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Registration Number: {{org_field_registration_no}}

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Verification of Expected Deaths by Registered Nurses Policy

1. Purpose

This policy sets out the arrangements for the safe, lawful and dignified verification of an expected adult death by a Registered Nurse at {{org_field_name}}. It distinguishes verification of the fact of death from certification of the medical cause of death and sets out the action required following verification.

The policy supports compliance with the Health and Social Care Act 2008 and the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, including Regulation 12 – Safe Care and Treatment, Regulation 17 – Good Governance and Regulation 18 – Staffing. It also supports compliance with Regulation 16 – Notification of Death of a Service User of the Care Quality Commission (Registration) Regulations 2009.

Verification of death confirms formally that death has occurred. It does not determine or certify the medical cause of death. Certification of the medical cause of death is a separate statutory process undertaken by an appropriately qualified medical practitioner or, in the limited circumstances permitted by legislation, a Medical Examiner.

Since 9 September 2024, every death in England and Wales must receive independent scrutiny either through investigation by a coroner or, for a non-coronial death, through the statutory Medical Examiner process. {{org_field_name}} will cooperate with the attending practitioner, Medical Examiner’s Office, coroner and other relevant agencies and will provide information and records required to support the lawful death-certification process.

All verification must be undertaken sensitively, safely and in a manner that respects the deceased person’s dignity, privacy, cultural and religious needs and the needs of their family or representatives.

2. Scope

This policy applies to Registered Nurses working at {{org_field_name}} who have received appropriate training, have been assessed as competent to undertake Registered Nurse Verification of Expected Adult Death and are working within their professional competence.

This policy applies to the verification of expected deaths of adults aged 18 years or over within the care home.

A Registered Nurse must not use the expected-death verification procedure where:

• the death was sudden or unexpected;
• suspicious circumstances are present or suspected;
• there is uncertainty as to whether death has occurred;
• there is uncertainty about the identity of the deceased person; or
• the Registered Nurse does not consider themselves competent or able to complete the verification safely.

Verification of death is separate from certification of the medical cause of death. A Registered Nurse undertaking verification under this policy must not complete a Medical Certificate of Cause of Death or purport to determine the medical cause of death.

Where there is any doubt about whether the expected-death pathway applies, the Registered Nurse must seek advice from the responsible GP, out-of-hours medical service or other appropriate medical practitioner and follow local coroner and emergency procedures as applicable.

3. Legal and Regulatory Framework

This policy must be read and implemented in accordance with the following legislation, regulations and national requirements, as amended from time to time:

• Health and Social Care Act 2008.
• Health and Social Care Act 2008 (Regulated Activities) Regulations 2014:
  • Regulation 9 – Person-centred Care;
  • Regulation 10 – Dignity and Respect;
  • Regulation 11 – Need for Consent;
  • Regulation 12 – Safe Care and Treatment;
  • Regulation 13 – Safeguarding Service Users from Abuse and Improper Treatment;
  • Regulation 17 – Good Governance; and
  • Regulation 18 – Staffing.
• Care Quality Commission (Registration) Regulations 2009, Regulation 16 – Notification of Death of a Service User.
• Births and Deaths Registration Act 1953, as amended.
• Coroners and Justice Act 2009.
• Notification of Deaths Regulations 2019, as amended.
• Medical Certificate of Cause of Death Regulations 2024.
• Medical Examiners (England) Regulations 2024.
• National Medical Examiner (Additional Functions) Regulations 2024.
• Care Act 2014, where safeguarding concerns arise.
• Mental Capacity Act 2005, where relevant to decisions made before death.
• Nursing and Midwifery Council – The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates.
• Hospice UK – Care After Death: Registered Nurse Verification of Expected Adult Death Guidance, current edition.
• Resuscitation Council UK guidance concerning cardiopulmonary resuscitation and DNACPR decisions.
• Relevant local coroner, Integrated Care Board, Medical Examiner and NHS arrangements.

All deaths must receive independent scrutiny. A death investigated by a coroner will follow the coronial process. A death not investigated by a coroner must undergo statutory Medical Examiner scrutiny before registration.

4. Criteria for Verification of Expected Deaths

A Registered Nurse may undertake verification of an expected adult death only where the nurse is trained and competent and is satisfied that the expected-death pathway is appropriate.

The following criteria must be considered before commencing verification:

• The person is aged 18 years or over.
• The death is expected and is consistent with an anticipated deterioration in the person’s health, usually associated with advanced, progressive or incurable illness.
• There are no suspicious circumstances associated with the death.
• The person’s identity can be confirmed from available records and information.
• Relevant clinical records are available to the Registered Nurse.
• An individualised decision concerning cardiopulmonary resuscitation would normally have been considered and documented as part of advance care planning.

A DNACPR decision concerns whether cardiopulmonary resuscitation should be attempted. It does not authorise death, does not determine the cause of death and does not itself constitute verification or certification of death.

Where the person is found deceased and a DNACPR decision is not available or cannot immediately be located, the Registered Nurse must assess whether there are unequivocal signs that death is irreversible and must clearly record the clinical basis for any decision not to commence cardiopulmonary resuscitation. Where death is not clearly irreversible, the Registered Nurse must follow the appropriate emergency and resuscitation procedure.

An Advance Decision to Refuse Treatment must not be treated as equivalent to a DNACPR decision unless its legally valid and applicable terms expressly cover the relevant treatment. Staff must follow the organisation’s Mental Capacity Act, advance care planning and resuscitation policies.

Where the circumstances are unusual, inconsistent with the expected clinical course, suspicious or otherwise give the Registered Nurse cause for concern, the Registered Nurse must not proceed using the expected-death verification pathway and must follow the unexpected or suspicious death procedure.

5. Nurse Competency and Training

Only Registered Nurses who have received appropriate training, have been assessed as competent and consider themselves competent to undertake the procedure may independently verify an expected adult death.

Training and competency assessment must cover:

• recognition of expected and unexpected death;
• the distinction between recognition, verification and certification of death;
• cardiopulmonary resuscitation and DNACPR considerations;
• the clinical examination required to verify death;
• identification of suspicious circumstances;
• legal and professional responsibilities;
• circumstances requiring escalation for possible coroner involvement;
• the role of the Medical Examiner;
• infection prevention and control;
• implantable medical devices, including implantable cardioverter defibrillators;
• documentation and record-keeping;
• communication with the attending practitioner and relevant healthcare professionals; and
• communication with and support for bereaved families and representatives.

Evidence of initial competency must be retained. Registered Nurses undertaking verification must maintain their competence, familiarise themselves with changes to current legislation, professional guidance and local procedures and reflect on their practice at least annually. Where competence cannot be demonstrated, further training, supervision or reassessment must take place before the nurse undertakes verification independently.

A Registered Nurse must not undertake verification where they do not feel competent or confident to do so.

6. Verification Procedure

6.1 Before commencing verification

The Registered Nurse must:

• confirm the identity of the person against available documentation, using appropriate identifying information such as full name, date of birth and NHS number;
• review the relevant clinical record, advance care planning information and DNACPR documentation where available;
• establish that the death was expected;
• consider whether there are any circumstances inconsistent with an expected natural death;
• undertake an appropriate environmental and infection prevention and control risk assessment;
• identify any known or suspected infectious disease;
• identify any implantable medical device, radioactive implant or implantable cardioverter defibrillator where this information is available; and
• ensure that the nurse is satisfied that the expected-death verification pathway is appropriate.

Before commencing the examination, the Registered Nurse should undertake a discreet examination for new or unexplained injury, trauma, bruising, unusual marks or other findings that might indicate suspicious circumstances.

Where suspicious circumstances are identified or suspected, the Registered Nurse must stop the expected-death verification procedure, avoid unnecessary disturbance of the person or immediate environment and follow the unexpected or suspicious death procedure, including contacting the police where appropriate.

All tubes, lines, drains, medication patches and pumps must initially remain in situ. Medication and fluid administration must be stopped. Such equipment must not be removed where a coroner referral or investigation is required unless authorised by the coroner or police.

6.2 Clinical verification examination

The person must be observed continuously for a minimum of five minutes to establish irreversible cardiorespiratory arrest.

During the verification examination the Registered Nurse must establish:

• Respiratory effort: absence of spontaneous respiratory effort throughout the five-minute observation period.
• Central pulse: absence of a central pulse on palpation for at least one minute.
• Heart sounds: absence of heart sounds on auscultation for at least one minute.
• Pupillary response: absence of pupillary response to light in both eyes.
• Motor or cerebral response: following five minutes of continued cardiorespiratory arrest, absence of motor response to an appropriate stimulus, such as a trapezius squeeze, or absence of cerebral response using an appropriate assessment in accordance with current national guidance.

If spontaneous cardiac or respiratory activity occurs at any time during the observation period, a further continuous five-minute observation period must commence.

If there is any uncertainty as to whether death has occurred, the Registered Nurse must not complete the verification and must seek urgent advice from an appropriate medical practitioner and follow emergency procedures as required.

6.3 Non-invasive ventilation

Where non-invasive ventilation remains in use, staff must recognise that ventilator-generated chest movement may mimic spontaneous breathing. The ventilator must be managed in accordance with the person’s clinical plan and current national guidance. After it has been stopped where appropriate, the full verification examination must be completed over the required five-minute period.

6.4 Time of death

For the purpose of Registered Nurse verification, the official time of death recorded in the care record and verification documentation is the time at which verification of death is completed, not the estimated time of the person’s last breath.

The family or representative should be informed sensitively that the recorded verification time may therefore be later than the time at which they observed the person’s last breath.

6.5 Following verification

The Registered Nurse must:

• complete the local Verification of Death documentation;
• make a contemporaneous entry in the person’s care record;
• notify the responsible GP or other appropriate attending medical practitioner using the agreed local process, including out-of-hours arrangements;
• notify the Registered Manager or person in charge;
• notify the person’s family or representative in accordance with the agreed care plan and their wishes;
• provide information required for the subsequent Medical Examiner or coroner process;
• identify and communicate any relevant infection risk, implantable medical device, radioactive implant or active implantable cardioverter defibrillator to the appropriate healthcare professional and funeral director or mortuary; and
• follow the organisation’s CQC notification procedure.

7. Communication and Family Support

The Registered Nurse and other staff involved following the death must communicate sensitively, clearly and respectfully with the deceased person’s family or representatives.

Staff must:

• explain, where appropriate, that verification of death confirms that the person has died but does not certify the medical cause of death;
• explain that the attending medical practitioner will consider the medical cause of death;
• explain that, where the death is not investigated by a coroner, it will undergo independent scrutiny by a Medical Examiner before registration;
• advise the family that the Medical Examiner’s Office will normally offer the deceased person’s representative an opportunity to discuss the cause of death and raise questions or concerns about the care provided;
• avoid giving assurances about the medical cause of death unless this has been confirmed by an appropriately authorised medical practitioner;
• explain the immediate next steps and provide appropriate bereavement information;
• respect religious, spiritual and cultural wishes as far as reasonably practicable; and
• record significant discussions and any concerns raised by family members or representatives.

Any concern raised by a relative or representative about abuse, neglect, unsafe care or circumstances surrounding the death must be escalated immediately in accordance with the safeguarding, incident-reporting and duty of candour procedures.

8. Documentation and Record-Keeping

A complete and contemporaneous record must be made of the verification and all subsequent actions.

The Registered Nurse must record:

• the deceased person’s full name, date of birth and other identifiers used to confirm identity;
• the date and time the verification examination commenced;
• the date and time verification was completed;
• confirmation that the death was expected;
• relevant DNACPR or advance care planning information considered;
• the absence of respiratory effort during the required observation period;
• the absence of a central pulse;
• the absence of heart sounds;
• the absence of pupillary response to light;
• the result of the assessment of motor or cerebral response;
• any unusual, unexplained or suspicious findings;
• any known or suspected infection risk;
• any known implantable medical device, radioactive implant or implantable cardioverter defibrillator;
• the name, signature and NMC PIN of the Registered Nurse completing verification;
• the date and time the responsible GP or other attending medical practitioner was informed;
• the date, time and details of communication with the family or representative;
• any information provided to or requested by the Medical Examiner’s Office, coroner, police or other statutory body;
• whether a CQC notification was required and, where submitted, the date and reference or acknowledgement number; and
• all further actions taken.

Records must be accurate, legible, attributable to the person making the entry and retained securely in accordance with the organisation’s records-management and data-protection requirements.

Where a death is unexpected, suspicious or gives rise to safeguarding or patient-safety concerns, all relevant records must be preserved and must not be altered, destroyed or inappropriately removed.

9. Deaths Requiring Coroner Consideration

The Registered Nurse must recognise circumstances that require escalation for consideration of referral or notification to the coroner.

A death must be escalated promptly to the responsible medical practitioner and the Registered Manager where there is reason to suspect that:

• the cause of death is unknown;
• the death was violent or unnatural;
• the death may have resulted from trauma or physical injury;
• the death may have resulted from poisoning;
• the death may have resulted from intentional self-harm;
• neglect, abuse or a failure of care may have caused or contributed to the death;
• the death may be related to a medical treatment or procedure;
• the death may be related to an injury or disease arising from the person’s employment or occupational exposure;
• the person died while in custody or another form of state detention; or
• another circumstance exists which, under current legislation or local coroner requirements, requires notification to or investigation by the coroner.

The statutory duty under the Notification of Deaths Regulations 2019 applies to registered medical practitioners in the circumstances specified by those Regulations. The Registered Nurse must therefore ensure that relevant facts and concerns are communicated promptly to the responsible medical practitioner and must follow local coroner procedures.

Where suspicious circumstances are identified:

• the expected-death verification procedure must not continue;
• the body and immediate environment must not be disturbed unnecessarily;
• tubes, lines, drains, medication patches, pumps and other devices must remain in situ;
• medicines and associated records must be secured and preserved;
• the Registered Manager or senior person in charge must be informed immediately; and
• the police must be contacted where criminal activity or a suspicious death is suspected.

Where the coroner accepts the death for investigation, staff must comply with all instructions from the coroner and police and must not remove devices or interfere with potential evidence unless expressly authorised.

10. Infection Prevention and Control Considerations

Standard infection prevention and control precautions must be followed when verifying and providing care after death.

Before undertaking verification, the Registered Nurse must assess the environment and any known or suspected infection risk.

Appropriate personal protective equipment must be selected and worn in accordance with the assessed risk of exposure to blood, body fluids, secretions, excretions or known or suspected transmissible infection and in accordance with the organisation’s current infection prevention and control procedures.

Hand hygiene must be undertaken before and after contact with the deceased person and following the removal of personal protective equipment.

Where the deceased person had or was suspected of having an infection that may present a risk to others, relevant information must be communicated to those who subsequently handle or care for the deceased person, including the funeral director or mortuary, subject to lawful information-sharing requirements.

Registered Nurses must identify and communicate relevant information concerning confirmed or suspected infectious diseases, radioactive implants and implantable medical devices.

The Registered Nurse must not assume that the presence of a notifiable infectious disease automatically requires referral of the death to the coroner. Coroner referral must be considered separately in accordance with Section 9.

11. Safeguarding Considerations

Where there is any concern that abuse, neglect, acts of omission, organisational abuse or poor care may have caused or contributed to a person’s death, the matter must be treated as a safeguarding concern and must be escalated immediately.

The Registered Nurse must:

• inform the Registered Manager or senior person in charge immediately;
• follow the CH13 – Safeguarding Adults from Abuse and Improper Treatment Policy;
• make or arrange an appropriate referral to the relevant local authority adult safeguarding service in accordance with local safeguarding procedures;
• preserve relevant records, medicines, equipment and other potential evidence;
• ensure that the body and environment are not disturbed unnecessarily where the circumstances may require police or coroner investigation;
• contact the police immediately where a crime or suspicious death is suspected;
• ensure the responsible medical practitioner is informed;
• ensure possible coroner involvement is considered in accordance with Section 9;
• make any statutory CQC notification required by the Care Quality Commission (Registration) Regulations 2009; and
• comply with the organisation’s duty of candour procedures where the statutory duty is engaged.

A safeguarding referral does not replace notification to the police, coroner, CQC or any other statutory body where a separate legal reporting requirement applies.

12. CQC Notification of Death

The Registered Person must notify the Care Quality Commission without delay of the death of a service user where required by Regulation 16 of the Care Quality Commission (Registration) Regulations 2009.

For a care home provider, this includes a death:

• which occurs while services are being provided in the carrying on of a regulated activity; or
• which has, or may have, resulted from the carrying on of a regulated activity.

The notification must include a description of the circumstances of the death and must be submitted using the current notification process and form specified by CQC.

The Registered Manager must ensure that:

• the CQC notification is submitted without delay;
• the information supplied to CQC is accurate and complete;
• the date of submission is recorded;
• the CQC acknowledgement, notification ID, case ID or other reference is retained; and
• any additional statutory notification required because of the circumstances of the death, including a safeguarding or other incident notification, is considered and submitted where required.

Notification to CQC does not replace any separate requirement to inform the attending practitioner, Medical Examiner, coroner, police, local authority safeguarding service or any other statutory body.

13. Medical Examiner and Death-Certification Process

Verification of death by a Registered Nurse is separate from certification of the medical cause of death.

Following verification, the responsible GP or other appropriate attending medical practitioner must be informed of the death using the locally agreed process.

For deaths that are not investigated by a coroner, the statutory Medical Examiner process applies.

An attending medical practitioner who attended the deceased during their lifetime may complete the Medical Certificate of Cause of Death where they are able to establish the cause of death to the best of their knowledge and belief and the death is not required to be notified to the coroner.

The previous requirement for a doctor to have attended the person within 28 days before death no longer applies.

The Medical Examiner will independently scrutinise the proposed cause of death and relevant medical records and will provide the deceased person’s representative with an opportunity to ask questions or raise concerns about the cause of death or care provided.

Following satisfactory scrutiny, the Medical Examiner’s Office will arrange for the Medical Certificate of Cause of Death to be sent to the registrar and will inform the deceased person’s representative when the death may be registered.

{{org_field_name}} must cooperate promptly with the Medical Examiner’s Office and must provide relevant records or information lawfully requested for the purpose of statutory scrutiny.

The Registered Nurse must not:

• complete or amend a Medical Certificate of Cause of Death;
• determine the certified medical cause of death;
• advise relatives that the cause of death has been formally certified before that process is complete; or
• imply that Registered Nurse verification replaces Medical Examiner scrutiny or coronial investigation.

Where the Medical Examiner, attending practitioner or coroner raises concerns about the care provided, these must be escalated immediately through the organisation’s safeguarding, incident-management, governance and duty of candour processes as applicable.

14. Staff Support and Debriefing

• Emotional well-being support is available for staff following the verification of death.
• A debrief session should be offered, particularly if the death was distressing.
• Access to occupational health and counselling for staff experiencing emotional impact.

15. Related Policies

• CH12-Safe Care and Treatment Policy
• CH13-Safeguarding Adults from Abuse and Improper Treatment Policy
• CH18-Risk Management and Assessment Policy
• CH27-Staff Supervision, Training, and Development Policy
• CH34-Confidentiality and Data Protection (GDPR) Policy

16. Policy Review

This policy will be formally reviewed at least annually and sooner where necessary following:

• a change in legislation or CQC regulatory requirements;
• amendment of national guidance for Registered Nurse Verification of Expected Adult Death;
• changes to the statutory Medical Examiner or coroner process;
• changes to Resuscitation Council UK guidance;
• a relevant safeguarding review, serious incident, complaint or death;
• an identified learning need arising from audit or governance review; or
• a change to local NHS, Medical Examiner or coroner arrangements.

The Registered Manager must ensure that amendments affecting staff practice are communicated promptly to relevant staff and that additional training or competency assessment is provided where required.

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Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}
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