The Chief Nursing Officer for Scotland guidance (DL9) states:

• Whilst recognising the need to attend to acutely ill patients as a priority, if confirmation of death takes an extended time, it can cause anxiety for family or relatives, and if in a communal setting, to other people and residents
• Funeral directors can only respectfully remove the deceased once the confirmation of death has been completed
• The new guidance supersedes and revokes previous 1995 Verification of death communications contained within the previous Chief Medical Officer and CNO letters; specifically the ability for registered healthcare professionals to confirm death in any circumstances
• Regardless of the cause of death, certification of death remains the sole responsibility of a registered medical practitioner
• Confirmation of death is a process that may be undertaken by suitably trained and competent registered healthcare professionals
• Involvement of the Procurator Fiscal in deaths occurs through reports from the Police, the Registrar, Registered Medical Officers or hospital doctors. However, anyone who has concerns about the circumstances of a death may still confirm death where appropriate, and make the report to the Procurator Fiscal if necessary.
• There are certain categories of deaths that must be enquired into, but the Procurator Fiscal may enquire into any death brought to his/her notice (extracted from CNO Letter, 2 May 2017).

NHS Education for Scotland (NES), have produced a Confirmation of Death Framework (http://sad.uk.net/atafter-death/confirmation-of-death) to assist Health Boards to implement the CNO letter (DL (2017) 9) and it offers clarity on the following:

• a change in terminology from verification of death/ pronouncement of life extinct/cessation of life to confirmation of death which is easily understandable by lay and professional persons
• recognition that registered health care professionals can confirm death (rather than the previous restriction to registered nurses only) in any circumstances (rather than the previous restriction to ‘expected deaths’ only)
• registered healthcare professionals are able to confirm death, recognising their accountability and autonomy, and there is no requirement for permission to be given for a specified period of time by a registered medical practitioner
• should the healthcare professional not be present at the time of death, then information from those who were present may be taken into account when completing documentation the healthcare professional confirming death does not have to have known or treated the deceased person in life.

All those professionals required to undertake confirmation of death in their practice should refer to the following NES resources to gain knowledge and skills required to undertake this role:
http://www.sad.scot.nhs.uk/atafter-death/confirmation-of-death/

Death is “the irreversible loss of the capacity for consciousness, combined with the irreversible loss of the capacity to breathe” (Academy of Royal Medical Colleges 2008).
In most cases death occurs after the heart and breathing stop. In this situation irreversible damage to the brain occurs due to the length of time in which the circulation has been absent.
In the circumstances of a sudden unexpected death the Registered Healthcare Professional will use professional judgement to assess whether the initiation of life preserving measures such as CPR should be attempted.

Unnatural or suspicious death
An unnatural or suspicious death is a death which cannot be entirely attributed to natural causes including:

• Suspicious death – i.e. where homicide cannot be ruled out
• Drug related death – including death due to adverse drug reactions, reportable under the Medicines and Healthcare products, Regulatory Agency (MHRA)
• Accidental Death – (including those resulting from falls)
• Deaths resulting from an accident in the course of employment
• Child deaths children from overlying or suffocation
• Deaths where the circumstances suggest the possibility of suicide

Any death that is considered to be suspicious or unnatural should be reported to the Procurator Fiscal – for further guidance refer to Reporting Deaths to the Procurator Fiscal (2015)

• Healthcare professionals registered with a statutory regulatory body are expected to comply with standards of behaviour and education, and ensure that they have the knowledge, skills and competence for safe practice
• The Nursing and Midwifery Council (NMC) and the Health and Care Professions Council (HCPC) in their respective Codes expressly require that a registered healthcare practitioner should, within their scope of practice, ensure they possess the requisite skills, knowledge and experience to undertake any element of their role, and to:
  ‘Maintain the knowledge and skills you need for safe and effective practice’
  ‘Complete the necessary training before carrying out a new role’
  ‘You must keep your knowledge and skills up to date and relevant to your scope of practice through continuing professional development

The Professional Regulatory Bodies do not place any restriction on the scope of practice, provided that the registrant is in possession of the requisite elements as noted above.
The most appropriate healthcare professional should confirm a persons’ death.
It is acceptable for the Registered Healthcare Professional to decline to confirm death and to request the attendance of a Medical Practitioner and/or Police Officer if there is an unusual situation.
Whilst there is no legal impediment to the involvement of healthcare support workers in confirming death, the letter from the CNO recommends that the role be limited to registered healthcare professionals only. This ensures individual professional accountability, which is central to ensuring effective public protection and public confidence.
Each Operational Lead Nurse will be responsible for keeping a register of the staff members that are undertaking confirmation of death within their role and undertake an annual review as to relevance to their practice role.

Refer to Confirmation of Death Flowchart Appendix 1

Organisational responsibilities

The Confirmation of Death process may be undertaken by Registered Healthcare Professionals who have been;

• Identified by their manager as having a need to carry out this role
• Assessed as competent and confident to undertake Confirmation of Death following self- directed learning and discussions provided by a Registered Healthcare Professional experienced in Confirmation of Death. This may involve an OSCE approach to check confidence and competence if practice in clinical situations is not easily undertaken and may involve the use of technology
• The Registered Healthcare Professional must have the necessary skills and knowledge to enable them to be competent in determining the physiological aspects of death. Additionally, they should be aware of the legal issues and accountability that relate to this extended role.

The required competencies, self directed learning activities and resources are provided in Appendix 2
The record of assessment of competencies is found in Appendix 3

Line manager's responsibilities

• To identify appropriate Registered Healthcare Professionals to undertake this clinical skill
• To identify appropriate assessors within clinical teams
• Ensure that staff have access to this Policy
• Implement agreed training or education programmes to support this Policy and practice
• Ensure evidence of training and competency
• Monitor compliance with the Policy and procedures by undertaking local review to evidence appropriate practice and documentation

Assessor's responsibilities

• To be a Registered Healthcare Professional experienced and competent in the confirmation of death process
• To support supervised practice of the clinical skills
• To ensure that the Registered Healthcare Professional has demonstrated the knowledge, skills and confidence to achieve the required competencies and confidence

Registered Healthcare Professional Responsibilities

• To integrate this skill into their practice for the benefit of persons and families in their care
• Following self-directed learning demonstrate the level of competence to undertake this skill; be accountable and responsible for maintaining professional knowledge and competence to ensure safe and effective practice (NMC 2018, HCPC 2016 ). This should be evidenced through, TURAS appraisal and personal development plans.
• To utilise this skill across NHS Highland and retain their record of learning and assessment of competence as evidence.
• To be aware of circumstances in which a death should be reported to the Procurator Fiscal 
• To complete the NHS Highland Confirmation of Death form for all deaths confirmed – Appendix 2

When completed, the Confirmation of Death form (Appendix 2) should be kept by the RHCP for inclusion in their patient record. It is the responsibility of the Registered Healthcare Professional completing the form to inform the patient’s GP Practice.

The Registered Medical Practitioner Responsibilities

• Either issue a medical certificate of cause of death or contact the procurator fiscal to discuss the (Certification of Death Scotland Act 2011).

https://www.webarchive.org.uk/wayback/archive/20181226011252/https%3A//www2.gov.scot/Topics/Health/Policy/BurialsCremation/Death-Certificate

The Registered HCP must give consideration and respect sensitive cultural and faith issues when looking after a person who has died. For example:

• Several Asian religions object to contact with the body. Disposable gloves should be worn and the body kept covered with a plain white sheet
•  Jewish patients should not be touched until twenty minutes after death.

Read the guidance document ‘A multi faith resource for Healthcare staff’ produced by NHS Education for Scotland.

When examining the body, the registered HCP will undertake the following in line with the ‘Academy of Medical Royal Colleges (2008) A Code of Practice for the diagnosis and confirmation of death’.
http://aomrc.org.uk/wp-content/uploads/2016/04/Code_Practice_Confirmation_Diagnosis_Death_1008-4.pdf

1. Check for absence of carotid pulse over one minute
2. Check for absence of heart sounds over one minute
3. Check for absence of respiratory sounds over one minute
4. Check there is no response to painful stimuli (e.g. trapezium squeeze or sternal rub)
5. Check for fixed dilated pupils (unresponsive to bright light)

Remember to note if a pacemaker or other implantable device is present
If all of the above are negative then death can be confirmed.
Where the patient is hypothermic, greater care needs to be taken before confirming death. The one-minute tests indicated above are inadequate and need to be of five minutes duration.

The confirming Registered Healthcare Professional must then:

• Complete the Confirmation of death form as shown in Appendix 2
• Enter details into person record
• Inform the relevant Registered Medical Practitioner of the requirement to certify death
• Inform the relevant registered medical practitioner responsible for issuing the medical certificate of cause of death
• The RHCP must inform the on-call Executive Director if it is a child who has died unexpectedly.
  For the purpose of documentation the attached proforma should be completed and then filed in both nursing and medical records. All documentation must be completed in line with good record keeping as outlined in ‘The Code’ (NMC, 2015) and Health & Care Professions Council ‘Standards of Conduct, Performance & Ethics’

Once the death has been confirmed and documentation completed, dignified care after death can be carried out in accordance with local procedure, the patient and relatives wishes and any religious or cultural requirements. It will be important for the healthcare professional to discuss any cultural requirements with the person’s family or carers to ensure that they perform this skill in an appropriately sensitive manner pertinent to that individual. Care after death will be performed as per Highland Policy & Procedure for ‘Care After Death’

After the confirmation of death and in accordance with local policy and procedure, parenteral drug administration equipment and other invasive appliances such as catheters or drains, or any life prolonging equipment should be removed as per NHSH guidelines.

Academy of Medical Royal Colleges (2008) A Code of Practice for the diagnosis and confirmation of death
http://aomrc.org.uk/wp-content/uploads/2016/04/Code_Practice_Confirmation_Diagnosis_Death_1008-4.pdf
Crown Office and Procurator Fiscal Service (2015) Reporting deaths to the Procurator Fiscal. Information and guidance for medical practitioners
‘Confirmation of death by Registered Healthcare Professionals in Scotland - a framework for implementation of DL (2017) 9’.
https://www.gov.scot/publications/confirmation-of-death-by-registered-healthcare-professionals-framework/
The Code, Professional Standards and Behaviour for Practice for Nurses and Midwives NMC (2018) 
https://www.nmc.org.uk/standards/code/
Health and care professions Council (HCPC) Standards (2016)
https://www.hcpc-uk.org/standards/
General Medical Council (2019) Good medical practice
https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/good-medical-practice
CNO letter 2017
https://www.sehd.scot.nhs.uk/dl/DL(2017)09.pdf
Certification of death Scotland Act (2011)
https://www2.gov.scot/Topics/Health/Policy/BurialsCremation/Death-Certificate
Support around death
http://www.sad.scot.nhs.uk/
A multi faith resource for Healthcare staff produced by NHS Education for Scotland. https://learn.nes.nhs.scot/50422/person-centred-care-zone/spiritual-care-and-healthcare-chaplaincy/resources/multi-faith-resource-for-healthcare-staff

NHS Highland Spiritual Care Policy
NHS Highland Cardio Pulmonary Resuscitation Policy

https://www.sad.scot.nhs.uk/atafter-death/confirmation-of-death/
http://www.sehd.scot.nhs.uk/cmo/CMO(2016)02.pdf
http://www.gov.scot/Resource/0048/00483863.pdf
http://www.rcn.org.uk/get-help/rcn-advice/confirmation-of-death

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