Last Offices Care of the Deceased UHL Policy Approved by: Policy & Guideline Committee Date Approved: 13 August 2010 Trust Reference: B28/2010 Version: 4 – PGC 3 June 2016 Supersedes: V3 Author / Jeanette Halborg Head of Nursing Clinical Originator(s): Support and Imaging Mark Burleigh Head Of Chaplaincy and Bereavement Services Name of Responsible Last Offices Care of the Deceased Patient Policy Committee/Individual: Task and Finish Group/End of Life and Palliative Care Committee Latest Review Date 3 June 2016 Next Review Date: May 2022 – Review Date Extension Approved at PGC 21.05.2021 CONTENTS Section Page 1 Introduction 3 2 Policy Aims 3 3 Policy Scope 3 4 Definitions 3 5 Roles and Responsibilities 4 6 Policy Statements, Standards, Procedures, Processes and Associated 5 Documents 7 Education and Training 5 8 Process for Monitoring Compliance 5 9 Equality Impact Assessment 6 10 Legal Liability 6 11 Supporting References, Evidence Base and Related Policies 6 12 Process for Version Control, Document Archiving and Review 7 Appendices Page One Declaring life extinct 10 Two Actions to be taken for suspicious death 12 Three Review referral to and contact with H.M. Coroner 14 Four Communication with the family 20 Five Post-mortem examination/taking tissue samples after death 25 Six Removal of Endotracheal Tubes (ET) 30 Seven Preparation of the deceased adult (“Last Offices”) 31 Eight Preparation of the deceased child (“Last Offices”) 38 Nine Transfer to the mortuary 46 Ten Risk of infection and use of body bags 54 Eleven Cultural and religious requirements 58 REVIEW DATES AND DETAILS OF CHANGES MADE DURING THE REVIEW V4 - review of V3 in May 2016, reformatted into latest Trust template. Complete Re- write of policy monitoring table, Appendix 2, Appendix 3 section 5.3,5.4,5.5, Appendix 4 update of clinical names in Responsibility Section 1.2, section all reference to Interserve and Directorates removed. V3 – review of Version 2 December 2013, reformatted into latest Trust template, appendix 5 added in and no longer a standalone document (Taking Samples after Death/Removal of ET Tubes Trust reference (B51/2009). V2 – review of V1 in August 2010, complete re-write and reformatted into latest Trust template. Approved by the Policy and Guideline Committee on 13th August 2010 and issued new Trust reference number (B28/2010). Last Offices Care of the Deceased Patient UHL Policy Page 2 of 61 V4 Approved by Policy and Guideline Committee on 3 June 2016 Trust Ref: B28/2010 Next Review: May 2022 – extension agreed at PGC 21/05/2021 NB: Paper copies of this document may not be most recent version. The definitive version is held on INsite Documents V1 approved by the Policy and Guideline Committee on 7th August 2006 as Last Offices Policy – Trust reference B36/2006. KEY WORDS Last Offices, End of Life, Deceased. 1 INTRODUCTION 1.1 This document sets out the University Hospitals of Leicester (UHL) NHS Trusts Policy and Procedures 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 POLICY AIMS The aim of this policy is to guide staff through the processes relevant to care of the deceased patient and their relatives to be used in conjunction with the attached appendices. 3 POLICY SCOPE 3.1 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). 3.2 For maternal deaths within UHL, please see “Maternal Death: Guidelines for the Management of Maternal Death, C2/2007”. 3.3 This policy does not apply to St Mary’s Birth Centre. 3.4 This policy does not cover the care of the non-viable foetus, stillborn baby or Neonatal death within Maternity or Neonatal services; please see following Documents for further information and advice: Policy for the Sensitive Disposal of Foetal Remains, Trust ref: B3/2007 Certification of Stillbirth and Neonatal Deaths on Labour Ward, Trust ref: C33/2010. Support for Women and Families Where the Outcome for the New-born Baby is Poor or Suspected to be Poor, Trust ref: C23/2011. 4 DEFINITIONS Last Offices: The term last offices relates to the care given to a body after death. Last Offices Care of the Deceased Patient UHL Policy Page 3 of 61 V4 Approved by Policy and Guideline Committee on 3 June 2016 Trust Ref: B28/2010 Next Review: May 2022 – extension agreed at PGC 21/05/2021 NB: Paper copies of this document may not be most recent version. The definitive version is held on INsite Documents 5 ROLES AND RESPONSIBILITIES 5.1 Chief Nurse – Executive Lead for this policy Responsible for informing the Trust Board of changes in practice and relevant information. 5.2 Registered Medical Staff Responsible for examining the deceased patient, declaring and documenting that life is extinct and assessing whether referral to H.M. Coroner is required. Responsible for completing the appropriate Medical Certificate for Cause of Death for non-coronial cases. 5.3 Registered Nursing and Midwifery Staff Are responsible for preparation of the deceased patient, completion of the Notification of Death Form, ensuring availability of personal protective clothing on the ward, initiating transfer to the mortuary, recording the date and time of release of the deceased from the ward, informing portering and mortuary staff of manual handling/infection/other known risks and providing support for the bereaved. 5.4 Care Assistants Under the supervision/instruction 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”(B24/2007). 5.5 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. 5.6 Ward Clerks Responsible for transferring the deceased patient’s case notes to Bereavement Services office; management of the deceased’s property in accordance with the “Management of Patient Property Policy and Procedures” Trust ref: B24/2007. 5.7 Duty Managers Responsible for the identification and administration at the point of release out of hours, under the “Policy for the Handling and Release of the Deceased and Products of Conception Outside of Normal Hours” and “Policy and Procedures for the Urgent Certification and Release of Deceased Outside of Normal Working Hours”. Inform Line Manager/Duty Manager immediately and follow their instructions. Duty Manager can be contacted by Switchboard. 5.8 Mortuary Department Staff Responsible for the provision of personal protective equipment in the mortuary, disinfectant and spill kits for their use. Last Offices Care of the Deceased Patient UHL Policy Page 4 of 61 V4 Approved by Policy and Guideline Committee on 3 June 2016 Trust Ref: B28/2010 Next Review: May 2022 – extension agreed at PGC 21/05/2021 NB: Paper copies of this document may not be most recent version. The definitive version is held on INsite Documents 5.9 Bereavement Services Responsible for the revision and printing of Notification of Death forms and the "Helpful Information Following a Death" booklet. Responsible for liaising with families in office hours regarding the viewing of the deceased. 5.10 Medical Examiners (Where Medical Examiners are in post) Responsible for the provision of advice on whether or not a death should be referred to the H.M. Coroner. Responsible for the provision of advice on how a death should be certified (e.g. how the Medical Certificate of the Cause of Death should be completed). Responsible for advising the appropriate team when review of a death is likely to provide information of relevance to the quality of healthcare provided during life. 5.11 UHL Facilities Responsible for the provision of manual handling training for portering staff, provision and maintenance of portering equipment. 6 POLICY STATEMENTS This policy is supported by the following procedures and all staff must follow these when caring for the deceased patient. Procedure / Process / Standard Appendix Declaring Life Extinct Appendix One Actions to be taken for Suspicious Death Appendix Two Review Referral to and Contact with H.M. Coroner Appendix Three Communication with the Family Appendix Four Post-Mortem Examination/Taking Tissue Samples After Death Appendix Five Removal of Endotracheal Tubes (ET) Appendix Six Preparation of the Deceased Adult (“Last Offices”) Appendix Seven Preparation of the Deceased Child (“Last Offices”) Appendix Eight Transfer to the Mortuary Appendix Nine Risk of Infection and Use of Body Bags Appendix Ten Cultural and Religious Requirements Appendix Eleven 7 EDUCATION AND TRAINING REQUIREMENTS 7.1 Any education and training requirements regarding this policy should be identified to the Line Manager through the appraisal process and addressed in the individual’s personal development plan. 7.2 How to perform last offices is included in the Health Care Assistant induction programme. 8 PROCESS FOR MONITORING COMPLIANCE 8.1 Key Performance Indicators/Audit Standards Last Offices Care of the Deceased Patient UHL Policy Page 5 of 61 V4 Approved by Policy and Guideline Committee on 3 June 2016 Trust Ref: B28/2010 Next Review: May 2022 – extension agreed at PGC 21/05/2021 NB: Paper copies of this document may not be most recent version. The definitive version is held on INsite Documents 9 EQUALITY IMPACT ASSESSMENT If the policy will have any impact on equality, this should be described here. Otherwise the statements below should be inserted (see section 6.6 of the UHL Policy for Policies for more detail): 9.1 The Trust recognises the diversity of the local community it serves.