Reports & recommendations

Serious Incident Procedures should be developed and put in place.

In the event of a serious incident the Chief Executive and Trust Board shall devise a suitable Serious Incident Procedure similar to those already in place for major disasters and review it from time to time making any necessary alterations.

When the procedure has been devised and prior to implementation the NHS Executive Regional Office shall assess its suitability and thereafter manage its performance, devising and instigating any necessary alterations from time to time.

In devising a Serious Incident Procedure the Chief Executive and Trust Board shall consider the need for a serious incident team independent of the hospital.

In devising a Serious Incident Procedure the Chief Executive and Trust Board shall take advice from and where necessary include within the serious incident team appropriate experts in bereavement, pathological reactions to bereavement and therapy.

The Chief Executive and Trust Board shall make available suitably trained staff for implementing the Serious Incident Procedure.

The Chief Executive and Trust Board shall inform all staff when a Serious Incident Procedure is in force.

The Chief Executive and Trust Board shall ensure the proper debriefing and support of all staff associated with a serious incident.

Universities and other public bodies shall adopt compatible procedures when acting in conjunction with an NHS serious incident.

Records should be reviewed and updated and an audit trail should be developed and put in place.

University records shall provide a confidential audit trail back to the clinical record.

University records shall identify receipt, use, dispersal and ultimate disposal of any organ or sample.

every hospital keep proper records (preferably computerised) as to the source, consent to retain, usage and disposal of organs and tissue;

every authorisation for release of organs for burial or cremation must not be completed until the content of the container is confirmed and the form counter-signed;

a moratorium must be declared if records of organ retention are inadequate during which there should be an immediate cataloguing of organs retained;

parents must never again be drip-fed information but should be kept fully informed.

Whatever the underlying contractual position, the relationship between Universities and Trusts, in respect of individuals and departments with dual clinical and academic functions, shall be one of the utmost good faith in both directions.

The duty of utmost good faith shall require either party to disclose to the other any substantial matter relating to the performance of the individual or department, whether clinical or academic.

Where there is any doubt as to whether a matter is of a substantial nature, if it relates to patient care the doubt shall always be resolved in favour of disclosure.

The appointment of clinical academics shall be approached with fair representation on each side reflecting the proposed split between clinical and academic sessions.

A single job description for clinical academics shall be drawn up jointly to represent a fair and realistic expectation of the work envisaged by both parties.

There shall be a joint procedure for disciplinary action against an individual perceived to be failing. It shall contain provision for immediate suspension from patient care as a minimum, irrespective of academic requirements and positions.

The relationship between Universities and funding bodies shall be of the utmost good faith and similar considerations shall apply.

There shall be close performance management of any new venture in its early stages and appropriate steps taken to modify the business plan as required.

Any substantial alteration in an existing venture shall be treated as if a new venture.

Where problems are identified a plan, jointly where necessary, shall be drawn up to resolve them as soon as possible.

If no solution is found after all diligent attempts, the parties should keep records of their attempts and the reasons why they have failed, such records to be lodged by way of report to the relevant NHS Executive Regional Office.

No clinician shall be appointed to a position of managerial authority in a hospital without having relevant clinical experience for the position.

No clinician should take effective control of a management position until trained in all necessary management techniques and in any relevant legal requirements.

No clinician shall be asked to take on responsibilities that impair the ability to carry out patient care to the appropriate standard.

Hospital managers shall be of a suitable background and calibre for the role expected of them, provided with all necessary training (including continued education) and themselves regularly appraised for the quality of their performance.

Hospital managers without medical qualification shall seek medical advice on matters requiring it. If there is doubt as to the need for advice on any matter relating to patient care, the doubt shall be resolved by seeking advice.

Clinicians wishing to retain organs or samples after the end of the Coroner’s process for the purposes currently allowed under the Human Tissue Act 1961 shall follow the Recommendations in Chapter 10.

Clinicians shall not mention to the next of kin the possibility of an examination under the Coroner’s jurisdiction unless the death is reportable to the Coroner.

Clinicians requesting a hospital post mortem examination after the Coroner has declined to authorise an examination shall make it clear to the next of kin that there is no compulsion remaining for such an examination.

Clinicians shall explain the contents and implications of a Coroner’s post mortem report to the next of kin as if the examination had been carried out as a hospital post mortem examination on their own recommendation.

The Home Office and the Coroners’ Society shall ensure all necessary medical education for Coroners.

The Home Office and the Coroners’ Society shall ensure all necessary training of Coroner’s Officers and ancillary staff.

Coroners shall be introduced, their function and procedures explained and the next of kin invited to express any specific concerns and requests.

If a decision is made not to authorise a post mortem examination, Coroners shall notify the next of kin of that decision and give sufficient reasons for the decision.

Coroners shall ensure the expeditious examination and recording of samples and organs.

Coroners shall establish efficient systems for securing final post mortem reports following histological examination.

Coroners shall ensure that all existing retained organs, tissue, blocks, slides, photographs and X-rays are specified within any preliminary and final post mortem reports.

The Department of Health, the Royal Colleges and medical schools shall instruct members of the medical profession in the precise terms and provisions of the Human Tissue Act 1961, on the basis of our analysis, and the need for strict compliance.

The class of persons relevant to the obtaining of fully informed consent shall be defined as the ‘next of kin’.

The class of ‘any surviving relative’ shall no longer be relevant to post mortem examination.

There shall be a programme of health education for the public relevant to the medical need for continued post mortem examination and access to organs and samples for therapeutic, educational and research purposes.

The Department of Health, the Royal Colleges and medical schools shall provide training for all those involved in obtaining fully informed consent.

The Human Tissue Act 1961 shall be amended to impose a criminal penalty by way of fine for breach of its provisions in order to encourage future compliance.

Following examination of the retained organs or tissue, there should be a meeting between the clinician and parents and referral for genetic counselling or other specialist advice if appropriate.

Local ethics committees be given a supervisory role to police approved research.

Explaining the circumstances of death, identifying when, where and who was present.

Arranging and attending a meeting for relatives with anyone who was present at the death if requested.

Encouraging a meeting between relatives and the treating clinician to explain the clinical circumstances of death and if requested arranging and attending the meeting.

Ensuring that relatives have a full explanation of the reasons for post mortem examination including therapeutic, medical education and research.

Explaining the need for consent to carry out a hospital post mortem examination (HPM) and the retention of organs.

Explaining that consent is necessary for the retention of organs following a Coroner’s post mortem examination (CPM) and that the consent must be obtained before the CPM is undertaken.

Ensuring relatives have sufficient time, privacy and support to reflect upon the request for consent to an HPM or the retention of organs following a CPM or an HPM.

Ascertaining whether the clinician will attend post mortem examination.

Facilitating meetings between parents, clinician and pathologist as appropriate.

Noting discussions between relatives, clinicians and pathologists and providing a copy to each party involved.

Developing and using information packs for relatives on all aspects of death in hospital.

Discussing counselling or long-term support needs with relatives, including the needs of wider family members and making contact with appropriate counselling/support agencies if requested.

Ensuring that relatives are aware of the full range of counselling/support resources available including those external to the hospital and bringing these matters to the attention of the relatives.

Accessing translation/interpreting services including services for people with hearing or visual impairment and providing appropriate written/taped information.

Assisting with any other individual problem presented by relatives in consequence of death.

Undertaking general liaison duties.