Arero Hospital Patient Death Protocol

Arero Hospital Patient Death and Care for
Deceased Policy
2022 G.C
I. Introduction
 This policy is developed to ensure proper care for Deceased patients. It

specifically states the procedure to be followed for dead body care, including
how the staff breaks or informs the families and also considers the cultural
ceremony to be followed.
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II. AIM
 The aim of this policy is to provide guidance to healthcare and other
supportive workers involved in the care and handling of the deceased
person. This includes guidance regarding specific infections and how
potentially infected bodies should be managed after death to minimize
infection risk.
 This policy should be read in conjunction with other relevant Arero

Hospital Infection Prevention and Control Policies.
III. ROLES AND RESPONSIBILITIES

The Chief Executive (CEO)
 The Chief Executive is responsible for the standards of continuing care

given to a patient who dies whilst in Arero Hospital care or who is dead on
arrival. This responsibility continues until the deceased are removed from
Hospital premises.
Infection Prevention and Control Committee (IPPS)
 The Infection Prevention and Control Team are responsible for advising and
supporting staff in the infection control management of a deceased person.
Mortuary Staff
 The Mortuary Staff are responsible for informing funeral directors

(Environmental Health Unit Head) of any precautions required, beyond
standard precautions.
Doctors or Nurses Certifying Death
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 Doctors or Nurses Certifying Death are responsible for the completion of the
Mortuary Admission Form in consultation with the nurse in charge of the
ward.
Ward/ Department Heads
 Ward/ Department Heads are responsible for ensuring that all staff handling
a deceased person are aware of the actions of this policy
Ward Staff
 Ward Staff involved in the care of a deceased person are responsible for
ensuring the actions of this policy are followed.
IV. CONFIRMATION OF DEATH
 Death must be certified by the patient’s doctor whenever possible. However

when this is not possible, or out of hours, the doctor covering the ward/dept
where the patient has died must be documented in the patients notes the time
he/she certified the death and the process followed.
 A death occurring in the hospital should be confirmed by at least an

attending physician or any independent practitioner and the nurse giving
care.
 A death summary should be completed and documented in the patient’s

medical record, to ensure accuracy and easy retrieval.
 In case of a need for pathologic examination and confirmation for cause of

death, a post mortem examination form shall be completed and the body
should be transferred to the pathology case team or morgue.
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V. SUDDEN UNEXPLAINED DEATH
 Any unexpected deaths should be reported to and investigated by the Quality
Unit i.e. CGQI unit.
VI. RELIGIOUS/ FAITH/ PERSONAL

CONSIDERATIONS
 Communities religious and faith shall be considered in caring for the
deceased patient;
 Some people may wish to assist with last offices and some religions/ faiths
prefer or require the family to perform last offices.
 This should be facilitated by ward staff if at all possible,
 If family members do wish to assist with last offices they should be

instructed to take the same infection control precautions as staff.
VII. LAYING OUT DECEASED PERSON

 Lay out deceased person supine, closing his/ her eyelids. (It is helpful to do
this as soon as possible as the smaller muscles in the face develop rigor
mortis very quickly.
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 If the eyes will not remain closed gently pull down the eye lid and place
some damp cotton wool on top. (This will need to be removed before
viewing and/ or transportation to the mortuary). Leave at least one or two
pillows in situ. Straighten limbs.
 Wash the deceased person, unless they have recently been washed, clean
nails, nostrils, ears and mouth, tidy hair.
 Clean dentures and replace them in the mouth if possible. If not, place in a
labeled denture pot to accompany the deceased person to the Mortuary.
(Document on mortuary admission form).
 Replace other prostheses whenever possible. If unable to do so, these also

need to accompany the deceased person to the mortuary.
 The parents may wish to be involved in bathing a Deceased Person.
VIII. IDENTIFICATION AND WRAPPING

 Put shroud or personal clothing on deceased person, unless requested to do
otherwise. Secure ankles together with tape.
 Ensure deceased person has an identification bracelet on wrist (primary

identifier).
 The deceased person should be wrapped in a sheet. The hand displaying the
wristband should be left outside the sheet allowing pottering staff to check
ID.
 Whilst awaiting porters’ attendance, leave 2 pillows under deceased person’s

head. Once ID has been checked with pottering staff the hand should be
closed in the sheet wrapping the deceased person completely. Sheet may be
secured with a small amount of tape. Do not wrap sheet too tightly,
particularly around the face.
 If the deceased person is likely to continue having leakage, in spite of

precautions, place in body bag. Body bags are also to be used in case of
certain infections,
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 Infectious cases – If a deceased person is known to have suffered from a
high risk or hazard this information must be entered onto the mortuary
admission form which will accompany them to the mortuary. For reasons of
confidentiality, neither labels nor form must state the diagnosis.
IX. TRANSPORTATION FROM WARDS

TO THE MORTUARY
 Protective clothing is not required by staff during transportation if proper
containment is adhered to and the patient is not removed from an isolation
room. If body fluid leakage or improper containment is noted at the time of
collection, removal should be halted until the ward nursing staff has rectified
the situation.
 Hands must be washed before returning to subsequent duties.
 Personal protective clothing (PPE) is available within the mortuary for use
when transferring the deceased.
 If the Next of Kin want to remove the deceased person from the ward; they
shall contact Chief Clinical officer or CEO
 For baby / child it might be preferable for a member of the nursing team to
transport the baby. There is a pram or Moses basket available for this
purpose.
 For parents who do not want their child to be in the mortuary, arrangements
can be made with environmental health officers to meet the porters at the
mortuary, as long as the medical certificate of cause of death, if needed, are
completed.
 The mortuary admission form will still have to be completed. Parents can
make their own personal arrangements and not use a funeral Service at
Hospital. Documentation shall still have to be completed.
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X. BODY STORAGE
 Following completion of necessary medical examinations, the body shall be
stored in the hospital’s morgue until it is collected by the patient’s relatives
or other responsible person.
XI. DECEASED PATIENT’S PROPERTY

 The personal property of the deceased person is to be listed in the ward
property book.
 All property must be labeled clearly with the deceased person’s name and
hospital number.
 Relatives should be advised to wash their hands after handling soiled

clothing.
 Relative or families of the deceased shall be properly identified and/or bring

necessary legal documents to get property of the deceased patients.
XII. POST – MORTEM PROCEDURES

 Infection Control in the mortuary as elsewhere is based on
universal/standard precautions, i.e. the prevention of contamination of
workers, irrespective of the knowledge of the deceased persons’ infection
status.
 Standard operating procedures (SOP) in the mortuary should include

documented risk assessments and control measures for infection risks.
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 Where a deceased person is not properly identified i.e. police cases, road
traffic collisions, these should be treated as high-risk cases, unless additional
information becomes available.
XIII. HANDOVER TO FUNERAL

DIRECTOR/Local Authority/Family
 Environmental health professionals and ambulance staff must be informed if
the body of the deceased person is a known or suspected infection hazard.
The information should not include diagnosis or confirmation of the
particular infectious agent but rather the route of transmission.
 Very occasionally there is a direct release of a deceased to an undertaker or

very rarely directly to a family member. This person will present with a
body release form to which the mortuary staff are obliged to respond to. In
this instance advice is to be given to this person on precautions in the event
that the deceased is infectious.
 If the patient does not have a next of kin, the local authority is responsible
for collecting the body.
 Transport arrangement shall be made to transfer the deceased patient to their

families or relatives.
XIV. TRAINING/ AUDIT AND

COMPLIANCE MONITORING
 Relevant information on Infection Control will be included in local
induction and mandatory programmers for nurses, healthcare assistants,
porters and mortuary staff. This will include hand hygiene and use of PPE.
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 All Hospital staff have a duty to incident report any failure to comply with
this policy. Infection Prevention & Control related incidents are reviewed
quarterly by the Infection Control Committee (ICC) and action taken as
required.
XV. APPLICABILITY
 This policy applies to all staff employed by Arero Hospital whether on a
permanent or temporary basis.
XVI. REVIEW
 This policy will be reviewed in 3 years or earlier if major changes are
required.
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What are the roles and responsibilities outlined in the policy?

What are the roles and responsibilities outlined in the policy?

What steps must be followed to confirm a patient's death?

What steps must be followed to confirm a patient's death?

Arero Hospital Patient Death and Care for

 This policy is developed to ensure proper care for Deceased patients. It

 This policy should be read in conjunction with other relevant Arero

III. ROLES AND RESPONSIBILITIES

 The Chief Executive is responsible for the standards of continuing care

Infection Prevention and Control Committee (IPPS)

 The Mortuary Staff are responsible for informing funeral directors

Doctors or Nurses Certifying Death

Ward/ Department Heads

IV. CONFIRMATION OF DEATH

 Death must be certified by the patient’s doctor whenever possible. However

 A death occurring in the hospital should be confirmed by at least an

 A death summary should be completed and documented in the patient’s

 In case of a need for pathologic examination and confirmation for cause of

VI. RELIGIOUS/ FAITH/ PERSONAL

 This should be facilitated by ward staff if at all possible,

 If family members do wish to assist with last offices they should be

VII. LAYING OUT DECEASED PERSON

 Replace other prostheses whenever possible. If unable to do so, these also

 The parents may wish to be involved in bathing a Deceased Person.

VIII. IDENTIFICATION AND WRAPPING

 Ensure deceased person has an identification bracelet on wrist (primary

 Whilst awaiting porters’ attendance, leave 2 pillows under deceased person’s

 If the deceased person is likely to continue having leakage, in spite of

IX. TRANSPORTATION FROM WARDS

 Hands must be washed before returning to subsequent duties.

XI. DECEASED PATIENT’S PROPERTY

 Relatives should be advised to wash their hands after handling soiled

 Relative or families of the deceased shall be properly identified and/or bring

XII. POST – MORTEM PROCEDURES

 Standard operating procedures (SOP) in the mortuary should include

XIII. HANDOVER TO FUNERAL

 Very occasionally there is a direct release of a deceased to an undertaker or

 Transport arrangement shall be made to transfer the deceased patient to their

XIV. TRAINING/ AUDIT AND

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