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{{org_field_name}}

Registration Number: {{org_field_registration_no}}

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Death of a Service User Policy

1. Purpose

The purpose of this policy is to provide clear guidance on how {{org_field_name}} responds to and manages the death of a service user with professionalism, dignity, and sensitivity. The policy ensures compliance with Care Inspectorate Wales (CIW) regulations, legal obligations, and best practice standards, ensuring that service users, families, staff, and external agencies are supported appropriately.

Our objectives are to:

• Ensure service users are treated with dignity and respect in life and death.
• Support staff in handling a service user’s passing with professionalism and sensitivity.
• Notify the appropriate authorities and agencies in line with legal and regulatory requirements.
• Provide bereavement support to families and carers.
• Conduct internal reviews where necessary to improve end-of-life care and service provision.

2. Scope

This policy applies to:

• All service users receiving care from {{org_field_name}}.
• Family members, carers, and legal representatives.
• All employees, including care workers, senior carers, and managers.
• The Registered Manager and Responsible Individual, who ensure compliance with regulations.
• External agencies, including CIW, GPs, district nurses, emergency services, and the coroner’s office if required.

3. Legal and Regulatory Framework

This policy is informed by, and will be implemented in accordance with, the following (as amended from time to time):

• Regulation and Inspection of Social Care (Wales) Act 2016.
• The Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, including Regulation 60 and Schedule 3 (notifications) and the statutory guidance issued under the 2016 Act.
• Social Services and Well-being (Wales) Act 2014 (including safeguarding duties and partnership working).
• Human Rights Act 1998 (including dignity, respect and family life).
• Mental Capacity Act 2005 (including advance decision-making and best-interests decision-making where applicable).
• Duty of candour requirements in the statutory guidance (openness, transparency and apology where appropriate).
• Death certification reforms and Medical Examiner arrangements in Wales (families may be contacted by the Medical Examiner service as part of the scrutiny of non-coronial deaths).
• Data Protection Act 2018 / UK GDPR and the common-law duty of confidentiality (information shared on a need-to-know basis, including after death).
• Health and Safety at Work etc. Act 1974 and RIDDOR 2013 where an incident connected to work activities may be reportable.

Where there is any doubt about whether an event is notifiable to CIW, the Registered Manager/Responsible Individual will take advice and err on the side of protecting people and reporting appropriately.

4. Recognising and Responding to the Death of a Service User

When a service user passes away, {{org_field_name}} follows a structured process to ensure that the death is managed with respect, efficiency, and compliance.

4.1 Immediate Actions Upon Discovering a Death

If a staff member finds a service user apparently deceased, they must:

• Treat the situation as an emergency until a qualified clinician confirms otherwise. Care staff must not certify or “pronounce” death unless they are appropriately trained and authorised to undertake verification under local clinical arrangements.
• If there are any signs of life, or any doubt, call 999 immediately and commence basic life support unless a valid DNACPR / end-of-life plan indicates otherwise and emergency services advise differently. This includes checking for any recorded advance statements/advance decisions, and details of any Lasting Power of Attorney (Health and Welfare), and following these in line with the care plan and applicable law.
• If the person is on an end-of-life pathway and death is expected, follow the documented end-of-life plan and contact the appropriate clinical professional (e.g., district nurse, hospice, GP/out-of-hours) to attend and start the verification/certification process. NHS Wales Shared Services Partnership
• Notify the office/on-call manager immediately and remain with the individual (unless personal safety requires withdrawal).
• Maintain the person’s privacy, dignity and respect (e.g., close curtains/door, limit access to the room, speak calmly and sensitively).
• Contact the next of kin / named representative in line with the care plan and confidentiality requirements, sharing only necessary information.
• Ensure the care record captures time found, who was contacted, actions taken, and any relevant observations.

4.2 Handling Unexpected or Suspicious Deaths

If the death is unexpected, unexplained, or there are any suspicious circumstances, staff must:

• Call 999 immediately and follow police/ambulance instructions.
• Do not move the person or disturb the environment (unless necessary to remove immediate danger).
• Contact the Registered Manager/on-call manager immediately.
• The Registered Manager will ensure relevant notifications/referrals are made without delay (including police/coroner where directed, safeguarding where indicated, and CIW where the event meets notification requirements).
• Complete an internal incident report and fully cooperate with any investigation.

5. Notification and Documentation

5.1 Notifying the Appropriate Authorities and Key People

The Registered Manager (or delegated senior) will ensure the following notifications are made as applicable:

• Appropriate NHS clinician/service to attend and complete the required verification/certification pathway (e.g., district nurse/hospice/GP/out-of-hours). Families may also be contacted by the Medical Examiner service as part of the scrutiny of non-coronial deaths.
• Next of kin / named representative in line with the care plan and confidentiality requirements.
• Commissioning authority (Local Authority/Health Board) where the package is commissioned/funded, and any other stakeholders specified in the care plan/contract.
• Safeguarding: Where there is any concern that abuse, neglect, unsafe care, or avoidable harm may have contributed, a safeguarding referral will be made immediately in line with the Safeguarding policy.
• Police/Coroner: Where directed by emergency services/clinicians, or where circumstances require.
• Care Inspectorate Wales (CIW): Notifications are made without delay and in writing via CIW Online, in the form CIW requires.
  CIW notification will be submitted where the death is connected to a notifiable event under Regulation 60 / Schedule 3, for example where it relates to:
  • a serious accident or injury (including where it results in death/shortening of life expectancy),
  • abuse or an allegation of abuse involving the provider/staff,
  • an incident reported to the police,
  • an outbreak of infectious disease, or
  • where accommodation is provided, the death of an individual and the circumstances.
    Where there is uncertainty, the Registered Manager will record the decision-making rationale and seek advice.

5.2 Internal Documentation and Records

After the death of a service user, the following records must be completed:

• Incident report, detailing the time, date, and circumstances of the death.
• Care records updated, including any last observations or interactions.
• Medication records reviewed, ensuring any remaining medication is disposed of correctly.
• Safeguarding records, if concerns arise regarding abuse or neglect.

How we manage this efficiently:

• A dedicated death reporting template ensures consistency in documentation.
• All staff receive training on completing records sensitively and accurately.

In addition, the following must be completed where applicable:

• Communication log (time/date/person spoken to and advice received: 999, NHS professionals, police, coroner, family, commissioner, CIW).
• Property/keys/equipment checklist (record any service keys, access fobs, telecare equipment, care equipment, and any property handed over; obtain signatures where possible).
• Care delivery records for the preceding period (call notes, MAR charts, body maps if relevant, risk assessments) must be secured and preserved for any investigation.
• Decision log documenting whether a CIW notification was submitted and the rationale (including “not required” decisions).

5.3 Duty of Candour (Openness and Honesty) following a Death

Where a death follows an incident, omission, or concern about the quality/safety of care, {{org_field_name}} will act with openness and transparency with the individual’s representative/family. This includes:

• providing a clear account of what is known at the time;
• explaining the steps being taken to review/investigate;
• providing updates and sharing outcomes where appropriate; and
• offering a sincere apology where appropriate.
  Staff will be supported to meet their professional duty of candour and to escalate any concerns promptly, without fear of victimisation.

5.4 Medicines, Equipment and Infection Prevention Following a Death

• Staff must not dispose of a service user’s medicines unless authorised within the medication policy and agreed with the family/clinician. As a minimum, remaining medicines should be secured and arrangements made for return/disposal via the appropriate route (e.g., community pharmacy), with a clear record of what was handed over and to whom.
• Where controlled drugs are present, staff will follow the Medication Policy and obtain management advice immediately.
• Any care equipment/telecare provided by the service or third parties (where known) must be recorded and arrangements made for collection/return.
• Standard and any additional infection prevention precautions must be followed (including PPE and cleaning of any equipment used), and any infectious disease concerns escalated per the Infection Control Policy.

6. Supporting Families and Carers

The death of a loved one is a difficult experience. {{org_field_name}} is committed to offering:

• Immediate emotional support to family members during notification.
• Signposting to bereavement counselling and support services.
• A follow-up call within a week of the death, offering further assistance if needed.
• A condolence letter or message, if appropriate and agreed upon by the family.

How we manage this efficiently:

• A bereavement support guide is available for families and staff.
• A list of local bereavement support services is maintained for referrals.

7. Managing the Impact on Staff and Service Users

7.1 Supporting Care Staff

• Staff involved in a service user’s death must be offered emotional support.
• Supervision sessions provide opportunities for staff to discuss concerns.
• Critical Incident Debriefs are offered if the death was distressing or unexpected.

7.2 Supporting Other Service Users

• Other service users who were close to the deceased are supported sensitively.
• Group discussions or one-to-one support sessions are offered if needed.

How we manage this efficiently:

• A staff well-being programme provides emotional support.
• A senior care worker is designated as a bereavement liaison.

8. Reviewing and Learning from Deaths

8.1 Internal Review Process

Following a service user’s death, {{org_field_name}} conducts:

• A review meeting to identify any improvements in end-of-life care.
• A risk assessment to determine if additional safeguards are needed.
• A CIW compliance check, ensuring all regulatory steps were followed.

8.2 Quality Improvement Actions

• Findings from reviews are used to improve care plans, staff training, and procedures.
• Lessons learned are shared (while maintaining confidentiality) to enhance service quality.

How we manage this efficiently:

• The Registered Manager will ensure a proportionate post-death review is completed, learning is recorded, and improvements are implemented and shared with staff (while maintaining confidentiality).
• Ongoing training ensures continuous improvement in end-of-life care.

9. Related Policies

This policy aligns with:

• End-of-Life and Palliative Care Policy (DCW42)​.
• Safeguarding Adults Policy (DCW13)​.
• Mental Capacity and DNAR Policy (DCW39)​.
• Risk Management and Assessment Policy (DCW18)​.

10. Policy Review

This policy will be reviewed annually or sooner if required due to legislative changes, business needs, or CIW updates. The Registered Manager and Responsible Individual are responsible for ensuring compliance.

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Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}
Reviewed on: {{last_update_date}}
Next Review Date: {{next_review_date}}
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