Care of Deceased SOP.Docx Filename Care of the Deceased Standard Operating Procedure
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Care of the Deceased SOP Document Control Title Care of the Deceased Standard Operating Procedure Author Author’s job title Lead Nurse Infection Prevention & Control Directorate Department Team/Specialty Nursing Infection Prevention & Control Date Version Status Comment / Changes / Approval Issued 0.1 Mar Draft Developed for consultation 2009 0.2 May Draft Amended following consultation 2009 1.0 Jun Final Approved by Subject Specialist Group consisting of Nurse 2009 Manger, Mortuary Manager, Infection Control Team and Chaplain. 1.1 Jul Revision The following statement added to procedure point 13: ‘or 2010 collected by the named Funeral Director if the patient has died in a community hospital’ 1.2 Aug Revision Amends by Corporate Affairs to document control report, 2010 filename and formatting. 1.3 Sep Revision Further amends made to incorporate all inputs. Contents 2010 list corrected. Appendix A added. Approved at Senior Nurse Forum in November 2010. 1.4 Dec Revision Final Corporate amendments; formatting and added 2010 hyperlinks prior to publication. 1.5 Apr Revision Updated and amended to incorporate ‘Care of the 2013 deceased – Infection Control Policy’, updated Deceased Patient Record & Notice of Death forms, and Community Hospital last offices procedure & checklist. Update to title. Amendments following consultation. Minor amendments by Corporate Governance to formatting for document map navigation and semi- automatic table of contents, document control report updated, hyperlinks added. Prompts and comments to author in red text. 1.6 June Revision Amendment to section 10 to ensure it is not ambiguous 2013 that lines etc. must not be removed from the deceased 1.7 June Revision Approved by Patient Safety Group on the 6th of June 2013 2013 subject to amendments to items 10.5 & 10.8. 2.0 Dec 13 Final Published on Bob. 3.0 Dec 19 Revision Updated in to latest SOP template Infection Prevention & Control Page 1 of 30 Care of the Deceased SOP 3.1 April Revision Re-write of SOP, updates on IPC precautions including 2021 Covid-19, Medical Examiner system and viewing the deceased. Updates appendices, references & associated documentation. 3.2 May Revision IPC content approved at Infection Prevention & Control 2021 Group. 3.3 June Revision Updates from Pathology Manager re: Medical Examiner 2021 reviewing inpatient deaths from SMCH, the mortuary fridge at SMCH and contacting funeral directors. Minor amendments to contacting the Bereavement Support Office and deletion of appendix F. 4.0 June Final Approved with minor changes at Patient Safety 2021 Operational Group 15.06.2021 Main Contact Lead Nurse Tel: Direct Dial – Infection Prevention & Control Tel: Internal – North Devon District Hospital Email: Raleigh Park Barnstaple, EX31 4JB Lead Director Director of Nursing Document Class Target Audience Standard Operating Procedure All staff who may perform last offices specifically: Clinical Site Managers Registered Nurses Senior Health Care Assistants Health Care Assistants Student Nurses Distribution List Distribution Method Senior Management Trust’s internal website All clinical leaders Superseded Documents Infection Control – Care of the Deceased Policy Issue Date Review Date Review Cycle Three years Consulted with the following Contact responsible for implementation stakeholders: and monitoring compliance: Infection Prevention & Control Mortuary Manager & Workforce Team Development facilitator Director of Nursing Associate Directors of Nursing Infection Prevention & Control Page 2 of 30 Care of the Deceased SOP Clinical Matrons Education/ training will be provided by: Community Matrons Workforce Development & Mortuary Team Pathology Service Manager Specialist Nurse Organ Chaplaincy Lead Bereavement Support Officer Mortuary Technicians Workforce Training Managers Ward/Department Managers Approval and Review Process Patient Safety Operational Group Infection Prevention & Control Decontamination Group Local Archive Reference G:\Infection Control Local Path G:\INFECTION CONTROL\IC Manual - Policies\SOPs\Care of the Deceased SOP\Working Drafts\Final version 4.0 Care of Deceased SOP.docx Filename Care of the Deceased Standard Operating Procedure Policy categories for Trust’s internal Tags for Trust’s internal website (Bob) website (Bob) Standard Operating Procedures Death, Dying, Last Offices, Bereavement, Tissue Donation Infection Prevention & Control Page 3 of 30 Care of the Deceased SOP CONTENTS Document Control ............................................................................................................... 1 1. Background .................................................................................................................. 5 2. Purpose ........................................................................................................................ 5 3. Scope ............................................................................................................................ 6 4. Location ........................................................................................................................ 6 5. Responsibilities ........................................................................................................... 6 6. Procedure ..................................................................................................................... 6 7. Last Offices - Standard Operating Procedures .......................................................... 9 8. What to tell bereaved relatives following a death at North Devon District Hospital …………………………………………………………………………………………………..14 9. What to tell bereaved relatives / next of kin following a death of an inpatient at a community hospital .......................................................................................................... 14 10. Viewings ..................................................................................................................... 15 11. Information ................................................................................................................. 16 12. References ................................................................................................................. 16 13. Associated Documentation ....................................................................................... 17 Appendix A – Deceased Patient Record Notice of Death ............................................... 19 Appendix B – Tissue Donation Flow Chart ..................................................................... 20 Appendix C - Tissue Donation Guide .............................................................................. 21 Appendix D – Community Hospital Checklist ................................................................. 23 Appendix E – Religious & Cultural Requirements .......................................................... 25 Appendix F – Notification of Infection Risk to Funeral Directors .................................. 27 Appendix G –Transmission-based precautions to key infection in the deceased ....... 28 Infection Prevention & Control Page 4 of 30 Care of the Deceased SOP 1. Background Caring for the deceased and providing support to families and friends is of profound importance, NDHT is committed to ensuring the compassionate handling of the deceased during this time. Last Offices are performed after confirmation of death and should be carried out within four hours of death. Last offices are defined as the nursing care given to a deceased patient that will continue to demonstrate dignity and respect for the individual. It involves the preparation of the deceased for transportation and presentation to the mortuary and should focus on the patient’s religious and cultural beliefs, respecting the patients, families and significant others traditions. It must also follow health, safety and legal guidelines ensuring the deceased is presented to the Mortuary or Funeral Director in a manner which ensures infection risks are minimised. In most circumstances the same infection control standard precautions to prevent the spread of infection that were used in life apply to deceased patients. However deceased patients with infections may pose a risk to healthcare workers and relatives thus it will be necessary to adopt additional transmission based precautions. If asked, staff should give the family, partners or friends the opportunity to view the deceased either in the ward or mortuary viewing suite If they wish to speak to a member of the hospital chaplaincy team please ring the NDDH switchboard (01271 322577) who will contact the NDDH duty or North community chaplain respectively, but please note an instant response is not always possible. The contact numbers of local clergy can be found in the telephone book under the church name, or the funeral director will make this contact on behalf of the deceased's family. At community hospital sites follow your local procedure for contacting a community chaplain. There are a number of other considerations to be taken into account when caring for the deceased such as their wishes with regard to Organ / Tissue donation, the completion of the Death Certificate and communication with the Medical Examiner, consideration of the need for informing the Coroner, and the correct documentation and communication for releasing the deceased to an undertaker. 2. Purpose 2.1. The Standard Operating Procedure (SOP) has been written to: Identify procedures for the care of the deceased. Ensure that the correct