uhl policy for the handling and release of the deceased outside normal hours dec 2009-3

8/7/2019 UHL Policy for the Handling and Release of the Deceased Outside Normal Hours Dec 2009-3

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Policy for the Handling and Release of the Deceased

Outside Normal Hours

Approved By

Date Approved

Trust Reference DRAFTVersion V1

Supersedes

Author / Originator(s) Eleanor Meldrum, Assistant Director of Nursing

Matthew Rogers, Mortuary Manager

Name of ResponsibleCommittee / Individual

Review Date January 2012


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Policy for the Handling and Release of the Deceased Outside Normal HoursApproved by xxxxxxxx on xxxxxxxxxxx

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CONTENTS PAGE

Section Page

1. Introduction ......................................................................................................... 32. Scope ................................................................................................................... 3

3. Roles and Responsibilities ............................................................................... 3

4. Handling and Release Procedures ................................................................... 4

5. Process for Monitoring Compliance ................................................................ 5

6. References and Useful Contacts ........................................................................ 5

7. Development, Consultation and Review ......................................................... 6

8. Dissemination, Implementation and Access .................................................. 69. Legal Liability ...................................................................................................... 6

Appendix One Formal Identification and Viewing of the Deceased 8

Appendix Two Actions for the Duty Manager Prior to the Release of theDeceased from the Mortuary

10

Appendix Three Reporting Deaths to H M Coroner 14

Appendix Four Completion of the Medical Certificate of Cause of Death 16

Appendix Five Flow Diagram for the Adult Medical Certificate of Cause ofDeath

17

Appendix Six Release of the Deceased from the Mortuary 18

Appendix Seven Flow Diagram for the Release of the Deceased 19

Appendix Eight Procedure for the Certification of a Stillbirth 20

Appendix Nine Procedure for the Release of a Non-Viable Fetus 21

Appendix Ten Procedure for the Release of Products of Conception 22

Appendix

Eleven

Leicester Registry Office Out of Hours Opening Times for

Registering a Death

23


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Policy for Handling and Release of the Deceased Outside Normal HoursApproved by xxxxxxxx on xxxxxxxxxxx

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1 INTRODUCTION

1.1 This document sets out the University Hospitals of Leicester (UHL) NHS Trust Policyfor dealing with the out of hours procedures relating to the handling and release ofdeceased patients forburial only.

The most commonly requested reason for out of hours (i.e. urgent) release of a body is

usually to meet the religious need for a speedy burial date but there may be otherlegitimate factors for consideration, other than the religious faith of the family. Ifrequests are received from families withoutthe expression of religious need then suchspecial requests must also be considered on their individual merits.

During the normal working hours between 9-4pm Monday to Friday, all urgent bodyrelease requests are managed by Bereavement Services who follow the StandardOperating Procedure for the Release of the Deceased and Completion of StatutoryDocumentation following Death.

2 SCOPE

2.1 The policy covers all three hospital sites within University Hospitals of Leicester NHSTrust (UHL) and applies to all deceased patients (adult and children), stillbirths, non-viable fetuses and products of conception requested for release outside normal hours.

2.2 The policy applies to all Duty Managers, on-call managers and Directors, registerednurses and midwives, doctors, Mortuary Services, Porters and Bereavement ServicesOfficers.

3 ROLES AND RESPONSIBILITIES

3.1 Porters

Responsible for allowing access to the Mortuary and to secure the department after release

and the use of storage and lifting equipment to remove the deceased onto a tray includingthe disinfection and return of the tray after release.

3.2 Duty Managers:

Responsible for responding to and coordinating all requests for the handling and release ofthe deceased outside of normal working hours (or when the mortuary is closed at theLeicester General and Glenfield during the week).

3.3 On call-managers and Directors

To provide additional advice and support to the ward staff or the Duty Manager (particularlyduring times of competing priorities for the Duty Manager who may need to delegate bedmanagement issues to on-call managers to allow a release to take place)

3.4 Head of Midwifery / Registered Midwifery Staff

Responsible for issuing the Hospital Non-Viable Foetal Burial Form or Pregnancy Loss Form

3.5 Registered Nurses

Responsible for informing the Duty Managers that the deceaseds next of kin have requestedthe early release of the body for burial.

3.6 Mortuary Staff - Anatomical Pathology Technician (APT)

To provide on-call advice and support to Duty Managers in the handling and release of the

deceased from the mortuary including the removal of drains, lines and catheters at the time

of release, where appropriate.

_________________________________________________________________________________________________


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Out of Hours is defined as the times that the Mortuary and Bereavement Services at the LRI, LGH and GH isclosed see Appendix One for details of opening hours

3.7 Senior Bereavement Services Officers / Bereavement Services Officers

To deliver the training required for Duty Managers and on-call managers in the release of thedeceased out of hours. On the next working day after every out of hours body release,Bereavement Services Officers will ensure that all statutory documentation has been

completed correctly and Duty Managers or doctors will be informed of any errors oromissions.

3.8 Head of Chaplaincy and Bereavement Services and UHL Admission andDischarge Manager

To develop and facilitate the delivery of training in the procedures outlined in this policy to allduty managers, on-call managers and Directors.

To audit compliance with the policy and deal with any untoward incidents or complaints thatarise from UHL staff or external agencies that do not follow the correct out of hours bodyrelease procedure

To take appropriate actions where necessary to prevent reoccurrence of any untowardincident or complaint

To communicate any amendments to the policy in a timely way to all staff involved in thehandling and release of the deceased outside normal hours.

3.9 Medical Director / Consultant Medical Staff and Junior Doctors

To support the development of training programmes for all medical staff in relation to

referring cases to HM Coroner and the completion of statutory paperwork following a patients

death and raise awareness amongst junior medical staff of their responsibilities with the

accurate and timely completion of the Medical Certificate of Cause of Death

4 HANDLING AND RELEASE OF THE DECEASED OUTSIDE NORMAL HOURS

Staff must follow the following procedures for the handling and release of the deceasedoutside normal hours as set out in the text and appendices of this Policy:

Appendix One Formal Identification and Viewing of the Deceased

Appendix Two Actions for the Duty Manager Prior to the Release of the Deceased from theMortuary

Appendix Three Reporting Deaths to H M CoronerAppendix Four Completion of the Medical Certificate of Cause of DeathAppendix Five Flow Diagram for the Medical Certificate of Cause of DeathAppendix Six Release of the Deceased from the MortuaryAppendix Seven Flow Diagram for the Release of the DeceasedAppendix Eight Procedure for the Certification of a StillbirthAppendix Nine Procedure for the Release of a Non-Viable FetusAppendix Ten Procedure for the Release of Products of Conception

Appendix Eleven Leicester Registry Office - Out of Hours Opening Times


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5 PROCESS FOR MONITORING COMPLIANCE

5.1 Key performance indicators / audit standards

a) Compliance with the policy by all staff involved in the handling and release of thedeceased outside normal hours using the following standards:-

Standard Release - If the deceased is not referred to HM Coroner and / or does notrequire a post-mortem or cremation, the body should be ready for release to the nextof kin or Funeral Directors within two working days following death (i.e. for deathsprior to noon, by the end of the next working day and for deaths after noon, by theclose of the second working day).

Urgent Release for religious or cultural requests - If the deceased is not referred toHM Coroner and does not require a post-mortem or Cremation; the body should beready for release to the next of kin or Funeral Directors as soon as possible afterdeath with no avoidable delays. Ideally, release should take place before duskfollowing the patients death, where time allows.

b) There will be no errors or avoidable delays in the completion of the statutorypaperwork that allows the urgent release of the deceased into the care of FuneralDirectors or a representative nominated by the next of kin.

5.2 Process and timescales for monitoring compliance

a) Bereavement Services will audit the time taken between the original request for theurgent release of the deceased to the time of the actual release from the Mortuary.

b) The Head of Chaplaincy and Bereavement Services to audit the number and type offormal complaints or concerns reported by the next of kin, Funeral Directors, faithgroups, HM Coroner or Superintendent Registrar regarding delays or problemsexperienced with the release of the deceased out of hours.

c) Audit results will be reviewed on a bi-monthly basis by the Head of Chaplaincy and

Bereavement Services and the Admission and Discharge Manager. Appropriateactions will be taken to address any issues that caused an avoidable delay to arelease.

d) Audit results will be reported to and monitored by the End of Life Care Board who willmake recommendations for improvement where required.

6. REFERENCES AND USEFUL LINKS AND CONTACTS

6.1 Related Documents

Death of a Patient: DMS Document: 26526

Last Offices Policy: DMS Document 32578 (Under Review)

Guidelines Following a Death of a Child: DMS Document: 31010

Management of Maternal Death: DMS Document: 16691

Sensitive Disposal of Foetal Remains DMS Document: 35054 (Under Review)

Patients Property Policy DMS Document : 24 / 2007

6.2 References

Births and Deaths Registration Act 1953 (c.20)

6.2 Links

Muslim Burial Council of Leicestershire

http://www.mbcol.org.uk/

Undertakers of Leicestershirehttp://www.uk-funerals.co.uk/funeral directors/leicestershire.html


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6.3 Contact telephone numbers

UHL Duty Manager LGH / LRI / GH Bleep via UHL Switchboard

Leicestershire Constabulary Police Control: 0116 2222 222

On-call Anatomical Pathology Technician: Bleep via UHL Switchboard

*HM Coroner for Leicester and South Leicestershire: 0116 225 2535(*normal working hours only)Leicester Registry Office - general enquiries or to make 0845 045 0901an appointment to register a birth or death(*normal working hours only - see appendix 10 for out of hours contact)

Muslim Burial Council of Leicester (MBCoL)

MBCOL Office: 0116 273 0141Salim Mangera: 07833 533 490 (Office Manager)Adam Sabat: 07801 101 786 (Trustee)

Mohamed Omarji: 07855 931 911 (Trustee)Zubeir Hassam: 07879 610 649 (Trustee)

A full list of the MBCOL Board can be found on the organisations website, www.mbcol.org.uk

7 DEVELOPMENT,CONSULTATION AND REVIEW

The Policy has been developed by a multi-professional group consisting of representativesfrom the UHL Duty Manager Team, Head of Chaplaincy and Bereavement Services,Bereavement Services, Mortuary and Pathology Services, Nursing and Midwifery, MedicalDirector, Infection prevention and Control and Service Equality.

The Policy has also been circulated for comments to HM Coroner, Superintendent Registrar,

MBCoL and to faith groups in Leicester.

The Head of Chaplaincy and Bereavement Services will be responsible for reviewing thePolicy at regular intervals, no more than two years apart (or earlier in response to changes innational guidelines or Coroners Reforms). The policy will also be reviewed in conjunctionwith the Medical Director, Mortuary, Duty Manager Team, HM Coroner, SuperintendentRegistrar, MBCoL and other faith groups in Leicester.

8 DISSEMINATION,IMPLEMENTATION AND ACCESS

The Document will be available on the UHL Document Management System (DMS) and willbe circulated to all staff with responsibilities for the handling and release of the deceased outof hours.

9 LEGAL LIABILITY

The Trust as an employer will assume vicarious liability for the acts of its staff, includingthose on honorary contracts, providing that:

Staff have undergone any suitable training identified as necessary under the termsof this policy or otherwise.

Staff have been fully authorised by their Line Manager and their Directorate toundertake the activity.

Staff fully comply with the terms of any relevant policies and/or procedures at all

times. Only depart from any relevant Trust Guidelines providing that such departure is

confined to the specific needs of individual circumstances. In healthcare deliverysuch departure shall only be undertaken where, in the judgement of the responsible


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clinician it is fully appropriate and justifiable such decision to be fully recorded inthe patients notes.

Staff are recommended to have Professional Indemnity Insurance cover in place for theirown protection in respect of those circumstances where the Trust does not automaticallyassume vicarious liability and where Trust support is not generally available.

These circumstances will include but are not limited to, those situation where the above

criteria do not apply or are not observed, private treatment (which may include SamaritanActs), and criminal investigations. Suitable Professional Indemnity Insurance Cover isgenerally available from the various Royal Colleges and Professional Institutions and Bodies.

For further information contact Assistant Director (Head of Legal Services) on ext 8960


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FORMAL IDENTIFICATION ANDVIEWING OF THE DECEASED Appendix One

Policy for the Handling and Release of the Deceased Outside Normal Hours

1. Formal Identification of the Deceased`

1.1 Formal identification of a deceased patient is only at the request of the police or theCoroners Office and usually only takes place at the Leicester Royal Infirmary (LRI)Mortuary. The on call Anatomical Pathology Technician (APT) at the LRI must becontacted via the Hospital Duty Manager to arrange formal identification

2. Procedure:

a) Check that the deceased is in the mortuary (by checking in the mortuary admissionbook and fridge) and is in a suitable condition to be viewed. Concerns should bediscussed with the police.

b) Deceased must be transferred from the fridge to viewing room (by the APT usingstandard precautions for infection prevention and control). The APT will prepare thedeceased and be present at the viewing

c) The Police or the Duty Managermust accompany the family to the Mortuary toensure that the APT is not alone within the department. Family members must beadvised not to touch or kiss the deceased. The family must not be left alone with thedeceased (to ensure that property is not removed without the knowledge of staff,and to ensure the safety of family members). Samples of hair can be removed bythe next of kin.

d) If valuables or property are removed for safekeeping or by the family, it must beentered and signed for in the UHL Property Book and the disclaimer signed (see

appendix five UHL Patients Property Policy document number.)e) If the deceased is already in a body bag they must not be removed from the bag.

The deceased must be transferred to viewing room in the body bag and that thebag is pulled back from the face of the deceased by the APT.

3. Viewing the Deceased in the Mortuary (LGH / GH / LRI)

3.1 Requests for adult viewings are not routinely performed outside of normal office hourson all three hospital sites because of the restricted mortuary service . It is desirablethat viewings are delayed until the next working day wherever possible. This allowsviewings to take place in a more supportive environment and for families to combineviewing with the visit to collect documentation particularly if they live a long distanceaway. However, all requests should be made via the Duty Manager who can contactthe on-call APT for advice or on-call managers for additional on-site bed and dutymanagement support whilst the Duty Manager is required to deal with requests.

a. Viewings of babies at the LGHViewing of babies may take place within the Maternity Unit outside of normal workinghours co-ordinated by the Maternity Unit staff who in turn, will contact the MaternityPorters to request the return of a deceased baby for viewing.

b. Viewings of babies at the LRI:Viewing of babies may take place within the Maternity Unit outside of normal workinghours co-ordinated by the Maternity Unit staff who in turn, will contact SERCO Portersto request the return of a deceased baby for viewing.

___________________________________________________________________________________________________Opening hours during the week for the Mortuary at the LGH is 12-4pm and the GH is 9am-12mday. DutyManagers will need to authorise body release outside of the normal opening hours of the Mortuary supported byBereavement Services and the Clinical Business Units who will support bed management processes.


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4.0 Requests from families for Visual Recordings or Images of the Deceased

Visual recordings of the deceased by next of kin within the viewing room arepermitted.

5.0 Visual Recordings or Images of Faulty Equipment Involved in Staff Incidents

Outside of normal working hours, the duty manager can authorise a visual recording

to be made in the event of an incident / adverse event (i.e. staff accident involvinglifting equipment / trolleys). In such cases the Mortuary Manager must be informed ofthe details of visual recordings.


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ACTIONS FOR THE DUTYMANAGER PRIOR TO THE

RELEASE OF THE DECEASEDFROM THE MORTUARY

Appendix Two


1. Actions to be taken by Duty Managers prior to the Release of the Deceased

Requests made by next of kin for the urgent release of the deceased should be madeby ward staff to the Duty Manager via bleep or switchboard. Prior to the releasetaking place, the following questions must be asked by the Duty Manager to ensurethat the correct process is followed;

1.2 Is this a burial or cremation?

a) UHL provides a limited service outside normal office hours that enables the urgentrelease of the deceased for burial only providing the relevant statutorydocumentation has been completed and is available prior to release.

b) Requests for cremation are not usually managed out of hours because:-

i) The burials and cremation office and Medical Referee require 72 hours noticebefore cremation can take place in order to comply with legislation and thiscommunication can only happen during normal working hours.

ii) It is unlikely that cremation form four and five of the cremation papers can becompleted outside of normal hours as they have to be completed by two differentdoctors one of whom MUST NOT have treated the patient during the last illness .

However, if release out of hours is still required, the Trust can only release thosedeceased who have a completed certificate for cremation. The Duty Managermustlocate the certificate in Bereavement Services to confirm the deceased is clear forremoval. The on-call APT can be contacted via switchboard if advice is required.

1.3 Is this a Coroners case?a) Full details of cases which are required to be referred to HM Coroner are given in

appendix three and initial judgment on whether or not to refer to the Coroner shouldbe made by the doctor or midwife certifying death or stillbirth. The Duty Managershould be consulted with any initial queries or concerns, who may, in turn, escalateissues to the on-call manager or Director. If it is determined that a referral is notnecessary a Medical Cause of Death Certificate may then be issued.

b) If it is decided that the case needs to be discussed with, or referred to, HM Coroner,contact should be made by ringing the mobile telephone number that is in a securelocation in Bereavement Services. Availability of HM Coroner is given in appendixthree.

c) If a case is accepted by HM Coronerthe deceased cannot be released from themortuary under any circumstances.

1.4 Is the request from someone who is entitled to deal with the patients funeraland/or estate? (Note: the release of a body and release of a patients property may involvedifferently entitled people).

a) The Medical Certificate of Cause of Death (MCCD) must be given to a person who islegally entitled to arrange the funeral and register the death. This person is known asthe Informant. The following persons are designated by the Births and Deathsregistration Act 1953 as qualified to give information concerning deaths in houses andpublic institutions and in order of preference they are:

Continued.


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Continued ..

1. A relative of the deceased present at death2. A relative of the deceased, in attendance during the last illness.3. A relative of the deceased, residing or being in the sub-district where the death

occurred.4. A person present at the death.

5. The Occupier (for patients with no known next of kin who die at UHL this is theSenior Bereavement Services Officer).

6. Any inmate of the house if he/she knew of the happening of the death.7. The person causing the disposal of the body (i.e. arranging the funeral).

b) Often the Informant and the Legally Entitled Next-of-Kin/Executor is the same person(e.g. the spouse or other close relative of the deceased patient). If the Informant andthe Entitled Next-of-Kin is not the same person, it may be necessary to issue theMCCD to the Informant but retain the deceased patients property until the EntitledNext-of-Kin/Executor can be identified and contacted to make arrangements withBereavement Services for its collection (see Appendix five of the UHL PatientsProperty Policy document number ..)

1.5 Is there a Medical Certificate of Cause of Death? (for adults / children / babiesover 28 days of age)

a) When a patient dies it is the statutory duty of the doctor who has attended the patient inthe last illness and has seen the patient alive at some point during the previous 14 days.to issue the MCCD (Births and Deaths Registration Act 1953). There is no clear legaldefinition of attended, but it is generally accepted to mean a doctor who has cared forthe patient during the illness that led to death and so is familiar with the patientsmedical history, investigations and treatment and be able to state the cause or causesof death to the best of their knowledge and belief. The presence of a doctor simply tocertify the death, without earlier involvement, does not entitle the doctor legally to

complete the documents. Further information on the completion of the MCCD pleaserefer to Appendix five.

There is no provision under current legislation to delegate this statutory duty to issuethe MCCD to any non-medical staff. In hospital, there may be several doctors in ateam caring for the patient but it is ultimately the responsibility of the consultant incharge of the patient's care to ensure that the death is properly certified. Anysubsequent enquiries, such as for the results of post-mortem or ante-morteminvestigations, will be addressed to the consultant

1.6 What if a legally entitled doctor is not available? (N.B. if no doctor or midwife isavailable to complete death certification then the release cannotproceed.

a) If an entitled doctor is not immediately available to complete certification, the DutyManager must explore the possibilities of who can certify the patients death byreviewing the medical notes and considering the possibility of contacting a doctor duringforthcoming shift changes. If the entitled doctor is off duty and it is a reasonable hour(i.e. during the day) the Duty Manager can consider contacting the doctor to ask if theywould be prepared to complete the certificate. There is no formal arrangement wherebyinsistence on attendance to complete certification can be enforced and so any requestrelies upon a doctors availability and goodwill NO PRESSURE MUST BE PUT ON ANOFF-DUTY DOCTOR TO COMPLETE CERTIFICATION.

Continued..


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Continued

b) However, there may be rare occasions, such as those listed below when there is nohospital / UHL doctor available who is legally entitled to write the Medical Certificateof Cause of Death:

Death in the Emergency Department (ED) - no doctor available to contact due toshift pattern/annual leave

ED doctor only verified the death they have not seen the patient alive

ED doctor does not know cause of death since patient died before anyexamination/tests carried out

Patient transferred to an Assessment Unit from ED (AMU / EMU / CDU / SAU) butdied before a doctor assessed the patient

Patient dies on a base ward but there is no doctor available to contact due to shiftpattern/annual leave

In these situations, the deaths are referred to the Coroner. The deceaseds GP iscontacted to ask if they would know a probable cause of death and issue the MCoDC.It is only via the Coroners office that a GP can issue when a patient dies in

hospital.

c) If an entitled doctor cannot be located then the Duty Manager must explain to the familythat all reasonable actions have been taken to meet their request but that it has notproved possible to contact an appropriately entitled doctor. However, reassurance canbe given that their request will be given urgent attention by Bereavement Services assoon as the office re-opens. Bereavement Services will need to be alerted of the needfor urgent release of the deceased by leaving written notification in the BereavementServices office.

1.7 Is this a live born baby dying before 28 days of life / stillbirth / non-viable foetus/ products of conception?

a) Live born babies who die before 28 days of life (known as a Neonatal Death)require a Medical Cause of Death of a Live-born Child Dying within the firstTwenty-Eight Days of Life. Still births, non-viable fetuses and products ofconception do not.

b) If the baby is over 24 weeks and has at no time shown signs of life then aCertificate of Still Birthwill be issued by the attending Doctor or Midwife. The Stillborn baby can then be registered with the certificate. The Maternity Bleep Holderand duty manager should liaise to ensure the certificate is completed.

c) If the baby, at any stage of pregnancy, showed signs of life then it must beregistered as a live birth and a neonatal death. Medical staff will have to completethe Medical Cause of Death of a live-born child dying within the first twenty-eight

days of life. The family will also have to register the babys birthwithin 6 weeks.Discussion of these cases with the UHL Legal Team and HM Coroner is advised.

d) If the baby is less than 24 weeks and has at no time shown signs of life it isclassed as a non-viable fetus. It does not need to be registered, but a Hospital /private non viable fetal burial form(referred to as either the 3-part or fetus form)will need to be issued to Bereavement Services by the ward/department so thatburial can take place (This does not apply out of hours).

e) The baby / fetus / fetal tissue under 16 weeks (miscarriage / termination / ectopicor molar pregnancy) is usually classed as Products of Conception (POC). Wardstaff should be asked if a Pregnancy Loss Formhas been issued and if it has,contact the on call APT for advice regarding the location of POCs in the mortuary.

See section regarding out of hours release in Policy for the Sensitive Disposal ofFetal Remains (DMS 35054).


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f) Products of Conception do not require any certification, although a Hospital /private non viable fetal burial form(referred to as either the 3-part or fetus form)will be issued by the ward/department if burial or cremation has been requested.The Declaration section on the form must also be completed by ward staff on thePregnancy Loss Form that accompanies the POCs.

1.8 Did the Patient have a notifiable infectious disease?

The body cannot be released out of hours if certain infections are present. The LastOffice Policy (Document number 32578) details the infections and precautionsrequired in these situations.

1.9 Does the deceased have any venous or arterial lines / urinary catheters / drainsetc?

The Last Offices Policy (Document number 32578) states that lines, catheters anddrains should not be removed on the ward following the patients death. However, ifan APT is present in the mortuary prior to release, lines etc. can be removed. If noAPT is present, then the Funeral Director or nominated representative collecting thedeceased should be informed that lines etc. are present.

1.10 Has human tissue / material been retained following a post mortem?

Retention of human tissue / material is indicated by the presence of a red formattached to the deceased. Under no circumstances should the deceased bereleased without contacting the on-call APT via switchboard to discuss the releaserequest.

1.11 Has a Request to Release Deceased form been completed?

A Request to Release form must be completed by those wishing to remove thedeceased. It must contain the deceaseds full name and at least one other positivepoint of identification. Blank forms are available in the Mortuary next to the Out of

Hours Register.A certificate for burial (green form) from the Registry Office is not required prior to therelease of the deceased for burial.

ONLY WHEN THE DUTY MANAGER IS SATISFIED THAT ALL OF THE ABOVECRITERIA HAS BEEN MET, CAN RELEASE TAKE PLACE (as per appendix four)

___________________________________________________________________________


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REPORTING DEATHS TOH M CORONER Appendix Three


1. Introduction

Registered medical practitioners have a duty to certify death where they know thecircumstances surrounding the death and have attended the patient within 14 days precedingdeath. Practitioners should note that a certificate cannot be issued if the case has beenaccepted by the Coroner. The reasons for referral may seem extreme in some instances butthey are essential.

2. Release of the Deceased Out of Hours

2.1 If a release of a deceased patient is required out of normal working hours but the Drbelieves that the case needs to be referred to the Coroner, contact with the Coronercan be made via the UHL Duty ManagerONLY. The Coroner can only be contactedat the following times:-

a) Out of Hours Weekdays between the hours ofand The Coroner mustnot be contacted outside of these hours (Is this OK? would there be anyexceptional circumstances to these times)

b) Weekends and Bank Holidays between the hours of ------ and ------- (?can contact bemade at weekends and bank holidays)

2.2 If HM Coroner needs to be contacted and agrees that the MCCD can be issued by aUHL doctor, the doctor will be asked to provide contact details of the deceaseds nextof kin. This is so the Coroner can confirm with the next of kin are satisfied with thecause of death before they will issue their paperwork (Pink Form A) to the LeicesterRegistrar. A death can not be registered until the Coroners form has been received by

the Leicester Registrar. This is a relatively new process for Bereavement Services thattakes place during working hours - will this process still occur out of hours?

2.3 If the patient dies out of hours but there is no need for urgent release, the Coronershould be contacted the next working day as normal.

2.4 If the deceased was in custody or was sectioned under the Mental Health Act, the bodycannot be released and the police must be informed via the Duty Manager.

3. Reporting Deaths

3.1 Registered Medical Practitioners are required by law to report deaths to H.M. Coronerif any of the following apply:-

a) The deceased was not attended by a Registered Medical Practitioner during his lastillness.

b) The deceased was not attended by a Registered Medical Practitioner immediately afterdeath or within 14 days preceding death.

c) The death is sudden, unexplained, violent, and unnatural or attended by suspiciouscircumstances.

d) The cause of death is unknown, or if there is any doubt regarding the cause of death.

e) The deceased is a child in foster care.

f) The death occurred in the following circumstances:

i. After an operation or invasive procedure necessitated by injury or disease within thepreceding 12 months.

ii. During an operation


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iii. Before recovery from the effects of any anaesthetic.

iv. The death may be related to a medical procedure or treatment whether invasive ornot

g) When it is believed there is a possibility the death was due to neglect, ill-treatment selfneglect or abortion

h) Still birth where there was any possibility of the child being born alivei) The deceased was detained under the Mental Health Act

j) Where it is believed the death is due to any kind of poisoning including alcohol, anddrugs either taken in therapy, in addiction, in suicide or accidentally.

k) When death occurs either directly or indirectly, following an injury or accident, includingthose associated with road traffic accidents of any date. Injuries may include burns,scalds, choking or other effects of foreign bodies, suffocation, concussion, woundsdrowning, and effects of heat or cold, sunstroke, lightning, fractures, electricity, electricshock.

l) The deceased is a person detained in prison or in any other place of detention, or is a

person who has recently been in police custody (Release within 24 hours of death)m) The deceased was in receipt of a disability pension/ war pension

n) When the death is believed to be due to an industrial injury, conditions associated withservice in H.M forces, or due to actual or suspected industrial diseases or industrialpoisonings as detailed below:-

a) Diseases of the Lungs:-

Any form of Pneumoconiosis, Asbestosis and Mesothelioma, Berylliosis.

Any Lung Disease qualified by an occupational term (e.g. Farmers Lung)

b) Other Diseases if Occupationally Related e.g.

Any form of barotrauma, Weils disease, hepatitis B or C, Anthrax

Malignancy related to any form of industrial exposure

Any form of industrial toxicity or poisoning.

0) At the request of the H. M. Coroner for Leicester and South Leicestershire, certaintreatment-related infections which are considered to have caused or contributed todeath must be referred to her office. In most cases there will be no requirement for anautopsy, but the final decision rests with the Coroner.

The following types of cases should be referred:

Within 24 hours of admission to hospital Deaths due to hospital acquired Clostridium Difficile infection Deaths due to hospital acquired MRSA infection Deaths due to infection following iatrogenic neutropenia Deaths due to infection following immunosuppressive therapy for transplantation,

autoimmune or other disease. Deaths due to infection of in-dwelling medical equipment. Any other case where medical treatment may have contributed to the

development of a fatal infection Signs of life before 24 weeks of pregnancy - discussion of these cases with the

UHL legal team and coroner is advised.

p) Any maternal death should also be referred to the Coroner, but in many cases a deathcertificate may be written and no post mortem will be requested

The coroners office can be contacted by telephone on 0116 2252534 or 0116 2252535


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Page 16 of23

COMPLETION OF THE MEDICALCERTIFICATE DEATH OF CAUSE OF

DEATH (MCCD)Appendix Four


Medical Certificate of Cause of Death (MCCD)

Adults

Children

Babies death

after 28 days ofage

- Medical Certificate of Cause of Death (MCCD) is controlled stationeryheld in the Bereavement Services (BS) Office or by the Duty Manager. Ifthe Doctor verifying the death is eligible to complete the MCCD (i.e.attended the deceased in the last illness and had seen them alive atsome time during the 14 days prior to death) then the MCCD should becompleted by the Dr at the same time as they verify the death. This willprevent avoidable delays in completing the paperwork

- Instructions on how to complete a MCCD is listed in the MedicalCertificate of Cause of Death Book.

- The completed copy of the MCCD must be placed in a sealed envelope

(legal requirement) with the Notice to Informant attached to the outsideof the envelope. The envelope can then be handed to the next of kin.

- The MCCD number can be given to Mortuary staff to inform them thedeceased is clear for removal.

Babies deathbefore 28 daysof age

Medical Certificate of Cause of Death of a live-born child dying within thefirst twenty-eight days of life

- Process for completing certificate as for MCCD above, parents stillhave to register the birth at the Leicester Register Office

- Certificates held in both BS office and securely on the Neonatal Unit(s)

Stillborn babies Certificate of Still Birth

-

Certificate and envelopes held securely on Delivery Suite- Liaise with maternity bleep holder for completion of certificate

Non-viable fetus

Products ofconception(POC) forprivate burialonly

POCs cannot bereleased out ofhours forcremation

Hospital / private non viable fetal burial form (referred to as either the 3-part form / fetus form)

- Form issued by and held securely on Gynaecology Wards and DeliverySuite. Parent or Funeral Director need the form which is required forrelease and the Cemeteries Office (the Cemeteries Office will not acceptapplication for burial / cremation without this form)

- The Cemeteries Office will not accept application for burial / cremationwithout this form

Pregnancy Loss Form (POC for cases before 16 weeks of pregnancy)- Issued by ward (form held on Gynaecology Wards and Delivery Suite)

and signed by Dr or Midwife- Declaration section on the Pregnancy Loss Form MUST be signed

Also refer to Policy for Sensitive Disposal of Fetal Remains for gestationsunder 16 weeks (DMS number 35054)

Products ofConception forHomeArrangements

(e.g. burial inthe patientsgarden)

Pregnancy Loss Form No certificate required- Issued by ward (form held on Gynaecology Wards)- Declaration on Pregnancy Loss Form MUST be signed (as confirmation

that the case is not a registerable birth or death)- Confirm with parent(s) that the fetal tissue is definitely having a burial at

home BEFORE RELEASE (if they intend to approach a funeral director ata later date the Hospital / private non viable fetal burial form is required)


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Page 17 of23

FLOW DIAGRAM FOR THECOMPLETION OF THE ADULT MCCD

FOR BURIALAppendix Five


Duty Manager is contacted need to check thatperson making the request is entitled

Is an eligble Doctor available to completeMCCD?

No

Yes

Does the case need referrin to HM Coroner?Unsure

Dr to contact Duty Manager or On-Call Manager for furtheradvice

Recordreasons for

non release in

BereavementServices office

Do not proceed

If coroner ishappy to

release

Doctor completes MedicalCertificate of Cause of Death orneonatal death certificate (under28 days of life) certificate.

Duty manager checks certificateis eligible and signed and

completes body release formwhich remains in BereavementService (BS) office.

Duty Manager leaves a messagein Bereavement Services toinform them when and whowasreleased.

Do not proceed

Deceased Next of Kin or their representative requests early release to Nurse in Charge

Yes(but only between thehours of ----- &------)

Hand medical certificate of cause of death to next of kin / representative in sealed envelope


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Page 18 of23

RELEASE OF THE DECEASED FROMTHE MORTUARY Appendix Six


1. Release at the Request of the Family

The deceased can only be released from the care of UHL NHS Trust into the custody of thenext of kin / executor of the estate or in most cases, a representative nominated by them. Forexample, a Funeral Director.

2. Release at the Request of the Coroner

The Coroners Removal Service will be required to complete a Request to Remove Deceasedform and the Out of Hours Mortuary Register.

3. Prior to arranging a time for collection of the deceased

The Duty Manager should check that

a) The Medical Certificate of Cause of Death has been completed.b) Deceased is in the Mortuary.c) There is no retained tissue / materiald) Any property belonging to the deceased which needs to be returned is availablee) Those collecting the deceased have an appropriate vehicle and receptacle (i.e. casket

and vehicle with tinted windows)f) Mortuary staff / porters are available for release. However, on rare occasions this aspect

may be the responsibility of the Duty Manager.

4. Procedure for Release

a) Check the release form / certificate number to confirm deceased is clear for release.b) Check mortuary register / fridge doors to identify the fridge location.

c) Wearing disposable gloves and apron clothing remove occupied tray and deceased fromfridge onto hoist in accordance with manufacturers instructions.

d) Check attached identity bands against request to release form confirming at least threepositive points of identification.

e) Ensure that the identity and condition of the deceased is also checked by the personcollecting them.

f) Use the request for release forms to complete the Out of Hours Release Register. Thiscan be found in the clerical area of the Fridge Room

g) Ensure that the person collecting the deceased undertakes the following actions:- Signs the out of hours register to confirm that the correct deceased has been

received into their custody in a satisfactory condition. Checks any property and signs the mortuary property book to confirm that the

property has been received. Give the blue copy of the property sheet to therecipient as a receipt.

h) Move deceased from the tray to the receptacle provided.i) Disinfect tray with an active solution of one part TriGene Advance to ten parts water.

Care should be taken to ensure that this is not witnessed by relatives of the deceased asit may be upsetting.

j) Return tray to original fridge space and close the door.k) Remove the name from the exterior of fridge door.l) Remove and appropriately dispose of protective clothing. Clean hands using appropriate

technique.m) Leave the request for release form in the mortuary with the Out of Hours Release

Register


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Page 19 of23

PROCEDURE FOR BODY RELEASEAFTER COMPLETION OF MCCD Appendix Seven


Yes

Liaise with mortuary staff and arrangetime of collection. Inform mortuary staff

of certificate number, to confirmcompletion of certification

No

Duty manager liaisewith porters to arrange

access to mortuary

Confirm no material has been retainedand that the next of kin has appropriatevehicle and receptacle prior to release.

Give time of access to next of kin

Porters removedeceased from fridgecontact on call APT

regarding POCs

Duty manager cross checks request forrelease form against identity band (id

number for POCs) attached to deceasedand checks for property

Next of kin gives completed copy of request for release to dutymanager.

If next of kin does not have a copy of the request to release then aform is completed in the mortuary

Duty manager records

details of release on outof hours register

Next of kin checks deceased and

signs out of hours register andremoves deceased

Are Mortuary staffavailable?


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Page 20 of23

PROCEURE FOR THECERTIFICATION OF A STILL BIRTH Appendix Eight


Mother requests early release

DM informed

Less than 24 weeksAND no signs of life

Signs of life before 24 weeks - Livebirth

More than 24 weeksAND no signs of life

Not a stillbirth follow process fornon-viable foetus

Neonatal Death Certificate (deathbefore 28 days of life) completed follow process as for previous chart

Still birth

Advise case discussed with legalteam and coroner (who may classify

case as stillbirth)

If case classified as a stillbirth followstillbirth process

If case classified as a neonatal death follow previous flow chart

Doctor or midwifecompletes stillbirth

certificate (liaise withmaternity bleep

holder)

Certificate given toNext of Kin to register

stillbirth


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Page 21 of23

PROCEDURE FOR RELEASE OF ANON-VIABLE FOETUS Appendix Nine



Duty manager informed

Less than 24 weeks and no signs of life non viable fetus

Ward staff (nursing / midwife / doctor) issues Hospital / Private Non-viableFetal Burial Form (also called the 3-part or fetus form) to Bereavement Servicesoffice

If fetus less than 16 weeks gestation Pregnancy Loss Form will also be issued confirm DECLARATION completed (see Policy for Sensitive Disposal of FetalRemains DMS no 35054)

Part 2 of the form completed in mortuary by duty manager and personcollecting the fetus at time of release

Both complete relevant sections on Pregnancy Loss form

Form then given to person collecting the fetus for the attention of the

cemeteries authority


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Page 22 of23

PROCEDURE FOR RLEASE OFPRODUCTS OF CONCEPTION Appendix Ten



Duty manager informed

Private burial or cremation Home arrangements

Ward staff (nursing / midwife /doctor) issues Hospital /

Private Non-viableFetal Burial Form (also calledthe 3-part or foetus form) toBereavement Services office

Pregnancy Loss Form issued check Declaration signed

Confirm mother has beengiven burial outside a

cemetery information sheet(documented on PregnancyLoss Form) and if not issue

copy (and sign on PLF)

Part 2 of the form completedin mortuary by duty manager

and person collecting thefetus / POCs at time of

release

Pregnancy Loss Form alsosigned by both duty manager

and person collecting thefetus / POCs

Form then given to personcollecting the fetus / POCs for

the attention of the

cemeteries authority

Pregnancy Loss Form alsosigned by both duty manager

and person collecting thefetus / POCs

NOTE:

Products of Conception do not have the

patients ID band, only the patients IDnumber on the box;

AND

Are stored in separate fridges in themortuary and not listed in the mortuary

registers CONTACT APT TO ADVISE ONLOCATION


23/23

Leicester Registry Office

Out of Hours Opening Times forRegistering a Death Appendix Eleven


The Registrar of Births and deaths provides an emergency service and may authorise a

burial outside regular hours. Information will be posted on the door of their office building inBowling Green Street, Leicester, providing details of how to contact the Registrar in anemergency. The information below may change in the event of any changes the duty rotaand therefore families or their representatives should be advised to visit the registry office inorder to obtain the information.

A certificate for burial (green form) from the Registry Office is not required prior to therelease of the deceased for burial.

Saturday Service

A death can be registered between 08.30 -12.00 but registering a death will only takeplace between any weddings that occur during the morning

Those wishing to register a death must go to the front entrance of the Town Hall.

Sunday and Bank Holidays

There is a 2 hour (10am -12 midday) on-call arrangement with the Registrars on aSunday or Bank Holiday

Emergency telephone number : 07970751329

A death can not be registered on Sunday but a green form will be issued to enable the

funeral to go ahead. This is released from the New Walk Centre not the Register Office.

The death then has to be registered during normal hours in the week at the Register

Office, Town Hall.