Verification of expected death policy

1 Policy summary

This policy provides the expectations for Verification of expected death within RDASH (Doncaster). The policy covers the procedure for deceased patients that were known to the community nursing service (RDASH inpatient or their own home) or St John’s Hospice. The policy outlines in detail the process for wider services who may not perform the procedure but need to guidance for who to contact after a patient has died. The policy is important due to the strict laws and processes for the deceased patient.

2 Introduction

Wilson, Laverty and Cooper (2016) define an expected and unexpected death as:

Expected death:

an expected death is the result of an acute or gradual deterioration in a patient’s health status, usually due to advanced progressive incurable disease. The death is anticipated, expected and predicted. Please note, for nurse verification a doctor must have seen the patient in the last 28 days

A sudden or unexpected death:

an unexpected death is a death that is not anticipated or related to a period of illness that has been identified as terminal. Where the death is completely unexpected there is a requirement to begin resuscitation (unless circumstances can be justified)

Verification of Expected Death is the procedure of determining whether a patient is deceased (RCN, 2016). A registered nurse (RN) can verify that an expected death has occurred if there is a local policy to support the RN. It is important to note that the law dictates that a medical certificate of cause of death (MCCD) is written by a registered medical practitioner in accordance with the Births and Deaths Registration Act 1953 (Wilson, Laverty and Cooper, 2016, BMA, 2016).

Verification of expected death by a competently trained RN allows for timely provision of appropriate care for the deceased and their family, thus minimising distress caused by unnecessary delays at such an emotional and vulnerable time.

Following the verification process the RN can instruct the timely removal of the deceased to the appropriate onward location for example, funeral directors.

In addition, if a situation is identified during the verification procedure that requires a referral to the coroner (section 5.2), the RN can explain the rationale and offer on-going support.

It is important to advise the family that there may be a delay between time of last breath (often reported by the family or carer) and time of verification of death, which is the official time of death. It is this time that should be documented in the patient’s records. Please note: if a patient takes their last breath before midnight and verification takes place after midnight, the official date of death remains as the date and time of verification.

An RN can only verify an expected death.

3 Purpose

The purpose of this policy is to provide guidance and set out the organisational arrangements for implementing best practice in relation to the verification of expected death procedure for both the unplanning and the hospice nursing teams.

To provide legislative guidance for situations requiring a referral to the coroner and local arrangements for referrals to the coroner within the Borough of Doncaster.

To provide guidance for nursing and medical colleagues supporting patients whose death, in the near future, is inevitable, enabling them to explain to patient, relatives, or carers the procedures that take place following an expected death and the services that may be involved.

4 Scope

This policy applies to:

registered nurses employed by RDaSH, working in unplanned nursing or the hospice (Doncaster care group only), who have been appropriately trained and have been assessed as competent in this procedure
all general practitioners (GP’s), and doctors working in RDaSH, who request an RDaSH employed RN to undertake the verification of expected death procedure during out of hours (community only) and all hours within the hospice

Other RDaSH inpatient settings are not included in this policy as they do not care regularly for patients at the end of life, therefore nurses working in those areas would not be required to verify expected death. When a patient is nearing the end of life in an inpatient setting, other than the hospice, see section 5.5.1

Refer to the transfer of deceased into the care of another service provider (expected and unexpected deaths) policy.

This policy will support the referring GP and, or doctor in their decision making when deciding when it is and is not appropriate to request a RN to verify that an expected death has occurred

5 Procedure

5.1 Guidance

The following guidance is based on best evidence and legislative guidance available. Throughout this guidance the coroner referral processes relate to referrals for the coroner within the Borough of Doncaster only.

Coroner processes may be different outside the Borough of Doncaster, therefore for patients who live in the community but reside outside the Borough of Doncaster, even if they are registered with a Doncaster GP, will be the responsibility of the requesting GP or doctor for out of hours services. RDaSH employed RN’s are unable to verify expected deaths regarded as out of area.

5.2 Situations that require a referral to the coroner

Every situation where the doctor treating the patient is unable to provide a medical certificate of the cause of death (MCCD).
Where the death may be due to suicide.
Where the death occurred in prison, police custody or another type of state, for example, including those detained in a mental health establishment detention.
Where the cause of death is unknown or unexpected.
Where the deceased had not been seen, in person or via video, by the medical practitioner within 28 days of the death (the ‘28 day rule’) for the condition from which the patient has died or where the certifying doctor did not see the deceased after death.
Where the cause of death may have been unnatural, violent or attended by suspicious circumstances.
Where the death may have been due to self-neglect or neglect by others.
Where death may be due to industrial disease or industrial poisoning or related to their employment history.
Where death is due to an abortion.
Where the death occurred during surgery or before full recovery from the effects of an anaesthetic that may contribute to the death.
Where there is any evidence of concern following examination of the body.
Where relatives express any concerns relating to professional management if related to the cause of death (Births and Deaths Registration Act 1953).

If a patient has an industrial disease and was expected to die an RN may verify death, however the RN must complete letter 2 (appendix F) and follow guidance in section 5.3.

It is important to note that a GP from the out of hours services cannot legally write a medical certificate showing the cause of death if they have not attended the deceased in the last 28 days for the condition which is known to be the cause of their death. (BMA, 2016)

If a patient is at the end of their life, and has been discharged home from the acute trust or hospice services but have not been seen (in person or via video) by their own GP within the last 28 days for the condition which is known to be the cause of their death, they do not routinely require a referral to the coroner because they will have been seen by a medical practitioner within the last 28 days in those clinical settings. In this scenario, ideally the patient’s GP should see the patient, in person or via video, as soon as possible so they can write the death certificate. If the GP is unable to write the death certificate, it is their responsibility to either locate the medical practitioner who can or refer to the coroner.

If a patient has a do not attempt cardiopulmonary resuscitation (DNACPR) order in place this does not automatically mean that the death is expected. Therefore, if a contraindication is identified, a referral to the coroner will be required.

5.2.1 Deprivation of liberty safeguards

Since Monday 3 April 2017 coroners no longer have a duty to undertake an inquest into the death of every person who was subject to an authorisation under the deprivation of liberty safeguards (known as DoLS) under the Mental Capacity Act 2005.

Any person subject to a DoLS authorisation who dies, their death need not be reported to the coroner unless the cause of death is unknown or where there are concerns that the cause of death was unnatural or violent, including where there is any concern about the care given having contributed to the persons death.

Any person with any concerns about how or why someone has come to their death can contact the coroner directly. This will not change where a person is subject to a DoLS authorisation (Chief Coroner, 2017).

5.3 Doncaster’s coroner’s out of hours referral process

It is important that RN’s trained to undertake the verification of expected death procedures, are aware of issues requiring a referral to the coroner before proceeding with the procedure (section 5.3) and be prepared for situations that may only be identified during the verification process that subsequently require a referral to the coroner. This can present difficulties for the RN, who at a sensitive time is supporting bereaved relatives but is required to inform the family and GP or doctor of a need to refer to the coroner. The professional position outlined in the NMC ‘The Code’ states that ‘Each RN is responsible for his or her own actions and omissions regardless of advice or directions from another professional’ (NMC 2016).

For community nursing services only:

if at the time of referral for verification of an expected death the GP and RN identify a situation that requires a referral to the coroner (section 5.3), the RN may attend to undertake the verification procedure however the RN has the right to decline. If the RN attends, then they must complete letter 2 (appendix D) and send this to the requesting GP following verification. The coroner requires the name of the healthcare professional who verified the death; please ensure this section of the letter is also completed. It is the requesting GP’s responsibility to complete all referrals to the coroner and to contact South Yorkshire Police (section 5.4)
if at the time of the verification of expected death procedure the RN identifies a situation that requires a referral to the coroner, that was not known at the time of the GP referral (see list above) the RN is required to contact the requesting GP, highlight the identified concerns, recommend a referral to the coroner and inform the requesting GP that they are unable to authorise the removal of the deceased to the funeral director. The RN will explain the situation to the relative or carers (details may be limited depending on reason for referral, for example, suspicious circumstances and complete a letter 2 (appendix F) for the requesting GP who will complete the referral for the coroner
if the requesting GP disagrees with the rationale offered by the RN it is the requesting GP’s responsibility to visit the patient and verify that death has occurred, and the RN will professionally request the GP to visit the deceased. If the GP declines the RN will escalate to their line manager for further advice

For hospice inpatient unit service only:

for coroner referral process, see care of the adult patient following death (last offices) SOP

5.4 South Yorkshire police response to referrals to Doncaster coroner

For community nursing services only:

When South Yorkshire Police receive a notification of a death requiring a referral to the coroner in Doncaster the police, irrespective of the time of day or night will:

liaise with family or relatives.
arrange to visit the home or residence of the deceased person to make a formal identification of the deceased with the family or relatives
complete Gen 18 paperwork (appendix G)
explain the plan of action following their visit
authorise the removal of the deceased to a specific funeral director and liaise with the coroner’s officers. The coroner’s officers will liaise with the relatives or carers and arrange further contact if required

5.5 Verification of expected death procedure (community services)

The order of the procedure developed for colleagues protection during the covid-19 pandemic has been adopted permanently for verification of expected death (appendix H)

When an expected death occurs outside normal GP working hours the GP out of hours service can contact an RN via the single point of access (SPA) and request that an RN visit to verify that an expected death has occurred.

Acceptance criteria:

the deceased must have been known to the RDASH community nursing service for end-of-life care prior to death (community only)
a valid DNACPR (ReSPECT with DNACPR decision or a Version 13 DNACPR document) must be in place (Wilson, Laverty and Cooper, 2016)
for nurse verification a doctor must have seen the patient, in person or via video, in the last 28 days
there is written documentation in the patient’s records (in a designated location) indicating that the patient is nearing the end of life
the deceased must reside within the Borough of Doncaster

5.5.1 Timely verification

Best practice dictates that verification should be carried out in a timely manner as it is key to the grieving process, causes minimal distress and allows time to offer support to the family:

in the community setting within 4 hours
in the Hospice setting within 1 hour

The RN will:

in a sensitive and supporting manner support the relatives or carers and offer a full rationale for their contact and procedures that they are required to undertake
confirm the identity of the patient with the relative or carer or designated person
clarify any cultural requirements that may affect the verification procedures

If no contraindications are identified the RN can proceed with the verification process (appendix F). However, the RN must not remove any parenteral or life prolonging equipment until after death has been verified and no suspicious circumstances are identified (Wilson, Laverty and Cooper, 2016). Furthermore, it is an offence to remove or otherwise interfere with a body or surrounding evidence without leave of the coroner where death has occurred in circumstances which may lead them to hold an inquest (Earland 2006)

the RN must notify the funeral directors of any implantable devices (ICD, Pacemaker). It is recommended that prior to death the RN arranges for an ICD device to be deactivated
it is the right of the RN to refuse to verify death and to request the attendance of the responsible doctor or police if there is an unusual situation (safeguarding issues, medication discrepancies). The procedure for an unexpected death must be followed (transfer of deceased patients policy) and the RN must not authorise the removal of the body to the funeral directors
verify that death has occurred following agreed procedures (appendix A, B, F). Verification of death requires the RN to assess the patient over a minimum timeframe of 5 minutes to establish that irreversible cardio-respiratory arrest has occurred, as well as specific additional observations. Any spontaneous return of cardiac or respiratory activity during this period of observation should prompt further five minutes observations (Wilson, Laverty and Cooper, 2016)

5.5.2 If an expected death occurs within an Doncaster inpatient unit (not hospice)

5.5.2.1 Prior to death

When the patient has been assessed as last days to short weeks of life and is to remain on the inpatient unit:

the patient should be referred to community nurses via SPA, this is to provide support for the patient and ward nurses who do not regularly care for patients at the end of life.
this referral is also required to meet the criteria for unplanned nursing to perform verification of expected death
the patient should also be referred to the Community End of Life team via SPA, who can provide guidance on prescribing and additional advice to the ward nurses, patient, and family

5.5.2.2 After expected death

Follow the process above for 5.5.

5.6 Verification of expected death procedure (in patient services)

For hospice inpatient services: when an expected death occurs, the RN will follow the verification of expected death procedures outlined in section 5.5. with the addition of:

if the expected death occurs within normal working hours and the RN is aware that a referral to the coroner will be required, they will inform the relatives and notify the doctor on duty. The doctor should then liaise with the coroner’s office (using on-line form), explain to the relatives why a referral is required and the process regarding issuing a death certificate. It would be regarded as best practice to discuss referral to the coroner with both the patient and the family prior to death when it is already known that a referral to the coroner will be required (industrial disease)
if an expected death occurs during out of hours services and no issues are identified that require a referral to the coroner the RN, following discussions with the relatives, can verify that an expected death has occurred and authorise the removal of the deceased. Ensure the doctor is informed as soon as possible, for example, the following morning if the death occurred during the night. The relatives will be informed about the processes for registering the death
the medical certificate for cause of death (MCCD) will be sent electronically, from the hospice or GP to the registrar’s office and a hardcopy will be sent in the post. The registrar’s office will contact the next of kin and arrange a time for them to register the death in person

5.7 Record keeping

The RN is required to ensure adequate records are maintained at all times in line with RDaSH healthcare record keeping policy and records management policy and the NMC The Code

The RN who verifies that an expected death has occurred will clearly document in the patient’s records or care plan on the Electronic palliative care coordinating systems (EPaCCs) that they have completed the verification of expected death procedure appropriate for their area (community, hospice)

The RN will explain to the relatives or carers what will happen next depending upon the situation encountered.

5.8 No contraindications Identified

The RN will authorise the removal of the deceased to a funeral director identified by the relatives or carers and explain to the family or carers the procedure for registering the death, the GP will send the MCCD electronically (see section 5.6), complete letter 1 (appendix I) and send a copy to the patient’s GP’s surgery as soon as possible (community only).

for Hospice Inpatient services, see section 5.6 for removal of the deceased following verification in and out of hours
the RN will explain how other agencies involved in the care of the deceased will be notified, for example, district nurse or specialist nurses or Macmillan or community matron
the RN will provide information for relatives or carers regarding what to do after death and can signpost to the government website (opens in new window)
the RN will provide contact details of the RN who verified the death
the RN will sign post to support information and follow up support as appropriate

5.9 Contraindications Identified that require a referral to the coroner

The RN will contact the requesting GP and advise that a referral to the coroner is required explaining the rationale for the decision made, complete letter 2 (appendix D), explain the referral process and police involvement to the relatives or carers and send letter 2 (appendix F) to the requesting GP (community only).

6 Training implications

6.1 Registered nurses undertaking verification of expected death procedures

Frequency: 3 yearly.
Length of training: 1 hours.
Delivery method: Face to face.
Training delivered by whom:
- community practice educators
- nurse consultant, hospice services
Where are the records of attendance held: Electronic staff record system (ESR).

7 Equality impact assessment screening

To access the equality impact assessment for this policy, please email rdash.equalityanddiversity@nhs.net to request the document.

7.1 Privacy, dignity and respect

The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, ‘not just clinically but in terms of dignity and respect’.

Consequently, the trust is required to articulate its intent to deliver care with privacy and dignity that treats all patients with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided).

7.1.1 How this will be met

No issues have been identified in relation to this policy.

7.2 Mental Capacity Act

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individual’s capacity to participate in the decision making process. Consequently, no intervention should be carried out without either the individual’s informed consent, or the powers included in a legal framework, or by order of the court.

Therefore, the trust is required to make sure that all employees working with individuals who use our service are familiar with the provisions within the Mental Capacity Act (2005). For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act (2005) to ensure that the rights of individual are protected and they are supported to make their own decisions where possible and that any decisions made on their behalf when they lack capacity are made in their best interests and least restrictive of their rights and freedoms.

7.2.1 How this will be met

No impact as patients are deceased.

8 Links to any other associated documents

9 References

10 Appendices

10.1 Appendix A Responsibilities, accountabilities and duties

10.1.1 Chief executive

The chief executive is responsible for making arrangements to support the safe and effective implementation, monitoring and review of this policy.

10.1.2 Medical director

The medical director is responsible for the implementation and monitoring of the policy

10.1.3 Medical colleagues an consultants

Consultants are responsible for the safe and effective implementation and monitoring of this policy.

10.1.4 Area clinical managers, modern matrons, team leader or ward managers

The area clinical managers or modern matrons or team leaders or ward managers are responsible for the safe and effective implementation of this policy.

In addition:

monitoring compliance relating to RN training and competency outlined in this policy
ensure appropriately trained RNs are available within their areas to undertake the verification of death procedure
monitor inappropriate referrals and actions taken

10.1.5 Registered nurses

All RN’s who have undertaken the required training, who are assessed as competent (appendix C and D) and have been assessed using RDASH clinical skills assessment tool (appendix E) to verify that an expected death has occurred are responsible for:

ensuring their knowledge and skills are kept up to date
ensuring they follow the verification of death procedures
ensuring documentation is accurate and up to date
ensuring referral to coroner’s office is requested in line with legislative guidance
ensuring escalation to senior colleagues if issues arise

10.2 Monitoring arrangements

10.2.1 Standard IRI reporting of incidents regarding issues relating to the verification of expected deaths

How: Number if IRI reports.
Who by:
- area clinical managers
- team leaders unit managers
- modern matrons
Reported to: Doncaster care group.
Frequency: Quarterly.

10.3 Appendix C Assessment specification (performance)

10.3.1 Aim

The RN can competently and confidently verify that an expected death has occurred.

10.3.2 Competency performance

10.3.1.2 Competence expectation

The registered nurse competently and confidently undertakes verification of expected death, and ensures that related documentation is completed.

Evidence Type:

direct observation
questioning
simulation
reflective

10.3.3 Practice record

Evidence of performance:
Type of evidence:
Date achieved:
Assessor:

Checks relevant patient records to ensure that death was expected and that the deceased had a DNACPR order in place (ReSPECT with DNACPR decision or Version 13 DNACPR)
Did the deceased require deactivation of an ICD?
Checks all necessary equipment is available and in working order.
Confirms correct identity of the patient.
Informs relatives or carers of verification process in a professional manner.
Performs hand decontamination pre and post procedure.
Maintains infection prevention and control standard precautions.
Respects privacy, dignity, cultural and religious beliefs at all times.
Lies deceased patient flat, leaves all tubes, lines, drains, medication patches and pumps in place (turning off pumps and fluids).
Follows the order of procedure according to the Covid-19 guidance (appendix H) to reduce risk of potential contamination.

Stages 10, 11 and 12 should take place over a minimum of 5 minutes.

Confirms with stethoscope the absence of heart sounds for 1 minute, places stethoscope on sheet or trolley ready for cleaning.
Confirms pupils are fixed and dilate and unresponsive to light (cerebral function) using a pen torch. Places pen torch on sheet or trolley ready for cleaning.
Observes for any signs of respiratory effort over 5 minutes. Does not place ear or face near the patient’s face.
Confirms the absence of carotid pulse for 1 minute, through the patient’s clothing.
No reaction to a Trapezius muscle squeeze (cerebral function or motor response). Carried out through patient’s clothing.
Repeats the above procedure over 5 minutes if any spontaneous return of cardiac or respiratory activity during the procedure.
Decontaminate equipment used in the process according to local policy.
Removes PPE according to policy.
Cleans equipment again.
Community, once removed PPE.
Hospice, once removed PPE and left the patient’s room.
Safely disposes of medication, if required.
Records physiological findings on EPaCCs.
Records date, time that the expected death was verified (official time of death) on EPaCCs.
Authorise removal of the deceased to appointed funeral directors.
Hospice, complete checklist, notify doctor, notify medical secretary who will instigate e-notification of death.
Community, inform the GP using letter 1 (appendix G).

10.4 Appendix D Assessment specification (knowledge)

10.4.1 Aim

The RN can competently and confidently verify that an expected death has occurred.

10.4.2 Competency knowledge

10.4.2.1 Competence expectation

The registered nurse competently and confidently undertakes verification of expected death, and ensures that related documentation is completed.

Evidence type:

direct observation
questioning
simulation
reflective

10.4.3 Practice diary

Evidence of knowledge:
Type of evidence:
Date achieved:
Assessor:

Defines expected death.
Explains the difference between verification and certification of death.
Explains the difference between time of last breath and official time of death.
Identifies situations when the death must be referred to the coroner.
Lists the patient details required to complete the procedure.
Describes the equipment required for verifying an expected death.
Explains the significance of:
- checking for responses to painful stimuli
- checking the absence of heart sounds with a stethoscope for 1 minute
- checking for the absence of carotid pulses for 1 minute
- checking the absence of breath sounds with observation over 5 minutes
- confirming that pupils are fixed and dilated and unresponsive to light
- checking the absence of response to the trapezius squeeze
- leaving tubes, lines and medication patches and pumps in place prior to verification
- deactivation of the ICD device
- explains the circumstances when the verification of death must be carried out by a medical practitioner
- discussed the cultural or religious needs the patient or family may have at the time of death
- describes how to manage a patient with a known infectious disease at the time of death, and the rationale for the order of the procedure
- explains what should be documented following the verification of an expected death
- explain what information the relatives or cares requires
- explains the procedure for the safe disposal of medication
- explain communication systems used to ensure all professional are aware that a death has occurred

10.5 Appendix E RDaSH clinical skills assessment tool

Appendix C RDaSH clinical skills assessment tool

10.6 Appendix F Letter 2 notification procedure following verification for community services

Appendix F Letter 2 Notification procedure following verification for community services

10.7 Appendix G Gen 18

Appendix G GEN 18

10.8 Appendix H Verification of expected death pre-checklist or procedure or GP communications

10.8.1 Order of procedure for verification of expected death (adults) adapted from the national guidance (Hospice UK 2020)

Infection control precautions, personal protective equipment (PPE) should be worn when carrying out verification of death on all adults, including those suspected of, or confirmed to be, COVID-19 positive, and by following UK Infection Prevention and Control (IPC) guides for safe PPE selection, and for donning and doffing PPE in non-aerosol generated procedures (see RDaSH guidance).
Procedure, use of PPE for carrying out the verification has been updated, and the order of the examination for verification of death has changed to protect the practitioner and minimise infection risk of contamination of equipment and PPE (see procedure guidelines below).
Medical certificate of the cause of death (MCCD), can be issued where a medical practitioner (doctor) has seen the deceased, in person, up to 28 days prior to death (previously 14 days). Verification can be completed by the nurse in these circumstances.
Referral to a Coroner: a person who is suspected of, or confirmed with, Covid 19 at the time of death is not a reason on its own to refer the death to the coroner (for reasons to refer to the coroner see verification of expected death policy).
Notifiable diseases, diagnosis of suspected (or confirmed) Covid 19 is a notifiable infectious disease, and must be reported to the Health Protection team by the medical registered practitioner (doctor) at the time of the suspected diagnosis.
Timely verification, best practice dictates that verification should be carried out in a timely manner, within 4 hours in the community setting or within 1 hour in the hospice.

Criteria, obtain a yes or no answer:

community, Is the patient known to community nursing service (check records)
death is expected and not accompanied by any suspicious circumstances. This includes when the person has died expectedly from or with Covid 19:
- no contraindications identified
the patient has a DNACPR decision (ReSPECT document or DNACPR V13) and it is recorded in the patient’s clinical notes
is it clear in the patient’s records that the patient was expected to die? Being cared for under the principles of end-of-life care?
has the doctor or GP seen the patient, in person, in the last 28 days

Nurse verification of expected death can occur in:

death occurs in a private residence, RDaSH inpatient setting, hospice, or residential home
it includes where the patient dies under the Mental Health Act including deprivation of liberty safeguards (DoLS)

If contraindications identified:

if contraindications are identified inform the appropriate person, for example, GP, recommend a referral to the coroner, agree appropriate person to verify death and send letter 2 (appendix D).

If RN is to verify the death, follow the procedure above but:

if contraindications identified do not authorise the removal of the deceased to the funeral director this is the responsibility of the police

10.8.2 Procedure guide

Personal protective equipment (PPE):

to maintain the safety of the RN carrying out the verification of death, these guidelines should be applied to all verification of expected adult death irrespective of any COVID-19 status (for example, not suspected, suspected, confirmed), by donning fluid resistant surgical mask (FRSM), gloves and apron as a minimum when carrying out the verification of death procedure

Equipment (cleaned in accordance with local procedure):

pen torch (for visits to patient’s own home, this equipment should be suitably cleaned prior to entering the home and prior to leaving)
stethoscope (for visits to patient’s own home, this equipment should be suitably cleaned prior to entering the home and prior to leaving)
Watch with second hand (for visits to patient’s own home, this equipment should be suitably cleaned prior to entering the home and prior to leaving)
FRSM
eye protection (see below)
disposable plastic apron
1 pairs of disposable gloves
sterile sheet or trolley
community, 2 small waste bags

The RN may need a clean buddy in order to help with infection control procedures.

Risk assessment (see trust guidance infection prevention and control):

eye protection or face visor, where there is a risk of contamination to the face from splashing secretions including body fluids, a FRSM and visor or goggles should be worn
disposable apron or gown, plastic aprons must be worn for all interactions to protect staff uniform from contamination
equipment, ensure stethoscope and pen torch are thoroughly cleaned with a 2 in 1 antimicrobial wipe, for example, Clinell universal wipe

Community:

if verification is to take place in a patient’s home, soapy hand wipes and, or alcohol hand gel can be used to decontaminate hands
where there are other members of the household present, ideally a distance of at least 2 metres (6 feet) must be maintained between you. If there are many family members present and where possible, ask them to leave the room, explaining why (need social distancing)
ensure two small waste bags are taken into the patient’s home. Any waste should be disposed of in the first bag, then double bagged prior to leaving the home

Procedures
Action	Rationale
Adopt standard infection control precautions: perform hand hygiene prior to donning selected PPE (see trust IPC guidance)	to ensure protection of the RN from cross-contamination to enable subsequent cleaning of the stethoscope and pen torch
Introduce self to family or carers if present, explain the reason for your attendance	To reassure family or carers and introduce self
Community: Complete a positive identity check with those present and available documentation Hospice: Check identify of the deceased by comparing the patient NHS number from a clinical record (drug chart) with name band	To correctly identify the deceased
Community confirm with the family or carer: deceased has been seen by a doctor within the last 28 days (in person) diagnosis	If yes, continue. If no, refer back to the GP To give RN information if needs referral to coroner. If industrial disease verify expected death and refer back to GP who will authorize removal of the deceased, letter 2
Check for documented individualised agreement to DNACPR in the clinical notes (ReSPECT with DNACPR decision or DNACPR V13) .	To ensure agreement of process
Identify any infectious diseases (see below), radioactive implants, implantable medical devices. Note, COVID-19 may not have been documented in the notes	To enable correct information to be passed on to ensure others involved in the care of the deceased are protected
Where applicable, ask a relative to ensure that a window is opened in the patient’s home for ventilation	To allow circulation of fresh air and reduce viral load
Open sterile sheet onto a clean surface and place suitably cleaned stethoscope and pen torch onto the sheet (community, this may be a dressing pack containing the required gloves, apron, waste bag and sterile sheet)	In readiness for the verification

Verification of death examination (the individual should be observed by the person responsible for verifying death for a minimum of five (5) minutes to establish that irreversible cardio-respiratory arrest has occurred. Note, a change in the order of examination to minimise contamination of equipment)
Action	Rationale
Lie the patient flat. Leave all tubes, lines, drains, medication patches and pumps, etc in situ (switching off flows of medicine and fluid administration if in situ) and spigot off as applicable and explain to those present why these are left	To ensure the patient is flat ahead of rigour mortis, and all treatments are in situ ahead of verifying death
Heart Sounds: using the stethoscope, listen for heart sounds through the clothing or nightclothes place stethoscope on sheet	To ensure there are no signs of cardiac output Ready for cleaning
Neurological response: using the pen torch, test both eyes for the absence of pupillary response to light place pen torch on the sterile sheet	To ensure there is no sign of cerebral activity Ready for cleaning
Respiratory effort: observe for any signs of respiratory effort over the five minutes. note, do not place your ear near to the person’s nose or mouth to listen for breathing	To ensure there are no signs of respiratory effort To avoid any risk of contamination
Central pulse: palpate for a central pulse (carotid) and if necessary through the clothing or night clothes	To ensure there are no signs of cardiac output
Motor response: after five minutes of continued cardio-respiratory arrest, test for the absence of motor response with the trapezius squeeze carry out the trapezius squeeze through the clothing or night clothes	To ensure there are no signs of no cerebral activity To minimise movement of the person and reduce contamination

Any spontaneous return of cardiac or respiratory activity during this period of observation should prompt a further five (5) minutes observations.
Action	Rationale
Hospice, ensure the patient is identified correctly with two name bands in situ completed with name, date of birth, address or NHS number	To ensure the patient is identifiable
Clean the stethoscope and pen torch with 2 in 1 antimicrobial wipe, for example, Clinell universal wipe and place clean sheet or Trolley	Follow infection control procedure for decontamination of equipment
Remove PPE in the correct order (see trust IPC guidance) including hand hygiene and place in waste bag (see trust guidance)	To eliminate cross-contamination from the equipment to anyone else
Community: after removal of PPE clean the stethoscope and pen torch again with 2 in 1 antimicrobial wipe, for example, Clinell universal wipe and place directly into nursing equipment bag Hospice: after removal of PPE, and once left the patient’s room, clean the stethoscope and pen torch again with 2 in 1 antimicrobial wipe, for example, Clinell universal wipe	Follow infection control procedure for decontamination of equipment
The RN verifying the death needs to complete the outcomes section in EPaCCs for verification of death in the clinical notes and record all discussions. Time of death is recorded as when verification of death is completed (for example, not when the death is first reported)	For legible documentation and legal requirements
The RN must notify the doctor of the death (including date and time) by the locally agreed procedure (community, letter 1 or 2 as appropriate)	To ensure consistent communication
The RN verifying the death must acknowledge the emotional impact of the death and ensure the bereaved family and friends are offered written information about “the next steps”	To ensure the family are supported during this difficult time

10.8.3 Notification of infectious diseases

Notifiable diseases are nationally reported in order to detect possible outbreaks of disease and epidemics as rapidly as possible, and it is important to note:

diagnosis of suspected (and, or confirmed) COVID-19 is a notifiable infectious disease
registered medical practitioners (doctor) have a statutory duty to inform their local health protection team of a diagnosis of a suspected notifiable infections disease, and without waiting for laboratory confirmation, at time of diagnosis (following usual processes)
all laboratories where diagnostic testing is carried out must notify Public Health England of any confirmation of a notifiable infectious disease
registered medical practitioners are required to report COVID-19 positive deaths to NHS England

10.9 Appendix I Letter 1 no contraindications

Appendix I Letter 1 No contraindications

Document control

Version: 3.3.
Unique reference number: 54.
Approved by: Clinical policies review and approval group.
Date approved: 02 April 2024.
Name of originator or author: Specialist palliative care nurse consultant.
Name of responsible individual: Chief nurse.
Date issued: 3 May 2024.
Review date: 30 May 2025.
Target audience: Registered nurses employed by RDaSH, working in unplanned nursing or the hospice (Doncaster case group only), who have been appropriately trained and have been assessed as competent in this procedure.

Page last reviewed: May 03, 2024
Next review due: May 03, 2025

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