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Northern Ireland Audit:Dying, Death and Bereavement
Policies, procedures and practices in hospital and hospice settings
2009
Funded by the Regional Multi-professional Audit Group this important audit was the first piece of work undertaken by the Northern Ireland Health and Social Care Bereavement Network. Its findings form the basis of the Bereavement Strategy for Health and Social Care Services in Northern Ireland which is launched in 2009.
The findings have identified the excellent work in hospitals and hospices across Northern Ireland in supporting patients, relatives and staff at the time of and following bereavement. The audit also identified the significant pressures experienced by the services and the need for ongoing training and support.
Thanks must be given to the Area Bereavement Coordinators for their central role in the audit and in the development of the Bereavement Strategy. The audit would not have been achievable without the active cooperation and enthusiasm of the NI Hospices and HPSS Trusts, in particular the clinical and management staff to whom special thanks is given.
Dr Patricia DonnellyNI Health & Social Care Bereavement Network
Foreword
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N.I. Audit: Dying, Death & Bereavement
Contents Page
EXECUTIVE SUMMARY
1. INTRODUCTION 1
1.1 Background and purpose of the audit 1
1.2 Scope of the audit 2
1.3 Audit methodology 4
2. OVERVIEW OF HSC TRUSTS AND THEIR SERVICES 6
2.1 Demographics and organisations 6
2.2. Staff groups and services 9
2.3 Mortuary services 10
2.4 Palliative care services 11
2.5 Chaplaincy services 11
3. PROMOTING SAFE AND EFFECTIVE CARE 13
3.1 Policies, guidelines and practices 13
3.1.1 Bereavement checklists 15
3.1.2 Identification and labelling 16
3.1.3 Issue of death certificates 17
3.1.4 Transfer of patients 17
3.1.5 Information and communication 18
3.2 Knowledge and skills 20
3.3 Staff support 24
4. CREATING A SUPPORTIVE EXPERIENCE 26
4.1 Environment and facilities 26
4.2 Care and support 29
4.3 Information and communication 35
5. RECOMMENDATIONS 40
6. APPENDICES 41
7. REFERENCES 58
8. ACKNOWLEDGEMENTS 61
9. N.I. AREA BEREAVEMENT COORDINATORS CONTACT DETAILS 62
ii
The Department of Health, Social Services and Public Safety (DHSSPS), in response to the Northern Ireland Human Organs Inquiry 2002, established the Northern Ireland Bereavement Network and appointed five Area Bereavement Coordinators (ABCs) to coordinate and develop bereavement care standards and training across the province.
Approximately 14,000 to 15,000 people die each year in Northern Ireland, over half of them in hospitals. In 2006-07, an audit was undertaken of 35 HPSS hospitals and all 5 hospices in Northern Ireland. The aims of the audit were to map current services across the province and identify the profile of need for care of the dying and bereaved, to inform the development of the strategy for bereavement care for Northern Ireland.
The audit was undertaken by the Bereavement Coordinator in each Health and Social Services Board area on behalf of the Bereavement Network for Northern Ireland. The Bereavement Coordinators posts were funded by the DHSSPS, following recommendations 9, 10 and 12 of the Human Organ Inquiry 2002.
It is recognised that care of dying patients and support of bereaved relatives requires a multi-disciplinary approach therefore this audit was divided into eight strands: 1. Demographics – information on the profile of deaths across Northern Ireland.
2. Organisational – information on services provided in HPSS and hospice including governance arrangements underpinning services.
3. Ward visits – information from a sample of wards in different specialities, in respect of policies, procedures and practices. 4. Mortuary services within HPSS – information on facilities and practices.
5. Chaplaincy service in HPSS and hospices – information on services provided and how patients’ spiritual needs are met.
6. Palliative care services – information on the make-up of teams and services provided.
7. Porters and funeral directors services – information on the transfer and release of deceased patients.
8. Individual staff questionnaires – information on knowledge, skills and experience of caring for dying patients and their families.
The audit identified areas of good practice, as well as pressures faced by staff in the acute hospital setting and the need for appropriate staff training and support systems.
The main findings of the audit, together with the outcomes of a number of workshops, have informed the development of the Northern Ireland HSC Strategy for Bereavement Care, to be published in 2009.
Executive Summary
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N.I. Audit: Dying, Death & Bereavement
1.1. Background and purpose of the audit
The Northern Ireland Human Organs Inquiry 2002 made specific recommendations 9, 10 and 12 in respect of bereavement care in public health services. In consequence the Northern Ireland Bereavement Network was established by the Department of Health Social Services and Public Safety (DHSSPS) as a partnership across Health & Social Care Trusts. Five Area Bereavement Coordinators (ABCs) were appointed to deliver the work of the Network, to coordinate and develop bereavement care standards and training within the health and social care sector across the province and to work in partnership with the non-statutory, voluntary and community sector
The Northern Ireland Audit on Dying, Death and Bereavement was commissioned by the DHSSPS and funded through the Regional Multi-professional Audit Group (RMAG). It is planned as a two stage audit with the second stage in years 2009/10 focusing on community services and user experience. The first stage undertaken in 2006/07, reported here, maps current services across the province and identifies the profile of need for the care of the dying and bereavement care in the HPSS and hospice service.
The audit assessed policies, procedures and practices in relation to death and bereavement care within hospitals and hospices across Northern Ireland. It was informed by national and regional standards alongside current legislation, core strategies, guidelines and literature, including the following:
• Births and Deaths Registration (Northern Ireland) Order (1976)
• Coroners Act (Northern Ireland) 1959 (Section 7)
• Human Tissue Act 2004
• DH (2003), NHS Chaplaincy: Meeting the Religious and Spiritual Needs of Patients and Staff
• DH (2005), When a Patient Dies: Advice on Developing Bereavement Services in the NHS
• DH (2006), Care and Respect in Death: Good Practice Guidance for NHS Mortuary Staff
• DHSSPS (2000), Partnerships in Caring: Standards for Service. A Review of Palliative Care
• DHSSPS (2003), Breaking Bad News: Regional Guidelines, Developed from Partnerships in Caring (2000)
• DHSSPS (2005), A Code of Good Practice on Post Mortem Examinations: A Careplan for Women who Experience a Miscarriage, Stillbirth or Neonatal Death
• DHSSPS (2005), Post Mortem Examinations - A Code of Good Practice: Rights of Patients and Relatives: Responsibilities of Professionals
• DHSSPS (2006), The Quality Standards for Health and Social Care: Supporting Good Governance and Best Practice in the HPSS
1. Introduction
1
• DHSSPSNI, PSNI, Court Service NI and HSENI (2006), Memorandum of Understanding: Investigating Patient or Client Safety Incidents (Unexpected Death or Serious Untoward Harm)
• Equality Commission NI and DHSSPS (2003), Racial Equality in Health and Social Care - Good Practice Guide
• Human Tissue Authority (2006), Codes of Practice
• National Institute for Health and Clinical Excellence (2004), Improving Supportive and Palliative Care for Adults with Cancer
• NHS Executive (2000), Resuscitation Policy
• NHS Estates (2005), A Place to Die with Dignity: Creating a Supportive Environment
The main findings of the audit, together with the outcomes of a number of workshops, whose participants were drawn from across the statutory, voluntary, private and community sectors which included individuals from a diverse range of faiths and interests, have already informed the Northern Ireland Health and Social Care Services Strategy for Bereavement Care.
1.2 Scope of the audit
The most recent year for which official figures were available prior to the audit being carried out was January-December 2005. During this year 14,224 deaths were registered in Northern Ireland; of these (Figure 1) 57% were reported to have occurred in ‘hospitals’, a further 16% in ‘nursing homes and other hospitals, including psychiatric hospitals’, and the remaining 27% in ‘all other places, for example private residences or public buildings’ (Eighty-fourth Annual Report of the Registrar General 2005).
Figure 1: Number and location of deaths registered in Northern Ireland in 2005 (Registrar General statistics)
Given that the majority of deaths in Northern Ireland occur within the hospital sector, it was the care and practices in relation to end of life and bereavement care across the province’s hospitals (as well as in all five of its hospices, given the central purpose of hospices in the care of terminally ill patients) that formed the focus of the current audit.
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N.I. Audit: Dying, Death & Bereavement
The population of Northern Ireland is estimated at just over 1.75 million. Table 1 shows the population distribution across the five current Health & Social Care Trusts; and the eighteen legacy HSS Trusts which were operational at the time of the audit. It is recognised that the Belfast Trust provides a number of specialist regional services to the wider population.
HSC Trust HSS Legacy Trusts Population
Belfast
HSC Trust
Belfast City Hospital Trust, Greenpark Trust, Royal
Group of Hospitals and Dental Hospital Trust, Mater Hospital Trust, South and East Belfast Trust, North
and West Belfast Trust.
340,000
Northern
HSC Trust
United Hospitals Trust, Causeway Trust, Homefirst
Community Trust.
450,000
South Eastern
HSC Trust
Ulster Community and Hospitals Trust, Down
Lisburn Trust.
335,000
Southern HSC Trust
Craigavon Area Hospital Group Trust, Craigavon and Banbridge Community Trust, Newry and Mourne
Trust, Armagh and Dungannon Trust.
343,000
Western
HSC Trust
Altnagelvin Hospital Trust, Sperrin Lakeland Trust,
Foyle Trust.
295,000
Table 1: Population and organisation of local HSC trusts
For ease of reference the remainder of this document will collate information and refer only to the new HSC Trust configurations.
The audit targeted every hospice as well as all the main acute and local hospitals and a significant proportion of minor and more specialist hospitals (specifically, in the areas of eldercare, mental health and learning disability) across Northern Ireland. The sample consisted of 35 hospitals (including an inpatient mental health unit) listed in Table 2 by HSC Trusts, and the 5 hospices listed by geographical location.
HSC Trust Hospitals Hospices
Belfast
HSC Trust
Belfast City Hospital, Royal Victoria Hospital,
Royal Jubilee Maternity Service, Royal Belfast Hospital for Sick Children, Mater
Hospital, Musgrave Park Hospital, Forster
Green Hospital, Muckamore Abbey Hospital, Knockbracken Healthcare Park.
Northern Ireland
Hospice Care
Northern
HSC Trust
Antrim Area Hospital, Mid-Ulster Hospital,
Whiteabbey Hospital, Causeway Hospital,
Moyle Hospital, Braid Valley Hospital, Dalriada Hospital, Robinson Memorial
Hospital, Holywell Hospital.
Northern Ireland
Children’s Hospice
South Eastern
HSC Trust
Ulster Hospital, Ards Hospital, Bangor
Hospital, Lagan Valley Hospital, Downe Hospital, Downshire Hospital.
Marie Curie
Hospice
Southern HSC Trust
Craigavon Area Hospital, South Tyrone Hospital, Daisy Hill Hospital, Lurgan Hospital,
Mullinure Hospital, Inpatient Psychiatry Unit,
St Luke’s Hospital, Longstone Hospital.
Southern Area Hospice Services
Western HSC Trust
Altnagelvin Hospital, Tyrone County Hospital, Erne Hospital.
Foyle Hospice
Table 2: Hospitals (n=35) and hospices (n=5) included in the audit
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1.3 Audit methodology
The Chief Executives with responsibility for each of the HSC hospitals and hospices referred to in Table 2 were invited to take part in the audit, and all agreed and signed up to the project. Trust and audit leads were identified to assist the Area Bereavement Coordinators in the collection of information.
The audit comprised eight strands and used a mixed methodology of both quantitative and qualitative data collection.
Demographics
Information on the profile of deaths occurring between 1st April 2005 and 31st March 2006 within each hospital and hospice was collected. This included the number and location of the deaths, the age profile of the deceased, including miscarriages, stillbirths and neonatal deaths, and also ‘consented’ (i.e. hospital) and ‘unconsented’ (coroners) post mortem examination activity.
Organisational
The identification and analysis of a number of aspects of service provision and governance arrangements was undertaken, including policies and protocols, which were in place for the care of dying and bereaved people within the various hospitals and hospices audited. Questionnaires were issued to the nominated leads within each hospice or trust.
Ward visits
Data collection proformas from specialties and wards within each hospital were completed by senior nursing staff: Semi-structured interviews were also used with managers of each ward (or their nominees or deputies) on a range of aspects of the care provided to dying and bereaved people.
Mortuary services
As the majority of patients who die in hospital are transferred to a mortuary, information was collected from pathology technicians or those with responsibility for policies, procedures and practices within each of those organisations which identified itself as having an ‘operational mortuary’ (i.e. one that has the facilities to carry out post mortem examinations and/or has refrigerated body storage). This included information on processes surrounding admission and release of the deceased, access to viewing facilities for bereaved people and the nature of training undertaken by staff.
Chaplaincy services
To assess how the spiritual needs of patients are met, information was collected on the services provided by chaplains, including their referral processes, the availability of literature and the facilities that are available for the use of chaplains. This was obtained either directly through meetings with lead chaplains or from managers with responsibly for chaplaincy services.
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N.I. Audit: Dying, Death & Bereavement
Palliative care services
Given their close involvement with dying patients and bereaved relatives, information was obtained directly from team members about the services provided by palliative care teams within acute hospital settings. This included their referral processes, the challenges inherent in providing their services and the training undertaken by members of the team.
Porters and funeral directors
In the majority of hospitals, portering teams are directly responsible for the transfer of deceased patients to mortuaries and some are involved in undertaking mortuary duties directly. A number of hospitals have service level agreements with funeral directors for the transfer and release of deceased patients. Information about the duties undertaken and the challenges in providing these services was obtained from portering managers and, where applicable, the contracted funeral directors.
Individual staff questionnaires
Given the importance of a multidisciplinary team and inter-agency approach to patient care, the final strand of the audit was aimed at a significant cross section of health care employees from a range of professional backgrounds who might be expected to come into contact with dying and bereaved people. In particular, their views were sought on the environments in which bereavement care is provided, the nature of the care itself, and the skills, training and support required and available to staff in relation to end of life care. The Area Bereavement Coordinators distributed over 3,500 questionnaires to wards, departments and key professionals throughout individual Trusts, of which 1,633 were returned for analysis.
The eight strands and the scope of the audit are summarised in Table 3.
Audit Strand Sources of Information
(with Numbers Included/Returned)
Demographics Hospitals (35) and hospices (5)
Organisational Hospitals (35) and hospices (5)
Ward visits Wards (140) and hospices (5)
Mortuary services Staff in operational mortuaries (12)
Chaplaincy services Chaplaincy teams in hospitals and hospices (33)
Palliative care services Palliative care teams in acute hospitals (11)
Porters and funeral directors
Portering teams (15) and funeral directors with service level agreements for portering and mortuary duties (5)
Staff questionnaires Individual staff members (1,633)
Table 3: The strands and scope of the audit
The figures in Table 3, apart from individual staff questionnaires, represent the numbers of organisations (i.e. hospitals and hospices), individual wards (including hospices) and services (mortuary, chaplaincy, palliative care and portering) from whom information was both requested and returned. Although a total of 35 individual hospitals were included in the audit, a single, corporate response was provided in respect of the Ulster, Ards and Bangor Hospitals. Although all organisations had a dedicated chaplaincy service, a number of chaplaincy services operated across more than a single organisation therefore while 27 chaplaincy services participated in the audit they covered 33 individual hospitals and hospices. The figure in the table for the staff questionnaires refers to the number of individual returns that were received.
Information returned was not always complete, particularly the individual staff questionnaires. For that reason, the audit results are presented by percentages as well as number of returns actually received.
5
2.1 Demographics and organisations
The types of inpatient care provided in each of the 35 hospitals and 5 hospices audited are presented in Figure 2. As expected, given the province’s increasingly aging population, a large majority of organisations (83%) provided elderly care facilities, with between 20% and 45% providing care in each of the acute, paediatric, maternity and mental health areas and fewer than 15% in any other major specialist area.
* Regional, ambulatory paediatrics (including outpatients), orthopaedic/rheumatology/neurology and elective
Figure 2: Types of care provided by hospitals and hospices in Northern Ireland (n=40)
The data is consistent with that presented in Figure 3, which shows the number of inpatient deaths recorded in each of the main specialist areas within the hospitals and hospices audited throughout the (financial) year 2005-06.
Figure 3: Inpatient deaths by specialist area (1 April 2005 to 31 March 2006)
2. Overview of HSC Trusts and Services Provided
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N.I. Audit: Dying, Death & Bereavement
In 2005/2006 in Northern Ireland there were 7,944 recorded inpatient deaths in total: 7,359 in the 35 HPSS hospitals and 585 in the 5 hospices. General medicine (with almost 40% of all inpatient deaths) recorded the highest percentage, followed by elderly care (with almost 20%). However, there will have been significant overlap between these two areas since a high proportion of deaths in general wards are from the older age group. The next-highest numbers of deaths were general surgery (11%), intensive care units (8%), hospices (7.5%) and cardiology wards (almost 7%). No other speciality accounted for more than 3% of the total recorded inpatient deaths for the year.
Data was collected from every intensive care and neonatal unit, emergency department and hospice across the province, as well as other specialist areas. In all, 25 wards from each of general medicine and elderly care (where the highest numbers of inpatient deaths occur) were visited; together this represents approximately one-third of all visits undertaken.
The number of wards and hospices visited within all of the specialist areas, along with their associated percentages of the overall total of 145, is presented in Table 4. Most organisations have separate wards for obstetrics and gynaecology; however in two of the facilities visited these areas shared a common ward. For the purpose of this audit, the joint wards have been treated separately from the other obstetrics and gynaecology wards.
Area of Speciality Number (and % of Overall Total)
of Facilities Visited
General medicine 25 (17%)
Elderly care 25 (17%)
General surgery 16 (11%)
Emergency department 16 (11%)
Intensive care unit 13 ( 9%)
Cardiology 13 ( 9%)
Paediatrics 8 ( 6%)
Obstetrics 8 ( 6%)
Gynaecology 7 ( 5%)
Neonatology 7 ( 5%)
Hospice 5 ( 3%)
Obstetrics and gynaecology 2 ( 1%)
Table 4: Number (and percentage of the overall total) of wards and hospices visited within each specialist area
The Miscarriage Association estimates that about a quarter of all pregnancies end in miscarriage. Although not recorded legally as ‘deaths’ if they occur before the age of 24 weeks gestation, miscarriages have a significant impact on the parents concerned, as well as on the care and support they require from staff.
A breakdown of the deaths within the 35 hospitals and 5 hospices, as well as those resulting from miscarriage or stillbirth, are presented in Figure 4. As predicted, the highest number of deaths was in the age group 65 years and over, while miscarriages constituted the second largest group. Whereas the overall number of deaths of children under the age of 18 years is low, it is recognised that the death of a child is especially traumatic for families.
7
Figure 4: Miscarriages, stillbirths and certified deaths in hospitals (n=35) and hospices (n=5), April 2005 – March 2006
Some hospital deaths, such as those that are unexpected or unexplained, require referral to the coroner and may be subject to a coroners (‘unconsented’) post mortem examination, while others may involve a hospital (‘consented’) post mortem examination being carried out.
Public confidence in the post mortem examination process decreased dramatically following the disclosure of the issues that led to the Human Organs Inquiry (2002). The subsequent introduction of new legislation (the Human Tissue Act 2004) has sought to address the shortcomings of earlier practices. The DHSSPS, for example, has introduced new codes of practice, consent forms and information booklets for use by staff and to support families of deceased patients who are undergoing hospital post mortem examinations. These include a careplan for women who experience a miscarriage, stillbirth or neonatal death.
For all of the miscarriages, stillbirths and deaths referenced in Figure 4, data was collected on the relative proportions of hospital (consented) and coroners (unconsented) post mortem examinations carried out within the different age ranges. This information is summarised in Figure 5.
Figure 5: Post mortems completed in respect of miscarriages, stillbirths and deaths in hospitals (n=35), 2005-2006
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N.I. Audit: Dying, Death & Bereavement
While the highest percentage of deaths occurred in the over-65 age group, there were relatively few post mortem examinations carried out on this population, as most deaths at that age are expected to be from natural causes or disease processes. The highest number of post mortem examinations was carried out on children under the age of 18 years, with almost half of all children who die in neonatal units undergoing a hospital (consented) post mortem examination.
2.2 Staff groups and services
In addition to the 145 ward visits, over 3500 questionnaires were issued to a variety of healthcare staff groups to collect information on their involvement and experience of caring for dying patients and their families. Of these, 1633 questionnaires were returned. Figure 6 presents a breakdown of the staff groups who responded to the questionnaire, along with the lengths of service of the 94% (1540) who volunteered that information.
Figure 6: Lengths of service of staff responding to the individual questionnaires (n=1540)
Nurses, by far the largest professional group employed by HSC trusts, provided over 60% of the questionnaires returned. In addition, over half the nurses who responded had been in service for 10 years or over, so they represented a significantly experienced group of staff.
The individual questionnaires asked staff about the frequency of their contact with patients who are dying, their families or with other staff involved with the care of dying patients. As can be seen from Figure 7, around one-third of those staff who responded to the questionnaire often deal with dying patients or others directly affected by their deaths (i.e. at least weekly), with similar numbers having such experiences at least monthly and less than monthly respectively, and only just over 5% having no such contact at all.
9
2.3 Mortuary services
Mortuaries are a vital part of the service the HPSS provides to patients who die in hospital and to bereaved families and friends (Care and Respect in Death, DOH 2005). There are four HSC Trust mortuaries where post mortem examinations are carried out – one in each of four of the five Trusts, with the fifth, the South Eastern Trust, having access to the post mortem facilities of the Belfast Trust.
Figure 8 summarises the different types of mortuary facility available in the hospitals and hospices included in the audit. A total of 18 organisations (45%) had access to a mortuary; 14 (35%) had designated areas where bodies could remain until collected by funeral directors; and in the remaining services (20%) it was practice for funeral directors to collect patients’ bodies directly from wards.
Figure 7: Frequency with which staff deal with issues of death and dying (n=1560)
Figure 8: Types of mortuary facilities within the 35 hospitals and 5 hospices
A total of 23 employees were identified as working within the mortuaries. Of these, 15 were qualified pathology technicians, 4 were mortuary attendants, and 2 each were designated porters and laboratory staff. Mortuary staff work a range of full-time, part-time and on-call hours, and some also have duties in other parts of the hospital.
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N.I. Audit: Dying, Death & Bereavement
2.4 Palliative care services
The audit identified the profile of specialist palliative care services across the region, with eleven specialist teams within the acute sector across Northern Ireland – three in the Belfast Trust, and two in each of the other four Trusts – based in the Altnagelvin, Antrim, Belfast City, Causeway, Craigavon Area, Lagan Valley, Mater, Daisy Hill, Royal, Erne and Ulster Hospitals respectively. Some of these teams work across both hospital and community sites. Operational policies were in place for 60% of the teams.
Representatives of each palliative care service were asked to identify the different professions in their respective teams. The results are summarised in Figure 9, which shows that whilst all eleven teams comprised specialist nursing staff and 82% had a consultant physician, other disciplines were much less likely to be included.
Figure 9: Professional membership of the specialist palliative care teams (n=11)
Recent needs assessments carried out in the palliative care sector have led to the development and inclusion of a limited number of specialist practitioners from disciplines such as speech and language therapy, physiotherapy, occupational therapy, nutrition and dietetics, social work and psychology.
2.5 Chaplaincy services
In recognition of the fact that the quality of services provided to the dying and bereaved can be enhanced through access to different forms of spiritual care (When a Patient Dies, Department of Health 2005), information about chaplaincy services was also collected as part of the audit.
Figure 10 summarises the extent to which the main religious denominations are represented within the 27 chaplaincy teams which, between them, served 33 of the hospitals and hospices included in the audit. Most Trusts employed a chaplain from each of the four main denominations, while it was widely reported that the Methodist chaplain liaises with other appropriate religious/spiritual representatives as required. Within the Northern Ireland Hospice, the spiritual needs of patients are attended to by two generic chaplains. It is also recognised that patients and families often use the services of their home/community church or organisation.
11
A policy relating to chaplaincy services was available in approximately 40% of the hospitals and hospices audited. During the ward and hospice visits, the majority of respondents (87%) reported that patients were asked on admission whether they wished their religious affiliation to be documented and if they permitted this information to be provided to the chaplaincy team. In situations where patients initially indicated they did not wish chaplaincy involvement, 78% of respondents advised that this decision would be revisited later, if appropriate, should the patient’s condition deteriorate.
As indicated in Figure 11, the chaplains themselves identified a range of facilities and support available to them in the performance of their duties.
Figure 10: Religious denominations represented within chaplaincy services (n=33 hospitals and hospices)
Figure 11: Facilities and support available to chaplaincy services (n=33 hospitals and hospices)
Over three-quarters of the chaplains indicated that they had dedicated offices, telephones and allocated time to meet together and for regular meetings with their respective directors. However, only about one-third had an opportunity for formal appraisal/development review, and just over 50% had access to each of a computer and administrative support.
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N.I. Audit: Dying, Death & Bereavement
All HSC trusts and hospices have a duty to provide safe and effective care by having robust governance arrangements in place that are in compliance with national and regional guidelines and legislation (see section 1.1).
3.1. Policies, guidelines and practices
All 35 hospitals and 5 hospices provided information in respect of their policies, procedures and guidelines associated with end of life and bereavement care. This information was collected from the organisation leads and key individuals within the services audited.
It is acknowledged that the availability of a written policy does not necessarily mean that it has been fully operationalised within a facility, while at the same time many good practices and procedures may take place on a regular basis that are not formalised in a written policy.
Policies and procedures available are presented in Table 5, ranked in order of frequency of availability. Not all organisations provided information in respect of every policy or procedure.
Policy/Procedure Area
Hospitals
Hospices
Accessing translation services 94% 60%
Do not attempt resuscitation 94% 100%
Reporting cases to the coroner 91% 100%
Cultural and religious practices 88% 100%
Death certification 82% 100%
Breaking bad news 77% 100%
Care of the dying pathway 74% 100%
Care plan for women who experience a miscarriage, stillbirth or neonatal
death*
73% Not applicable
Post mortem processes 71% 40%
Cremation 69% 80%
Memorandum of understanding 68% 100%
Information for relatives 62% 100%
Burial by hospital (if no next-of-kin) 61% 60%
Advance directives 51% 60%
Identification of the deceased 49% 60%
Bereavement care 46% 80%
Chaplaincy/Spiritual care 46% 100%
Sudden death protocols 42% 20%
Table 5: Hospitals (n=31-35) and hospices (n=3-5) reporting compliance with bereavement-related policies and procedures (*Note: applicable to 19 hospitals only)
Hospices had evidence of a higher level of written policies in these areas, as expected in services specialising in end of life care. And while organisations generally had in place policies, procedures and guidelines relating to statutory or legal obligations in end of life and after death care, those that bore no statutory obligation to direct or enhance supportive care tended to be less evident within the hospitals, such as the policy on bereavement and spiritual care.
3. Promoting Safe and Effective Care
13
To promote safe and effective care in both hospitals and hospices, it is clear that further development and standardisation of policies is required, for example hospitals need to develop protocols in relation to sudden death and identification of the deceased.
Policies relating to care after death are commonly referred to as ‘last offices’. As can be seen from Figure 12, they include a number of elements of care.
Figure 12: Hospitals (n=35) and hospices (n=5) reporting compliance with policies and procedures relating to “last offices”
As last offices are required for the management of every death and are carried out regularly in hospitals and hospices, it would be reasonable to anticipate 100% compliance in each of these areas. For some, however, most notably the removal of implants and viewing of the deceased, the compliance rate was as low as 60% or less.
Ward managers reported a variety of methods used to inform staff about policies and procedures (Figure 13). Ward induction was the most commonly used (in 95% of the wards and hospices for whom returns were provided), closely followed by team meetings (91%) and training courses (62%). Supervision and the intranet were identified in just under half of all facilities each, although it is likely that the use of these latter methods will increase in the future.
Figure 13: Methods used to inform staff about policies and procedures (n=140 wards and hospices)
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N.I. Audit: Dying, Death & Bereavement
During the year for which audit demographic information was available (2005-06), 149 children died before the age of 18 years and 81 babies were stillborn (Figure 4). The death of a baby or child is always a difficult experience for family members as well as for staff, as was made clear by their responses to the audit. Specific policies are necessary to both support staff and to ensure that parents’ wishes are carried out in a safe and sensitive manner.
The audit identified 50 wards where parents may be expected to require support before, at the time of and/or after the death of a child. Different Trusts used a variety of checklists and booklets; there were not always written policies in place to support some of the practices that are carried out, such as those concerning information for parents wishing to take their deceased child directly to their home by car.
As the majority of patients who die in hospital are transferred to a mortuary, those individuals with responsibility for mortuaries were asked about the availability of written policies and procedures aimed at supporting their practices. The procedures and guidelines available are summarised in Figure 14, with a variation reported in the policies available in different mortuaries and some practices not always supported by written policies.
Figure 14: Policies, procedures and guidelines available within mortuaries (n=12)
3.1.1 Bereavement checklists
Some facilities use bereavement checklists to ensure that all necessary actions are taken at the time of a patient’s death and that families receive adequate information to assist them. These can be part of an end of life care pathway or a separate checklist which has been developed to address the needs of a specific area.
15
Figure 15 summarises the availability of checklists across the different specialist areas. It demonstrates a degree of variability across areas, with obstetrics and gynaecology and neonatology units reporting the greatest use of bereavement checklists (100%) and emergency departments – with their high proportion of sudden deaths having fewest (20%).
3.1.2 Identification and labelling
Correct identification and labelling of a deceased patient is vital to avoid the risk of misidentification, which could lead in turn to the wrong body being released.
Ward managers identified the methods used in their respective departments to identify bodies before transfer out of their wards to the mortuary or a funeral director. The results are summarised in Figure 16.
Figure 15: Usage of death and bereavement checklists (n=141)
Figure 16: Use of identification accompanying bodies being transferred from wards and hospices (n=142)
16
N.I. Audit: Dying, Death & Bereavement
Three separate means of identification were listed by the ward managers: patient identification armbands, mortuary forms and patient identification labels. All three were said to be used by 62% of respondents, while 99% reported the use of at least one such form of identification. In the survey of policy and procedures (section 3.1) it is noted that only 46% of hospitals and 60% of hospices had a written policy/procedure for patient identification.
3.1.3 Issue of death certificates
In cases where death is due to natural causes, it is a legal requirement for a Medical Certificate of Cause of Death (MCCD) to be completed by a doctor who has treated the patient within the previous twenty-eight days. There are a number of situations, where, if the cause of death is unknown, unexpected or where there are suspicious circumstances, the doctor has a duty to report the death to the coroner.
In Northern Ireland it is usually the cultural practice for a short interval from death to burial/ cremation and it is good practice for the death certificate to be given to the family as soon as practicable to facilitate this. However, the audit identified that it is issued at the time of death in only 50% of cases. Ward managers specified the reasons for the delay in death certificates being issued, with responses presented in Figure 17.
Figure 17: Reasons offered by ward managers (n=95) for a delay in issuing a death certificate
Two reasons were identified for delay: the most common (accounting for 63%) was that changes in junior doctors’ working hours mean the duty doctor has not attended the patient personally, and the issue of the certificate has to wait for the return of a doctor who has treated the patient. The second reason (accounting for the 37%) was that the circumstances of the death may require discussion with a consultant and contact with the Coroner for advice as to whether a death certificate can be issued or if further investigation is required.
3.1.4 Transfer of patients
The audit identified three different methods of the transfer of deceased patients from wards:
• Removal by a designated funeral director, under a service level agreement, to a mortuary;
• Removal by portering staff to a mortuary or holding area;
• Removal by a family funeral director to external premises.
17
Portering managers and funeral directors were asked about the modes of transport used. For children and adults, concealment trolleys were the usual means of transport. For morbidly obese patients (bariatric patients) where the body mass is greater than 40, (National Clinical Excellence definition) transfer generally takes place in the patient’s bed. There were a number of different modes of transport available for the transfer of babies, with Moses baskets and small transfer boxes the most frequently used. Fifty per cent of respondents reported that the transfer of babies and children is a particularly difficult duty to perform.
Figure 18: Means of transportation used for the transfer of deceased patients within hospitals, as reported by portering managers and contracted funeral directors (n=20)
Figure 18 outlines the means of transportation used for the transfer of deceased patients within hospital sites. Half of all cases were reported to have been transferred by foot, 40% in a hospital van, and the remaining 15% in a funeral director’s vehicle, with bodies at times transferred by a combination of means.
3.1.5. Information and communication
Portering managers and those funeral directors carrying out portering and mortuary duties under service level agreements were asked about the information provided to them at the time of a deceased patient’s transfer from a ward. Their responses are summarised in Figure 19, which indicates that information provided by ward staff varied considerably particularly that provided when a request for a body to be removed was being made.
Figure 19: Information provided to porters and contracted funeral directors (n=20)when removing a body from a ward
18
N.I. Audit: Dying, Death & Bereavement
Some of the porters and funeral directors were given information verbally and others through a mortuary identification form. Given the importance of effective communication on issues such as infection control, identification and release, these figures must be viewed as unexpectedly low.
The information reported as being provided by ward staff to mortuary staff and family funeral directors is presented in Figure 20. As expected, this is more than the information provided to those transferring bodies to the mortuaries (Figure 19). Ward staff appear to provide mortuary staff with a greater amount of information than they do to private funeral directors; although mortuary staff also communicate relevant information to the funeral directors.
Figure 20: Information reported by ward managers (n=145) as being provided to mortuary staff and family funeral directors
Trusts have their own individual mortuary forms which accompanied 75% of bodies being transferred to mortuaries with mortuary staff reporting a range of information being provided on the forms (Figure 21). The information provided varied according to whether the mortuary had, or did not have, a post mortem facility, although this was not consistent.
Figure 21: Information provided to mortuary staff (n=12) when receiving a body
19
Mortuary staff reported the information recorded when a patient’s body is released to funeral directors. Figure 22 shows that whereas all mortuaries with a post mortem facility recorded the date and time of release, the name of the staff member releasing the body and the name of the funeral director collecting the body, not all mortuaries without post mortem facilities recorded this information.
3.2. Knowledge and skills
It is essential that those involved in the care of people who are dying and the bereaved are skilled and experienced, so they feel confident about the care and support they give. They should have adequate opportunities to develop their knowledge, understanding, self-awareness and skills (When a Patient Dies, Department of Health 2005).
In both the ward visits and the staff questionnaires, respondents were asked about the availability and uptake of training specific to end of life and bereavement care. Figure 23 sets out the various topics in which staff had received training. It is recognised that while staff may not have had formalised training many have developed knowledge and skills in these subjects through experience and on-the-job training.
Figure 22: Information recorded in mortuaries when patients’ remains are released
20
Figure 23: Percentage of staff responding to the questionnaires who had trainingin care of the dying and their relatives (n=1633)
N.I. Audit: Dying, Death & Bereavement
Staff were asked about their level of confidence in delivering end of life and bereavement care. The results are presented in Figure 24.
Figure 24: Percentages of staff expressing themselves confident in the delivery of end of life and bereavement care
The ward managers (who provided the information on the ward visits) reported themselves to be significantly more confident in the delivery of all aspects of end of life and bereavement care than did staff who responded by questionnaire, a possible reflection of the high level of experience of the ward managers. Talking to bereaved children and supporting people from different cultures were the most difficult duties for all staff to perform.
Staff were asked about additional training that would be helpful in the performance of their roles. Over 60% of both ward managers and individual staff members indicated they would find a range of training helpful as set out in Figure 25.
Figure 25: Percentages of staff who would find additional training helpful
21
Specialist palliative care team members reported on additional training they had received in bereavement care. As Figure 26 indicates, this ranged from postgraduate bereavement and/or local hospital or hospice courses, with over 25% of team members having attended both.
Figure 26: Additional bereavement care training undertaken by specialist palliative care team members (n=11)
Chaplains reported additional training in bereavement care they had undertaken (Figure 27), with local hospital/hospice chaplaincy training undertaken by more than half the chaplains audited.
Figure 27: Additional bereavement care training undertaken by chaplains (n=33)
In addition almost one-third of chaplains reported not having received additional end of life or bereavement care training. It is assumed they would have received training in the provision of spiritual care to the sick and dying as part of their initial professional training with such care also forming part of their respective ministries outside the hospital setting.
22
N.I. Audit: Dying, Death & Bereavement
All funeral directors with service level agreements for portering and mortuary duties reported that they had already received training in all relevant areas. The nature and extent of the training provided to porters in relation to their mortuary duties is summarised in Figure 28.
Figure 28: Training courses for portering teams (n=15)
Most of the porters’ training to date had been in relation to manual handling and infection control, with at least 80% having received training in each of these areas, with fewer than 10% having received training in multi-cultural and religious practices; this has clear implications for the handling of deceased bodies. Over half of those audited identified that additional training in each of the areas of multi-cultural and religious practices, death, grief and bereavement, interpersonal and communication skills and multi-disciplinary working would be helpful. A number of portering managers also indicated the value of on-the-job training.
Mortuary staff reported on the training they had undertaken specific to their role, summarised in Figure 29.
Figure 29: Training courses accessed by mortuary staff
23
Some areas of additional training (e.g. in respect of bereavement care or health and safety) were identified by staff in all types of mortuaries. Some training such as that in coroners law were highlighted only by staff in mortuaries with post mortem facilities with others, such as in infection control or refrigeration control identified only by staff in mortuaries without post mortem facilities. However, some of this additional training will have been received by some mortuary staff as 15 of the 23 designated mortuary staff were qualified pathology technicians with recognised advanced training. 3.3. Staff support
It is essential that all those who care for and support dying and bereaved people, regardless of their roles, should be provided with support for themselves (When a Patient Dies, Department of Health 2005).
Staff participating in both the ward visits and the individual staff questionnaires were asked about the support systems in place throughout their organisations, with Figure 30 summarising the responses of both groups. The ward managers, reflecting their levels of experience, were more aware of appropriate staff support systems than individual staff members who responded to the questionnaires.
Figure 30: Staff support systems identified as being in place
Figure 31 summarises the responses given by mortuary staff on the availability of staff support systems. All mortuary staff recognised the value of peer support with all also aware on how to access the services of occupational health departments.
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N.I. Audit: Dying, Death & Bereavement
The chaplains included in the audit were asked about the services that they provide specifically to members of staff with responses presented in Figure 32.
Figure 31: Support systems available to mortuary staff (n=12 services)
Figure 32: Services provided by chaplains to members of staff (n=33)
This finding suggests that chaplains offer support to staff in three main ways: through direct contact/support, staff training (usually at staff inductions into new posts) and participation in hospital remembrance services. These were reported to be offered by approximately two-thirds, one-half and one-third of chaplains respectively. Staff training was considered by a number of chaplains to be helpful in building good relationships and informing staff of their roles within ward teams.
25
It is recognised that dying people and their families have a right to be treated with dignity and respect and to be cared for in an appropriate environment (section 1.1).
4.1. Environment and facilities
During ward visits, staff were asked to rate the suitability of the environmental aspects of their ward/department for meeting the needs of, and being supportive to, patients who are dying and their families. Their responses are presented in Figure 33.
Figure 33: Percentage of wards and hospices rated ‘excellent’ or ‘good’ overall by their ward managers (n=145)
As predicted hospices, with their central focus on the care of dying patients, were rated the highest overall in terms of the suitability of their environment for the provision of care to those who are dying and their families. General medical wards, the clinical area identified previously as having the highest death rate (Figure 3), but also amongst the busiest within the hospital sector, were rated the lowest.
Figure 34: Environmental aspects of wards/facilities rated ‘excellent’ or ‘good’ by staff
Staff in ward visits and questionnaires, were also asked to rate specific aspects of the environments. As Figure 34 indicates, the ward managers consistently rated all aspects of
4. Creating a Supportive Experience
26
N.I. Audit: Dying, Death & Bereavement
their wards higher than did other members of staff. A significant number of staff in their individual questionnaire responses indicated a level of concern about the limitations of their respective environments for the provision of appropriate end of life care and bereavement support.
Figure 35: Availability of private areas designated for the use of relatives, as reported by ward managers (n=142)
Staff responses on the availability of private areas designated for the use of relatives are presented in Figure 35. Such areas were available in every neonatal unit and combined obstetrics and gynaecology ward included in the audit, and in over 85% of intensive care units and emergency departments. Appropriate facilities were least likely to be provided in dedicated obstetric wards. General medical wards, where most deaths occur, were rated as having fewer appropriate areas for such purposes as breaking bad news than most other clinical environments.
Difficult discussions with families were reported to take place in six different types of locations, summarised in Figure 36.
Figure 36: Locations where difficult discussions take place with relatives, as reported by ward managers (n=144)
27
Offices constituted by far the most common location for difficult discussions, such as those of ward manager, doctor or other health care professional (52%), with sizeable numbers taking place also in either designated quiet rooms or relatives’ spaces (26%) or in side wards or single rooms (12%), if available. While staff clearly made efforts to find quiet areas in which to have such difficult discussions with family members, a small number identified that, due to ongoing pressures in acute wards in particular, it was not always possible to identify appropriate locations. As a result, discussions did at times occur in wholly unsuitable places, including corridors and at patients’ bedsides.
Given the design of older hospitals in particular, the limited availability of single rooms and also a growing need for isolation rooms for patients with infectious conditions, it is often not possible to care for dying patients in single rooms. Ward managers were therefore asked to indicate the extent to which single rooms were allocated to dying patients. Their responses are summarised in Figure 37, according to clinical speciality.
Figure 37: Facilities in which dying patients are cared for in single rooms on more than 75% of occasions, as reported by ward managers (n=133)
Within the hospital sector, there was an inverse relationship between the number of deaths that take place within the speciality and the provision of single rooms, i.e. there was a greater likelihood of a dying patient being cared for in a single room in a speciality where relatively few deaths occur than in areas where deaths are more frequent. However 80% of deaths in hospices occurred in single rooms.
Mortuary staff were asked about their viewing facilities and other environmental factors for relatives. Figure 38 indicates that those mortuaries where post mortems are carried out have a greater range of facilities available.
28
N.I. Audit: Dying, Death & Bereavement
It was evident in discussion with staff that, despite the availability of designated viewing areas in the vast majority of mortuaries, viewing by families was not encouraged in some of the smaller mortuaries. This appeared to be related to the presence of qualified staff.
Some of the most difficult situations that mortuary staff reported they had to deal with included the support of relatives viewing bodies brought directly to the mortuary following accidents and other traumatic incidents.
4.2. Care and support
When engaging in one-to-one contact, patients and families should be enabled to express their needs and preferences through sharing expertise and responsibility and facilitating informed choice (When a Patient Dies, Department of Health 2005).
Given the importance of working in partnership with patients and families, ward managers were asked about whether they explore the wishes and feelings of patients who are dying; figure 39 sets out the results. Every manager from an elderly or a gynaecology ward reported routinely exploring the wishes and feelings of their dying patients, where appropriate. This contrasts with just over 30% of staff from emergency departments reported doing so. The practice in emergency departments may not be unexpected given the higher frequency of sudden deaths that occur. It is recognised that these types of discussions may need to be carried out by experienced staff with advanced communication skills.
Figure 38: Viewing arrangements and other facilities available at mortuaries
29
Figure 39: Ward managers from different specialist areas who reported that they routinely explore the wishes and feelings of dying patients (n=137)
All managers were asked during ward visits about the use of a care of the dying pathway in their wards. Currently, only adult wards reported using this system with the development of a separate care of the dying pathway for use within a number of children’s services being considered. Only responses from managers of adult wards are reported in Figure 40.
Figure 40: Areas where the care of the dying pathway is operational, as reported by ward managers (n=124)
As expected, general medicine, as the clinical area with the highest number of inpatient deaths, is also the area within which the care of the dying pathway is most frequently used. It is also used extensively in cardiology wards, but rarely in obstetrics or emergency departments. Overall, staff comments were very positive about the benefits of the care of the dying pathway, which they felt helped to ensure a holistic approach to end of life care.
Figure 41 summarises the extent to which ward managers reported that relatives have the opportunity to speak to an appropriate nurse, doctor and/or hospital chaplain. Although staff reported it to be increasingly difficult to give families the amount of time they may need in busy clinical areas, staff were reported to often make themselves available (95-100%).
Figure 41: Extent to which relatives were afforded an opportunity to speak to a health care professional about their relative’s death, as reported by ward managers (n=145)
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N.I. Audit: Dying, Death & Bereavement
Senior staff were asked to identify those individuals and groups, from the statutory or voluntary sector, with a remit for care of the dying, after-death care or support for the bereaved. A total of 23 organisations were identified, the most frequently cited of which are presented in Figure 42.
Figure 42: Services most frequently identified by senior managers (n=37) as having a link to bereavement care
Cruse Bereavement Care was by far the most frequently identified organisation, cited by over 70% of the managers. Of the rest, only those services provided by palliative care teams, Macmillan nurses, SANDS and hospital chaplains were identified by more than 20% of respondents. And of the 12 services not included within Figure 42 – care of the dying pathway coordinators, clinical psychologists, Marie Curie services, bereavement volunteers, Bliss for Babies, Child Bereavement Trust, Miscarriage Association, Ulster Cancer Foundation, Area Bereavement Coordinators, community hospice nurses, occupational health services and PSNI Family liaison officers – each was identified by fewer than 10% of managers.
Specialist palliative care and chaplaincy teams were asked about the availability of written information on their respective services. As can be seen from Figure 43, 82% of the former and 67% of the latter indicated that such information is available.
Figure 43: Specialist palliative care teams (n=11) and chaplaincy services (n=33) for which written information was available
31
Appropriate and timely referral to specialist palliative care teams is essential to ensure that patients and families receive the support and advice they require. Specialist palliative care teams were consequently asked about both the source of their referrals and the nature of the services they provide.
As can be seen from Figure 44, all specialist palliative care teams reported that they received referrals from wards and that, given the nature of their illnesses, on admission some patients were already known to their services.
Figure 44: Sources of referral to specialist palliative care teams (n=11)
Figure 45 indicates that symptom management, advice and support were the core services provided by all specialist palliative care teams, followed by education and training, including the promotion of end of life care pathways (73%), referral on to community services (64%) and the provision of follow-up support (55%). It was evident from discussions with ward staff during the audit that the support and advice they received from the palliative care teams on the use of the end of life care pathway was particularly appreciated.
Figure 45: Services provided by specialist palliative care teams (n=11)
32
Patients are usually informed on admission of the availability of a hospital chaplaincy service and asked if they wish to have their religious denomination recorded and provided to the appropriate chaplain. Efforts are made by chaplains to visit as many patients on their lists as possible, but where this does not occur routinely the chaplains concerned were asked to indicate in what other ways they receive referrals to visit patients.
Figure 46 details the responses provided by the four chaplains concerned. All indicated that they receive requests directly from patients and/or their families, while in three cases the chaplains reported that they were either familiar with patients prior to their admissions or that they were informed of individuals either directly from the wards or during chaplains’ ward visits.
Figure 46: Referrals to chaplains where not all patients are visited (n=4)
The chaplains stressed the importance of timely referrals from ward staff, especially for patients who are dying, and indicated that in some instances they had been notified too late to be able to offer support to the patients, who had already died. The opportunity to build up a relationship with a patient’s family prior to his/her death can be of assistance when offering support at the time of the death and afterwards.
The various services which the chaplains provide are summarised in Figure 47.
Figure 47: Services provided by chaplains (n=33) to patients and/or their families
N.I. Audit: Dying, Death & Bereavement33
All chaplains carry out routine ward visits and visits to ill patients, and the vast majority (90%) provide the sacraments and undertake funeral services for patients without families. Some chaplains (40%) undertake a number of specifically child-related services, such as infants’ or children’s remembrance services or naming services for babies.
Portering managers and those funeral directors who were contracted to perform portering and mortuary duties were asked both about their duties and responsibilities in relation to hospital mortuaries and about their involvement with families. Figure 48 indicates their key responsibilities, both independently and under the supervision of mortuary staff.
Figure 48: Duties undertaken by portering teams and funeral directors with portering and mortuary duties (n=20)
It is clear that the porters and contracted funeral directors carry out most of their four key duties independently. However, it is also evident that no single duty was performed in any more than 50% of the sites that were audited.
The larger acute hospitals tended to have at least one qualified pathology technician or designated mortuary attendant in post, whereas in a number of smaller hospitals portering staff were responsible for mortuary duties required, in liaison with ward staff and funeral directors. It was notable during the audit that some of the senior portering staff had been carrying out their duties for many years and were very familiar with all the processes involved, as well as with the sensitivities required in dealing with bereaved families.
34
N.I. Audit: Dying, Death & Bereavement
4.3. Information and communication
The audit identified a range of systems used by wards, departments and hospices to notify other professionals of a patient’s death (Figure 49). The most common means was through a senior nurse on duty contacting the patient’s GP directly (28%), although 5% of facilities had no recognised system at all in place for the notification of other professionals.
Figure 49: Systems in place for the notification of other professionals, as reported by ward managers (n=142)
It was also identified that no reporting system is entirely robust and that communication can break down at times, resulting in either a delay or the relevant professional not being informed of the patient’s death. This has the potential to cause undue upset to bereaved families, such as when they receive a letter offering an appointment to a person who has already died.
Ward staff were asked about the information provided to families at the time of a patient’s death (Figure 50). In nearly all cases families were informed if the coroner was contacted or if the Medical Certificate for Cause of Death has been issued. Other information commonly provided to families at the time of a patient’s death included potential health and safety risks, the return of the deceased person’s property and notification that the remains may be released. It is perhaps surprising, in light of the importance of these latter reasons, that each of them was identified by fewer than 100% of the staff who were audited as information that would routinely be provided to families.
Figure 50: Information given to the family by the ward, as reported by ward managers (n=102–121)
35
Following the recommendation of the Human Organs Enquiry 2002, the DHSSPS introduced new consent forms to be completed by the deceased’s next-of-kin in cases where a hospital post mortem examination is indicated, along with booklets aimed at supporting families through this process. Obtaining consent in such cases involves discussions with families aimed at enabling them to make informed choices. In the case of post mortem examinations directed by the coroner, consent for the procedure is not required, although the families’ wishes regarding the disposal of tissue does need to be sought. The Coroner’s Service NI has produced a booklet to support these processes.
It is expected that senior doctors and nursing staff will offer information and support to families at such difficult times, and Figure 51 summarises the responses in the audit of ward managers when asked about the information provided to families when a post mortem examination is required.
Figure 51: Information provided to families when a post mortem is required, as reported by ward managers (n=113-131)
Explanations and discussions with families, as well as answering their questions and providing them with relevant booklets were all identified practices within at least 97% of wards, although copies of consent forms were provided in only 94% of cases.
The nature of any written information provided to bereaved parents on those wards and departments which may be expected to experience the deaths of babies and/or children is summarised in Figure 52.
Figure 52: Written information provided to parents of deceased babies or children,as reported by ward managers (n=33-50)
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N.I. Audit: Dying, Death & Bereavement
Given that almost half of all children who die in a neonatal unit undergo a hospital post mortem, it is no surprise that information booklets in respect of post mortems on children and babies were the most commonly provided, in at least 80% each of the respective wards and departments. It is increasingly common for parents to take the bodies of their children directly home by car immediately following their deaths, where this was expected; only 20% of the relevant wards and departments had a written policy to support this practice.
Ward managers were asked about other information and resources they provided to bereaved families (Figure 53). There was evidence of families being directed towards a number of voluntary organisations (in particular, Cruse Bereavement Care) in 78% of wards and departments; 74% provided families with forms to assist in registering the death; 62% provided booklets specifically designed to assist bereaved people; and 54% provided information in relation to the arranging of funerals.
Figure 53: Other information and resources provided to bereaved relatives, as reported by ward managers (n=142)
Ward and hospice managers were also asked about arrangements for the collection of Medical Certificates of Cause of Death in situations where they had not been issued at the time of death. Their responses are provided in Figure 54.
Figure 54: The collection of death certificates in hospital and hospice settings, as reported by ward managers
37
Within the hospices, certificates were reported to be collected either from the ward (in 60% of cases) or from reception or a general office (20%). Collection from the ward was also reported as the most common procedure within the hospital sector (77%), where a further 28% reported their collection from a mortuary instead. However, it can be difficult for a family member to return to a mortuary or ward in which their relative had died a short time previously and a representative may be able to collect the certificate on a relative’s behalf. It is noted that 18% of the hospital ward managers in the audit indicated that death certificates were collected by funeral directors.
To facilitate the customary three-day burial practice in Northern Ireland, it is important for all organisations to ensure the timely issue of death certificates. It is also important that accurate and transparent records regarding the issue and collection of death certificates be maintained.
Ward managers were asked whether or not follow-up meetings to discuss a patient’s death were routinely offered to bereaved families. The percentages of units within each clinical area reporting that such follow-up meetings were always offered to families are presented in Figure 55.
Figure 55: Wards and hospices offering follow-up meetings with bereaved families, as reported by ward managers (n=143)
There were only two clinical areas where every ward concerned provided routine follow-up meetings with families: obstetrics and joint obstetrics and gynaecology services. Follow-up meetings were not routinely offered in the majority of other units, either in the hospital or the hospice sector, such meetings were reported as being provided at the request of families.
When asked about how families were provided with the results of post mortem examinations, the ward managers responded as set out in Figure 56.
38
N.I. Audit: Dying, Death & Bereavement
The audit findings show that over 35% of ward managers were unable to identify how families received the results of post mortem examinations – suggesting there was often a lack of communication between the various parties involved. Of the others, the most common means was through face-to-face meetings with relevant professionals (identified by 32% of respondents), followed by contact with the patient’s GP (23%) and through the coroners office or liaison officer (19%). Seven percent reported that the results of post mortem examinations had been relayed to family members over the telephone.
Ward and hospice managers were also asked to identify any methods they employed to obtain feedback from their service users, with responses summarised in Figure 57.
Figure 56: Means of informing families with the results of post mortem examinations, as reported by ward managers (n=145)
Figure 57 : Methods employed by wards and hospices to secure user feedback, as reported by ward managers (n=143)
By far the most common method employed was through the receipt of complaints and compliments (reported by 87% of the managers audited). Thank you cards and gifts were reported by 39%, with families returning to the ward, charitable donations, and asking family members throughout their relative’s stay in the unit each recorded by fewer than 15% of the managers.
Equally small percentages of the managers reported using more formal means of securing service user feedback, including user questionnaires (10%) or focus groups (4%).
No service within the hospital or hospice sector identified a systematic approach of collecting or using user feedback on their services.
39
Results from this audit identified a wide range of services and information across the NI Health and Social Care Services and within Hospices for the care of dying patients and to support bereaved people. There are, however, variations in the standards and organisation of such services. No overarching system or set of policies were in place to ensure appropriate standards. In consequence the following recommendations are set out to improve the quality and organisation of these important services.
1. A strategy for bereavement care within the Health and Social Care Services should be developed to inform the direction of end of life and bereavement care in Northern Ireland.
2. HSC Trusts should develop an overarching policy which incorporates core policies around care of the dying and the management of death. As a minimum this should include written guidance on the following:
• Last offices (including cultural and religious requirements)
• All aspects of identification, transfer, storage, viewing and release of bodies
• A minimum agreed set of information which complies with health and safety requirements should be noted on a mortuary form which accompanies the body.
• The issue of the Medical Certificate of Cause of Death
• Reporting deaths to the Coroners Service
• The management of sudden, unexpected death and the preservation of evidence in forensic cases
• A clear system for informing other professionals of the death
3. Corporate and local induction should cover issues concerning death and bereavement as relevant to the role of the staff concerned.
4. Trusts must offer training in consent for hospital post mortem examinations to those senior medical staff who may be required to seek consent.
5. Staff should be made aware of support systems available to them.
6. As identified by staff, there should be opportunities for staff development and training in the care of dying patients and bereaved relatives (see Appendix 7).
7. The use of the care of the dying pathway should be promoted as a minimum safe standard.
8. Trusts should have operational policies for chaplains’ services.
9. Governance systems should ensure learning from complaints made by bereaved families.
10. Systems should be developed to obtain feedback from bereaved relatives.
11. Information booklets for bereaved relatives should be audited.
12. New capital builds and refurbishment programmes should include areas to promote privacy and dignity for dying patients and bereaved families.
5. Recommendations
40
N.I. Audit: Dying, Death & Bereavement
Appendices
ContentsNo Audit Criteria Page
1 Organisational Audit Standards 42
2 Mortuary Services Audit Standards 44
3 Chaplaincy Services Audit Standards 46
4 Palliative Care Services Audit Standards 48
5 Porters and Funeral Directors Services Audit Standards
49
6 Ward Managers Questionnaire Results 50
7 Individual Staff Questionnaire Results 52
8 Standards Documents 57
41
1.
Org
anis
atio
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Au
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Sta
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ard
s
42
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A
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R
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on
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1.
Ch
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by
th
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rga
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ati
on
10
0%
9
7.5
%
“All
NH
S T
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pro
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, sta
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ith
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mm
un
ity r
ep
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s.”
- 2
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Tru
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ma
y w
ish
to
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me
nt
ca
re t
he
y p
rovid
e.”
– 1
“C
ha
pla
incy-s
pir
itu
al
ca
re is
ce
ntr
al
to p
rovid
ing
su
pp
ort
a
nd
a
ssis
tan
ce
to
th
e
be
rea
ve
d.
All
NH
S T
rusts
sh
ou
ld e
nsu
re t
ha
t th
e d
yin
g a
nd
re
ce
ntly b
ere
ave
d a
re
ab
le t
o a
cce
ss c
ha
pla
incy s
erv
ice
s a
t th
e a
pp
rop
ria
te t
ime
.” –
2
2.
Th
e f
oll
ow
ing
po
lic
ies
/gu
ide
lin
es
co
nc
ern
ing
de
ath
an
d
be
rea
ve
me
nt
are
in
pla
ce
:
a.
Acce
ssin
g in
terp
retin
g s
erv
ice
s
10
0%
9
0.0
%
“Pa
tie
nts
sh
ou
ld b
e a
ble
to
co
mm
un
ica
te w
ith
he
alth
wo
rke
rs in
th
e la
ngu
ag
e t
he
y
fee
l co
mfo
rta
ble
with
.” -
3
b.
A
dva
nce
Dir
ective
10
0%
5
2.5
%
“ In
div
idu
als
m
ay h
ave
a
n a
dva
nce
d
ire
ctive
o
r liv
ing
w
ill sp
ecifyin
g h
ow
th
ey
wo
uld
lik
e t
o b
e t
rea
ted
in
th
e c
ase
of
futu
re i
nca
pa
city.
……
Fa
ilure
to
re
sp
ect
su
ch
an
ad
va
nce
re
fusa
l ca
n r
esu
lt in
le
ga
l a
ctio
n a
ga
inst
the
pra
ctitio
ne
r.”
- 4
c.
Be
rea
ve
me
nt
Ca
re
10
0%
5
0.0
%
“All
NH
S T
rusts
sh
ou
ld p
rovid
e su
pp
ort
a
nd
a
dvic
e to
fa
mili
es a
t th
e tim
e o
f b
ere
ave
me
nt.
” -
5
d.
Bre
akin
g b
ad
ne
ws
10
0%
8
0.0
%
“Im
ple
me
nta
tio
n
of
the
R
eg
ion
al
Gu
ide
line
s
for
Bre
akin
g
Ba
d
Ne
ws
is
the
re
sp
on
sib
ility
of
ea
ch
HP
SS
Tru
st,
HP
SS
an
d V
olu
nta
ry P
rovid
ers
, in
pa
rtn
ers
hip
w
ith
ed
uca
tio
n p
rovid
ers
an
d in
div
idu
al p
rofe
ssio
na
ls”.
- 6
e.
Bu
ria
l b
y h
osp
ita
l (i
f n
o n
ext
of
kin
) *h
osp
ice
s n
ot
inclu
de
d
10
0%
6
2.9
%*
n=
35
“C
hild
ren
Ord
er
(NI)
19
95
, H
ea
lth
an
d P
ers
on
al
So
cia
l S
erv
ice
s (
NI)
Ord
er
19
72
(A
rtic
le2
5&
39
), H
ea
lth
a
nd
P
ers
on
al
So
cia
l S
erv
ice
s (N
I) O
rde
r 1
99
1(A
rtic
le2
5)
an
d W
elfa
re S
erv
ice
s A
ct
(NI)
19
71
(S
ectio
n 2
5).
f.
Ca
re o
f th
e d
yin
g p
ath
wa
y:
10
0%
7
4.4
%
“P
rovid
er
org
an
isa
tio
ns s
ho
uld
en
su
re t
ha
t m
an
ag
ed
syste
ms t
o e
nsu
re b
est
pra
ctice
in
ca
re o
f th
e d
yin
g p
atie
nts
are
im
ple
me
nte
d b
y a
ll m
ultid
iscip
lina
ry
tea
ms.
Th
is m
igh
t in
clu
de
th
e L
ive
rpo
ol C
are
of
the
Dyin
g p
ath
wa
y”
– 8
g.
Ca
re p
lan
fo
r p
reg
na
ncy lo
ss,
stillb
irth
an
d n
eo
na
tal d
ea
th
10
0%
7
5.0
%
(n=
16
) D
HS
SP
S -
9
h.
Ch
ap
lain
cy /
sp
iritu
al ca
re
10
0%
5
2.5
%
“NH
S T
rusts
ma
y w
ish
to
co
nsid
er
ho
w b
est
to p
rovid
e s
pir
itu
al ca
re a
s a
n in
teg
ral
pa
rt o
f th
e o
ve
rall
be
rea
ve
me
nt
ca
re t
he
y p
rovid
e.
Th
is m
ay b
e b
est
led
th
rou
gh
a
he
alth
ca
re c
ha
pla
in o
r sim
ilar
role
an
d T
rusts
ma
y w
ish
to
ta
ke
in
to a
cco
un
t th
e
NH
S
gu
ida
nce
fo
r m
an
ag
ers
a
nd
th
ose
in
vo
lve
d
in
the
p
rovis
ion
o
f ch
ap
lain
cy/s
pir
itu
al ca
re issu
ed
in
20
03
”. –
2
i.
De
ath
ce
rtific
atio
n
10
0%
8
2.5
%
“Mo
st
ho
sp
ita
ls w
ill h
ave
a w
ritt
en
re
co
rd o
f p
roce
du
res t
o b
e u
se
d f
ollo
win
g t
he
d
ea
th o
f a
pa
tie
nt
in o
rde
r to
co
mp
lete
a f
act
of
de
ath
fo
rm (
if u
se
d),
th
e m
ed
ica
l C
au
se
of
De
ath
Ce
rtific
ate
, a
cre
ma
tio
n f
orm
(if n
ee
de
d)
an
d t
he
do
cu
me
nta
tio
n
ne
ce
ssa
ry t
o p
erm
it t
he
re
lea
se
of
the
de
ce
ase
d f
rom
th
e h
osp
ita
l, a
nd
to
pa
ss o
n
the
ne
ce
ssa
ry d
ocu
me
nta
tio
n t
o t
he
ne
xt
of
kin
.” –
1
N.I. Audit: Dying, Death & Bereavement43
Au
dit
Cri
teri
a
Sta
nd
ard
A
ch
iev
ed
R
ati
on
ale
j.
Cre
ma
tio
n
10
0%
6
5.0
%
As a
bo
ve
.
k.
Cu
ltu
ral a
nd
re
ligio
us o
bse
rva
nce
s
10
0%
8
7.5
%
“Ad
eq
ua
te a
rra
ng
em
en
ts a
re m
ad
e f
or
the
sp
iritu
al, r
elig
iou
s,
sa
cra
me
nta
l, r
itu
al
an
d c
ultu
ral re
qu
ire
me
nts
ap
pro
pri
ate
to
th
e n
ee
ds,
ba
ckg
rou
nd
an
d t
rad
itio
n o
f a
ll p
atie
nts
an
d s
taff
, in
clu
din
g t
ho
se
of
no
sp
ecifie
d f
aith
.” –
2
l.
Do
no
t a
tte
mp
t re
su
scita
tio
n
10
0%
9
5.0
%
“NH
S
Tru
sts
ch
ief
exe
cu
tive
s
are
a
ske
d
to
en
su
re
tha
t th
e
ap
pro
pri
ate
re
su
scita
tio
n p
olic
ies w
hic
h r
esp
ect
pa
tie
nts
rig
hts
are
in
pla
ce
, u
nd
ers
too
d b
y a
ll re
leva
nt
sta
ff,
an
d a
cce
ssib
le t
o t
ho
se
wh
o n
ee
d t
he
m,
an
d t
ha
t su
ch
po
licie
s a
re
su
bje
ct
to a
pp
rop
ria
te a
ud
it a
nd
mo
nito
rin
g a
rra
ng
em
en
ts”
– 1
0
m.
Id
en
tifica
tio
n o
f th
e d
ece
ase
d
10
0%
4
7.5
%
“Mo
rtu
ary
se
rvic
es f
ollo
win
g g
oo
d p
ractice
will
ha
ve
a p
olic
y in
pla
ce
wh
ich
co
ve
rs
the
pro
ce
du
res n
ece
ssa
ry f
or
the
id
en
tifica
tio
n o
f
de
ce
ase
d p
eo
ple
s b
od
ies a
nd
th
eir
po
sse
ssio
ns”
– 1
2
n.
In
form
atio
n f
or
rela
tive
s
10
0%
6
5.0
%
“Th
e p
rovis
ion
of
wri
tte
n i
nfo
rma
tio
n (
listin
g a
nd
de
scri
bin
g s
ou
rce
s o
f su
pp
ort
, h
elp
line
s
an
d
we
b-b
ase
d
info
rma
tio
n,
for
exa
mp
le)
is
reco
mm
en
de
d
to
he
lp
pe
op
le w
ho
are
bere
ave
d m
an
ag
e t
he
pra
ctica
l a
rra
ng
em
en
ts n
ece
ssa
ry a
fte
r a
d
ea
th.”
– 1
o.
La
st
off
ice
s w
ith
r
eg
ard
to
: i.
M
an
ua
l
ha
nd
ling
ii.
I
nfe
ctio
n c
on
tro
l iii
. C
ultu
ral &
re
ligio
us p
ractice
s
iv.
Tra
nsfe
r o
f th
e d
ece
ase
d
v.
Id
en
tifica
tio
n
vi.
No
tifica
tio
n t
o o
the
r d
ep
art
me
nts
vii.
R
em
ova
l o
f im
pla
nts
viii
. R
etu
rn o
f p
rop
ert
y a
nd
va
lua
ble
s
ix.
V
iew
ing
th
e d
ece
ase
d
10
0%
1
00
%
10
0%
1
00
%
10
0%
1
00
%
10
0%
1
00
%
10
0%
82
.5%
8
7.5
%
89
.7%
6
2.5
%
80
.0%
8
2.5
%
45
.0%
8
2.5
%
55
.0%
“It
is re
co
mm
en
de
d th
at
NH
S T
rusts
co
nsid
er
pu
ttin
g in
p
lace
a
w
ritt
en
p
olic
y
ratifie
d b
y t
he
Tru
st
Bo
ard
, co
ve
rin
g a
ll se
rvic
es r
ela
tin
g t
o d
ea
th &
be
rea
ve
me
nt.
” -
1
- 2
1
p.
Po
st
mo
rte
m p
roce
sse
s
10
0%
6
7.5
%
11
an
d 1
9
q.
Re
po
rtin
g c
ase
s t
o t
he
Co
ron
er
10
0%
9
2.5
%
13
, 2
2
r.
Su
dd
en
de
ath
pro
toco
ls
10
0%
3
7.5
%
“Su
ch
po
licie
s s
ho
uld
id
en
tify
be
rea
ve
me
nt
ca
re p
ath
wa
ys f
or
bo
th e
xp
ecte
d a
nd
u
ne
xp
ecte
d d
ea
ths”
- 1
s.
Ava
ilab
ility
of
Me
mo
ran
du
m o
f u
nd
ers
tan
din
g f
or
inve
stig
atin
g
pa
tie
nt/
clie
nt
sa
fety
in
cid
en
ts…
10
0%
6
5.0
%
“Th
e
me
mo
ran
du
m
will
ta
ke
e
ffe
ct
in
cir
cu
msta
nce
s
of
un
exp
ecte
d
de
ath
o
r se
rio
us u
nto
wa
rd h
arm
re
qu
irin
g i
nve
stig
atio
n b
y t
he
po
lice
, co
ron
ers
or
HS
EN
I se
pa
rate
ly o
r jo
intly.”
-
14
2.
Mo
rtu
ary
Ser
vice
s A
ud
it S
tan
dar
ds
44
Au
dit
Cri
teri
a
Sta
nd
ard
A
ch
iev
ed
R
ati
on
ale
1.
Th
e f
oll
ow
ing
vie
win
g a
rra
ng
em
en
ts a
re i
n p
lac
e:
a)
Re
lative
s c
an
vie
w t
he
de
ce
ase
d in
th
e m
ort
ua
ry
b)
Mo
rtu
ary
is c
lea
rly s
ign-p
oste
d f
rom
th
e h
osp
ita
l e
ntr
an
ce
c)
Do
orb
ell
or
inte
rco
m t
o g
ain
acce
ss
d)
Acce
ss t
o s
an
ita
ry f
acili
tie
s
e)
Acce
ss t
o d
rin
kin
g w
ate
r f)
W
aitin
g a
rea
with
co
mfo
rta
ble
ch
air
s
g)
De
sig
na
ted
vie
win
g a
rea
h)
Sp
ecia
l a
rra
ng
em
en
ts f
or
vie
win
g b
ab
ies/c
hild
ren
i)
Ca
pa
city t
o a
cco
mm
od
ate
re
ligio
us/c
ultu
ral ri
tua
ls
j)
Ca
pa
city t
o h
old
re
ligio
us s
erv
ice
s
k)
All
are
as a
re w
he
elc
ha
ir a
cce
ssib
le
10
0%
1
00
%
10
0%
1
00
%
10
0%
1
00
%
10
0%
1
00
%
10
0%
1
00
%
10
0%
(n=
12
)
1
00
.0%
8
3.3
%
66
.7%
8
3.3
%
50
.0%
8
3.3
%
91
.7%
5
0.0
%
10
0.0
%
75
.0%
9
3.8
%
“…
mo
rtu
ary
fa
cili
tie
s w
ou
ld id
ea
lly n
ee
d t
o in
clu
de
at
lea
st
on
e p
riva
te,
co
mfo
rta
ble
ro
om
w
he
re a
bo
dy c
an
be
se
en
by r
ela
tive
s a
nd
oth
ers
. F
acili
tie
s s
ho
uld
be
de
sig
ne
d t
o c
ate
r fo
r a
ll a
ge
gro
up
s”
- 1
“
Co
nsid
era
tio
n sh
ou
ld b
e g
ive
n to
a
ll a
pp
roa
ch
es,
ad
jace
ncie
s a
nd
ro
ute
s (e
ntr
an
ce
s a
nd
d
ep
art
ure
s),
eg
th
e jo
urn
ey f
or
the
be
rea
ve
d f
rom
th
e p
lace
of
de
ath
to
th
e m
ort
ua
ry”
– 1
an
d
20
“A v
iew
ing
ro
om
will
usu
ally
be
de
co
rate
d a
nd
fu
rnis
he
d in
a w
ay w
hic
h w
ill h
elp
pe
op
le f
ee
l ca
lm a
nd
ca
red
fo
r…a
nd
ea
sy c
ha
irs s
o t
ha
t if t
he
y w
ish
, re
lative
s c
an
sta
y w
ith
th
e d
ece
ase
d
pe
rso
n f
or
a w
hile
in
co
mfo
rt”-
12
“D
ea
th a
nd
be
rea
ve
me
nt
aff
ect
ind
ivid
ua
ls in
diffe
ren
t w
ays.
Th
eir
re
sp
on
se
is a
lso
in
flu
en
ce
d
by t
he
ir b
elie
fs,
cu
ltu
re,
relig
ion
, va
lue
s,
se
xu
al o
rie
nta
tio
n,
life-s
tyle
or
so
cia
l d
ive
rsity.
Mo
rtu
ary
se
rvic
e s
taff
will
be
ale
rt t
o in
div
idu
al n
ee
ds,
an
d b
e f
lexib
le in
att
em
ptin
g t
o m
ee
t th
em
.” -
12
2.
Th
e f
oll
ow
ing
do
cu
me
nta
tio
n a
cc
om
pa
nie
s p
ati
en
t’s
re
ma
ins
fro
m t
he
wa
rd/d
ep
art
me
nt
to t
he
mo
rtu
ary
: a
) P
atie
nt
ID la
be
l b
) W
rist/
an
kle
ID
ba
nd
c)
Mo
rtu
ary
fo
rm
10
0%
1
00
%
10
0%
(n=
12
) 7
5.0
%
10
0.0
%
75
.0%
“It
is r
eco
mm
en
de
d t
ha
t N
HS
Tru
sts
ha
ve
in
pla
ce
: se
cu
re s
yste
ms f
or
the
id
en
tifica
tio
n o
f b
od
ies,
in o
rde
r to
en
su
re t
ha
t th
e c
orr
ect
bo
dy is p
rep
are
d f
or
vie
win
g a
nd
/or
rele
ase
fo
r cre
ma
tio
n o
r b
uri
al”
- 1
3.
Mo
rtu
ary
sta
ff a
re i
nfo
rme
d o
f th
e f
oll
ow
ing
: a
) C
ultu
ral/re
ligio
us r
eq
uir
em
en
ts
b)
He
alth
an
d s
afe
ty r
isks
c)
Pro
pe
rty o
n b
od
y
d)
Pa
ce
ma
ke
r in
situ
e)
Tu
be
s/d
rain
s e
tc in
situ
f)
If d
ea
th c
ert
ific
ate
issu
ed
g)
If b
od
y is f
or
cre
ma
tio
n
h)
If r
em
ain
s c
an
be
re
lea
se
d
i)
If b
od
y n
ee
ds t
o b
e h
eld
: I.
F
or
ho
sp
ita
l p
ost
mo
rte
m
II.
Fo
r d
ecis
ion
of
Co
ron
er
j)
If C
oro
ne
r in
vo
lve
d
10
0%
1
00
%
10
0%
1
00
%
10
0%
1
00
%
10
0%
1
00
%
10
0%
1
00
%
10
0%
(n=
12
) 9
1.7
%
10
0.0
%
83
.3%
6
6.7
%
75
.0%
7
5.0
%
66
.7%
7
5.0
%
10
0.0
%
10
0.0
%
75
.0%
“M
ort
ua
ry a
nd
be
rea
ve
me
nt
se
rvic
es w
ill n
ee
d t
o h
ave
in
pla
ce
ro
bu
st
me
ch
an
ism
s f
or
co
mm
un
ica
tin
g in
form
atio
n a
bo
ut
the
de
ce
ase
d p
atie
nt…
this
will
en
su
re t
ha
t a
ny r
ele
va
nt
info
rma
tio
n f
rom
th
e f
am
ily is p
asse
d t
o m
ort
ua
ry s
taff
.” -
12
“M
ort
ua
ry s
erv
ice
s w
ill h
ave
in
pla
ce
fa
cili
tie
s,
pro
toco
ls a
nd
pro
ce
du
res w
hic
h e
na
ble
sta
ff t
o
pro
vid
e t
he
re
qu
ire
d s
erv
ice
eff
icie
ntly,
eff
ective
ly a
nd
to
ap
pro
pri
ate
clin
ica
l sta
nd
ard
s”
- 1
2
“Ca
re n
ee
ds t
o b
e t
ake
n t
o id
en
tify
im
pla
nte
d d
evic
es,
wh
ere
ap
pro
pri
ate
, a
s t
he
se
will
pre
se
nt
a h
aza
rd a
t cre
ma
tio
n”
- 1
“
Be
fore
a d
ece
ase
d p
ers
on
s b
od
y is r
ele
ase
d,
mo
rtu
ary
sta
ff s
ho
uld
ch
eck t
ha
t a
ll n
ece
ssa
ry
do
cu
me
nta
tio
n is c
om
ple
te a
nd
th
e d
ece
ase
d p
ers
on
’s id
en
tity
is c
on
firm
ed
bo
th b
y t
he
m
ort
ua
ry s
taff
an
d t
he
pe
rso
n t
o w
ho
m t
he
bo
dy is r
ele
ase
d”
– 1
2
“All
po
st-
mo
rte
ms m
ust
be
ca
rrie
d o
ut
in a
pre
mis
es lic
en
ce
d b
y t
he
HT
A in
acco
rda
nce
with
th
e c
on
ditio
ns o
f th
e lic
en
ce
”- 2
4
“In
Co
ron
er’
s c
ase
s,
it is im
po
rta
nt
tha
t th
ere
is a
n a
gre
ed
pro
toco
l in
pla
ce
to
en
su
re t
ha
t th
ere
is n
o
co
nfu
sio
n a
bo
ut
wh
o is r
esp
on
sib
le f
or
the
cu
sto
dy a
nd
re
lea
se
of
the
bo
die
s o
f th
e d
ece
ase
d”
– 1
2
4.
Th
e f
oll
ow
ing
po
lic
ies
are
in
pla
ce
: a
) R
eco
rd k
ee
pin
g
b)
Re
ce
ivin
g,
ide
ntify
ing
, se
cu
rin
g,
sto
rin
g a
nd
re
lea
sin
g
bo
die
s,
org
an
s a
nd
tis
su
es
c)
Lo
ne
wo
rke
r d
) P
rep
ara
tio
n f
or
vie
win
g
e)
Su
pp
ort
ing
re
lative
s
f)
Lia
iso
n p
roto
co
ls w
ith
Co
ron
er
Se
rvic
e a
nd
PS
NI
g)
Co
ron
er’
s p
ost
mo
rte
ms –
acce
ss t
o m
ort
ua
ry o
ut o
f h
ou
rs
h)
Infe
ctio
n c
on
tro
l
10
0%
1
00
%
10
0%
1
00
%
10
0%
1
00
%
10
0%
1
00
%
66
.7%
7
5.0
%
58
.3%
6
6.7
%
33
.3%
5
8.3
%
66
.7%
1
00
.0%
“Mo
rtu
ary
se
rvic
es w
ill h
ave
in
pla
ce
fa
cili
tie
s,
pro
toco
ls a
nd
pro
ce
du
res w
hic
h e
na
ble
sta
ff t
o
pro
vid
e t
he
re
qu
ire
d s
erv
ice
eff
icie
ntly,
eff
ective
ly a
nd
to
ap
pro
pri
ate
clin
ica
l sta
nd
ard
s”
- 1
2
“M
ort
ua
ry s
erv
ice
s s
ho
uld
ha
ve
in
pla
ce
a p
olic
y o
n d
ocu
me
nta
tio
n p
roce
du
res”
- 1
2
“M
ort
ua
ry s
erv
ice
s…
will
ha
ve
a p
olic
y in
pla
ce
wh
ich
co
ve
rs t
he
pro
ce
du
res n
ece
ssa
ry f
or
the
id
en
tifica
tio
n o
f d
ece
ase
d p
eo
ple
’s b
od
ies a
nd
th
eir
po
sse
ssio
ns”
- 1
2
“W
he
re f
am
ilie
s h
ave
in
div
idu
al, c
ultu
ral o
r re
ligio
us p
refe
ren
ce
s c
on
ce
rnin
g t
he
sto
rage
, h
an
dlin
g,
tra
nsp
ort
atio
n o
r p
rese
nta
tio
n o
f th
e d
ece
ase
d p
ers
on
, th
ese
ne
ed
to
be
ca
refu
lly
do
cu
me
nte
d a
nd
acco
mm
od
ate
d w
he
reve
r p
ossib
le.”
-1
2
“As a
re
su
lt o
f th
e iso
late
d lo
ca
tio
n o
f m
ost
mo
rtu
ari
es a
nd
th
e s
hift
pa
tte
rns m
ain
tain
ed
by
sta
ff,
a r
isk a
sse
ssm
en
t w
ill u
su
ally
be
un
de
rta
ke
n a
nd
ad
he
ren
ce
to
a L
on
e W
ork
er
po
licy
en
co
ura
ge
d a
mo
ng
all
mo
rtu
ary
sta
ff. -
12
N.I. Audit: Dying, Death & Bereavement45
i)
Mo
vin
g a
nd
ha
nd
ling
j)
Re
mo
va
l o
f th
e d
ece
ase
d o
uts
ide
wo
rkin
g h
ou
rs
k)
Dis
aste
r p
lan
nin
g
l)
Ma
na
ge
me
nt
of
ma
ss f
ata
litie
s
m)
Su
pp
ort
ing
ch
ildre
n t
o v
iew
de
ce
ase
d r
ela
tive
s
n)
Sta
ff s
up
po
rt
o)
Co
mp
lain
ts p
roce
du
re
p)
Acce
ssin
g in
terp
rete
rs
q)
Ma
na
ge
me
nt o
f p
ers
on
al p
rop
ert
y o
f th
e d
ece
ase
d
10
0%
1
00
%
10
0%
1
00
%
10
0%
1
00
%
10
0%
1
00
%
10
0%
10
0.0
%
66
.7%
7
5.0
%
66
.7%
3
7.5
%
58
.3%
8
3.3
%
66
.7%
6
6.7
%
“It
is im
po
rta
nt
tha
t th
e d
ece
ase
d is p
rese
nte
d in
th
e b
est
po
ssib
le w
ay.
Mo
rtu
ary
se
rvic
es
sh
ou
ld h
ave
in
pla
ce
a p
olic
y o
n t
his
issu
e”
- 1
2
“It
ma
y b
e im
po
rta
nt
for
be
rea
ve
d f
am
ilie
s t
o s
ee
an
d s
pe
nd
tim
e w
ith
th
e p
ers
on
wh
o h
as d
ied
d
uri
ng
th
e t
ime
th
ey a
re in
th
e m
ort
ua
ry.
Mo
rtu
ari
es n
ee
d t
o h
ave
in
pla
ce
po
licie
s t
o s
up
po
rt
go
od
pra
ctice
lo
ca
lly”
- 1
2
“M
ort
ua
ry s
erv
ice
s s
ho
uld
ha
ve
in p
lace
a p
olic
y o
n c
om
mu
nic
atin
g w
ith
be
rea
ve
d f
am
ilie
s”
- 1
2
“If
a d
ea
th h
as b
ee
n r
efe
rre
d t
o t
he
co
ron
er…
co
nsid
era
tio
n s
ho
uld
be
giv
en
as t
o h
ow
be
st
arr
an
ge
me
nts
ca
n b
e m
ad
e f
or
the
fa
mily
to
dis
cu
ss (
or
rece
ive
) in
form
atio
n f
rom
th
e c
oro
ne
r o
r co
ron
er’s o
ffic
er;
clo
se
lia
iso
n w
ith
th
ose
ag
en
cie
s is t
he
refo
re im
po
rta
nt
in t
his
re
sp
ect”
- 1
H
ea
lth
& S
afe
ty a
t W
ork
Act,
19
74
- 1
8
“A
ll sta
ff in
vo
lve
d,
in w
ha
teve
r ro
le…
sh
ou
ld h
ave
acce
ss t
o a
ra
ng
e o
f fo
rma
l a
nd
in
form
al
su
pp
ort
” -
1
“T
he
org
an
isa
tio
n h
as a
n e
ffe
ctive
co
mp
lain
ts a
nd
re
pre
se
nta
tio
n p
roce
du
re…
” -
15
“
Mo
rtu
ary
se
rvic
es s
ho
uld
ha
ve
a s
yste
m in
pla
ce
to
im
ple
me
nt
se
cu
rity
of
pe
rso
na
l p
osse
ssio
ns o
n t
he
de
ce
ase
d’s
bo
dy,
or
de
live
ry t
o t
he
mo
rtu
ary
with
th
e d
ece
ase
d.”
– 1
2
5.
Sta
ff r
ec
eiv
e t
rain
ing
on
th
e f
oll
ow
ing
po
lic
ies
: a
) R
eco
rd k
ee
pin
g
b)
Re
ce
ivin
g,
ide
ntify
ing
, se
cu
rin
g,
sto
rin
g a
nd
re
lea
sin
g
bo
die
s,
org
an
s a
nd
tis
su
es
c)
Lo
ne
wo
rke
r d
) P
rep
ara
tio
n f
or
vie
win
g
e)
Su
pp
ort
ing
re
lative
s
f)
Lia
iso
n p
roto
co
ls w
ith
Co
ron
er
Se
rvic
e a
nd
PS
NI
g)
Co
ron
er’
s p
ost
mo
rtem
s –
acce
ss t
o m
ort
ua
ry o
ut
of
ho
urs
h
) In
fectio
n c
on
tro
l i)
M
ovin
g a
nd
ha
nd
ling
j)
Re
mo
va
l o
f th
e d
ece
ase
d o
uts
ide
wo
rkin
g h
ou
rs
k)
Dis
aste
r p
lan
nin
g
l)
Ma
na
ge
me
nt
of
ma
ss f
ata
litie
s
m)
Su
pp
ort
ing
ch
ildre
n t
o v
iew
de
ce
ase
d r
ela
tive
s
n)
Sta
ff s
up
po
rt
o)
Co
mp
lain
ts p
roce
du
re
p)
Acce
ssin
g in
terp
rete
rs
q)
Ma
na
ge
me
nt
of
pe
rso
na
l p
rop
ert
y o
f th
e d
ece
ase
d
10
0%
1
00
%
10
0%
1
00
%
10
0%
1
00
%
10
0%
1
00
%
10
0%
1
00
%
10
0%
1
00
%
10
0%
1
00
%
10
0%
1
00
%
10
0%
41
.7%
5
0.0
%
25
.0%
4
1.6
%
41
.6%
5
0.0
%
50
.0%
5
8.3
%
66
.7%
5
0.0
%
41
.6%
4
1.6
%
41
.6%
2
5.0
%
33
.3%
2
5.0
%
41
.7%
“All
sta
ff in
vo
lve
d in
de
live
rin
g m
ort
ua
ry s
erv
ice
s s
ho
uld
pa
rtic
ipa
te in
ed
uca
tio
n a
nd
tra
inin
g
tha
t is
ap
pro
pri
ate
to
th
eir
ro
le.
Tru
sts
sh
ou
ld,
the
refo
re,
ma
ke
tra
inin
g a
nd
le
arn
ing
o
pp
ort
un
itie
s a
va
ilab
le t
o m
ort
ua
ry s
taff
at
all
leve
ls t
o e
na
ble
th
em
to
de
ve
lop
: a
ccu
rate
, p
ractica
l kn
ow
led
ge
of
ho
sp
ita
l p
olic
y a
nd
pro
ce
du
res,
an
d r
ele
va
nt
leg
isla
tio
n”
- 1
2
“W
he
re r
isk a
sse
ssm
en
ts in
dic
ate
a n
ee
d,
syste
ms s
uch
as p
an
ic a
larm
s a
nd
lo
ne
wo
rke
r d
evic
es s
ho
uld
be
in
pla
ce
an
d u
nd
erp
inn
ed
by s
uita
ble
an
d s
uff
icie
nt
su
pp
ort
pro
ce
du
res t
o
pro
tect
sta
ff”
– 1
2
“S
taff
wh
o w
ork
in
mo
rtu
ari
es s
ho
uld
be
tra
ine
d in
th
e r
isks o
f th
eir
wo
rk a
nd
en
vir
on
me
nt
an
d
sh
ou
ld k
no
w h
ow
to
avo
id o
r m
inim
ise
th
ese
ris
ks”
– 1
2
6.
Th
e f
oll
ow
ing
su
pp
ort
sy
ste
ms
are
av
ail
ab
le f
or
sta
ff:
a)
Pe
er
su
pp
ort
b
) C
ase
re
vie
w
c)
Su
pp
ort
an
d c
ou
nse
llin
g
d)
Re
fle
ctive
pra
ctice
e)
Re
ferr
al to
Occu
pa
tio
na
l H
ea
lth
f)
Co
nfid
en
tia
l co
un
se
llin
g
10
0%
1
00
%
10
0%
1
00
%
10
0%
1
00
%
10
0.0
%
50
.0%
5
0.0
%
25
.0%
1
00
.0%
6
6.7
%
“T
his
are
a o
f w
ork
ca
n b
e p
art
icu
larl
y d
em
an
din
g,
an
d it
is im
po
rta
nt
tha
t sta
ff s
ho
uld
ha
ve
a
cce
ss t
o a
ra
ng
e o
f fo
rma
l a
nd
in
form
al su
pp
ort
. T
ime
sh
ou
ld b
e a
lloca
ted
to
en
su
re t
ha
t sta
ff
are
ab
le t
o a
cce
ss t
he
su
pp
ort
th
ey n
ee
d”
- 1
2
“All
sta
ff s
ho
uld
als
o h
ave
op
po
rtu
nitie
s t
o d
eve
lop
th
eir
un
ders
tan
din
g a
nd
pra
ctice
th
rou
gh
m
ech
an
ism
s s
uch
as c
linic
al su
pe
rvis
ion
, ca
se
re
vie
w,
cri
tica
l in
cid
en
t a
na
lysis
an
d r
isk
ma
na
ge
me
nt
me
etin
gs”-
1
3.
Ch
apla
incy
Ser
vice
s A
ud
it S
tan
dar
ds
46
Au
dit
Cri
teri
a
Sta
nd
ard
A
ch
iev
ed
R
ati
on
ale
1.
Na
me
d c
o-c
oo
rdin
ato
r/le
ad
ch
ap
lain
of
the
ch
ap
lain
cy
s
erv
ice
10
0%
6
3.6
%
(n=
33
) “
Th
e c
ha
pla
incy s
erv
ice
is h
ea
de
d b
y a
de
dic
ate
d m
em
be
r o
f th
e c
ha
pla
incy t
ea
m”
- 2
2.
Po
lic
y f
or
the
ch
ap
lain
cy
se
rvic
e
10
0%
42
.4%
(n
=3
0)
"Cle
ar
line
s o
f a
cco
un
tab
ility
/ma
na
ge
me
nt
are
esta
blis
he
d t
o e
na
ble
a c
on
sis
ten
t sta
nd
ard
a
nd
qu
alit
y o
f se
rvic
e f
or
all
pa
tie
nts
an
d s
taff
" -2
3.
Jo
b d
es
cri
pti
on
fo
r c
ha
pla
ins
10
0%
84
.8%
(n
=3
3)
“A
pp
oin
tme
nts
to
ch
ap
lain
cy-
Ho
sp
ita
l ch
ap
lain
cy a
pp
oin
tme
nts
are
NH
S t
rust
ap
po
intm
en
ts.
HR
de
pa
rtm
en
ts w
ith
in t
rusts
will
ad
vis
e o
n t
rust
ap
po
intm
en
t p
roce
du
res…
Pa
ne
l o
f a
sse
sso
rs…
sh
ou
ld b
e id
en
tifie
d t
o p
rovid
e a
dvic
e o
n s
uch
issu
es a
s jo
b d
escri
ptio
ns…
” -
2
HS
S (
TC
7)
8/2
00
4 C
od
e O
f C
on
du
ct
Fo
r N
HS
He
alth
ca
re C
ha
pla
ins s
tate
s t
ha
t N
HS
e
mp
loye
rs in
co
rpo
rate
th
e c
ode
in
to c
on
tra
cts
of
em
plo
ym
en
t -
23
4.
Wri
tte
n i
nfo
rma
tio
n i
s a
va
ila
ble
ab
ou
t th
e c
ha
pla
inc
y
se
rvic
e
10
0%
6
6.7
%
(n=
33
) S
ee
ab
ove
re
fere
nce
“Tru
sts
ma
y in
form
pa
tie
nts
ab
ou
t th
e a
va
ilab
ility
of
ch
ap
lain
cy s
erv
ice
s f
or
exa
mp
le t
hro
ug
h
info
rma
tio
n le
afle
ts a
nd
we
lco
me
pa
cks”
- 2
5.
Th
e f
oll
ow
ing
ve
rba
l/w
ritt
en
in
form
ati
on
is
pro
vid
ed
by
th
e
ch
ap
lain
cy
se
rvic
e:
a)
Sp
iritu
al su
pp
ort
bo
okle
t fo
r p
atie
nts
b
) R
eco
rd o
f vis
it in
pa
tie
nt
no
tes
c)
Re
co
rd o
f a
dm
inis
tra
tio
n o
f sa
cra
me
nts
in
pa
tie
nt
no
tes
d)
Re
co
rd o
f vis
it in
ch
ap
lain
s n
ote
s
e)
Re
co
rd o
f a
dm
inis
tra
tio
n o
f sa
cra
me
nt
in c
ha
pla
ins n
ote
s
f)
Vis
itin
g c
ard
le
ft if
ap
pro
pri
ate
g
) N
otifica
tio
n o
f a
dm
issio
n t
o p
atie
nts
’ o
wn
fa
ith
le
ad
er
10
0%
1
00
%
10
0%
1
00
%
10
0%
1
00
%
10
0%
(n=
33
) 6
3.6
%
30
.3%
6
3.6
%
54
.5%
4
2.4
%
93
.9%
9
7.0
%
“Ad
eq
ua
te a
rra
ng
em
en
ts a
re m
ad
e f
or
the
sp
iritu
al, r
elig
iou
s,
sa
cra
me
nta
l, r
itu
al a
nd
cu
ltu
ral
req
uir
em
en
ts a
pp
rop
ria
te t
o t
he
ne
ed
s,
ba
ckg
rou
nd
an
d t
rad
itio
n o
f a
ll p
atie
nts
an
d s
taff
in
clu
din
g t
ho
se
of
no
sp
ecifie
d f
aith
” -
2
6.
Th
e f
oll
ow
ing
se
rvic
es
are
pro
vid
ed
by
ch
ap
lain
s:
a)
Ro
utin
e w
ard
vis
its
b)
Vis
its t
o ill
pa
tie
nts
c)
Vis
its t
o b
ere
ave
d r
ela
tive
s
d)
Pro
vis
ion
of
sa
cra
me
nts
e
) N
am
ing
se
rvic
e f
or
ba
bie
s
f)
Su
nd
ay s
erv
ice
s
g)
Mid
-we
ek s
erv
ice
s
h)
Re
me
mb
ran
ce
se
rvic
es f
or
ch
ildre
n
i)
Re
me
mb
ran
ce
se
rvic
es f
or
infa
nts
j)
R
em
em
bra
nce
se
rvic
es f
or
sta
ff
k)
Fu
ne
ral se
rvic
es f
or
pa
tie
nts
with
no
re
lative
s
l)
Inp
ut
to m
ultid
iscip
lina
ry t
ea
m m
ee
tin
gs
m)
Inp
ut
to d
isa
ste
r p
lan
n)
Inp
ut
to c
linic
al d
eb
rie
fin
g s
essio
ns
o)
Sta
ff s
up
po
rt
p)
Sta
ff t
rain
ing
10
0%
1
00
%
10
0%
1
00
%
10
0%
1
00
%
10
0%
1
00
%
10
0%
1
00
%
10
0%
1
00
%
10
0%
1
00
%
10
0%
1
00
%
(n=
33
) 1
00
.0%
1
00
.0%
7
5.8
%
97
.0%
3
9.4
%
72
.7%
4
5.5
%
36
.4%
3
3.3
%
30
.3%
9
0.9
%
42
.4%
4
8.5
%
27
.3%
6
9.7
%
51
.5%
“T
rusts
sh
ou
ld e
nsu
re t
ha
t th
e D
yin
g a
nd
re
ce
ntly b
ere
ave
d a
re a
ble
to
acce
ss c
ha
pla
incy
se
rvic
es a
t th
e a
pp
rop
ria
te tim
e”
- 2
“
Ch
ap
lain
s a
re t
he
tru
st
exp
ert
s o
n a
rra
ng
ing
an
d p
rovid
ing
litu
rgie
s a
nd
ce
rem
on
ies t
o m
ee
t th
e n
ee
ds o
f th
e b
ere
ave
d,
esp
ecia
lly in
th
e c
ase
of
ne
on
ata
l, c
hild
de
ath
an
d in
an
nu
al
se
rvic
es f
or
the
be
rea
ve
d”
- 2
“
Ch
ap
lain
cy t
ea
ms s
ho
uld
be
in
vo
lve
d in
Tru
st
em
erg
en
cy p
lan
s…
. a
nd
th
eir
ro
les c
lea
rly
de
fin
ed
” U
se
ful co
ntr
ibu
tors
to
de
bri
ef.
- 2
N.I. Audit: Dying, Death & Bereavement47
Au
dit
Cri
teri
a
Sta
nd
ard
A
ch
iev
ed
R
ati
on
ale
7.
Fu
ne
ral
se
rvic
es
ca
n b
e p
rov
ide
d o
n s
ite
10
0%
5
0.0
%
8.
Th
e f
oll
ow
ing
tra
inin
g i
s p
rov
ide
d f
or
ch
ap
lain
s b
y t
he
T
rus
t:
a)
Ch
ild p
rote
ctio
n
b)
Ma
nu
al h
an
dlin
g
c)
Infe
ctio
n c
on
tro
l d
) F
ire
pre
ve
ntio
n
e)
Tru
st
ind
uctio
n
f)
D
ata
pro
tectio
n
10
0%
1
00
%
10
0%
1
00
%
10
0%
1
00
%
51
.5%
2
7.6
%
72
.4%
4
4.8
%
62
.1%
4
8.3
%
“T
rusts
are
re
sp
on
sib
le f
or
tra
inin
g a
nd
de
ve
lop
me
nt…
ap
pro
pri
ate
tra
inin
g a
nd
de
ve
lop
me
nt
inve
stm
en
t sh
ou
ld b
e m
ad
e t
o a
va
ilab
le t
o a
ll m
em
be
rs o
f th
e c
ha
pla
incy t
ea
m. -
2
9.T
he
ch
ap
lain
cy
se
rvic
e h
as
ac
ce
ss
to
th
e f
oll
ow
ing
su
pp
ort
: a
) A
lloca
ted
tim
e f
or
ch
ap
lain
s t
o m
ee
t to
ge
the
r b
) M
ee
tin
gs w
ith
Dir
ecto
r c)
Inte
rpre
tin
g s
erv
ice
s
d)
Ad
min
istr
ative
sta
ff
e)
Ap
pra
isa
l/d
eve
lop
me
nt
revie
w
f)
Co
rpo
rate
in
form
atio
n v
ia c
ircu
latio
n lis
ts
10
0%
1
00
%
10
0%
1
00
%
10
0%
1
00
%
85
.7%
7
8.6
%
67
.9%
5
3.6
%
32
.1%
9
2.9
%
“Th
e a
nn
ua
l a
pp
rais
al p
roce
ss s
ho
uld
id
en
tify
tra
inin
g n
ee
ds a
nd
wa
ys t
o m
ee
t th
em
” -2
10
. T
he
fo
llo
win
g f
ac
ilit
ies
are
av
ail
ab
le t
o c
ha
pla
ins
: a
) C
ha
pla
incy o
ffic
e
b)
Te
lep
ho
ne
c)
An
sw
er
ma
ch
ine
d)
Co
mp
ute
r e
) P
ag
er/
ble
ep
f)
Mu
lti-fa
ith
wo
rsh
ip r
oo
m
g)
Ch
ap
el
h)
Qu
iet
roo
m f
or
co
nfid
en
tia
l su
pp
ort
of
clie
nts
i)
D
ed
ica
ted
ca
r p
ark
ing
fo
r e
me
rge
ncy c
alls
1
00
%
10
0%
1
00
%
10
0%
1
00
%
10
0%
1
00
%
10
0%
1
00
%
90
.6%
8
1.3
%
21
.9%
5
0.0
%
59
.4%
4
3.8
%
65
.6%
7
1.9
%
37
.5%
“T
rusts
sh
ou
ld p
rovid
e a
cce
ssib
le a
nd
su
ita
ble
sp
ace
s f
or
pra
ye
r, r
efle
ctio
n a
nd
re
ligio
us
se
rvic
es w
hic
h a
re o
pe
n t
o p
atie
nts
an
d s
taff
24
ho
urs
a d
ay. -
2
4.
Pal
liat
ive
Car
e S
ervi
ces
Au
dit
Sta
nd
ard
s
48
Au
dit
Cri
teri
a
Sta
nd
ard
A
ch
iev
ed
R
ati
on
ale
1.
Po
lic
y f
or
sp
ec
iali
st
pa
llia
tiv
e c
are
se
rvic
e i
n p
lac
e
1
00
%
63
.6%
“
Cle
ar
refe
rra
l p
ath
wa
ys t
o s
pe
cia
list
pa
llia
tive
ca
re s
erv
ice
s w
ill b
e in
pla
ce
w
ith
in e
ach
tru
st/
pro
vid
er”
- 1
6
“T
ho
se
pro
vid
ing
ge
ne
ralis
t m
ed
ica
l a
nd
nu
rsin
g s
erv
ice
s s
ho
uld
ha
ve
acce
ss t
o
sp
ecia
list
ad
vic
e a
t a
ll tim
es”
- 8
“
Sp
ecia
list
pa
llia
tive
Ca
re s
erv
ice
s m
ust
be
pro
vid
ed
by a
n a
pp
rop
ria
tely
qu
alif
ied
a
nd
exp
eri
en
ce
d m
ultip
rofe
ssio
na
l te
am
, n
orm
ally
le
ad
by a
co
nsu
lta
nt
in
pa
llia
tive
me
dic
ine
” -
16
“Ea
ch
mu
ltid
iscip
lina
ry t
ea
m o
r se
rvic
e s
ho
uld
im
ple
me
nt
pro
ce
sse
s t
o e
nsu
re
eff
ective
in
ter-
pro
fessio
na
l co
mm
un
ica
tio
n w
ith
in t
ea
ms a
nd
be
twe
en
th
em
an
d
oth
er
se
rvic
e p
rovid
ers
…”
- 8
2.
Wri
tte
n i
nfo
rma
tio
n i
s p
rov
ide
d a
bo
ut
the
sp
ec
iali
st
pa
llia
tiv
e c
are
se
rvic
es
10
0%
8
1.8
%
“Co
mm
issio
ne
rs a
nd
pro
vid
er
org
an
isa
tio
ns s
ho
uld
en
su
re t
ha
t p
atie
nts
an
d
ca
rers
ha
ve
ea
sy a
cce
ss t
o a
ra
ng
e o
f h
igh
qu
alit
y in
form
atio
n m
ate
ria
ls.”
– 8
3.
Pa
llia
tive
ca
re t
ea
m h
as
ac
ce
ss
to
th
e f
oll
ow
ing
su
pp
ort
: (a
) A
lloca
ted
tim
e f
or
tea
m t
o m
ee
t to
ge
the
r (b
) A
dm
inis
tra
tive
su
pp
ort
(c
) A
pp
rais
al/d
eve
lop
me
nt
revie
w
10
0%
1
00
%
10
0%
(n=
11
) 8
1.8
%
90
.9%
1
00
.0%
“All
pro
vid
ers
of
pa
llia
tive
ca
re s
ho
uld
ha
ve
me
ch
an
ism
s in
pla
ce
to
en
su
re s
taff
h
ave
acce
ss t
o r
eg
ula
r su
pp
ort
, e
.g.
mu
ltip
rofe
ssio
na
l ca
se
dis
cu
ssio
ns,
clin
ica
l su
pe
rvis
ion
an
d a
ra
ng
e o
f syste
ms f
or
pe
rso
na
l su
pp
ort
” -
16
4.
Ad
dit
ion
al
Tra
inin
g
(a)
Ind
ica
te if
tea
m m
em
be
rs h
ave
un
de
rta
ke
n a
dd
itio
na
l tr
ain
ing
a
nd
de
ve
lop
me
nt
in b
ere
ave
me
nt
ca
re (
fre
e t
ext
listin
g)
10
0%
10
0%
( fr
ee
te
xt
resp
on
se
s
ind
ica
ted
all
tea
ms h
ad
a
dd
itio
na
l tr
ain
ing
)
“Pro
vid
er
org
an
isa
tio
ns s
ho
uld
id
en
tify
sta
ff w
ho
ma
y b
en
efit
fro
m t
rain
ing
an
d
sh
ou
ld f
acili
tate
th
eir
pa
rtic
ipa
tio
n in t
rain
ing
an
d o
ng
oin
g d
eve
lop
me
nt.
In
div
idu
al
pra
ctitio
ne
rs s
ho
uld
en
su
re t
he
y h
ave
th
e k
no
wle
dg
e a
nd
skill
s r
eq
uir
ed
fo
r th
e
role
s t
he
y u
nd
ert
ake
” 8
“ S
pe
cia
list
pa
llia
tive
ca
re:
All
sta
ff s
ho
uld
ha
ve
exp
eri
en
ce
in
th
e p
alli
ative
ca
re
en
vir
on
me
nt
an
d h
ave a
n a
ccre
dite
d,
reco
gn
ise
d o
r sp
ecia
list
qu
alif
ica
tio
n,
ap
pro
pri
ate
to
th
eir
sp
ecia
list
gro
up
in
pa
llia
tive
ca
re/m
ed
icin
e”
– 1
6
5.
Pa
llia
tiv
e c
are
te
am
co
ntr
ibu
te t
o b
ere
av
em
en
t c
are
(a
) In
dic
ate
wa
y(s
) in
wh
ich
te
am
co
ntr
ibu
te t
o
be
rea
ve
me
nt
ca
re (
fre
e te
xt
listin
g)
10
0%
1
00
%
( fr
ee
te
xt
resp
on
se
s
ind
ica
ted
all
tea
ms m
ad
e
va
rio
us
co
ntr
ibu
tio
ns
to
be
rea
ve
me
nt
ca
re)
“Asse
ssm
en
t a
nd
dis
cu
ssio
n o
f p
atie
nts
’ n
ee
ds f
or
ph
ysic
al, p
sych
olo
gic
al, s
ocia
l,
sp
iritu
al a
nd
fin
an
cia
l su
pp
ort
sh
ou
ld b
e u
nd
ert
ake
n a
t ke
y p
oin
ts (
su
ch
as a
t d
iag
no
sis
, a
t co
mm
en
ce
me
nt,
du
rin
g,
an
d a
t th
e e
nd
of
tre
atm
en
t; a
t re
lap
se
; a
nd
w
he
n d
ea
th is a
pp
roa
ch
ing
). -
8
“Th
is c
an
be
dis
tre
ssin
g t
ime
fo
r fa
mili
es a
nd
fri
en
ds a
nd
re
tain
ing
ve
rba
l in
form
atio
n m
ay b
e d
ifficu
lt.
It is im
po
rta
nt th
at
the
y a
re m
ad
e a
wa
re o
f b
ere
ave
me
nt
issu
es,
bo
th a
bo
ut
the
gri
evin
g p
roce
ss a
nd
ab
ou
t h
ow
to
acce
ss
he
lp a
nd
su
pp
ort
lo
ca
lly”
– 1
7
N.I. Audit: Dying, Death & Bereavement
5.
Po
rter
s an
d F
un
eral
Dir
ecto
rs S
ervi
ces
Au
dit
Sta
nd
ard
s
49
^ T
ota
l o
ut
of
15
as t
he 5
SL
A s
erv
ice
s r
esp
on
de
d t
ha
t 1
(c)
wa
s n
ot
ap
plica
ble
. ^^ T
ota
l o
ut
of
18
as 2
se
rvic
es r
esp
on
de
d t
ha
t 1
(d
) w
as n
ot
ap
plica
ble
. ^^^T
ota
l o
ut
of
14
as 4
SL
A s
erv
ice
s a
nd
2 p
ort
eri
ng
se
rvic
es s
tate
d t
ha
t 1
(f)
wa
s n
ot
ap
plica
ble
. ^^^^T
ota
l o
ut
of
13
as 5
SL
A s
erv
ice
s a
nd
2 p
ort
eri
ng
se
rvic
es s
tate
d t
ha
t 1
(g
) w
as n
ot
ap
plica
ble
.
Au
dit
Cri
teri
a
Sta
nd
ard
A
ch
iev
ed
R
ati
on
ale
1.
Th
e f
oll
ow
ing
in
form
ati
on
if
giv
en
wh
en
po
rte
rin
g t
ea
m i
s
co
nta
cte
d t
o r
em
ov
e a
bo
dy
fro
m t
he
wa
rd:
a)
Na
me
of
the
de
ce
ase
d
b)
He
alth
an
d s
afe
ty issu
es:
(i)
Infe
ctio
n c
on
tro
l (i
i)
We
igh
t c)
Cu
ltu
ral/re
lig
iou
s r
eq
uir
em
en
ts
d)
Pro
pe
rty o
n b
od
y
e)
Tu
be
s/d
rain
s in
situ
f)
If D
ea
th C
ert
ific
ate
issue
d
g)
If r
em
ain
s c
an
be
re
lea
se
d
h)
If C
oro
ne
r in
vo
lve
d
10
0%
1
00
%
10
0%
1
00
%
10
0%
1
00
%
10
0%
1
00
%
10
0%
70
.0%
7
0.0
%
70
.0%
7
3.3
%^
44
.4%
^^
55
.0%
5
7.1
%^^^
61
.5%
^^^^
50
.0%
Ma
na
gin
g t
he
re
ce
ipt,
sto
rag
e a
nd
re
lea
se
of
de
ce
ase
d p
eo
ple
an
d t
he
ir p
rop
ert
y
sa
fely
, se
cu
rely
, e
ffic
ien
tly,
eff
ective
ly a
nd
ap
pro
pri
ate
ly is t
he
co
re b
usin
ess o
f m
ort
ua
ry s
erv
ice
s. -
12
A
ud
it C
rite
ria
S
tan
da
rd
Ac
hie
ve
d
Ra
tio
na
le
SL
A
(n=
5)
Po
rte
rs
(n=
15
)
2.
P
ort
eri
ng
te
am
ha
ve
re
ce
ive
d t
he
fo
llo
win
g
tra
inin
g t
o
he
lp i
nc
rea
se
sk
ills
an
d c
on
fid
en
ce
:
a)
De
ath
, g
rie
f a
nd
be
rea
ve
me
nt
(to
th
e a
pp
rop
ria
te le
ve
l)
b)
Inte
rpe
rso
na
l a
nd
co
mm
un
ica
tio
n s
kills
c)
Ro
les a
nd
se
rvic
es p
rovid
ed
by o
the
r m
em
be
rs o
f th
e m
ulti-
dis
cip
lin
ary
te
am
e.g
. m
ort
ua
ry s
erv
ice
s,
ch
ap
lain
s
d)
Mu
lti-cu
ltu
ral a
nd
re
lig
iou
s p
ractice
s
e)
Ma
nu
al h
an
dlin
g
f)
Infe
ctio
n c
on
tro
l
10
0%
1
00
%
10
0%
1
00
%
10
0%
1
00
%
10
0%
1
00
%
10
0%
1
00
%
10
0%
1
00
%
0.0
%^
0.0
%^
0.0
%^
7.1
%^
86
.7%
8
0.0
%
All m
ort
ua
ry s
taff
will n
ee
d t
o b
e a
wa
re o
f cu
rre
nt
he
alth
an
d s
afe
ty
leg
isla
tio
n a
nd
gu
ida
nce
an
d w
ill re
ce
ive
tra
inin
g t
o e
na
ble
th
em
to
w
ork
sa
fely
. T
rusts
sh
ou
ld m
ake
tra
inin
g a
nd
le
arn
ing
op
po
rtu
nitie
s
ava
ila
ble
to
mo
rtu
ary
sta
ff a
t a
ll le
ve
ls t
o e
na
ble
th
em
to
de
ve
lop
.-
12
Au
dit
Cri
teri
a
Sta
nd
ard
A
ch
iev
ed
R
ati
on
ale
3.
T
he
fo
llo
win
g m
ec
ha
nis
ms
are
cu
rre
ntl
y i
n p
lac
e o
r w
ou
ld
lik
e t
o b
e s
ee
n d
ev
elo
pe
d t
o s
up
po
rt t
he
po
rte
rin
g t
ea
m t
o
ca
re f
or
dy
ing
pa
tie
nts
an
d t
he
ir r
ela
tiv
es
: a
) In
form
al su
pp
ort
fro
m p
ee
rs
b)
Co
nfid
en
tia
l o
ne
to
on
e s
up
po
rt f
rom
ma
na
ge
r/d
esig
na
ted
co
lle
ag
ue
/me
nto
r to
ta
lk t
hro
ug
h t
he
exp
eri
en
ce
c)
De
dic
ate
d ‘d
e-b
rie
fin
g’ tim
e w
ith
pe
ers
fo
llo
win
g
pa
rtic
ula
rly t
rau
ma
tic s
itu
atio
ns (
as d
ete
rmin
ed
by t
he
sta
ff)
d)
De
dic
ate
d ‘d
e-b
rie
fin
g’ tim
e w
ith
th
e m
ulti-p
rofe
ssio
na
l te
am
fo
llo
win
g p
art
icu
larl
y t
rau
ma
tic s
itu
atio
ns (
as
de
term
ine
d b
y t
he
sta
ff)
e)
Co
nfid
en
tia
l o
ne
to
on
e s
up
po
rt f
rom
me
mb
er
of
sta
ff
exte
rna
l to
th
e w
ard
/de
pa
rtm
en
t f)
A
cce
ss t
o e
xte
rna
l su
pp
ort
or
co
un
se
llin
g s
erv
ice
s
10
0%
1
00
%
10
0%
1
00
%
10
0%
1
00
%
10
0%
9
0.0
%
55
.0%
4
5.0
%
55
.0%
6
5.0
%
Th
is a
rea
of
wo
rk c
an
be
pa
rtic
ula
rly d
em
an
din
g a
nd
it
is im
po
rta
nt
tha
t sta
ff
sh
ou
ld h
ave
acce
ss t
o a
ra
ng
e o
f fo
rma
l a
nd
in
form
al su
pp
ort
. –
12
6.
War
d M
anag
er Q
ues
tio
nn
aire
Res
ult
s
50
Au
dit
Cri
teri
a
Ex
pe
cte
d %
A
ch
iev
ed
%
Nu
mb
er
of
res
po
ns
es
T
ota
l n
=1
45
1.
Re
sp
on
de
nts
ra
ted
th
e f
oll
ow
ing
as
pe
cts
of
the
wa
rd e
nv
iro
nm
en
t e
xc
ell
en
t/g
oo
d:
a.
Sp
ace
b
. P
riva
cy
c.
No
ise
le
ve
ls
d.
Te
lep
ho
ne
acce
ss
e.
Ava
ilab
ility
of
foo
d
f.
Re
st
facili
tie
s
g.
Ba
thro
om
fa
cili
tie
s
h.
Qu
iet
sp
ace
s f
or
pra
ye
r o
r co
nte
mp
latio
n
i.
Pa
rkin
g f
acili
tie
s
j.
Mo
rtu
ary
fa
cili
tie
s*
*Exce
ptio
n:
No
mo
rtu
ary
on
site
10
0%
(o
ve
rall)
1
00
%
10
0%
1
00
%
10
0%
1
00
%
10
0%
1
00
%
10
0%
1
00
%
10
0%
53
.7%
4
5.5
%
56
.5%
4
0.4
%
82
.5%
5
7.2
%
48
.9%
4
3.8
%
51
.0%
4
7.5
%
64
.8%
n=
14
19
a
n=
14
5
n=
14
5
n=
14
1b
n=
14
3c
n=
14
5
n=
14
1b
n=
14
4d
n=
14
5
n=
14
5
n=
12
5e
,f
2.
Re
sp
on
de
nt
ind
ica
ted
th
at
are
as
de
tail
ed
in
qu
ali
ty m
ea
su
re 1
ne
ed
ed
im
pro
ve
d
0%
8
0.6
%
n
=1
39
a
3.
Re
sp
on
de
nt
ind
ica
ted
th
at
the
fo
llo
win
g i
nfo
rma
tio
n i
s p
rov
ide
d t
o p
ati
en
ts a
nd
re
lati
ve
s i
n e
ith
er
wri
tte
n o
r v
erb
al
form
: a.
Lo
ca
tio
n o
f p
ub
lic p
ho
ne
s
b.
Lo
ca
tio
n o
f to
ilets
c.
Ca
r p
ark
ing
arr
an
ge
me
nts
d
. C
ha
pla
incy s
erv
ice
e.
Acce
ss t
o f
oo
d/b
eve
rag
es
10
0%
1
00
%
10
0%
1
00
%
10
0%
92
.3%
9
5.8
%
71
.0%
9
3.6
%
97
.6%
n=
14
3
n=
14
3
n=
13
8
n=
14
1
n=
14
0
4.
Re
sp
on
de
nt
ind
ica
ted
th
at
the
re i
s 2
4 h
r a
cc
es
s t
o f
oo
d /
be
ve
rag
es
1
00
%
70
.6%
n
=1
43
5.
Re
sp
on
de
nt
ind
ica
ted
th
at
foo
d a
nd
be
ve
rag
es
are
lo
ca
ted
wit
hin
a f
ive
min
ute
wa
lk f
rom
th
e w
ard
10
0%
9
3.0
%
n=
10
0
6.
Re
sp
on
de
nt
ind
ica
ted
th
at
the
re i
s a
pri
va
te a
rea
de
sig
na
ted
fo
r re
lati
ve
s o
n t
he
wa
rd
1
00
%
66
.9%
n
=1
42
7.
Re
sp
on
de
nt
ind
ica
ted
th
at
sin
gle
ro
om
s a
re a
lwa
ys
pri
ori
tis
ed
fo
r d
yin
g p
ati
en
ts
10
0%
6
3.4
%
n=
13
4
8.
Re
sp
on
de
nt
ind
ica
ted
th
at
dy
ing
pa
tie
nts
are
ca
red
fo
r in
a s
ing
le r
oo
m 5
1 –
10
0%
of
tim
es
10
0%
7
9.9
%
n=
13
4
9.
Re
sp
on
de
nt
ind
ica
ted
th
at
pa
tie
nts
are
alw
ay
s a
sk
ed
if
the
ir r
eli
gio
us
aff
ilia
tio
n c
an
be
do
cu
me
nte
d
1
00
%
86
.6%
n
=1
42
10
. R
es
po
nd
en
ts i
nd
ica
ted
th
at
pa
tie
nts
are
as
ke
d i
f th
is i
nfo
rma
tio
n c
an
be
pa
ss
ed
to
th
e c
ha
pla
inc
y s
erv
ice
1
00
%
79
.4%
n
=1
41
11
. R
es
po
nd
en
t in
dic
ate
d t
ha
t th
e p
ati
en
ts i
nit
ial
de
cis
ion
ab
ou
t c
on
tac
t w
ith
th
e c
ha
pla
inc
y s
erv
ice
is
re
vis
ite
d
1
00
%
95
.7%
n
=9
2
12
. R
es
po
nd
en
t in
dic
ate
d t
ha
t th
e c
are
of
the
dy
ing
pa
thw
ay
is
op
era
tio
na
l w
ith
in t
he
de
pa
rtm
en
t *E
xc
ep
tio
n:
pa
ed
iatr
ic w
ard
s (
8)
10
0%
5
8.1
%
n=
13
1
N.I. Audit: Dying, Death & Bereavement51
13
. R
es
po
nd
en
t in
dic
ate
d t
ha
t s
taff
me
mb
ers
ro
uti
ne
ly e
xp
lore
th
e w
ish
es
an
d f
ee
lin
gs
of
dy
ing
pa
tie
nts
re
ga
rdin
g
the
ir d
ea
th
10
0%
7
6.6
%
n=
13
7
14
. P
are
nts
are
off
ere
d t
he
op
po
rtu
nit
y t
o t
ak
e t
he
ir d
ec
ea
se
d c
hil
d o
r b
ab
y f
rom
th
e w
ard
to
ho
me
in
th
eir
ow
n c
ar
*Ex
ce
pti
on
: a
du
lt w
ard
s (
10
7)
10
0%
6
8.4
%
n=
38
15
. R
es
po
nd
en
t in
dic
ate
d t
ha
t e
lem
en
ts o
f th
e r
em
ov
al
pro
ce
ss
co
uld
be
im
pro
ve
d
0%
4
2.2
%
n=
90
16
. R
es
po
nd
en
t in
dic
ate
d t
ha
t th
e f
oll
ow
ing
do
cu
men
tati
on
/id
en
tifi
ca
tio
n r
ou
tin
ely
ac
co
mp
an
ies
th
e p
ati
en
ts’
rem
ain
s
fro
m t
he
wa
rd/d
ep
t:
a.
Pa
tie
nt
ID L
ab
el
b.
Wri
st/
an
kle
ID
ba
nd
c.
Mo
rtu
ary
/ID
fo
rm
d.
De
ath
Ce
rtific
ate
e
.
C
rem
atio
n f
orm
10
0%
a
. 8
5.0
%
b.
97
.9%
c.
85
.3%
d
. 5
7.8
%
e.
41
.3%
a.
n=
12
7
b.
n=
14
0
c.
n=
13
6
d.
n=
13
5
e.
n=
12
6
17
. T
he
fo
llo
win
g i
nfo
rma
tio
n i
s p
rov
ide
d t
o f
am
ilie
s o
f th
e d
ec
ea
se
d w
he
n a
po
st
mo
rte
m i
s r
eq
uir
ed
: a
. D
iscu
ssio
n c
ove
rin
g p
urp
ose
, p
roce
du
res a
nd
th
eir
ch
oic
es
b.
Re
leva
nt
bo
okle
t c.
Co
py o
f co
nse
nt
form
10
0%
1
00
%
10
0%
a.
99
.2%
b
. 9
9.2
%
c.
97
.2%
n=
12
9
n=
12
2
n=
10
9
18
. R
es
po
nd
en
ts i
nd
ica
ted
th
at
rela
tiv
es
are
giv
en
th
e o
pp
ort
un
ity
to
sp
ea
k t
o t
he
fo
llo
win
g p
rofe
ss
ion
als
pri
or
to
the
ir r
ela
tiv
e’s
de
ath
: a
. C
on
su
lta
nt/
Re
g/S
taff
Gra
de
b.
Do
cto
r o
n d
uty
c.
Nu
rse
d
.
H
osp
ita
l C
ha
pla
in
10
0%
1
00
%
10
0%
1
00
%
a.
99
.3%
b
. 9
7.8
%
c.
10
0%
d
. 9
7.1
%
n=
13
8
n=
13
7
n=
14
0
n=
13
9
19
. R
es
po
nd
en
ts i
nd
ica
ted
th
at
rela
tiv
es
are
giv
en
th
e D
ea
th C
ert
ific
ate
at
the
tim
e o
f th
eir
re
lati
ve
s d
ea
th a
t le
as
t a
pp
rox
ima
tely
51
% o
f th
e t
ime
10
0%
5
6.8
%
n=
13
9
20
. R
es
po
nd
en
ts i
nd
ica
ted
th
at
a f
oll
ow
-up
me
eti
ng
is
alw
ay
s o
ffe
red
to
th
e f
am
ily
to
dis
cu
ss
th
e p
ati
en
t’s
de
ath
1
00
%
30
.1%
n
=1
43
21
. R
es
po
nd
en
t in
dic
ate
d t
ha
t th
ey
re
ce
ive
th
e f
oll
ow
ing
fe
ed
ba
ck
fro
m f
am
ilie
s r
eg
ard
ing
th
e c
are
pro
vid
ed
be
fore
, a
t th
e t
ime
an
d a
fte
r th
e r
ela
tiv
e’s
de
ath
: a
. U
se
r q
ue
stio
nn
air
es
b.
Fo
cu
s g
rou
ps
c.
Co
mp
lain
ts/c
om
plim
en
ts
d.
No
fe
ed
ba
ck
e.
Oth
er
10
0%
1
00
%
10
0%
1
00
%
10
0%
a.
9.7
%
b.
4.1
%
c.
85
.5%
d
. 1
4.5
%
e.
37
.9%
n=
14
5
n=
14
5
n=
14
5
n=
14
5
n=
14
5
22
. R
es
po
nd
en
ts i
nd
ica
ted
th
at
the
y c
an
re
fer
rela
tiv
es
dir
ec
tly
to
an
oth
er
se
rvic
e (
sta
tuto
ry o
r v
olu
nta
ry)
for
info
rma
tio
n o
r s
up
po
rt
10
0%
7
9.4
%
n=
14
1
7.
Ind
ivid
ual
Sta
ff Q
ues
tio
nn
aire
Res
ult
s
52
G
EN
ER
AL
IN
FO
RM
AT
ION
T
ota
l n
um
be
r o
f re
sp
on
se
s =
16
32
Re
sp
on
se
ra
te 4
0%
1
. C
urr
en
t o
rga
nis
ati
on
of
em
plo
ym
en
t
Be
lfa
st
HS
C T
rust
24
.0%
(3
88
)
No
rth
ern
HS
C T
rust
21
.2%
(3
42
)
So
uth
Ea
ste
rn H
SC
Tru
st
16
.4%
(2
65
)
So
uth
ern
HS
C T
rust
18
.2%
(2
94
)
We
ste
rn H
SC
Tru
st
1
6.5
% (
26
6)
Ho
sp
ice
3
.7%
(5
9)
(To
tal n
um
be
r o
f re
sp
on
de
nts
= 1
61
4)
2.
Sp
ec
ific
sp
ec
iali
ty/r
ole
wit
hin
cu
rre
nt
ho
sp
ita
l/h
os
pic
e?
Me
dic
al
8
.4%
(1
36
)
Re
gis
tere
d N
urs
e
61
.5%
(9
97
)
Re
gis
tere
d M
idw
ife
0.7
% (
11
)
So
cia
l W
ork
er
(Acu
te)
3.1
% (
50
)
Allie
d H
ea
lth
Pro
fessio
na
l 9
.3%
(1
51
)
He
alth
ca
re A
ssis
tan
t 9
.8%
(1
59
)
Ad
min
istr
ative
2.8
% (
45
)
Do
me
stic/H
ote
l S
erv
ice
s
4.4
% (
72
)
(To
tal n
um
be
r o
f re
sp
on
de
nts
= 1
62
1)
3.
Le
ng
th o
f ti
me
em
plo
ye
d w
ith
in t
he
he
alt
h a
nd
so
cia
l c
are
se
cto
r:
Le
ss t
ha
n 1
ye
ar
4.5
% (
73
)
1 –
5 y
ea
rs
30
.2%
(4
90
)
6 –
10
ye
ars
1
4.0
% (
22
8)
Mo
re t
ha
n 1
0 y
ea
rs
51
.3%
(8
34
)
(To
tal n
um
be
r o
f re
sp
on
de
nts
= 1
62
5)
4.
Ho
w o
fte
n i
n y
ou
r d
ay
to
da
y w
ork
do
yo
u h
av
e c
on
tac
t (e
.g.
fac
e t
o f
ac
e o
ve
r th
e t
ele
ph
on
e o
r w
ritt
en
co
rre
sp
on
de
nc
e)
wit
h t
he
fo
llo
win
g:-
a)
Pa
tie
nts
wh
o a
re d
yin
g
Ne
ve
r 7
.6%
(1
21
)
Le
ss t
ha
n o
nce
a m
on
th
31
.7%
(5
05
)
1-3
tim
es a
mo
nth
3
1.0
% (
47
2)
Mo
re t
ha
n 4
tim
es a
mo
nth
2
9.6
% (
83
4)
(To
tal n
um
be
r o
f re
sp
on
de
nts
= 1
59
2)
N.I. Audit: Dying, Death & Bereavement53
b)
Re
ce
ntl
y b
ere
av
ed
fa
mil
y m
em
be
rs
Ne
ve
r 6
.2%
(9
7)
Le
ss t
ha
n o
nce
a m
on
th
41
.7%
(6
49
)
1-3
tim
es a
mo
nth
2
9.3
% (
45
6)
Mo
re t
ha
n 4
tim
es a
mo
nth
2
2.7
% (
35
3)
(To
tal n
um
be
r o
f re
sp
on
de
nts
= 1
55
5)
c
) S
taff
wh
o h
av
e c
are
d f
or
dy
ing
pa
tie
nts
Ne
ve
r 4
.4%
(6
8)
Le
ss t
ha
n o
nce
a m
on
th
27
.0%
(4
21
)
1-3
tim
es a
mo
nth
2
3.3
% (
36
4)
Mo
re t
ha
n 4
tim
es a
mo
nth
4
5.3
% (
70
7)
(To
tal n
um
be
r o
f re
sp
on
de
nts
= 1
56
0)
EN
VIR
ON
ME
NT
AN
D F
AC
ILIT
IES
A
ud
it C
rite
ria
Exp
ecte
d P
erc
en
tag
e
Actu
al P
erc
en
tag
e A
ch
ieve
d
5a
.Th
e f
oll
ow
ing
as
pe
cts
of
the
ho
sp
ita
l e
nv
iro
nm
en
t/fa
cil
itie
s p
rov
ide
d f
or
dy
ing
pa
tie
nts
a
nd
th
eir
fa
mil
ies
are
ex
ce
lle
nt/
go
od
:-
a)
Sp
ace
1
00
%
33
.6%
(5
42
)
b)
Pri
va
cy
10
0%
3
5.9
% (
58
2)
c)
No
ise
le
ve
ls
10
0%
1
9.1
% (
30
9)
d)
Te
lep
ho
ne
acce
ss f
or
fam
ilie
s 1
00
%
47
.5%
(7
20
)
e)
Ava
ilab
ility
of
foo
d f
or
fam
ilie
s 1
00
%
30
.2%
(4
88
)
f)
Re
st
facili
tie
s f
or
fam
ilie
s 1
00
%
21
.0%
(3
38
)
g)
Ba
thro
om
fa
cili
tie
s f
or
fam
ilie
s 1
00
%
20
.5%
(3
30
)
h)
Pa
rkin
g f
acili
tie
s 1
00
%
33
.7%
(5
45
)
i)
Mo
rtu
ary
fa
cili
tie
s 1
00
%
32
.9%
(5
27
)
j)
Qu
iet
pla
ce
s f
or
co
nte
mp
latio
n a
nd
pra
ye
r 1
00
%
42
.5%
(6
86
)
k)
Wri
tte
n g
uid
an
ce
/ in
form
atio
n
10
0%
4
1.9
% (
67
6)
5b
. H
os
pit
al
en
vir
on
me
nt/
fac
ilit
ies
pro
vid
ed
re
qu
ire
s i
mp
rov
em
en
ts
0%
9
1.8
% (
11
33
)
TR
EA
TM
EN
T A
ND
CA
RE
A
ud
it C
rite
ria
E
xp
ec
ted
Pe
rce
nta
ge
Ac
tua
l P
erc
en
tag
e A
ch
iev
ed
6a
. C
are
giv
en
be
fore
de
ath
co
uld
be
im
pro
ve
d f
or:
-
i) P
atie
nts
0
%
42
.9%
(6
82
)
ii) F
am
ilie
s 0
%
54
.4%
(8
55
)
b.
Ca
re g
ive
n a
t ti
me
of
de
ath
, c
ou
ld b
e im
pro
ve
d f
or:
-
i) P
atie
nts
0
%
32
.6%
(5
11
)
ii) F
am
ilie
s 0
%
41
.8%
(6
48
)
c.
Ca
re g
ive
n a
fte
r d
ea
th,
co
uld
be
im
pro
ve
d f
or:
-
i) P
atie
nts
0
%
29
.4%
(4
50
)
ii) F
am
ilie
s 0
%
43
.0%
(6
59
)
54
ST
AF
F S
KIL
LS
, T
RA
ININ
G &
SU
PP
OR
T
Au
dit
Cri
teri
a
Ex
pe
cte
d P
erc
en
tag
e
Ac
tua
l P
erc
en
tag
e A
ch
iev
ed
7.
Re
sp
on
de
nts
sta
ted
th
ey
are
co
mfo
rta
ble
wit
h t
he
fo
llo
win
g;-
a)
Bre
akin
g,
or
be
ing
pre
se
nt
at
the
de
live
ry o
f b
ad
ne
ws
10
0%
2
4.1
% (
33
9)
b)
Me
etin
g t
he
fo
llow
ing
ne
ed
s o
f p
atie
nts
wh
o a
re d
yin
g a
nd
th
eir
fa
mily
: i)
P
hysic
al n
ee
ds
10
0%
4
5.6
% (
66
3)
ii)
Em
otio
na
l n
ee
ds
10
0%
2
9.9
% (
44
1)
iii)
Sp
iritu
al n
ee
ds
10
0%
2
7.7
% (
38
5)
iv)
So
cia
l n
ee
ds
10
0%
3
0.6
% (
42
7)
c)
Dis
cu
ssin
g d
ea
th a
nd
dyin
g
10
0%
2
2.2
% (
32
5)
d)
Ta
lkin
g t
o p
eo
ple
wh
o h
ave
be
en
re
ce
ntly b
ere
ave
d
10
0%
2
4.0
% (
36
9)
e)
Su
pp
ort
ing
a c
hild
wh
ose
re
lative
is d
yin
g
10
0%
1
1.8
% (
14
3)
f)
Su
pp
ort
ing
pe
op
le f
rom
diffe
ren
t cu
ltu
res
10
0%
9
.5%
(1
39
)
g)
Pa
rtic
ipa
tin
g in
fo
llow
-up
me
etin
gs s
ho
uld
re
lative
s w
ish
to
re
turn
to
th
e h
osp
ita
l o
r d
iscu
ss
asp
ects
of
the
pa
tie
nt’s c
are
1
00
%
20
.3%
(2
38
)
8.
Th
e f
oll
ow
ing
ad
dit
ion
al
ed
uc
ati
on
/tra
inin
g t
o i
nc
rea
se
sk
ills
an
d c
on
fid
en
ce
in
ca
rin
g f
or
the
dy
ing
an
d t
he
ir r
ela
tiv
es
ha
s b
ee
n p
rev
iou
sly
re
ce
ive
d:
a)
De
ath
, g
rie
f a
nd
be
rea
ve
me
nt
(to
th
e a
pp
rop
ria
te le
ve
l)
10
0%
1
9.5
% (
29
5)
b)
Inte
rpe
rso
na
l a
nd
co
mm
un
ica
tio
n s
kill
s
10
0%
2
8.2
% (
42
7)
c)
Th
e r
ole
s a
nd
se
rvic
es p
rovid
ed
by o
the
r m
em
be
rs o
f th
e m
ulti-d
iscip
lina
ry t
ea
m e
.g.
mo
rtu
ary
se
rvic
es,
ch
ap
lain
s
10
0%
1
1.0
% (
16
3)
d)
Mu
lti-cu
ltu
ral a
nd
re
ligio
us p
ractice
s
10
0%
4
.7%
(7
1)
e)
Eth
ica
l is
su
es r
ela
tin
g t
o e
nd
of
life
ca
re f
or
exa
mp
le a
dva
nce
dir
ective
s,
do
no
t re
su
scita
te
ord
ers
, p
atie
nt
au
ton
om
y v
ers
us r
ela
tive
s w
ish
es a
nd
with
ho
ldin
g/w
ith
dra
wa
l o
f tr
ea
tme
nt
10
0%
1
3.1
% (
19
2)
f)
Sp
iritu
al su
pp
ort
at
the
en
d o
f lif
e
10
0%
1
1.0
% (
15
7)
g)
De
live
rin
g b
ad
ne
ws t
o p
atie
nts
an
d t
he
ir r
ela
tive
s
10
0%
2
3.1
% (
31
8)
h)
Eq
ua
lity a
nd
hu
ma
n r
igh
ts
10
0%
1
4.6
% (
22
0)
i)
Oth
er
10
0%
1
2.7
% (
13
)
N.I. Audit: Dying, Death & Bereavement55
Bre
ak
do
wn
of
qu
es
tio
n 8
T
he
fo
llow
ing
ta
ble
is a
bre
akd
ow
n o
f tr
ain
ing
re
ce
ive
d,
tra
inin
g r
eq
uir
ed
/no
t re
qu
ire
d a
s in
dic
ate
d b
y r
esp
on
de
nts
(in
re
latio
n t
o a
dd
itio
na
l e
du
ca
tio
n/t
rain
ing
to
in
cre
ase
skill
s a
nd
co
nfid
en
ce
in
ca
rin
g f
or
the
dyin
g a
nd
th
eir r
ela
tive
s):
Ha
ve
re
ce
ive
d t
rain
ing
W
ou
ld b
e h
elp
ful
Wo
uld
no
t b
e h
elp
ful
a)
De
ath
, g
rie
f a
nd
be
rea
ve
me
nt
(to
th
e a
pp
rop
ria
te le
ve
l)
19
.5%
(2
95
) 7
0.1
% (
11
44
) 2
.9%
(4
4)
b)
Inte
rpe
rso
na
l a
nd
co
mm
un
ica
tio
n s
kill
s
28
.2%
(4
27
) 6
0.9
% (
92
3)
7.1
% (
10
7)
c)
Th
e r
ole
s a
nd
se
rvic
es p
rovid
ed
by o
the
r m
em
be
rs o
f th
e m
ulti-d
iscip
lina
ry
tea
m e
.g.
mo
rtu
ary
se
rvic
es,
ch
ap
lain
s
11
.0%
(1
63
) 7
7.4
% (
11
45
) 7
.0%
(1
04
)
d)
Mu
lti-cu
ltu
ral a
nd
re
ligio
us p
ractice
s
4.7
% (
71
) 8
7.2
% (
13
16
) 3
.9%
(5
9)
e)
Eth
ica
l is
su
es r
ela
tin
g t
o e
nd
of
life
ca
re f
or
exa
mp
le a
dva
nce
dir
ective
s,
do
no
t re
su
scita
te o
rde
rs,
pa
tie
nt
au
ton
om
y v
ers
us r
ela
tive
s w
ish
es a
nd
w
ith
ho
ldin
g/w
ith
dra
wa
l o
f tr
ea
tme
nt
13
.1%
(1
92
) 7
9.8
% (
11
67
) 3
.1%
(4
5)
f)
Sp
iritu
al su
pp
ort
at
the
en
d o
f lif
e
11
.0%
(1
57
) 7
5.0
% (
10
75
) 7
.4%
(1
06
)
g)
De
live
rin
g b
ad
ne
ws t
o p
atie
nts
an
d t
he
ir r
ela
tive
s
23
.1%
(3
18
) 6
9.4
% (
95
4)
4.1
% (
57
)
h)
Eq
ua
lity a
nd
hu
ma
n r
igh
ts
14
.6%
(2
20
) 7
2.7
% (
10
96
) 6
.8%
(1
03
)
i)
Oth
er
12
.7%
(1
3)
44
.1%
(4
5)
3.9
% (
4)
Au
dit
Cri
teri
a
Ex
pe
cte
d P
erc
en
tag
e
Ac
tua
l P
erc
en
tag
e A
ch
iev
ed
9.
Th
e f
oll
ow
ing
as
pe
cts
of
su
pp
ort
wh
en
pa
rtic
ipa
tin
g i
n t
he
ca
re o
f d
yin
g p
ati
en
ts a
nd
th
eir
fa
mil
ies
are
c
urr
en
tly
in
pla
ce
g)
Info
rma
l su
pp
ort
fro
m y
ou
r p
ee
rs
10
0%
6
7.6
% (
10
64
)
h)
Co
nfid
en
tia
l o
ne
to
on
e s
up
po
rt f
rom
ma
na
ge
r/d
esig
na
ted
co
llea
gu
e/m
en
tor
to t
alk
thro
ug
h t
he
exp
eri
en
ce
10
0%
3
8.1
% (
58
8)
i)
Clin
ica
l S
up
erv
isio
n
10
0%
4
1.6
% (
64
5)
j)
Ca
se
re
vie
w/c
ritica
l in
cid
en
t a
na
lysis
1
00
%
26
.5%
(4
03
)
k)
De
dic
ate
d “
de-b
rie
fin
g”
tim
e w
ith
yo
ur
pe
ers
fo
llow
ing
pa
rtic
ula
rly t
rau
ma
tic s
itu
atio
ns (
as d
ete
rmin
ed
by t
he
sta
ff)
10
0%
2
1.2
% (
33
1)
l)
De
dic
ate
d “
de-b
rie
fin
g”
tim
e w
ith
th
e m
ulti-p
rofe
ssio
na
l te
am
fo
llow
ing
pa
rtic
ula
rly t
rau
ma
tic s
itu
atio
ns (
as
de
term
ine
d b
y t
he
sta
ff)
10
0%
1
4.0
% (
22
0)
m)
Co
nfid
en
tia
l o
ne
to
on
e s
up
po
rt f
rom
me
mb
er
of
sta
ff e
xte
rna
l to
th
e w
ard
/de
pa
rtm
en
t to
ta
lk t
hro
ug
h t
he
e
xp
eri
en
ce
1
00
%
17
.2%
(2
68
)
n)
Acce
ss t
o e
xte
rna
l su
pp
ort
or
co
un
se
llin
g s
erv
ice
s
10
0%
2
4.7
% (
38
6)
56
Bre
ak
do
wn
of
Qu
es
tio
n 9
Th
e t
ab
le b
elo
w is a
bre
akd
ow
n o
f th
at
wh
ich
is c
urr
en
tly in
pla
ce
or
wo
uld
be
he
lpfu
l, w
he
n p
art
icip
atin
g in
th
e c
are
of
dyin
g p
atie
nts
an
d t
he
ir r
ela
tive
s a
s in
dic
ate
d b
y r
esp
on
de
nts
:
Au
dit
Cri
teri
a
Cu
rre
ntl
y i
n p
lac
e
Wo
uld
be
he
lpfu
l D
on
’t k
no
w
a)
Info
rma
l su
pp
ort
fro
m y
ou
r p
ee
rs
67
.6%
(1
06
4)
26
.7%
(4
21
) 5
.7%
(9
0)
b)
Co
nfid
en
tia
l o
ne
to
on
e s
up
po
rt f
rom
ma
na
ge
r/d
esig
na
ted
co
llea
gu
e/m
en
tor
to t
alk
th
rou
gh
th
e e
xp
eri
en
ce
38
.1%
(5
88
) 4
6.0
% (
71
0)
16
.0%
(2
47
)
c)
Clin
ica
l S
up
erv
isio
n
41
.6%
(6
45
) 3
4.3
% (
53
2)
2
4.1
% (
37
4)
d)
Ca
se
re
vie
w/c
ritica
l in
cid
en
t a
na
lysis
2
6.5
% (
40
3)
50
.1%
(7
61
) 2
3.4
% (
35
6)
e)
De
dic
ate
d “
de-b
rie
fin
g”
tim
e w
ith
yo
ur
pe
ers
fo
llow
ing
pa
rtic
ula
rly t
rau
ma
tic
situ
atio
ns (
as d
ete
rmin
ed
by t
he
sta
ff)
21
.2%
(3
31
) 6
5.6
% (
10
25
) 1
3.2
% (
20
6)
f)
De
dic
ate
d “
de-b
rie
fin
g”
tim
e w
ith
th
e m
ulti-p
rofe
ssio
na
l te
am
fo
llow
ing
p
art
icu
larl
y t
rau
ma
tic s
itu
atio
ns (
as d
ete
rmin
ed
by t
he
sta
ff)
14
.0%
(2
20
) 6
7.7
% (
10
65
) 1
8.3
% (
28
7)
g)
Co
nfid
en
tia
l o
ne
to
on
e s
up
po
rt f
rom
me
mb
er
of
sta
ff e
xte
rna
l to
th
e
wa
rd/d
ep
art
me
nt
to t
alk
th
rou
gh
th
e e
xp
eri
en
ce
1
7.2
% (
26
8)
50
.7%
(7
90
) 3
2.1
% (
50
1)
h)
Acce
ss t
o e
xte
rna
l su
pp
ort
or
co
un
se
llin
g s
erv
ice
s
24
.7%
(38
6)
50
.8%
(7
92
) 2
4.5
% (
38
2)
N.I. Audit: Dying, Death & Bereavement
8.
Sta
nd
ard
s D
ocu
men
ts
57
No
.
Do
cu
me
nt
1
De
pa
rtm
en
t o
f H
ea
lth
(2
00
5)
Wh
en
a P
atie
nt
Die
s;
Ad
vic
e o
n D
eve
lop
ing
Be
rea
ve
me
nt
Se
rvic
es in
th
e N
HS
. D
OH
2
De
pa
rtm
en
t o
f H
ea
lth
(2
00
3)
NH
S C
ha
pla
incy:
Me
etin
g t
he
Re
ligio
us a
nd
Sp
iritu
al N
ee
ds o
f P
atie
nts
an
d S
taff
. D
OH
3
De
pa
rtm
en
t o
f H
ea
lth
(2
00
3).
So
cia
l S
erv
ice
s a
nd
Pu
blic
Sa
fety
Ra
cia
l E
qu
alit
y in
He
alth
an
d S
ocia
l C
are
Go
od
Pra
ctice
Gu
ide
. D
OH
4
De
pa
rtm
en
t o
f H
ea
lth
, S
ocia
l S
erv
ice
s a
nd
Pu
blic
Sa
fety
(2
00
3)
Re
fere
nce
Gu
ide
to
Co
nse
ntin
g f
or
Exam
ina
tio
n,
Tre
atm
en
t o
r C
are
. D
HS
SP
SN
I
5
De
pa
rtm
en
t o
f H
ea
lth
(2
00
1)
Th
e R
em
ova
l R
ete
ntio
n a
nd
Use
of
Hu
ma
n O
rga
ns a
nd
Tis
su
e f
rom
Po
st
Mo
rte
m E
xa
min
atio
ns.
Ad
vic
e f
rom
th
e C
hie
f M
ed
ica
l O
ffic
er
D.O
.H.
6
De
pa
rtm
en
t o
f H
ea
lth
, S
ocia
l S
erv
ice
s a
nd
Pu
blic
Sa
fety
(2
00
3)
Bre
akin
g B
ad
Ne
ws G
uid
elin
es.
DH
SS
PS
NI
7
He
alth
an
d P
ers
on
al S
ocia
l S
erv
ice
s (
NI)
Ord
er
19
91
(A
rtic
le 2
5)
an
d W
elfa
re S
erv
ice
s A
ct
(NI)
19
71
(S
ectio
n 2
5).
B
uri
al o
r C
rem
atio
n o
f th
e D
ea
d.
Th
e C
hild
ren
(N
ort
he
rn I
rela
nd
) O
rde
r 1
99
5,
Art
icle
34
. C
hild
ren
Lo
oke
d A
fte
r b
y a
n A
uth
ori
ty.
8
Na
tio
na
l In
stitu
te f
or
Clin
ica
l E
xce
llen
ce
(2
00
4)
Imp
rovin
g S
up
po
rtiv
e a
nd
Pa
llia
tive
Ca
re f
or
Ad
ults w
ith
Ca
nce
r. N
ICE
9
De
pa
rtm
en
t o
f H
ea
lth
, S
ocia
l S
erv
ice
s a
nd
Pu
blic
Sa
fety
(2
00
5)
Ca
re p
lan
fo
r W
om
en
Who
Exp
eri
en
ce
a M
isca
rria
ge
, S
tillb
irth
or
Ne
on
ata
l D
ea
th.
DH
SS
PS
NI
10
R
esu
scita
tio
n G
uid
elin
es 2
00
5. R
esu
scita
tio
n C
ou
ncil
(UK
), L
on
do
n
11
D
ep
art
me
nt
of
He
alth
, S
ocia
l S
erv
ice
s a
nd
Pu
blic
Sa
fety
(2
00
5)
Po
st
Mo
rte
m E
xa
min
atio
ns -
A C
od
e o
f G
oo
d P
ractice
: R
igh
ts o
f P
atie
nts
an
d R
ela
tive
s:
Re
sp
on
sib
ilitie
s o
f P
rofe
ssio
na
ls.
DH
SS
PS
NI
12
D
ep
art
me
nt
of
He
alth
(2
00
6)
Ca
re a
nd
Re
sp
ect
in D
ea
th:
Go
od
Pra
ctice
Gu
ida
nce
fo
r N
HS
Mo
rtu
ary
Sta
ff.
DO
H
13
C
oro
ne
rs A
ct
(19
59
) N
ort
he
rn I
rela
nd
Se
ctio
n 7
Th
e C
oro
ne
rs S
erv
ice
No
rth
ern
Ire
lan
d:
Info
rma
tio
n le
afle
ts (
20
06
)
1)
Co
ron
ers
Se
rvic
e
2)
Co
ron
ers
In
qu
est
3)
Co
ron
ers
po
st
mo
rte
m E
xa
min
atio
n:
Info
rma
tio
n f
or
Re
lative
s
4)
Th
e C
oro
ne
rs L
iais
on
Off
ice
r
14
D
ep
art
me
nt
of
He
alth
, S
ocia
l S
erv
ice
s a
nd
Pu
blic
Sa
fety
, P
olic
e S
erv
ice
(N
I), C
ou
rt S
erv
ice
NI,
He
alth
an
d S
afe
ty E
xe
cu
tive
(N
I) (
20
06
) M
em
ora
nd
um
of
Un
de
rsta
nd
ing
: In
ve
stig
atin
g
Pa
tie
nt
or
Clie
nt
Sa
fety
In
cid
en
ts (
Un
exp
ecte
d D
ea
th o
r S
eri
ou
s U
nto
wa
rd H
arm
) (D
HS
SP
SN
I)
15
D
ep
art
me
nt
of
He
alth
, S
ocia
l se
rvic
es a
nd
Pu
blic
Sa
fety
(2
00
6)
Th
e Q
ua
lity S
tan
da
rds f
or
He
alth
an
d S
ocia
l C
are
. D
HS
SP
SN
I
16
D
ep
art
me
nt
of
He
alth
, S
ocia
l S
erv
ice
s a
nd
Pu
blic
Sa
fety
(2
00
0)
Pa
rtn
ers
hip
s in
Ca
rin
g:
Sta
nd
ard
s f
or
Se
rvic
e.
A R
evie
w o
f P
alli
ative
Ca
re.
DH
SS
SN
I
17
L
ive
rpo
ol C
are
Pa
thw
ay –
Go
al 1
8 B
ere
avem
en
t L
ea
fle
t, D
ata
Dic
tio
na
ry 2
00
6 –
Ma
rie
Cu
rie
Pa
llia
tive
Ca
re I
nstitu
te,
Liv
erp
oo
l
18
H
ea
lth
an
d S
afe
ty A
t W
ork
Act
19
74
19
D
ep
art
me
nt
of
He
alth
an
d S
ocia
l S
erv
ice
s a
nd
Pu
blic
Sa
fety
(2
00
5)
Ca
re p
lan
s,
Co
nse
nt
Fo
rms a
nd
In
form
atio
n f
or
Re
lative
s f
or
a H
osp
ita
l P
ost
Mo
rte
m E
xa
min
atio
n o
f
I.
A b
ab
y
II.
A
ch
ild
II.
An
ad
ult
IV
. H
isto
pa
tho
log
ica
l e
xa
min
atio
n a
nd
dis
po
sa
l o
f e
arl
y m
isca
rria
ge
s (
DH
SS
PS
NI)
20
N
HS
Esta
tes 2
00
5:
A p
lace
to
die
with
dig
nity:
Cre
atin
g a
Su
pp
ort
ive
En
vir
on
me
nt.
DO
H
21
R
oya
l M
ars
de
n H
osp
ita
l M
an
ua
l o
f C
linic
al N
urs
ing
Pro
ce
du
res (
20
04
) 6
tth
ed
. L
ast
Off
ice
s P
roce
du
re.
Bla
ckw
ell
Pu
blis
hin
g L
td.
Oxfo
rd
22
B
irth
s a
nd
De
ath
s R
eg
istr
atio
n (
No
rth
ern
Ire
lan
d)
Ord
er
19
76
23
D
ep
art
me
nt
of
He
alth
, S
ocia
l S
erv
ice
s a
nd
Pu
blic
Sa
fety
(2
00
4)
Cir
cu
lar
HS
S (
TC
7)
8/2
00
4 C
od
e O
f C
on
du
ct
Fo
r N
HS
He
alth
ca
re C
ha
pla
ins
24
H
um
an
Tis
su
e A
uth
ori
ty (
20
06
) C
od
e o
f P
ractice
3:
Po
st
Mo
rte
m E
xa
min
atio
n.
HT
A
Births and Deaths Registration (Northern Ireland) Order. 1976. http://www.opsi.gov.uk/RevisedStatutes/Acts/nisi/1976/cnisi_19761041_en_3
Coroners Act (1959) Northern Ireland Section 7. http://www.opsi.gov.uk/RevisedStatutes/Acts/apni/1959/capni_19590015_en_1
Coroners Service Northern Ireland (2006) Information leaflets
1) Coroners Inquest2) Coroners Post Mortem Examination: Information for Relatives3) Coroners Service4) The Coroners Liaison Officer http://www.coronersni.gov.uk/publications.htm
Department of Health (2000) NHS Executive Resuscitation Policy. HSC 2000/028. DOH. http://www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/Healthservicecirculars/DH_4004244
Department of Health (2001) The Removal Retention and Use of Human Organs and Tissue from Post Mortem Examinations. Advice from the Chief Medical Officer D.O.H. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4064942
Department of Health (2003) NHS Chaplaincy: Meeting the Religious and Spiritual Needs of Patients and Staff. DOH. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4073108
Department of Health (2005) When a Patient Dies; Advice on Developing Bereavement Services in the NHS. DOH. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4122191
Department of Health (2006) Care and Respect in Death: Good Practice Guidance for NHS Mortuary Staff. DOH. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4137969
Department of Health and Social Services and Public Safety (2005) Care plans, Consent Forms and Information for Relatives for a Hospital Post Mortem Examination. DHSSPSNI. http://www.dhsspsni.gov.uk/index/hss/hoi-home/hoi-postmortem.htm
Department of Health Social Services and Public Safety (2003). Racial Equality in Health and Social Care: Good Practice Guide. DHSSPSNI. http://www.dhsspsni.gov.uk/raceeqhealth_contents.pdf
Department of Health, Social Services and Public Safety (2000) Partnerships in Caring: Standards for Service. A Review of Palliative Care. DHSSSNI. http://www.dhsspsni.gov.uk/pallcare.pdf
References
58
N.I. Audit: Dying, Death & Bereavement
Department of Health, Social Services and Public Safety (2003) Breaking Bad News Guidelines. DHSSPSNI. http://www.dhsspsni.gov.uk/breaking_bad_news.pdf
Department of Health, Social Services and Public Safety (2003) Reference Guide to Consenting for Examination, Treatment or Care. DHSSPSNI. http://www.dhsspsni.gov.uk/consent_referenceguide.pdf
Department of Health, Social Services and Public Safety (2004) Circular HSS (TC7) 8/2004 Code of Conduct for NHS Healthcare Chaplains. DHSSPSNI.
Department of Health, Social Services and Public Safety (2005) Care plan for Women Who Experience a Miscarriage, Stillbirth or Neonatal Death. DHSSPSNI. http://www/dhsspsni.gov.uk/hoi-careplan.pdf
Department of Health, Social Services and Public Safety (2005) Post Mortem Examinations - A Code of Good Practice: Rights of Patients and Relatives: Responsibilities of Professionals. DHSSPSNI. http://www.dhsspsni.gov.uk/postmotrem.pdf
Department of Health, Social Services and Public Safety (2006) The Quality Standards for Health and Social Care. DHSSPSNI. http://www.dhsspsni.gov.uk/qpi_quality_standards_for_health_social_care.pdf
Department of Health, Social Services and Public Safety, Police Service NI, Court Service NI, Health and Safety Executive NI (2006) Memorandum of Understanding: Investigating Patient or Client Safety Incidents (Unexpected Death or Serious Untoward Harm). DHSSPSNI. http://www.dhsspsni.gov.uk/mou_investigating_patient_or_client_safety_incidents.pdf
Department of Health, Social Services and Public Safety. (2002). Human Organs Inquiry: Report from Inquiry Chair; John O’Hara QC. DHSSPSNI. http://www.dhsspsni.gov.uk/hoi-mainreport.pdf
Health and Personal Social Services (NI) Order 1991 (Article 25) Provision of Accommodation. http://www.opsi.gov.uk/si/si1991/Uksi_19910194_en_9.htm#mdiv25
Health and Safety At Work Act 1974.http://www.opsi.gov.uk/RevisedStatutes/Acts/ukpga/1974/cukpga_19740037_en_1
Human Tissue Act (2004) http://www.opsi.gov.uk/acts/acts2004/ukpga_20040030_en_1
Human Tissue Authority (2006) Code of Practice 3: Post Mortem Examination. HTA. http://www.hta.gov.uk/guidance/codes_of_practice.cfm
Liverpool Care Pathway – Goal 18 Bereavement Leaflet, Data Dictionary 2006 – Marie Curie Palliative Care Institute, Liverpool. http://www.mcpcil.org.uk/liverpool_care_pathway/view_the_lcp_and_associated_documentation/goal_definitions
59
National Institute for Clinical Excellence (2006) Clinical Guideline 43: Obesity; guidance on prevention, identification, assessment and management of overweight and obesity in adults and children. NICE. http://www.nice.org.uk/nicemedia/pdf/word/CG43NICEGuideline.doc
National Institute for Clinical Excellence (2004) Improving Supportive and Palliative Care for Adults with Cancer. NICE. http://www.nice.org.uk/nicemedia/pdf/csgspmanual.pdf
NHS Estates 2005: Improving the Patient Experience series; A place to die with dignity: Creating a Supportive Environment. Design Brief Working Group. http://195.92.246.148/nhsestates/knowledge/knowledge_content/home/home.asp
Northern Ireland Statistics and Research Agency (2006) Registrar General Northern Ireland 2005 Annual Report. NISRA. http://www.nisra.gov.uk/archive/dempgraphy/publications/annual_reports/2005/chpt1.pdf
Resuscitation Guidelines (2005) Resuscitation Council (UK) http://resus.org.uk/pages/bls.pdf
Royal Marsden Hospital Manual of Clinical Nursing Procedures (2004) 6th ed. Last Offices Procedure. Blackwell Publishing Ltd. Oxford
The Children (Northern Ireland) Order 1995, Article 34. Children Looked After by an Authority. http://www.opsi.gov.uk/si/si1995/uksi_19950755_en_1
Welfare Services Act (NI) 1971 (Section 25). Burial or Cremation of the Dead. http://www.opsi.gov.uk/RevisedStatutes/Acts/apni/1971/capni_19710002_en_1
60
N.I. Audit: Dying, Death & Bereavement
The Northern Ireland Health and Social Care Bereavement Network would like to acknowledge the work of the Audit Department South Eastern Health and Social Care Trust who provided the lead for this regional audit and in particular Debbie Schofield in her role as audit lead, whose patience direction and support has greatly enhanced the quality of this audit.
We would like to thank the members of the steering group at the Department of Health, Social Services and Public Safety NI, chaired by Mr Martin Bradley Chief Nursing Officer, who provided the network with invaluable support and direction.
We would also like to thank former members of the network who inspired us in the early stages of the project. Sharon McCloskey, Area Bereavement Coordinator, Southern Trust, Ruth Smith, Assistant Director Surgery, South Eastern Trust, John Mone, Director of Nursing And Quality, Craigavon Area Hospital Group Trust, Ann McVey, Assistant Director of Nursing, Craigavon Area Hospital Group Trust, Irene Duddy, Director of Nursing, Altnagelvin Hospital Trust and Alice McParland, Interim Deputy Director of Nursing, United Hospitals Trust.
This audit was undertaken at a time of great change within health and social care in Northern Ireland. The co-operation of staff at all levels throughout the legacy trusts during this time was greatly appreciated.
Finally the Network would like to acknowledge the leadership, inspiration and commitment of Dr Patricia Donnelly, Divisional Director Clinical Services, Belfast Trust, to this project.
Acknowledgements
61
Name Address Telephone Numbers
Barbara BankheadPhyllis Tweed (secretary)
Northern HSC Trust
Bush HouseBush Road AntrimBT41 2QB
Work (028) 9442 4992Trust mobile: 07841 468 824Phyllis (028) 9442 4000 Ext 2191Fax No: (028) 9442 4675
Barbara.Bankhead@northerntrust.hscni.net
Carole McKeemanCathy McCartney (secretary)
Western HSC Trust
Medical DirectorateRoom 2Centrepoint BuildingAltnagelvin Area HospitalGlenshane RoadDerryBT47 6SB
Work (028) 7134 5171 Ext 5545Work mobile 07841 970 715Cathy (028) 7134 5171 Ext 5548
Carole.McKeeman@westerntrust.hscni.netCathy.McCartney@westerntrust.hscni.net
Paul McCloskeyLucille Crossley (secretary)
South Eastern HSC Trust
Home 3The Ulster HospitalUpper Newtownards RoadDundonaldBelfast BT16 1RH
Work (028) 9048 4511 Ext 2398Work mobile 07841 103 955Lucille (028) 9048 4511 Ext 3674
Paul.McCloskey@setrust.hscni.netLucille.Crossley@setrust.hscni.net
Anne CoyleMarina Hamilton (secretary)
Southern HSC Trust
The RowansCraigavon Area Hospital68 Lurgan RoadPortadownBT63 5QQ
Work (028) 3861 3861Work mobile 07702 923 161Marina (028) 3861 3862
Anne.Coyle@southerntrust.hscni.netMarinaR.Hamilton@southerntrust.hscni.net
Heather RussellJulie McQuillan (secretary)
Belfast HSC Trust
Clinical Services Division1st Floor, Bostock HouseRoom 104Royal Victoria HospitalGrosvenor RoadBelfast BT12 6BA
Work (028) 9063 3904Work mobile 07920 186 935Julie (028) 9063 3193
Heather.Russell@belfasttrust.hscni.netJulie.McQuillan@belfasttrust.hscni.net
For further information regarding this Audit, please contact the relevant Bereavement Coordinator for your Trust.
NI Area Bereavement Coordinators Contact Details
62
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