Policy for the Handling and Release of the Deceased

Outside Normal Hours

Approved By
Date Approved
Trust Reference DRAFT
Version V1
Supersedes
Author / Originator(s) Eleanor Meldrum, Assistant Director of Nursing
Matthew Rogers, Mortuary Manager
Name of Responsible
Committee / Individual
Review Date January 2012
 CONTENTS PAGE

Section Page

1. Introduction ......................................................................................................... 3
2. Scope ................................................................................................................... 3
3. Roles and Responsibilities ............................................................................... 3
4. Handling and Release Procedures ................................................................... 4
5. Process for Monitoring Compliance ................................................................ 5
6. References and Useful Contacts ........................................................................ 5
7. Development, Consultation and Review ......................................................... 6
8. Dissemination, Implementation and Access .................................................. 6
9. Legal Liability ...................................................................................................... 6

Appendix One Formal Identification and Viewing of the Deceased 8

Appendix Two Actions for the Duty Manager Prior to the Release of the 10
Deceased from the Mortuary
Appendix Three Reporting Deaths to H M Coroner 14
Appendix Four Completion of the Medical Certificate of Cause of Death 16
Appendix Five Flow Diagram for the Adult Medical Certificate of Cause of 17
Death
Appendix Six Release of the Deceased from the Mortuary 18
Appendix Seven Flow Diagram for the Release of the Deceased 19
Appendix Eight Procedure for the Certification of a Stillbirth 20
Appendix Nine Procedure for the Release of a Non-Viable Fetus 21
Appendix Ten Procedure for the Release of Products of Conception 22
Appendix Leicester Registry Office Out of Hours Opening Times for 23
Eleven Registering a Death

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1 INTRODUCTION
1.1 This document sets out the University Hospitals of Leicester (UHL) NHS Trust Policy
for dealing with the out of hour’s procedures¹ relating to the handling and release of
deceased patients for burial only.
The most commonly requested reason for out of hours (i.e. urgent) release of a body is
usually to meet the religious need for a speedy burial date but there may be other
legitimate factors for consideration, other than the religious faith of the family. If
requests are received from families without the expression of religious need then such
special requests must also be considered on their individual merits.

During the normal working hours between 9-4pm Monday to Friday, all urgent body
release requests are managed by Bereavement Services who follow the Standard
Operating Procedure for the Release of the Deceased and Completion of Statutory
Documentation following Death.

2 SCOPE
2.1 The policy covers all three hospital sites within University Hospitals of Leicester NHS
Trust (UHL) and applies to all deceased patients (adult and children), stillbirths, non-
viable fetuses and products of conception requested for release outside normal hours.
2.2 The policy applies to all Duty Managers, on-call managers and Directors, registered
nurses and midwives, doctors, Mortuary Services, Porters and Bereavement Services
Officers.

3 ROLES AND RESPONSIBILITIES

3.1 Porters
Responsible for allowing access to the Mortuary and to secure the department after release
and the use of storage and lifting equipment to remove the deceased onto a tray including
the disinfection and return of the tray after release.
3.2 Duty Managers:
Responsible for responding to and coordinating all requests for the handling and release of
the deceased outside of normal working hours (or when the mortuary is closed at the
Leicester General and Glenfield during the week).
3.3 On call-managers and Directors
To provide additional advice and support to the ward staff or the Duty Manager (particularly
during times of competing priorities for the Duty Manager who may need to delegate bed
management issues to on-call managers to allow a release to take place)
3.4 Head of Midwifery / Registered Midwifery Staff
Responsible for issuing the Hospital Non-Viable Foetal Burial Form or Pregnancy Loss Form
3.5 Registered Nurses
Responsible for informing the Duty Managers that the deceased’s next of kin have requested
the early release of the body for burial.
3.6 Mortuary Staff - Anatomical Pathology Technician (APT)
To provide on-call advice and support to Duty Managers in the handling and release of the
deceased from the mortuary including the removal of drains, lines and catheters at the time
of release, where appropriate.

_________________________________________________________________________________________________

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¹ Out of Hours is defined as the times that the Mortuary and Bereavement Services at the LRI, LGH and GH is
closed – see Appendix One for details of opening hours

3.7 Senior Bereavement Services Officers / Bereavement Services Officers

To deliver the training required for Duty Managers and on-call managers in the release of the
deceased out of hours. On the next working day after every out of hours body release,
Bereavement Services Officers will ensure that all statutory documentation has been
completed correctly and Duty Managers or doctors will be informed of any errors or
omissions.

3.8 Head of Chaplaincy and Bereavement Services and UHL Admission and
Discharge Manager
To develop and facilitate the delivery of training in the procedures outlined in this policy to all
duty managers, on-call managers and Directors.
To audit compliance with the policy and deal with any untoward incidents or complaints that
arise from UHL staff or external agencies that do not follow the correct out of hours body
release procedure
To take appropriate actions where necessary to prevent reoccurrence of any untoward
incident or complaint
To communicate any amendments to the policy in a timely way to all staff involved in the
handling and release of the deceased outside normal hours.

3.9 Medical Director / Consultant Medical Staff and Junior Doctors

To support the development of training programmes for all medical staff in relation to
referring cases to HM Coroner and the completion of statutory paperwork following a patients
death and raise awareness amongst junior medical staff of their responsibilities with the
accurate and timely completion of the Medical Certificate of Cause of Death

4 HANDLING AND RELEASE OF THE DECEASED OUTSIDE NORMAL HOURS

Staff must follow the following procedures for the handling and release of the deceased
outside normal hours as set out in the text and appendices of this Policy:

Appendix One Formal Identification and Viewing of the Deceased

Appendix Two Actions for the Duty Manager Prior to the Release of the Deceased from the
Mortuary
Appendix Three Reporting Deaths to H M Coroner
Appendix Four Completion of the Medical Certificate of Cause of Death
Appendix Five Flow Diagram for the Medical Certificate of Cause of Death
Appendix Six Release of the Deceased from the Mortuary
Appendix Seven Flow Diagram for the Release of the Deceased
Appendix Eight Procedure for the Certification of a Stillbirth
Appendix Nine Procedure for the Release of a Non-Viable Fetus
Appendix Ten Procedure for the Release of Products of Conception
Appendix Eleven Leicester Registry Office - Out of Hours Opening Times

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5 PROCESS FOR MONITORING COMPLIANCE
5.1 Key performance indicators / audit standards
a) Compliance with the policy by all staff involved in the handling and release of the
deceased outside normal hours using the following standards:-
Standard Release - If the deceased is not referred to HM Coroner and / or does not
require a post-mortem or cremation, the body should be ready for release to the next
of kin or Funeral Directors within two working days following death (i.e. for deaths
prior to noon, by the end of the next working day and for deaths after noon, by the
close of the second working day).
Urgent Release for religious or cultural requests - If the deceased is not referred to
HM Coroner and does not require a post-mortem or Cremation; the body should be
ready for release to the next of kin or Funeral Directors as soon as possible after
death with no avoidable delays. Ideally, release should take place before dusk
following the patient’s death, where time allows.
b) There will be no errors or avoidable delays in the completion of the statutory
paperwork that allows the urgent release of the deceased into the care of Funeral
Directors or a representative nominated by the next of kin.
5.2 Process and timescales for monitoring compliance
a) Bereavement Services will audit the time taken between the original request for the
urgent release of the deceased to the time of the actual release from the Mortuary.
b) The Head of Chaplaincy and Bereavement Services to audit the number and type of
formal complaints or concerns reported by the next of kin, Funeral Directors, faith
groups, HM Coroner or Superintendent Registrar regarding delays or problems
experienced with the release of the deceased out of hours.
c) Audit results will be reviewed on a bi-monthly basis by the Head of Chaplaincy and
Bereavement Services and the Admission and Discharge Manager. Appropriate
actions will be taken to address any issues that caused an avoidable delay to a
release.
d) Audit results will be reported to and monitored by the End of Life Care Board who will
make recommendations for improvement where required.
6. REFERENCES AND USEFUL LINKS AND CONTACTS
6.1 Related Documents
Death of a Patient: DMS Document: 26526
Last Offices Policy: DMS Document 32578 (Under Review)
Guidelines Following a Death of a Child: DMS Document: 31010
Management of Maternal Death: DMS Document: 16691
Sensitive Disposal of Foetal Remains DMS Document: 35054 (Under Review)
Patients Property Policy DMS Document : 24 / 2007
6.2 References
Births and Deaths Registration Act 1953 (c.20)
6.2 Links
Muslim Burial Council of Leicestershire
http://www.mbcol.org.uk/
Undertakers of Leicestershire
http://www.uk-funerals.co.uk/funeral directors/leicestershire.html

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6.3 Contact telephone numbers
UHL Duty Manager LGH / LRI / GH Bleep via UHL Switchboard
Leicestershire Constabulary Police Control: 0116 2222 222
On-call Anatomical Pathology Technician: Bleep via UHL Switchboard
*HM Coroner for Leicester and South Leicestershire: 0116 225 2535
(*normal working hours only)
Leicester Registry Office - general enquiries or to make 0845 045 0901
an appointment to register a birth or death
(*normal working hours only - see appendix 10 for out of hours contact)

Muslim Burial Council of Leicester (MBCoL)

MBCOL Office: 0116 273 0141
Salim Mangera: 07833 533 490 (Office Manager)
Adam Sabat: 07801 101 786 (Trustee)
Mohamed Omarji: 07855 931 911 (Trustee)
Zubeir Hassam: 07879 610 649 (Trustee)

A full list of the MBCOL Board can be found on the organisations website, www.mbcol.org.uk

7 DEVELOPMENT, CONSULTATION AND REVIEW

The Policy has been developed by a multi-professional group consisting of representatives
from the UHL Duty Manager Team, Head of Chaplaincy and Bereavement Services,
Bereavement Services, Mortuary and Pathology Services, Nursing and Midwifery, Medical
Director, Infection prevention and Control and Service Equality.
The Policy has also been circulated for comments to HM Coroner, Superintendent Registrar,
MBCoL and to faith groups in Leicester.
The Head of Chaplaincy and Bereavement Services will be responsible for reviewing the
Policy at regular intervals, no more than two years apart (or earlier in response to changes in
national guidelines or Coroners Reforms). The policy will also be reviewed in conjunction
with the Medical Director, Mortuary, Duty Manager Team, HM Coroner, Superintendent
Registrar, MBCoL and other faith groups in Leicester.

8 DISSEMINATION, IMPLEMENTATION AND ACCESS

The Document will be available on the UHL Document Management System (DMS) and will
be circulated to all staff with responsibilities for the handling and release of the deceased out
of hours.

9 LEGAL LIABILITY
The Trust as an employer will assume vicarious liability for the acts of its staff, including
those on honorary contracts, providing that:
• Staff have undergone any suitable training identified as necessary under the terms
of this policy or otherwise.
• Staff have been fully authorised by their Line Manager and their Directorate to
undertake the activity.
• Staff fully comply with the terms of any relevant policies and/or procedures at all
times.
• Only depart from any relevant Trust Guidelines providing that such departure is
confined to the specific needs of individual circumstances. In healthcare delivery
such departure shall only be undertaken where, in the judgement of the responsible
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 clinician it is fully appropriate and justifiable – such decision to be fully recorded in
the patient’s notes.
Staff are recommended to have Professional Indemnity Insurance cover in place for their
own protection in respect of those circumstances where the Trust does not automatically
assume vicarious liability and where Trust support is not generally available.
These circumstances will include but are not limited to, those situation where the above
criteria do not apply or are not observed, private treatment (which may include Samaritan
Acts), and criminal investigations. Suitable Professional Indemnity Insurance Cover is
generally available from the various Royal Colleges and Professional Institutions and Bodies.
For further information contact Assistant Director (Head of Legal Services) on ext 8960

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 FORMAL IDENTIFICATION AND
VIEWING OF THE DECEASED Appendix One
Policy for the Handling and Release of the Deceased Outside Normal Hours

1. Formal Identification of the Deceased`

1.1 Formal identification of a deceased patient is only at the request of the police or the
Coroners Office and usually only takes place at the Leicester Royal Infirmary (LRI)
Mortuary. The on call Anatomical Pathology Technician (APT) at the LRI must be
contacted via the Hospital Duty Manager to arrange formal identification
2. Procedure:
a) Check that the deceased is in the mortuary (by checking in the mortuary admission
book and fridge) and is in a suitable condition to be viewed. Concerns should be
discussed with the police.
b) Deceased must be transferred from the fridge to viewing room (by the APT using
standard precautions for infection prevention and control). The APT will prepare the
deceased and be present at the viewing
c) The Police or the Duty Manager must accompany the family to the Mortuary to
ensure that the APT is not alone within the department. Family members must be
advised not to touch or kiss the deceased. The family must not be left alone with the
deceased (to ensure that property is not removed without the knowledge of staff,
and to ensure the safety of family members). Samples of hair can be removed by
the next of kin.
d) If valuables or property are removed for safekeeping or by the family, it must be
entered and signed for in the UHL Property Book and the disclaimer signed (see
appendix five UHL Patients Property Policy document number….)
e) If the deceased is already in a body bag they must not be removed from the bag.
The deceased must be transferred to viewing room in the body bag and that the
bag is pulled back from the face of the deceased by the APT.
3. Viewing the Deceased in the Mortuary (LGH / GH / LRI)
3.1 Requests for adult viewings are not routinely performed outside of normal office hours
on all three hospital sites because of the restricted mortuary service². It is desirable
that viewings are delayed until the next working day wherever possible. This allows
viewings to take place in a more supportive environment and for families to combine
viewing with the visit to collect documentation particularly if they live a long distance
away. However, all requests should be made via the Duty Manager who can contact
the on-call APT for advice or on-call managers for additional on-site bed and duty
management support whilst the Duty Manager is required to deal with requests.
a. Viewings of babies at the LGH
Viewing of babies may take place within the Maternity Unit outside of normal working
hours co-ordinated by the Maternity Unit staff who in turn, will contact the Maternity
Porters to request the return of a deceased baby for viewing.
b. Viewings of babies at the LRI:
Viewing of babies may take place within the Maternity Unit outside of normal working
hours co-ordinated by the Maternity Unit staff who in turn, will contact SERCO Porters
to request the return of a deceased baby for viewing.
___________________________________________________________________________________________________
²Opening hours during the week for the Mortuary at the LGH is 12-4pm and the GH is 9am-12mday. Duty
Managers will need to authorise body release outside of the ‘normal’ opening hours of the Mortuary supported by
Bereavement Services and the Clinical Business Units who will support bed management processes.

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4.0 Requests from families for Visual Recordings or Images of the Deceased
Visual recordings of the deceased by next of kin within the viewing room are
permitted.
5.0 Visual Recordings or Images of Faulty Equipment Involved in Staff Incidents
Outside of normal working hours, the duty manager can authorise a visual recording
to be made in the event of an incident / adverse event (i.e. staff accident involving
lifting equipment / trolley’s). In such cases the Mortuary Manager must be informed of
the details of visual recordings.

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 ACTIONS FOR THE DUTY
MANAGER PRIOR TO THE
RELEASE OF THE DECEASED Appendix Two
FROM THE MORTUARY Policy for the Handling and Release of the Deceased Outside Normal Hours

1. Actions to be taken by Duty Managers prior to the Release of the Deceased

Requests made by next of kin for the urgent release of the deceased should be made
by ward staff to the Duty Manager via bleep or switchboard. Prior to the release
taking place, the following questions must be asked by the Duty Manager to ensure
that the correct process is followed;
1.2 Is this a burial or cremation?
a) UHL provides a limited service outside normal office hours that enables the urgent
release of the deceased for burial only providing the relevant statutory
documentation has been completed and is available prior to release.
b) Requests for cremation are not usually managed out of hours because:-
i) The burials and cremation office and Medical Referee require 72 hours notice
before cremation can take place in order to comply with legislation and this
communication can only happen during normal working hours.
ii) It is unlikely that cremation form four and five of the cremation papers can be
completed outside of normal hours as they have to be completed by two different
doctors one of whom MUST NOT have treated the patient during the last illness .
However, if release out of hours is still required, the Trust can only release those
deceased who have a completed certificate for cremation. The Duty Manager must
locate the certificate in Bereavement Services to confirm the deceased is clear for
removal. The on-call APT can be contacted via switchboard if advice is required.
1.3 Is this a Coroner’s case?
a) Full details of cases which are required to be referred to HM Coroner are given in
appendix three and initial judgment on whether or not to refer to the Coroner should
be made by the doctor or midwife certifying death or stillbirth. The Duty Manager
should be consulted with any initial queries or concerns, who may, in turn, escalate
issues to the on-call manager or Director. If it is determined that a referral is not
necessary a Medical Cause of Death Certificate may then be issued.
b) If it is decided that the case needs to be discussed with, or referred to, HM Coroner,
contact should be made by ringing the mobile telephone number that is in a secure
location in Bereavement Services. Availability of HM Coroner is given in appendix
three.
c) If a case is accepted by HM Coroner the deceased cannot be released from the
mortuary under any circumstances.
1.4 Is the request from someone who is ‘entitled’ to deal with the patient’s funeral
and/or estate? (Note: the release of a body and release of a patient’s property may involve
differently entitled people).

a) The Medical Certificate of Cause of Death (MCCD) must be given to a person who is
legally entitled to arrange the funeral and register the death. This person is known as
‘the Informant’. The following persons are designated by the Births and Deaths
registration Act 1953 as qualified to give information concerning deaths in houses and
public institutions and in order of preference they are:

Continued…….

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Continued ………..

1. A relative of the deceased present at death

2. A relative of the deceased, in attendance during the last illness.
3. A relative of the deceased, residing or being in the sub-district where the death
occurred.
4. A person present at the death.
5. The Occupier (for patients with no known next of kin who die at UHL this is the
Senior Bereavement Services Officer).
6. Any inmate of the house if he/she knew of the happening of the death.
7. The person causing the disposal of the body (i.e. arranging the funeral).

b) Often the Informant and the Legally Entitled Next-of-Kin/Executor is the same person
(e.g. the spouse or other close relative of the deceased patient). If the Informant and
the Entitled Next-of-Kin is not the same person, it may be necessary to issue the
MCCD to the Informant but retain the deceased patient’s property until the Entitled
Next-of-Kin/Executor can be identified and contacted to make arrangements with
Bereavement Services for its collection (see Appendix five of the UHL Patients
Property Policy document number …..)
1.5 Is there a Medical Certificate of Cause of Death? (for adults / children / babies
over 28 days of age)
a) When a patient dies it is the statutory duty of the doctor who has attended the patient in
the last illness and has seen the patient alive at some point during the previous 14 days.
to issue the MCCD (Births and Deaths Registration Act 1953). There is no clear legal
definition of “attended”, but it is generally accepted to mean a doctor who has cared for
the patient during the illness that led to death and so is familiar with the patient’s
medical history, investigations and treatment and be able to state the cause or causes
of death to the best of their knowledge and belief. The presence of a doctor simply to
certify the death, without earlier involvement, does not entitle the doctor legally to
complete the documents. Further information on the completion of the MCCD please
refer to Appendix five.
There is no provision under current legislation to delegate this statutory duty to issue
the MCCD to any non-medical staff. In hospital, there may be several doctors in a
team caring for the patient but it is ultimately the responsibility of the consultant in
charge of the patient's care to ensure that the death is properly certified. Any
subsequent enquiries, such as for the results of post-mortem or ante-mortem
investigations, will be addressed to the consultant
1.6 What if a legally entitled doctor is not available? (N.B. if no doctor or midwife is
available to complete death certification then the release cannot proceed.

a) If an entitled doctor is not immediately available to complete certification, the Duty

Manager must explore the possibilities of who can certify the patients death by
reviewing the medical notes and considering the possibility of contacting a doctor during
forthcoming shift changes. If the entitled doctor is off duty and it is a reasonable hour
(i.e. during the day) the Duty Manager can consider contacting the doctor to ask if they
would be prepared to complete the certificate. There is no formal arrangement whereby
insistence on attendance to complete certification can be enforced and so any request
relies upon a doctor’s availability and goodwill NO PRESSURE MUST BE PUT ON AN
OFF-DUTY DOCTOR TO COMPLETE CERTIFICATION.

Continued………..

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Continued……………
b) However, there may be rare occasions, such as those listed below when there is no
hospital / UHL doctor available who is legally entitled to write the Medical Certificate
of Cause of Death:
• Death in the Emergency Department (ED) - no doctor available to contact due to
shift pattern/annual leave
• ED doctor only verified the death they have not seen the patient alive
• ED doctor does not know cause of death since patient died before any
examination/tests carried out
• Patient transferred to an Assessment Unit from ED (AMU / EMU / CDU / SAU) but
died before a doctor assessed the patient
• Patient dies on a base ward but there is no doctor available to contact due to shift
pattern/annual leave
In these situations, the deaths are referred to the Coroner. The deceased’s GP is
contacted to ask if they would know a probable cause of death and issue the MCoDC.
It is only via the Coroner’s office that a GP can issue when a patient dies in
hospital.
c) If an entitled doctor cannot be located then the Duty Manager must explain to the family
that all reasonable actions have been taken to meet their request but that it has not
proved possible to contact an appropriately entitled doctor. However, reassurance can
be given that their request will be given urgent attention by Bereavement Services as
soon as the office re-opens. Bereavement Services will need to be alerted of the need
for urgent release of the deceased by leaving written notification in the Bereavement
Services office.
1.7 Is this a live born baby dying before 28 days of life / stillbirth / non-viable foetus
/ products of conception?
a) Live born babies who die before 28 days of life (known as a Neonatal Death)
require a ‘Medical Cause of Death of a Live-born Child Dying within the first
Twenty-Eight Days of Life’. Still births, non-viable fetuses and products of
conception do not.
b) If the baby is over 24 weeks and has at no time shown signs of life then a
‘Certificate of Still Birth’ will be issued by the attending Doctor or Midwife. The Still
born baby can then be registered with the certificate. The Maternity Bleep Holder
and duty manager should liaise to ensure the certificate is completed.
c) If the baby, at any stage of pregnancy, showed signs of life then it must be
registered as a live birth and a neonatal death. Medical staff will have to complete
the ‘Medical Cause of Death of a live-born child dying within the first twenty-eight
days of life’. The family will also have to register the baby’s birth within 6 weeks.
Discussion of these cases with the UHL Legal Team and HM Coroner is advised.
d) If the baby is less than 24 weeks and has at no time shown signs of life it is
classed as a non-viable fetus. It does not need to be registered, but a ‘Hospital /
private non viable fetal burial form’ (referred to as either the 3-part or fetus form)
will need to be issued to Bereavement Services by the ward/department so that
burial can take place (This does not apply out of hours).
e) The baby / fetus / fetal tissue under 16 weeks (miscarriage / termination / ectopic
or molar pregnancy) is usually classed as Products of Conception (POC). Ward
staff should be asked if a ‘Pregnancy Loss Form’ has been issued and if it has,
contact the on call APT for advice regarding the location of POCs in the mortuary.
See section regarding out of hours release in Policy for the Sensitive Disposal of
Fetal Remains (DMS 35054).

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 f) Products of Conception do not require any certification, although a ‘Hospital /
private non viable fetal burial form’ (referred to as either the 3-part or fetus form)
will be issued by the ward/department if burial or cremation has been requested.
The ‘Declaration’ section on the form must also be completed by ward staff on the
Pregnancy Loss Form that accompanies the POCs.

1.8 Did the Patient have a notifiable infectious disease?

The body cannot be released out of hours if certain infections are present. The Last
Office Policy (Document number 32578) details the infections and precautions
required in these situations.
1.9 Does the deceased have any venous or arterial lines / urinary catheters / drains
etc?
The Last Offices Policy (Document number 32578) states that lines, catheters and
drains should not be removed on the ward following the patient’s death. However, if
an APT is present in the mortuary prior to release, lines etc. can be removed. If no
APT is present, then the Funeral Director or nominated representative collecting the
deceased should be informed that lines etc. are present.
1.10 Has human tissue / material been retained following a post mortem?
Retention of human tissue / material is indicated by the presence of a red form
attached to the deceased. Under no circumstances should the deceased be
released without contacting the on-call APT via switchboard to discuss the release
request.
1.11 Has a ‘Request to Release Deceased’ form been completed?
A Request to Release form must be completed by those wishing to remove the
deceased. It must contain the deceased’s full name and at least one other positive
point of identification. Blank forms are available in the Mortuary next to the Out of
Hours Register.
A certificate for burial (green form) from the Registry Office is not required prior to the
release of the deceased for burial.

ONLY WHEN THE DUTY MANAGER IS SATISFIED THAT ALL OF THE ABOVE
CRITERIA HAS BEEN MET, CAN RELEASE TAKE PLACE (as per appendix four)
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 REPORTING DEATHS TO
H M CORONER Appendix Three
Policy for the Handling and Release of the Deceased Outside Normal Hours

1. Introduction
Registered medical practitioners have a duty to certify death where they know the
circumstances surrounding the death and have attended the patient within 14 days preceding
death. Practitioners should note that a certificate cannot be issued if the case has been
accepted by the Coroner. The reasons for referral may seem extreme in some instances but
they are essential.
2. Release of the Deceased Out of Hours
2.1 If a release of a deceased patient is required out of normal working hours but the Dr
believes that the case needs to be referred to the Coroner, contact with the Coroner
can be made via the UHL Duty Manager ONLY. The Coroner can only be contacted
at the following times:-
a) Out of Hours Weekdays between the hours of………and ……… The Coroner must
not be contacted outside of these hours (Is this OK? – would there be any
exceptional circumstances to these times)
b) Weekends and Bank Holidays between the hours of ------ and ------- (?can contact be
made at weekends and bank holidays)
2.2 If HM Coroner needs to be contacted and agrees that the MCCD can be issued by a
UHL doctor, the doctor will be asked to provide contact details of the deceased’s next
of kin. This is so the Coroner can confirm with the next of kin are satisfied with the
cause of death before they will issue their paperwork (Pink Form A) to the Leicester
Registrar. A death can not be registered until the Coroner’s form has been received by
the Leicester Registrar. This is a relatively new process for Bereavement Services that
takes place during working hours - will this process still occur out of hours?
2.3 If the patient dies out of hours but there is no need for urgent release, the Coroner
should be contacted the next working day as normal.
2.4 If the deceased was in custody or was sectioned under the Mental Health Act, the body
cannot be released and the police must be informed via the Duty Manager.
3. Reporting Deaths
3.1 Registered Medical Practitioners are required by law to report deaths to H.M. Coroner
if any of the following apply:-
a) The deceased was not attended by a Registered Medical Practitioner during his last
illness.
b) The deceased was not attended by a Registered Medical Practitioner immediately after
death or within 14 days preceding death.
c) The death is sudden, unexplained, violent, and unnatural or attended by suspicious
circumstances.
d) The cause of death is unknown, or if there is any doubt regarding the cause of death.
e) The deceased is a child in foster care.
f) The death occurred in the following circumstances:
i. After an operation or invasive procedure necessitated by injury or disease within the
preceding 12 months.
ii. During an operation

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 iii. Before recovery from the effects of any anaesthetic.
iv. The death may be related to a medical procedure or treatment whether invasive or
not
g) When it is believed there is a possibility the death was due to neglect, ill-treatment self
neglect or abortion
h) Still birth where there was any possibility of the child being born alive
i) The deceased was detained under the Mental Health Act
j) Where it is believed the death is due to any kind of poisoning including alcohol, and
drugs either taken in therapy, in addiction, in suicide or accidentally.
k) When death occurs either directly or indirectly, following an injury or accident, including
those associated with road traffic accidents of any date. Injuries may include burns,
scalds, choking or other effects of foreign bodies, suffocation, concussion, wounds
drowning, and effects of heat or cold, sunstroke, lightning, fractures, electricity, electric
shock.
l) The deceased is a person detained in prison or in any other place of detention, or is a
person who has recently been in police custody (Release within 24 hours of death)
m) The deceased was in receipt of a disability pension/ war pension
n) When the death is believed to be due to an industrial injury, conditions associated with
service in H.M forces, or due to actual or suspected industrial diseases or industrial
poisonings as detailed below:-
a) Diseases of the Lungs:-
• Any form of Pneumoconiosis, Asbestosis and Mesothelioma, Berylliosis.
• Any Lung Disease qualified by an occupational term (e.g. Farmers Lung)
b) Other Diseases if Occupationally Related e.g.
• Any form of barotrauma, Weils disease, hepatitis B or C, Anthrax
• Malignancy related to any form of industrial exposure
• Any form of industrial toxicity or poisoning.

0) At the request of the H. M. Coroner for Leicester and South Leicestershire, certain
treatment-related infections which are considered to have caused or contributed to
death must be referred to her office. In most cases there will be no requirement for an
autopsy, but the final decision rests with the Coroner.
The following types of cases should be referred:
• Within 24 hours of admission to hospital
• Deaths due to hospital acquired Clostridium Difficile infection
• Deaths due to hospital acquired MRSA infection
• Deaths due to infection following iatrogenic neutropenia
• Deaths due to infection following immunosuppressive therapy for transplantation,
autoimmune or other disease.
• Deaths due to infection of in-dwelling medical equipment.
• Any other case where medical treatment may have contributed to the
development of a fatal infection
• Signs of life before 24 weeks of pregnancy - discussion of these cases with the
UHL legal team and coroner is advised.
p) Any maternal death should also be referred to the Coroner, but in many cases a death
certificate may be written and no post mortem will be requested
The coroners office can be contacted by telephone on 0116 2252534 or 0116 2252535

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 COMPLETION OF THE MEDICAL
CERTIFICATE DEATH OF CAUSE OF
Appendix Four
DEATH (MCCD) Policy for the Handling and Release of the Deceased Outside Normal Hours

Medical Certificate of Cause of Death (MCCD)

Adults - Medical Certificate of Cause of Death (MCCD) is controlled stationery

held in the Bereavement Services (BS) Office or by the Duty Manager. If
the Doctor verifying the death is eligible to complete the MCCD (i.e.
attended the deceased in the last illness and had seen them alive at
some time during the 14 days prior to death) then the MCCD should be
Children completed by the Dr at the same time as they verify the death. This will
prevent avoidable delays in completing the paperwork
- Instructions on how to complete a MCCD is listed in the Medical
Certificate of Cause of Death Book.
Babies – death - The completed copy of the MCCD must be placed in a sealed envelope
after 28 days of
(legal requirement) with the ‘Notice to Informant’ attached to the outside
age
of the envelope. The envelope can then be handed to the next of kin.
- The MCCD number can be given to Mortuary staff to inform them the
deceased is clear for removal.

Babies – death Medical Certificate of Cause of Death of a live-born child dying within the
before 28 days first twenty-eight days of life
of age - Process for completing certificate as for MCCD above, parents still
have to register the birth at the Leicester Register Office
- Certificates held in both BS office and securely on the Neonatal Unit(s)
Stillborn babies Certificate of Still Birth
- Certificate and envelopes held securely on Delivery Suite
- Liaise with maternity bleep holder for completion of certificate
Non-viable fetus Hospital / private non viable fetal burial form (referred to as either the 3-
part form / fetus form)
Products of
conception - Form issued by and held securely on Gynaecology Wards and Delivery
(POC) for Suite. Parent or Funeral Director need the form which is required for
private burial release and the Cemeteries Office (the Cemeteries Office will not accept
only application for burial / cremation without this form)
- The Cemeteries Office will not accept application for burial / cremation
POCs cannot be without this form
released out of Pregnancy Loss Form (POC for cases before 16 weeks of pregnancy)
hours for - Issued by ward (form held on Gynaecology Wards and Delivery Suite)
cremation and signed by Dr or Midwife
- Declaration section on the Pregnancy Loss Form MUST be signed
Also refer to Policy for Sensitive Disposal of Fetal Remains for gestations
under 16 weeks (DMS number 35054)

Products of Pregnancy Loss Form – No certificate required

Conception for - Issued by ward (form held on Gynaecology Wards)
Home - Declaration on Pregnancy Loss Form MUST be signed (as confirmation
Arrangements that the case is not a registerable birth or death)
- Confirm with parent(s) that the fetal tissue is definitely having a burial at
(e.g. burial in home BEFORE RELEASE (if they intend to approach a funeral director at
the patient’s a later date the Hospital / private non viable fetal burial form is required)
garden)

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 FLOW DIAGRAM FOR THE
COMPLETION OF THE ADULT MCCD
Appendix Five
FOR BURIAL Policy for the Handling and Release of the Deceased Outside Normal Hours

Deceased Next of Kin or their representative requests early release to Nurse in Charge

Duty Manager is contacted – need to check that

person making the request is ‘entitled’

No
Is an eligble Doctor available to complete Do not proceed
MCCD?

Yes

Does the case need referring to HM Coroner?

Unsure

Yes
(but only between the
hours of ----- &------) Dr to contact Duty Manager or On-Call Manager for further
advice

Doctor completes Medical

Certificate of Cause of Death or
neonatal death certificate (under
28 days of life) certificate.
Record
If coroner is reasons for
Duty manager checks certificate
is eligible and signed and
happy to non release in
completes body release form release Bereavement
which remains in Bereavement Services office
Service (BS) office.

Duty Manager leaves a message

in Bereavement Services to
inform them when and who was Do not proceed
released.

Hand medical certificate of cause of death to next of kin / representative in sealed envelope

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 RELEASE OF THE DECEASED FROM
THE MORTUARY Appendix Six
Policy for the Handling and Release of the Deceased Outside Normal Hours

1. Release at the Request of the Family

The deceased can only be released from the care of UHL NHS Trust into the custody of the
next of kin / executor of the estate or in most cases, a representative nominated by them. For
example, a Funeral Director.
2. Release at the Request of the Coroner
The Coroners Removal Service will be required to complete a Request to Remove Deceased
form and the Out of Hours Mortuary Register.
3. Prior to arranging a time for collection of the deceased
The Duty Manager should check that
a) The Medical Certificate of Cause of Death has been completed.
b) Deceased is in the Mortuary.
c) There is no retained tissue / material
d) Any property belonging to the deceased which needs to be returned is available
e) Those collecting the deceased have an appropriate vehicle and receptacle (i.e. casket
and vehicle with tinted windows)
f) Mortuary staff / porters are available for release. However, on rare occasions this aspect
may be the responsibility of the Duty Manager.
4. Procedure for Release
a) Check the release form / certificate number to confirm deceased is clear for release.
b) Check mortuary register / fridge doors to identify the fridge location.
c) Wearing disposable gloves and apron clothing remove occupied tray and deceased from
fridge onto hoist in accordance with manufacturer’s instructions.
d) Check attached identity bands against request to release form confirming at least three
positive points of identification.
e) Ensure that the identity and condition of the deceased is also checked by the person
collecting them.
f) Use the request for release forms to complete the Out of Hours Release Register. This
can be found in the clerical area of the Fridge Room
g) Ensure that the person collecting the deceased undertakes the following actions:-
• Signs the out of hours register to confirm that the correct deceased has been
received into their custody in a satisfactory condition.
• Checks any property and signs the mortuary property book to confirm that the
property has been received. Give the blue copy of the property sheet to the
recipient as a receipt.
h) Move deceased from the tray to the receptacle provided.
i) Disinfect tray with an active solution of one part TriGene Advance to ten parts water.
Care should be taken to ensure that this is not witnessed by relatives of the deceased as
it may be upsetting.
j) Return tray to original fridge space and close the door.
k) Remove the name from the exterior of fridge door.
l) Remove and appropriately dispose of protective clothing. Clean hands using appropriate
technique.
m) Leave the request for release form in the mortuary with the Out of Hours Release
Register

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 PROCEDURE FOR BODY RELEASE
AFTER COMPLETION OF MCCD Appendix Seven
Policy for the Handling and Release of the Deceased Outside Normal Hours

Are Mortuary staff

available?

Liaise with mortuary staff and arrange

No Yes time of collection. Inform mortuary staff
of certificate number, to confirm
completion of certification

Duty manager liaise Confirm no material has been retained

with porters to arrange and that the next of kin has appropriate
access to mortuary vehicle and receptacle prior to release.
Give time of access to next of kin

Next of kin gives completed copy of request for release to duty

manager.
If next of kin does not have a copy of the request to release then a
form is completed in the mortuary

Porters remove Duty manager cross checks request for

deceased from fridge release form against identity band (id
contact on call APT number for POCs) attached to deceased
regarding POCs and checks for property

Next of kin checks deceased and Duty manager records

signs out of hours register and details of release on out
removes deceased of hours register

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 PROCEURE FOR THE
CERTIFICATION OF A STILL BIRTH Appendix Eight
Policy for the Handling and Release of the Deceased Outside Normal Hours

Mother requests early release

  DM informed  

 
  

Less than 24 weeks Signs of life before 24 weeks - Live More than 24 weeks
AND no signs of life birth AND no signs of life

  

Not a stillbirth – Neonatal Death Certificate (death Still birth

follow process for before 28 days of life) completed –
non-viable foetus follow process as for previous chart

 

Advise case discussed with legal Doctor or midwife

team and coroner (who may classify completes stillbirth
case as stillbirth) certificate (liaise with
maternity bleep
If case classified as a stillbirth – follow holder)
stillbirth process
Certificate given to
If case classified as a neonatal death Next of Kin to register
– follow previous flow chart stillbirth

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 PROCEDURE FOR RELEASE OF A
NON-VIABLE FOETUS Appendix Nine
Policy for the Handling and Release of the Deceased Outside Normal Hours

Mother requests early release

Duty manager informed

Less than 24 weeks and no signs of life – non viable fetus

Ward staff (nursing / midwife / doctor) issues Hospital / Private Non-viable

Fetal Burial Form (also called the 3-part or fetus form) to Bereavement Services
office

If fetus less than 16 weeks gestation Pregnancy Loss Form will also be issued
– confirm DECLARATION completed (see Policy for Sensitive Disposal of Fetal
Remains DMS no 35054)

Part 2 of the form completed in mortuary by duty manager and person

collecting the fetus at time of release

Both complete relevant sections on Pregnancy Loss form

Form then given to person collecting the fetus for the attention of the
cemeteries authority

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 PROCEDURE FOR RLEASE OF
PRODUCTS OF CONCEPTION Appendix Ten
Policy for the Handling and Release of the Deceased Outside Normal Hours

Mother requests early release

Duty manager informed

 

Private burial or cremation Home arrangements

 

Ward staff (nursing / midwife / Confirm mother has been

doctor) issues Hospital / given ‘burial outside a
Private Non-viable cemetery’ information sheet
Fetal Burial Form (also called (documented on Pregnancy
the 3-part or foetus form) to Loss Form) and if not issue
Bereavement Services office copy (and sign on PLF)

Pregnancy Loss Form issued

– check Declaration signed

 

Part 2 of the form completed Pregnancy Loss Form also

in mortuary by duty manager signed by both duty manager
and person collecting the and person collecting the
fetus / POCs at time of fetus / POCs
release

Form then given to person NOTE:

collecting the fetus / POCs for
the attention of the Products of Conception do not have the
cemeteries authority patient’s ID band, only the patient’s ID
number on the box;

AND
Pregnancy Loss Form also
signed by both duty manager Are stored in separate fridges in the
and person collecting the mortuary and not listed in the mortuary
fetus / POCs registers CONTACT APT TO ADVISE ON
LOCATION

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 Leicester Registry Office
Out of Hours Opening Times for
Registering a Death Appendix Eleven
Policy for the Handling and Release of the Deceased Outside Normal Hours

The Registrar of Births and deaths provides an ‘emergency service’ and may authorise a
burial outside regular hours. Information will be posted on the door of their office building in
Bowling Green Street, Leicester, providing details of how to contact the Registrar in an
emergency. The information below may change in the event of any changes the duty rota
and therefore families or their representatives should be advised to visit the registry office in
order to obtain the information.

A certificate for burial (green form) from the Registry Office is not required prior to the
release of the deceased for burial.

Saturday Service
• A death can be registered between 08.30 -12.00 but registering a death will only take
place between any weddings that occur during the morning
• Those wishing to register a death must go to the front entrance of the Town Hall.

Sunday and Bank Holidays

• There is a 2 hour (10am -12 midday) on-call arrangement with the Registrars on a
Sunday or Bank Holiday
• Emergency telephone number : 07970751329
• A death can not be registered on Sunday but a green form will be issued to enable the
funeral to go ahead. This is released from the New Walk Centre not the Register Office.
• The death then has to be registered during normal hours in the week at the Register
Office, Town Hall.

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