The Policy for the Reporting, Management and Investigation of Adverse Incidents (including Serious Untoward Incidents)

Document No: P057

Appendix C3:

Guidance on Working with Families after an Unexpected Death

This good practice guidance has emerged from staff’s experiences of dealing with perhaps the most difficult event of all in mental health practice, an unexpected death.

  1. General Principles
  • Always contact the family: Staff are often concerned about the reaction of families to contact from the mental health services after a relative has died unexpectedly, and about intruding into the family’s grief. However, feedback from relatives is that hearing nothing from the service is what angers/upsets them most, because it is taken to mean that we donot care about what has happened. Services working well with relatives have as much contact as possible, without being intrusive.
  • Make everything as easy as possible. The relatives will be dealing with many issues both psychologically and practically. They need simple, straightforward interactions with the mental health service so that bureaucracy does not add to their distress. They may need things to be repeated, or conversations to be summarised in writing. It may be helpful for them to have one person as point of contact with the Trust.
  1. Immediate actions
  1. Ensuring the family know about the death. If the death occurs whilst the service user is an inpatient, the member of staff in charge at the time must ascertain that the relatives have been told (this is normally done by the police). The details of the initial contact should be relayed to the Line Manager. If the death occurs in the community, the team may have obtained the information through various possible routes, but the Team Manager should ascertain the state of knowledge of the relatives at the earliest opportunity.
  2. Expressing condolences and establishing a single point of contact. The Team Manager must be informed, and will write a letter of condolence which will also tell the relatives the name and the contact number of the nominated contact person (the Family Liaison Worker). This role should be allocated within 72 hours. A letter from the Team Manager does not preclude other members of the team writing their own letter(s), nor does the appointment of a Family Liaison Worker preclude other staff meeting with the family, where appropriate, although the Family Liaison Worker should be aware of such meetings.
  3. The Bereavement Policygives details about a range of practical issues which need to be addressed when someone dies and contains the procedures that should be followed
  1. The named contact should discuss with the team if it is appropriate to contact the relatives in due course to obtain details of the funeral arrangements.
  1. Ongoing support

Ongoing support for the family is provided by the Family Liaison Worker. Their roleis to provide a single point of contact for the family in order to:

  • Provide practical information (see Bereavement Policy) in relation to dealing with personal effects, obtaining a death certificate, explaining (if appropriate) the role of the coroner and ensuring that the family have information and telephone numbers to contact for further information.
  • Ensure that they have all the relevant information to help them during the initial stages of bereavement.
  • Identify and help the family engage other agencies which could provide them with assistance
  • Identify unresolved issues or concerns which the family have in connection with the care provided by the Trust and to establish the appropriate mechanisms (through meetings etc) to help the family articulate their concerns and come to resolve these issues
  • Guide the family through any internal processes – UnexpectedDeath Audits (UDA’s)/Root Cause Analysis which may be undertaken
  • Identify the extent to which the family wish to be involved with any internal investigation and ensure that they are provided with timely and regular information
  • Provide feedback to the Trust on concerns that the family have to ensure these are dealt with in a timely fashion and to minimise the risk to individual members of staff during an inquest.

The identity of the Family Liaison Worker

The Family Liaison Worker could be of any discipline but it is most likely, in the case of an inpatient death, to be a ward Manager or Modern Matron. For community deaths it may be the Team Manager or Care Coordinator. This person:

  • Should have sufficient authority to reassure the family on any internal investigations which will take place and explain the processes to them
  • Should not be a person who could be the focus of anger from the relatives or may be implicated by the family in a complaint

The skills of the Family Liaison Worker

It should be recognised that the role of the Family Liaison Worker can be demanding and extend over a significant period of time. Sufficient training should be invested in this individual who must have a clear understanding of his/her role and expectations. The Family Liaison Worker should possess the following skills:

  • Have a good understanding of the grieving process
  • A good understanding of the internal processes to help provide information and support in a timely and sensitive fashion
  • Have excellent communication skills and be able to liaise with a grieving family and also other agencies including senior management teams
  • Have good organisational skills and assist in the process of convening meetings with the family and Trust staff as appropriate

Outlines of the Process

It is essential that the contact with the family be managed individually depending on the needs of the family. Guidance on communicating with families following an incident is contained in the Being Open Policy.

There are some basic processes which have to be observed in all cases to provide a structure to this process. The Family Liaison Worker should, therefore:

  • Make personal contact with the family within 5 days and arrange a meeting (if the family are in agreement) at that time. They should confirm their role at this time.
  • Identify the needs of the family and document the planned intervention in a file, which will later be added to the deceased persons health record.
  • Document the concerns of the family and the mechanisms by which these are to be addressed.
  • Listen to what the relatives have to say, in particular any complaints or issues they want explained. However, the purpose of meeting is not to try and offer any explanation of why things happened as they did or any views as to whether care could have been different. This would risk prejudging the outcome of the audit and jumping to conclusions on the basis of an incomplete picture, which could then be difficult to move away from at a later date when the full picture emerges. It is appropriate, however, to incorporate any relevant issues the relatives have into the management investigation, and the audit process.
  • Be the link coordinator between the Trust and the family, and be informed of the progress of the UDA to pass on to the family
  • Ensure that the UDA chairis kept informed of the key issues that the family want to have addressed and convene meetings as required and requested by the family.
  • Anticipate that input will be time limited to 6 months – or the completion of the UDA process. It should be noted that this is not a counselling service and if further support is required the Family Liaison Worker should encourage the family to engage with independent counselling services.
  • Be responsible for maintaining records and reviewing the process with their line manager (at the end of their input) so that those interventions which were particularly helpful are identified and any lessons learned are shared.

Record Keeping

Feedback from the family, and the management of their concerns, is an important risk management issue. Learning from the way in which death is managed is central to improving the quality of care the trust provides to relatives. Only by ensuring that the process is accurately documented and, therefore, open to scrutiny and review can these important lessons be learned. It is a central feature to this process that the Family Liaison Worker not only records the contact made with the family but identifies the processes that the family found useful.

A dedicated Family Care Plan should be completed in all cases and kept on the ward / work area of the Family Liaison Worker. Any other communication that clinical staff have with the family should be filed alongside this document and will eventually be filed with the Health and Social Care records. The Family Care Plan should be referred to by the UDA Chair, the Associate Director for Risk and Compliance, the Complaints Manager and by the relevant manager /Trust Solicitor prior to inquests. When the term of involvement with the family is over this document should be sent to the Associate Director for Risk and Compliance for final analysis before filing with the deceased’s medical records.

  1. Following the Trust’s investigation of the death

Once the Unexpected Death Audit has been completed, the report should be shared with the family.

  1. Post-audit meeting. After the final version of the audit has been agreed (accompanied by a clear action plan for any recommendations) the Family Liaison Worker should contact the relatives to arrange a meeting. The likely appropriate members of staff to attend this meeting will be the Family Liaison Worker, the Area Manager and the chair of the audit. Family members may be accompanied by a friend or advocate if they wish.
  2. The purpose of a post-audit meeting is to:
  3. Express condolences once again, and ask after the relatives’ welfare
  4. Listen to any further issues they may wish to discuss
  5. Go through the audit report with them, and either answer questions they have, or agree how they will be answered later
  6. Share what is known about the inquest arrangements, and what the procedures will be at the inquest
  7. Review any need for further contact or meetings
  8. Good practice points regarding meetings
  • Meetings need to be arranged at a time and place convenient for the relatives
  • Sensitivity needs to be shown in the choice of venue

Drinks and tissues need to be provided

  • One and a half hours is probably a good duration to aim for – much longer and the relatives will be exhausted, much shorter and it may appear rushed. However, the room should be booked out for longer – either the relatives or the staff may need it to gather their thoughts after the meeting has finished, before they leave.
  • Any documentation should be given out at the meeting, not sent ‘cold’ beforehand. There should be sufficient copies for all attendees.
  • Thought should be given as to the balance of attendees – too many staff meeting one or two relatives can appear either defensive or intimidating
  • Staff may understandably find such meetings difficult – as will the relatives. It may help to start the meeting by asking the relatives to talk a little about the deceased – particularly as one or more of the staff may not have known the deceased in life.
  • There should be an opportunity for the staff to be debriefed by their line manager(s) after a meeting.
  • The chair of the meeting should summarise at the end, and give the relatives the opportunity to cover any other points before winding up.
  • Meetings should be followed by a letter summarising the main points that were discussed, and confirming any ongoing arrangements
  • It is not appropriate for either the audit report, or for the staff at the meeting, to name individual staff in discussions about the patient’s care.
  • It is appropriate to discuss issues of concern at a meeting, but not to attempt to answer a formal complaint, which should be dealt with through the complaints procedure.
  • Staff need to be aware that they must have due regard to patient confidentiality in respect of the deceased.
  1. Resources for Family Liaison Workers and bereaved relatives

The Department of Health have produced a leaflet for relatives bereaved by suicide, entitled Help is at Hand. This may be a useful resource for families and carers and for those supporting them. It is available from:

http://www.dh.gov.uk/en/AdvanceSearchResult/index.htm?searchTerms=help+is+at+hand

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