Guidance

Coronavirus (COVID-19): verifying death in times of emergency

Published 5 May 2020

Applies to England

• Publication for Wales

Applies to: England (see publication for Wales)

1. Background and what this guidance covers

This guidance is designed to clarify existing practice for the verification of death outside of hospitals and to provide a framework for safe verification of death in this coronavirus (COVID-19) emergency period. It’s for all cases outside hospital when verification of death may be completed by people who have been trained to do so in line with their employer’s policies, including medical practitioners, registered nurses or paramedics. It’s also to be exercised by other non-medical professionals, usually and normally independent of family members, who are verifying death using remote clinical support. This helps avoid long delays in waiting for verification before the deceased person can be moved when medical practitioners are unavailable, which can be distressing for their families and those close to them.

All registered professionals must follow their professions’ code of practice and conduct. These require professionals to acknowledge the limits of their professional competence and only undertake practice and accept responsibility for those activities in which they are competent.

Non-medical professionals should not experience any pressure to verify deaths. If they are not comfortable or equipped to verify, they should defer to medical colleagues or refer on to NHS 111, the patient’s general practice or another provider of primary medical services. If they are content to verify, they can use remote clinical support.

This guidance can be applied to verification of all expected deaths during this emergency period, at the end of which the guidance will be reviewed. An expected death is the result of acute or gradual deterioration in the patient’s health and often due to advanced disease and terminal illness. The guidance should be applied for both confirmed and unconfirmed COVID-19 cases. It is relevant to all adult deaths in all settings (healthcare, social care and domiciliary settings and circumstances), with the exception of when a case must be reported to the coroner.

The coroner must be notified for any death that is unexpected, unnatural, violent or of an unknown cause. An unexpected death is one that is not anticipated or related to a known illness that has been previously identified, or unnatural or unexplained. The Notification of Deaths Regulations 2019 (the Regulations) provides that a death is typically considered to be unnatural if it has not resulted entirely from a naturally occurring disease process running its natural course, where nothing else is implicated. Regulation 3 (1) provides a list of circumstances requiring notification of death to the coroner. The coroner will also investigate all deaths that occur in prison or otherwise in state detention, such as young offender institutions, police custody and in hospitals, where the deceased is detained under the Mental Health Act 1983. A person with a deprivation of liberty safeguard (DoLS) in place is not considered to be in state detention.

COVID-19 as a cause of death (or contributory cause) is not a reason on its own to refer a death to the coroner under the Coroners and Justice Act 2009. That COVID-19 is a notifiable disease under the Health Protection (Notification) Regulations 2010 does not mean referral to a coroner is required by virtue of its notifiable status.

This guidance does not duplicate existing verification of death and care after death policies and procedures that already exist locally and nationally.

2. Verification of death in this period of emergency: standard operating procedure (SOP)

Hospital settings

This includes deaths occurring in an acute hospital including confirmed or unconfirmed COVID-19 cases.

Verification of death is performed by a medical practitioner or registered nurse (who is trained to do so).

Community settings

This includes deaths occurring in a community setting including confirmed or unconfirmed COVID-19 cases.

Verification of death is performed by professionals trained to do so in line with their employers’ policies (for example medical practitioners, registered nurses or paramedics) or by others with remote clinical support.

Equipment to assist verification of death

This includes:

• pen torch or mobile phone torch
• stethoscope (optional)
• watch or digital watch timer
• appropriate personal protective equipment (PPE)

Process of verification in this period of emergency

1. Check the identity of the person – for example photo ID.

2. Record the full name, date of birth, address, NHS number and, ideally, next of kin details.

3. The time of death is recorded as the time at which verification criteria^{[footnote 1]} are fulfilled.

For remote clinical support

During core practice hours, call the person’s registered general practice.

Outside core practice hours, call NHS 111 where a clinician will provide remote support to work through the verification process (see annex).

3. Other considerations

Unexpected deaths, whether child or adult, must be notified to the coroner using agreed policies. In all such cases, lines, drains, endotracheal tubes, for example, must not be removed without the express approval of the coroner. The verifier, and the clinician providing remote support (if used) have a responsibility to consider, as far as possible, whether there’s any reason to notify the death to the police or coroner.

If a parenteral infusion is in place, for example syringe drivers in a community setting, and the death is not notifiable to the coroner, the infusion must be stopped at the time of verification of death by simply removing the battery. Removing the device, accurate recording of residual drugs and safe disposal of equipment and medicines should take place in line with local policies and procedures.

Verification of death is the process of confirming the fact of death. It is different to certification of the cause of death. Certification of the cause of death is the responsibility of an attending medical practitioner via a medical certificate of cause of death (MCCD) completed later.

Where there are existing local arrangements that enable timely verification, these should not be disrupted.

Appropriate personal protective equipment (PPE) should be used in line with the latest guidance, consisting of disposable plastic apron, disposable plastic gloves and a fluid-resistant surgical mask.

Following verification of death, care after death must be performed according to the wishes of the deceased as far as reasonably possible. The deceased should be transferred to the mortuary or funeral directors as soon as practicable. Public Health England (PHE) guidance on the care of the deceased with suspected or confirmed coronavirus must be followed.

Every reasonable practical step must be made to inform people important to the patient when a patient’s condition is deteriorating or immediately following the patient’s death, if earlier contact has not been possible. In some instances, people important to the patient may request not to be disturbed at night. Any such agreement made must be documented and notification of death made at the agreed time.

Handwashing, and cleaning and decontamination of any equipment used for verification, for example torch and phone, should take place in line with section 13 of the PHE guidance.

4. Key resources:

1. Academy of Medical Royal Colleges, A code of practice for the diagnosis and confirmation of death, 2008

2. Special Edition of Care After Death: Registered Nurse Verification of Expected Adult Death (RNVoEAD) guidance

3. Guidelines for verification of death by paramedics – produced by the Joint Royal Colleges Ambulance Liaison Committee

4. Royal College of General Practitioners (RCGP) resource

Annex: Guidance for remote clinical support for verification of death

This process assumes that resuscitation has already been ruled out.

During core practice hours these actions should be conducted by a clinician from the patient’s practice.

Outside core practice hours the below actions should be carried out by a clinician working as part of the NHS 111 or Integrated Urgent Care Clinical Assessment Service (IUC CAS) (this would include ‘out of hours’ providers).

General considerations

• it’s important that you have enough time to carry out this procedure in a compassionate manner
• the below steps should be recorded in your organisation’s host IT system
• be aware of any cultural or religious requirements
• identify the person verifying and their role
• ensure the verifier has considered privacy and dignity prior to verifying – such as ensuring only essential persons are in attendance or checking with family whether they wish for only persons of the same sex to verify the body
• establish the circumstances immediately prior to the death and any patient history. You, and the verifier, need to be satisfied that there is no reason to refer this death to the police or coroner

Key questions

• Is this an unexpected death? If yes, report to coroner
• Is there any sign of a suspicious death? If yes, report to police
• Have you established the identity of the deceased person, for example using photo ID?

The verification process

Ask the verifier to complete the following checks:

Neurological system

To check	Confirmed
Check pupils are dilated and fixed (unresponsive to light directed into both eyes using a torch).
Check there is no response to painful stimuli. If you squeeze the muscle between the neck and the shoulder (the trapezius), do they respond?

Respiratory system

To check	Confirmed
Check that there is no movement of the chest wall for 3 minutes by observing the chest (you may need to advise removal of clothing to expose the chest or abdomen).

Circulatory system

To check	Confirmed
Advise verifier to find the site of the carotid pulse and check for 1 minute that pulse is absent.

Reassessment

To check	Confirmed
Wait 10 minutes and repeat the actions above.

Record that verification has been completed

Record in line with your organisational policy.

Suggested item to record	Recorded
1. Full name, date of birth, address and NHS number (if available) of person whose death is being verified
2. Name of person verifying
3. Role of person verifying
4. Who is present
5. Circumstances of death (location, who first noted it, anyone present at the time of death)
6. Outcome of verification, including time of death
7. Any discussions with staff or relatives
8. Any concerns from staff or relatives

Confirmation of Identity

For the purpose of confirming the identity of the deceased, it is recommended that an appropriate identity document is provided to the remote verifier, for example via the video call or separate secure email.

Following verification

Be clear about removal from the deceased or safe keeping of items such as jewellery. Inform the key person(s) of the next steps in the process and the range of options available to them.

1. Medical practitioners, registered nurses and paramedics, who are trained and competent to carry out verification of death, must adhere to their profession-specific guidance. ↩