence of life (to be repeated after 10 mins)

                            Initials                                   Initials                                  Initials
    Respiration                                   Cardiac                                 Cerebral
                          1st     2nd                                 1st    2nd                               1st     2nd
There are no                              There is no                                There is no
signs of                                  femoral or carotid                         response to
spontaneous                               pulse palpable (1                          painful stimuli
respiration (1                            minute)
minute)
There are no                              There are no                               Pupils are
breath sounds (1                          heart sounds (1                            unresponsive to
minute using a                            minute using a                             light
stethoscope)                              stethoscope)
                                                                                     Pupils are fixed


Comments.




Absence of life verified by:
Name
Designation
Signature                                                                    Date
Contact No.

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                                                   Care After Death

Notification
Next of Kin                       Yes / No     Say whom:
                                               By whom:
Care Home                         Yes / No     By whom:
EOL Key Worker                    Yes / No     By whom:
GP out of hours                   Yes / No     By whom:
Funeral Director                  Yes / No     By whom:
Coroner’s Office                  Yes / No     By whom:
GP Practice                       Yes / No     By whom:
Minister of Religion              Yes / No     By whom:

1.    Procedure following death                                                                 Y     N
          • Check if patient has an infectious disease
          • Carry out any requested specific religious/spiritual/cultural needs
          • Coroner’s post mortem discussed if needed
2.    Procedures for last offices followed in accordance with relevant policy or                Y     N
      discussion with family
3.    Family/other given information on next steps, e.g. (any/all of the following)             Y     N
          • Arrange to see Registrar
          • Explain mortuary viewing
          • Collection of death certificate
4.    Tissue donation discussed                                                                 Y     N
          • Do the family wish to speak to the tissue transplant co-ordinator?
             (07699 704933 24hrs)
5.    Necessary written documentation given to the appropriate person, e.g.                     Y     N
          • What happens next
          • Bereavement support

Circumstances where a death needs to be reported to the Coroner.
     • The cause of death is unknown.                                                           Y         N
     • The deceased was not seen by a doctor in the 14 days prior to death.                     Y         N
     • Deaths with a medical problem e.g.                                                       Y         N
        • The patient has been in hospital for less than 24hrs, the death occurs
           whilst in theatre or shortly after an operation, the doctors cause of death
           includes the word “failure”, there is a suspicion something has gone
           wrong with medical treatment, there is a known complaint about medical
           treatment, death follows an untoward incident.
     • There are suspicions there has been “neglect” by a carer, or the deceased                Y         N
        does not appear to have looked after him or herself properly, or has refused
        treatment.
     • The cause may be unnatural e.g.                                                          Y         N
        • Due to an accident (including a fall), murder or manslaughter, suicide,
           industrial disease, substance misuse.
     • There are unusual or disturbing features.
                                                                                                Y         N
     • The treating doctor is on holiday or otherwise unavailable.
                                                                                                Y         N
     • Clostridium Difficile.                                                                   Y         N
If in doubt – report.

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Appendix 3




                                                             North Somerset

                           VERIFICATION OF
                           EXPECTED DEATH
                        COMPETENCY WORKBOOK




This workbook, alongside recognized, training will help with the ratification of your
competencies in verifying an expected death.

The objectives of the competencies are: -
   • To ensure you feel competent and capable to carry out the procedure.
   • To ensure you are fully aware of the total procedure and your role in it.
   • To ensure you are aware of your responsibilities, and those of others.

The competencies should be completed alongside a trainer or nurse who has already
passed their own competencies. This will help to disseminate the knowledge and skills.




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                                      COMPETENCY WORKSHEET

Name ……………………………………………………….

Date of completion…………………………………………


                  Competency                                    Signature                   Date
     Background to the procedure


     Key factors to consider when carrying out
     this procedure

     Legal implications of the role of the nurse


     Equipment and paperwork that are
     required to carry out this procedure

     How to check identity according to local
     policy

     How to check there are no signs of life


     Location of carotid pulse


     Use of a stethoscope to listen for heart
     sounds

     Use of a stethoscope to listen for breath
     sounds

     Examination of pupils to check if they are
     fixed and unresponsive

     Use of painful stimuli to assess response


     Procedure following examination




Name of assessor ……………………………………………..
Signature of assessor …………………………………………
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                                     Competency Workbook Notes

1.          Important to ensure the registered nurse name on sheet.

2.          Date of completion of competency important so that the nurse from that date is
            deemed competent to carry out this procedure if required and that s/he is happy to
            do so.

3.          It is important that the nurse has an awareness of why the training is needed and
            the background to it. This should include:
                 • Improving end of life care for all patients.
                 • That confirmation of an expected death is an important stage in the grieving
                    process
                 • That continuity with family and carers helps support them during this
                    process.

4.          Key factors to consider:
               • Who wants to be present
               • Their understanding of the nurses role
               • Any language or communication barriers that will impede the understanding
                  of the key persons involved
               • Privacy and prevention of interruption.

5.          Legal implications - here the NMC guidance should be quoted so the assessor
            is certain the nurse has full awareness of their role.

6.          List of equipment needed: - stethoscope, torch, patient notes, all documentation
            pertaining to the procedure - Appendix A, B, C, D, E.

7.          Checking identity - ensure that this is the patient, according to local guidelines.

8.          Check no signs of life by observation of the chest, calling their name holding their
            hand to stimulate a response.

9.          Check where a carotid pulse can be found, and other reasons why it may be
            difficult to find. Get nurse to show assessor where their carotid pulse is.

10.         Use of a stethoscope - ensure nurse knows how to use one and where heart
            sound should be heard, and to listen to their own.

11.         Use of stethoscope - nurse to show where breath sound can be heard and to
            listen to his or her own.

12.         Examination of pupils-why they are fixed and dilated, how this part of the
            procedure would be carried out.

13.         Considerations for the finishing of the procedure:
              • Ensure written information is left with key persons in a suitable format.
              • Ensure a detailed explanation of the procedure to follow verification, i.e.
                  informing doctor, they then certify the removal of the deceased.
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                  •     Answer any queries or questions, at all times being compassionate and
                        supportive. Identify who also needs to be notified of the death, professional
                        colleagues that have been involved with the care of the deceased.

            Once the trainer/assessor is happy that the nurse is competence they can sign off
            the competency.

            In some circumstances this can take more than one time.




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              Appendix 4

                      FLOWCHART FOR VERIFICATION OF INEVITABLE EXPECTED DEATH BY
                                          REGISTERED NURSE




Box 1.                                                                                 Death expected
An expected death is:                                                                  See Box 1

A case where discussions have taken
place between the medical and
nursing team and the patients                                      Decision made for                   Palliative care being
relatives and a decision has been                                  no active medical                   provided by nursing
made and documented that no further                                intervention                        staff
intervention is appropriate.


                                                                                        Decisions
                                                                                        documented in
                                                                                        records



                                                                        Patient dies at home, relatives contact
                                                                        nursing service




                                          Box 2.
                                          Nurse check physiological signs to ascertain that death has occurred
                                             • Absence of a carotid pulse over one minute
                                             • Absence of heart sounds over one minute
                                             • Absence of respiratory movements and breath sounds over one minute
                                             • Fixed pupils (unresponsive to bright lights)
                                             • No response to painful stimuli (e.g. Sternal rub)



        In most cases Doctor issues                                                       The nurse records in the patients
        death certificate, within 24                                                      records
        hours or next working day. In                                                     • The date and time of death
        some cases, e.g. death from                                                       • Identify or, if the deceased
        industrial disease, a post                 Death notified to the                      were alone, of the person who
        mortem and inquest will be                 patient’s GP                               found the body
        required                                                                          • Time of verification
                                                                                          • Circumstances of death
                                                                                          • Clinical signs of death noted
                                                                                          • Name of Doctor informed and
                                                                                              the time and date this took
                               Provision of support to family/carers, and                     place
                               referral to undertaker of family’s choices
                               desired by relatives




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Appendix 5

 ACTION TO BE TAKEN BY NURSES IN CASES OF REPORTED UNEXPECTED DEATH OR
                                COLLAPSE.




        Check for signs of life. Examine patient for conditions that are unequivocally associated with death.




                        If signs of life call                        Resuscitation should not be
                        emergency ambulance                          attempted if there are conditions
                        services (999)                               Unequivocally associated with
                        Continue to provide                          death. These are:
                        appropriate care,
                        including full resuscitation                 •    Hypostasis and rigor mortis
                        if necessary, until                          •    Decapitation
                        emergency service arrives                    •    Massive cranial and cerebral
                                                                          destruction
                                                                     •    Hemicorporectomy
                                                                     •    Decomposition/Putrefaction




                                                                         See Box 2 Verification of
                                                                         inevitable expected death for
                                                                         verification procedure. Then
                                                                         follow procedure for action to
                                                                         be taken after verification of
                                                                         an unexpected death.




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Appendix 6

                ACTION TO BE TAKEN AFTER VERIFICATION OF UNEXPECTED DEATH




  Practitioner verifies death




                                                                  •    Take steps to preserve the scene
  Does the death need reporting to                                •    Ask control to contact the police
  the Coroner?                                   Yes                   and advise them of a suspicious
                                                                       death
                                                                  •    Police will inform Coroner if
                                                                       necessary
                                                                  •    Remain at the scene
                                                                  •    Complete Verification of Death
                                                                       form (Appendix 2)




                    No




  •     Offer condolences and information
  •     If appropriate provide support to
        family/carers in taking further action
        e.g. contacting undertaker
  •     Provide relatives with information
        leaflet
  •     Complete Verification of Death form
        (appendix 2)




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