Ref: PATH 02 Policy for the sensitive disposal of fetal remains of less than 24 weeks of gestation INITIATED BY: Cellular Pathology Service manager APPROVED BY: Pathology Integrated Governance Group DATE APPROVED: 30/5/2014 VERSION: 1.0 OPERATIONAL DATE: 30/5/2014 DATE FOR REVIEW: 30/5/2015 DISTRIBUTION: Cwm Taf University Health Board Policies and Procedures SharePoint site FREEDOM OF INFORMATION STATUS: Open Ref:PATH 02 Policy V 1.0 CONTENTS Policy Definition......................................................................................i 1. Purpose...........................................................................................1 2. Policy Statement..............................................................................1 3. Principles.........................................................................................1 4. Scope .............................................................................................2 5. Legislative and NHS Requirements.....................................................2 6. Procedure........................................................................................2 7. Training Implications......................................................................14 8. Review, Monitoring and Audit Arrangements......................................14 9. Managerial Responsibilities..............................................................14 10. Retention or Archiving.....................................................................15 11. Non Conformance...........................................................................15 12. Equality Impact Assessment Statement.............................................15 13. References....................................................................................15 Appendix A - Schedule of cremation and support services ………..…………. 17 Appendix B - Certificate of Midwife/Nurse Practitioner or Medical Practitioner in respect of fetal remains and application for cremation of fetal remains ....…… 18 Appendix C - Equality Impact Assessment..............................................19 Appendix D - Training Impact Assessment..............................................32 Policy Definition A policy is a high level overall guide, which sets the boundaries within which action will take place, and should reflect the philosophy of the organisation or department. It provides a prescribed plan for staff to follow, which should not be deviated from. i Ref:PATH 02 Policy V 1.0 1. Purpose This policy aims to ensure that all fetal remains of less than 24 weeks gestation resulting from all circumstances of loss of pregnancy, are disposed of in a sensitive and dignified manner. 2. Policy Statement Cwm Taf University Health Board ensures that all fetal remains of less than 24 weeks gestation resulting from all circumstances of loss of pregnancy, are disposed of in a sensitive and dignified manner. 3. Principles The emphasis throughout this policy is on the mother‘s wishes as it relates to the fetus from her body and her confidential health information. Also the consent paperwork (see section 6.5.8) has to be checked by laboratory staff who receive the remains and are remote from the clinical setting. It has been agreed that this must be the mother or the same health professional who signed part B of the form so that the staff performing the check is assured that the person signing the form has had the information required and has the right to give consent, e.g. a signature from a partner with a different surname may not be identified as such by laboratory staff. This was also stipulated by the crematoria as part of the workable agreement. All references to partner is general in its interpretation and would include same-sex/civil partner and surrogate partner. Adherence to the principles of equality, dignity and human rights will be of paramount importance. Sensitivity is also of utmost importance and it is recognised that the whole experience could be even more traumatic for some individuals depending on their circumstances e.g. if they were particularly young or older mothers or if they had a learning disability or mental health issue which could affect their understanding. Every effort will be made to communicate in a manner appropriate to the mother, both verbally and in writing in order to meet specific communication needs (e.g. if they have a sensory loss) and language needs (e.g. if they wish to communicate in Welsh or any other language). The All Wales Standards for Accessible Communication for People with Sensory Loss and the Cwm Taf Policy on Accessing an Interpreter would be particularly relevant. See section 6 for further details. 1 Ref:PATH 02 Policy V 1.0 4. Scope This policy applies to all areas of the health board in which an early loss of pregnancy may occur. It applies specifically to: • Maternity, labour and gynae wards • Theatres • Bodywise clinics • Accident and Emergency department, • Pathology • Mortuary. • Spiritual care team Each area should develop their own standard operational procedures or care pathways to support the implementation of this policy. 5. Legislative and NHS Requirements The policy upholds the guidelines set out by The Royal College of Nursing, the Still birth and Neonatal Death Society (SANDS), The Human Tissue Authority (HTA) and the Institute of Cemetery & Crematorium Management (ICCM). It also complies with the Equality Act 2010. This policy should be read in conjunction with the Cultural Toolkit which can be found on the Equality and Diversity site on Sharepoint. 6. Procedure CONTENTS Section Title 6.1 Consultation list 6.2 Introduction 6.3 Principles of care 6.4 Terminology 6.5 Summary of procedures 6.5.1 Photography 6.5.2 Postmortem examination 6.5.3 Private funeral arrangements 6.5.4 Parents wishing to take their baby home 6.5.5 Health board communal cremation of fetal remains 6.5.6 Spiritual care services 6.5.7 Confidentiality and storage of records 2 Ref:PATH 02 Policy V 1.0 6.5.8 Certification of fetal remains 6.5.9 Transfer of fetal remains or remains to the cellular pathology department (RGH) or mortuary (PCH) 6.5.10 Cellular pathology department / mortuaries 6.5.11 Transfer of fetal remains to the crematorium 6.5.12 Cremation process 6.5.13 Service agreement 7 Histology Investigation 6.1 Consultation list Name and title Date consulted Consultant Histopathologist, Assistant Medical 31/3/14 Director and HTA specialist Consultant Histopathologist, Clinical Director of 31/3/14 Pathology. Consultant Histopathologist 31/3/14 Directorate Manager, Pathology 31/3/14 PQuality Manager, Pathology 31/3/14 APT, Mortuary PCH 3/2/14 Medical Director / Consultant Gynaecologist 1/4/14 Consultant in Obstetrics and Gynaecology 1/4/14 Consultant, Community gynaecology 1/4/14 Senior Midwife, Obstetrics Gynaecology and 20/3/14 Sexual Health Senior Nurse, Womens Sexual and Reproductive 26/3/14 Health Head of Midwifery, Womens Sexual and 1/4/14 Reproductive Health Senior Nurse Manager, Theatres 1/4/14 Lead Chaplain PCH 1/4/14 Chaplain RGH 1/4/14 Rhondda Cynon Taff CBC 20/3/14 Superintendent and registrar, Llwydcoed 20/3/14 crematorium. 6.2 Introduction The limit of viability for fetal survival outside the womb is currently set at 24 weeks gestation. Fetal demise within the uterus, prior to 24 weeks gestation, is referred to as an early loss of pregnancy and the remains are not registered as a still birth. On the basis of its potential to develop into a human being, the fetus is entitled to respect, according it a status broadly comparable to a living person. Subsequently, fetal remains of less than 24 3 Ref:PATH 02 Policy V 1.0 weeks gestation cannot be disposed of as clinical waste. Cwm Taf University Health Board has an obligation to dispose of fetal remains of less than 24 weeks gestation in a sensitive, dignified and ethical manner. The policy refers solely to the care, rights and privileges of the mother. It is not intended to be disrespectful to the duty of care to the father, same sex partner or other partner if different to the father, or other family members, whether there be mutual agreement or dissent in regard to any action relating to the loss of pregnancy or subsequent arrangements. Information relating or provided to the mother may only be given to her partner or husband with her permission. The death of a baby, for what ever reason and at any stage of pregnancy, represents a unique form of bereavement. A loss of pregnancy at any stage can affect parents and partners profoundly and sensitive and supportive care is required. It is important to recognise that the needs of individuals and the circumstances surrounding loss of pregnancy can vary widely and therefore flexibility in the application of this policy may be required (e.g. specific cultural requirements) within the parameters defined by legislation and professional guidelines. Parents should be given the same choices for disposal of fetal remains of less than 24 weeks gestation as for a still born child and the options should be explained to them in a clear and sensitive manner taking account of their communication needs and any language barriers, both verbally and in writing by appropriately trained health professionals. It is acknowledged that parents sometimes do not wish to be involved in the arrangements for disposal and it is important to respect their wishes. Some however return to enquire about the disposal months or years later so it is important to ensure that records are kept with regards to sensitive disposal.