A brief guide to organising a Hospital PM examination in NHS GGC and how to fill in the - PowerPoint Presentation

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A brief guide to organising a Hospital PM examination in NHS GGC and how to fill in the Hospital Post-Mortem Authorisation form

Hospital autopsies are done on a Tuesday and Thursday at the QEUH. All PM examinations in NHS GGC are done at this facility.

Please ring the QEUH mortuary on ext. 59357 if you are thinking of organising a Hospital PM examination as they can advise you on how to obtain the Authorisation form and information pack for the bereaved, and can also inform you as to when the next PM slot is available.

After obtaining the authorisation form (usually from the Mortuary at your hospital), please take time to review it carefully

before

speaking to the family. If you have any questions as to how it should be filled in, please refer to the rest of this presentation and then ring the Pathology department at QEUH and ask to speak to one of the Consultant Pathologists.

If the form is filled in incorrectly

it cannot be accepted and the examination cannot take place.

The form cannot be altered once the top copy has been removed and given to the family, and any subsequent amendments require the presence of the family and witness.

So please ensure you are familiar with how to complete the form correctly BEFORE speaking to the family, and if in any doubt contact the Pathology department.

Please provide a brief Clinical Summary along with the case notes and a reliable phone number on which the Pathologist can contact you after the examination, so as to provide an update on the PM findings. This is particularly important in cases where the MCCD is to be completed after the PM.

The form is triplicate in format.

Please give the top (white) copy to the family after they have signed it.

Send the 2 bottom copies with the medical notes and Clinical Summary to the Mortuary.

If using Patient ID stickers, please ensure that a sticker is affixed to

each

sheet.

INSERT

PATIENT

NAME

HERE

One of the first issues to raise with the person authorising the examination is if they were aware of any objections the deceased may have had to a post-mortem examination.

If the deceased had ever indicated that they were unwilling for a post mortem to be carried out, a Hospital PM examination cannot take place, regardless of the relatives’ wishes.

Authorising a Hospital PM in Scotland automatically authorises the retention and storage of

tissue samples

as part of the PM examination. These are small pieces of tissue, 1-2cm in size. These are not returned to the body after the examination.

This is in contrast with

organs,

dealt with under section 2 (see later).

A normal (full) hospital PM examination will involve examination of the organs in the head, neck, chest, abdomen and pelvis.

Limited PM examination is possible and involves the examination of specific body areas and their organs e.g. the head; the chest; the abdomen or any combination of these areas.

Note: Ticking all 3 boxes in section 1B (i.e. Head AND chest AND abdomen) is equivalent to a full PM, and so section 1A should be selected instead.

Section 2 relates to the retention and use of

whole organs

(not tissue, which is dealt with under section 1).

Whole organs are very seldom retained at post mortem examination, the exception being in some neuropathology PM examinations where there may be a reason to retain the brain.

If there is a question as to whether or not organs need to be retained in a particular PM, please discuss with a Consultant Pathologist

prior

to meeting with the family to sign this form. The pathologist can then advise on how to fill in section 2.

If there is no intention to retain organs, section 2 can be scored out.

Please tick this box to confirm there are no other requests from the relatives regarding the examination.

The member of staff discussing authorisation should ensure that the matters raised here have been covered and these 3 boxes ticked.

It is not expected that many people will leave instructions in the event of their death relating to PM examination (covered by the second box) but if so, please attach a copy.

Please only fill this area out if

ORGANS

have been retained under section 2.

It is recommended that senior medical staff obtain authorisation.

This does not necessarily mean consultants.

Trainee doctors can seek authorisation but FY doctors should not seek authorisation on their own (they can however act as witnesses – see below).

Nursing staff cannot seek authorisation, but can act as witnesses.

The doctor signing this area

CANNOT

act as witness to their own signature.

DOCTOR SIGNS HERE

RELATIVE SIGNS HERE

WITNESS SIGNS HERE

Another member of medical staff, nursing staff or another family member can witness the signing of this form.

Further information

QEUH Mortuary 0141 354 9357

Dept. of Pathology, QEUH 0141 354 9500

For further information for hospital staff on clinical, practical and legislative issues around death, please visit the NES ‘Support Around Death’ website

http://www.sad.scot.nhs.uk