PROCEDURE FOR THE SENSITIVE DISPOSAL OF THE NON VIABLE FETUS

Size: px
Start display at page:

Download "PROCEDURE FOR THE SENSITIVE DISPOSAL OF THE NON VIABLE FETUS"

Transcription

1 DIRECTORATE OF PATHOLOGY Standard Operating Procedure PROCEDURE FOR THE SENSITIVE DISPOSAL OF THE NON VIABLE FETUS (i.e. up to 23 weeks and 6 days gestation) Recommending Committee: Approving Signature: Designation: Pathology Management Dr Sheila Kelly Consultant Histopathologist Date: April 2010 Version Number: 5 Date: April 2010 Review Date: March 2012 Responsible Officer: Karen Unsworth Equality Impact Assessment Outcome Level (high, medium, low) LOW Review date March 2012

2 Appendix 1 Minimum Data Set For Approval Process Title Procedure for the sensitive disposal of the Non Viable Fetus Author/s Departmental Service Manager Cellular Pathology/Mortuary Services Responsible officer Departmental Service Manager Cellular Pathology/Mortuary Services Purpose To ensure correct pathway is followed for sensitive disposal of the Non Viable Fetus Reference Page 10 of document Approval date April 2010 Implementation date April 2010 Amendment date April 2010 Version number 5 Review date April 2012 Consultation/recommending Obstetrics, Gynaecology and groups Midwifery Services Bereavement Office Pathology Department Clinical Risk Management Department Spiritual Care Department Cremation Authorities Royal Liverpool Children s Hospital- Alder Hey (RLCH) Histology Department Approved by Consultant Histopathologist Target population/distribution Clinical Staff For information to Laboratory and Mortuary staff Training needs Ward based training Financial consequences N/A Superseded document Procedure for the sensitive disposal of the Non Viable Fetus Version 4 Equality impact assessment April 2010 Page 2 of 10

3 Contents Clinical (Ward Based) Procedure o Non-Viable Fetuses Up To 15 Weeks And 6 Days Gestation/Products Of Conception. o Non- Viable Fetuses From 16 Weeks To 23 Weeks And 6 Days Gestation. Laboratory Procedure Implemenation And Audit N.B. The procedures for stillbirths are covered in the document: 'Procedure for the Sensitive Disposal of Stillborn infants' The procedure for live births at any gestational age are covered in the document Procedure for the Sensitive Disposal of Live births All enquiries relating to individual cases should initially be made to the Bereavement Office (Extension 1336), who will co-ordinate the Trust response. Further copies are available on the Intranet Page 3 of 10

4 CLINICAL (WARD BASED) PROCEDURE The procedures for dealing with products of conception and /or recognisable fetal remain up to 23 weeks and 6 days gestation are the same for all clinical staff. (See appendix 1 and appendix 2 Midwives documentation) The specimen should be fixed in formalin ONLY after appropriate ward based investigations are complete e.g. cytogenetics (COSHH 3, sensitiser). SPECIMENS WHICH ARE RECEIVED WITHOUT A COMPLETED CONSENT FORM AND/OR THE MINIMUM DATA SET FOR IDENTIFICATION AND/ OR APPROPRIATE CLINICAL DETAILS WILL BE RETURNED - THUS DELAYING THE REPORT Non-viable fetuses up to 15 weeks and 6 days gestation/products of conception. 1) Non- viable fetuses up to 15 weeks and 6 days gestation and products of conception undergo histological examination at Whiston. 2) These specimens MUST be placed in an appropriately sized opaque specimen container and covered with formalin. (COSHH 3, sensitiser) 3) The mother MUST complete Consent form 10. NOTE: Where communication is necessary with the patient/carer/next of kin Alternative formats of communication will be available on request (e.g. translation services, sign language services) 4) Clinical staff MUST: Complete Healthcare Professionals section of Consent Form 10. The white copy is to be sent to the Histology Department with the specimen and completed histology request form. The yellow copy is to be given to the mother. The blue copy is sent to the Bereavement Office. The pink copy is filed in the mother's medical records. 5) The specimen container MUST be labelled with the following information: mother's name a minimum of two from- Maternal date of birth, unit number, address date of miscarriage hazard status (as necessary) location (ward / department) Page 4 of 10

5 6) The specimen container MUST be accompanied by a signed completed histology request form giving the following information mother's name a minimum of two from - Maternal date of birth, unit number, address date of miscarriage hazard status (as necessary) location (ward / department) Consultant clinical information 7) If the mother does not wish for histopathological examination to be performed: Consent form 10 MUST be completed The fetus or products of conception must be placed in appropriately sized opaque specimen container and covered with formalin (COSHH 3, sensitiser) The white copy of Consent form 10 and a completed Histology request form are sent with the specimen to the Histology department for sensitive disposal. Non- viable fetuses from 16 weeks to 23 weeks and 6 days gestation. Fetus and Placenta to go to RLCH (Alder Hey) for post-mortem examination. 1) If the parents wish to have a post-mortem examination of a fetus from 16 weeks to 23 weeks and 6 days gestation this is carried out at RLCH (Alder Hey). 2) The Royal Liverpool Children s Hospital (Alder Hey) consent booklet and a Consent form 10 MUST be completed by the mother. 3) Clinical staff MUST: Complete Healthcare Professionals section of Consent Form 10. The white copy is to be sent to the Mortuary with the specimen. The yellow copy is to be given to the mother. The blue copy is sent to the Bereavement Office. The pink copy is filed in the mother's medical records. 4) The fetus and placenta should be placed in an appropriately sized opaque specimen container. 5) The specimen container MUST be labelled with the following information: mother's name a minimum of two from- Maternal date of birth, unit number, address date of miscarriage hazard status (as necessary) location (ward / department) Page 5 of 10

6 6) Clinical staff MUST complete a Royal Liverpool Children s Hospital - Alder Hey Request for fetal, perinatal or infant post mortem examination form. Mothers GP details MUST be completed. The fetus and placenta are sent to Whiston Mortuary together with the following: Document Required Request for fetal, perinatal or infant post mortem examination form. Photocopy of Mother s relevant case sheets Completed copy of Consent form 10 Blue copy of page 11 RLCH Blue copy of page 12 RLCH Blue copy of page 13 RLCH Blue copy of page 14 RLCH Blue copy of page 15 RLCH Blue copy of page 17 RLCH Blue copy of page 18 RLCH Blue copy of page 19 RLCH Notes This must be fully completed and signed. These must be sent This must be completed This must be completed This must be completed and one of the boxes ticked Child s name & unit number must be completed and one of A, B or C ticked Child s name & unit number must be completed and one of the boxes ticked Child s name & unit number must be completed and one of the boxes ticked This must be completed This must be completed Only if an interpreter has been used. UNLESS ALL THESE COMPLETED DOCUMENTS ARE RECEIVED, THE FETUS WILL NOT BE ACCEPTED IN THE WHISTON MORTUARY. RLCH WILL NOT CARRY OUT A POST-MORTEM EXAMINATION WITHOUT THE CORRECTLY COMPLETED PAPERWORK. 7) The fetus and placenta are transferred to RLCH (Alder Hey) by the Trust contracted Funeral director. Page 6 of 10

7 Non- viable fetuses from 16 weeks to 23 weeks and 6 days gestation cont d. Fetus not for examination Even if the mother does not wish for histopathological examination of the fetus Consent form 10 MUST be completed. The fetus must be placed in appropriately sized opaque specimen container and sent to Whiston Mortuary with the white copy of Consent form 10. Placenta only to go to RLCH (Alder Hey) for examination 1) If only the placenta is being sent to RLCH for examination the placenta must be placed in an appropriately sized opaque specimen container and covered with formalin (COSHH 3, sensitiser). 2) Complete the form Royal Liverpool Children s Hospital Alder Hey Request for examination of the placenta and a Histology request form. 3) Send the placenta and both completed request forms to Histology department at Whiston. 4) The placenta will be transferred to RLCH (Alder Hey) via Trust transport. Page 7 of 10

8 LABORATORY PROCEDURE St Helens and Knowsley Teaching Hospitals NHS Trust 1) Only specimens with an accompanying completed Consent Form 10 and a Histology Request Form will be given an accession number. Any specimens sent without either of the forms or an incomplete Consent form 10 MUST be returned to original sender/location. (See Histology SOPs 1.0, 1.3). 2) The completed consent form must accompany the request form through the laboratory and the reporting process and be filed with the request form. 3) The lid of the specimen container is labelled with a red spot. If the mother indicates on Consent form 10 that they wish any taken tissue to be reunited with the products of conception/fetus then the lid of the specimen container is also labelled with a green spot.(see Histology SOP 7.7). 4) The specimen should be examined by a pathologist and if following this it is determined that the specimen consists only of maternally derived tissues i.e. placenta/ decidua, the specimen can be disposed as per Trust policy (See Histology SOP 7.3) 5) If the examining pathologist identifies fetal tissues a Fetal tissue retention document and a Cremation Document (respecting individual religious, cultural and other wishes where cremation may not be appropriate) are to be completed by a Consultant Pathologist. These forms will be stored in the Fetal Retention Document file within the Histology department. 6) The pathological examination of such specimens will be tailored to take account of completed consent form: - if no consent has been obtained for the examination of fetal parts, placental tissue only will be sampled for microscopic examination, and examination of fetal tissues will be limited to external description and measurement. 7) When pathological investigations are complete the specimen must be sealed in a Bitran bag and placed in a casket labelled with the minimum data set for identification and the laboratory accession number. Specimens will be submitted for sensitive disposal unless the completed Consent form 10 indicates other arrangements are required (see point 9)). 8) Specimens are stored in the laboratory for 6 week, after which they are transferred to the Mortuary accompanied by the Fetal tissue retention document, cremation documents and photocopy of Consent form 10. (See Histology SOP 7.4). A record of all specimens sent for sensitive disposal is kept in the Histology department. Page 8 of 10

9 9) Specimens are stored in the Mortuary for 1 week, after which the specimens are collected by the Trust contracted funeral director for sensitive disposal. The Fetal tissue retention document must be completed by the Mortuary staff and the Funeral director. Four copies are made, one sent to the Histology Department, one to the Bereavement Office, one to be kept in file in the mortuary and one given to the funeral director. The Funeral director also takes the Cremation documents and the photocopy of Consent form10. The original completed document to be sent to the Medical Records Department to be filed in the mother's medical record. 10) If the family wish to be involved with the sensitive disposal of the specimen, the Bereavement Office should contact the Histology laboratory (ext. 1828) who will prepare the specimen for collection by the Funeral director. On the day of collection the relevant parts of 'Fetal tissue retention document' are completed by the member of Histology staff handing over the specimen and the Funeral director. Three copies are made, one given to the Funeral director, one sent to the Bereavement Office and one to be kept in file in the Histology department. The original completed document to be sent to the Medical Records Department to be filed in the mother's medical record. NOTES: All specimens can be tracked through the Histology department by use of the Telepath computer system or the filed paper records which are kept for 30 years. If anyone wishes to have a copy of the Histology SOPs listed please contact the department on ext COSHH hazards are numbered: 1 = Toxic 5 = Irritant 2 = Corrosive 6 = Explosive 3 = Harmful 7 = Oxidising 4 = Highly Flammable 8 = Toxic Fumes under Fire Conditions More detailed information in the form of Data Sheets is available in the Histology COSHH Handbook. Staff should familiarise themselves with COSHH data prior to performing a procedure. Page 9 of 10

10 Implementation and Audit St Helens and Knowsley Teaching Hospitals NHS Trust Implementation This policy will be available on the Trust intranet and will be a controlled document via the Pathology Quality Management System. Full adherence to the policy will be implemented one calendar month after authorisation. Audit Audit of compliance will be undertaken as part of the annual internal audit of the Pathology Quality Management System. References Human Tissue Authority Code of Practice 5 Disposal of Human Tissue September 2009 The Cremation (England and Wales) Regulations 2008 (effective January 2009) Page 10 of 10

PARTICULARS, SCHEDULE 2 THE SERVICES, A SERVICE SPECIFICATION

PARTICULARS, SCHEDULE 2 THE SERVICES, A SERVICE SPECIFICATION E12/S/b 2013/14 NHS STANDARD CONTRACT FOR PERINATAL PATHOLOGY PARTICULARS, SCHEDULE 2 THE SERVICES, A SERVICE SPECIFICATION Service Specification No. Service Commissioner Lead Provider Lead Period Date

More information

Management of Hospital Post-mortem Examinations

Management of Hospital Post-mortem Examinations Management of Hospital Post-mortem Examinations Draft Standards February 2016 Healthcare Improvement Scotland is committed to equality and diversity. We have assessed these draft standards for likely impact

More information

Site visit inspection report on compliance with HTA minimum standards. London School of Hygiene & Tropical Medicine. HTA licensing number 12066

Site visit inspection report on compliance with HTA minimum standards. London School of Hygiene & Tropical Medicine. HTA licensing number 12066 Site visit inspection report on compliance with HTA minimum standards London School of Hygiene & Tropical Medicine HTA licensing number 12066 Licensed under the Human Tissue Act 2004 for the storage of

More information

Cardiff and Vale University Health Board: WASTE MANAGEMENT OPERATIONAL PROCEDURES APPENDIX 8

Cardiff and Vale University Health Board: WASTE MANAGEMENT OPERATIONAL PROCEDURES APPENDIX 8 ANATOMICAL WASTES Cardiff and Vale University Health Board: APPENDIX 8 1 Defining Anatomical Waste Anatomical waste is defined for the purposes of this procedure as a 'recognisable' body part, tissue or

More information

Gloucestershire Hospitals

Gloucestershire Hospitals Gloucestershire Hospitals NHS Foundation Trust TRUST NON CLINICAL POLICY MATERNITY SERVICES HEALTH RECORDS B0556 Any hard copy of this document is only assured to be accurate on the date printed. The most

More information

Women, Children and Sexual Health Division Maternity Services. Guideline: Anti D- Prophylaxis

Women, Children and Sexual Health Division Maternity Services. Guideline: Anti D- Prophylaxis Women, Children and Sexual Health Division Maternity Services Guideline: Anti D- Prophylaxis 1. Introduction The National Institute for Clinical Excellence recommend routine antenatal anti-d prophylaxis

More information

AUSTRALIA AND NEW ZEALAND FACTSHEET

AUSTRALIA AND NEW ZEALAND FACTSHEET AUSTRALIA AND NEW ZEALAND FACTSHEET What is Stillbirth? In Australia and New Zealand, stillbirth is the death of a baby before or during birth, from the 20 th week of pregnancy onwards, or 400 grams birthweight.

More information

SARASOTA MEMORIAL HOSPITAL POLICY

SARASOTA MEMORIAL HOSPITAL POLICY SARASOTA MEMORIAL HOSPITAL POLICY TITLE PATIENT EXPIRATION, INCLUDING FETAL DEATH, PRONOUNCING OF PATIENT, AUTOPSY REQUESTS, POST- MORTEM CARE & MEDICAL EXAMINER CASES EFFECTIVE DATE: REVIEWED/REVISED

More information

Guidance in Relation to Requirements of the Abortion ACT 1967. For all those responsible for commissioning, providing and managing service provision

Guidance in Relation to Requirements of the Abortion ACT 1967. For all those responsible for commissioning, providing and managing service provision Guidance in Relation to Requirements of the Abortion ACT 1967 For all those responsible for commissioning, providing and managing service provision May 2014 Title: Guidance in Relation to Requirements

More information

ENC Li Subject Access Request Procedure

ENC Li Subject Access Request Procedure Subject Access Request Procedure Version: 1.0 Page 1 of 23 Document control Document Information Document Name: Location: Consultation: Initial approval: Supersedes: Description: Audience: Contact details

More information

08 LC 29 3403S. The House Committee on Judiciary offers the following substitute to SB 381: A BILL TO BE ENTITLED AN ACT

08 LC 29 3403S. The House Committee on Judiciary offers the following substitute to SB 381: A BILL TO BE ENTITLED AN ACT The House Committee on Judiciary offers the following substitute to SB : A BILL TO BE ENTITLED AN ACT To amend Chapter 0 of Title of the Official Code of Georgia Annotated, relating to vital records, so

More information

Help and advice during your bereavement

Help and advice during your bereavement Help and advice during your bereavement Information leaflet The James Cook University Hospital We would like to express our sincere condolences to you and your family at this sad time. This booklet aims

More information

Dear Colleague COMMENCEMENT OF THE CERTIFICATION OF DEATH (SCOTLAND) ACT 2011. Purpose

Dear Colleague COMMENCEMENT OF THE CERTIFICATION OF DEATH (SCOTLAND) ACT 2011. Purpose Chief Medical Officer Directorate T: 0131-244 5066 E: mini.mishra@scotland.gsi.gov.uk Dear Colleague COMMENCEMENT OF THE CERTIFICATION OF DEATH (SCOTLAND) ACT 2011 Purpose 1. This letter is to inform you

More information

NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST UMBILICAL CORD BLOOD COLLECTION AT NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST BY THIRD PARTIES POLICY

NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST UMBILICAL CORD BLOOD COLLECTION AT NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST BY THIRD PARTIES POLICY NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST UMBILICAL CORD BLOOD COLLECTION AT NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST BY THIRD PARTIES POLICY Documentation Control Reference Date approved Approving Body

More information

Assessment of Fetal Growth

Assessment of Fetal Growth Assessment of Fetal Growth Unit / Trust: 1. INTRODUCTION The aim of this guideline template is to outline the methods used to assess fetal growth and the referral pathways utilising customised antenatal

More information

NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE CENTRE FOR CLINICAL PRACTICE QUALITY STANDARDS PROGRAMME

NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE CENTRE FOR CLINICAL PRACTICE QUALITY STANDARDS PROGRAMME NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE CENTRE FOR CLINICAL PRACTICE QUALITY STANDARDS PROGRAMME standard topic: Specialist neonatal care Output: standard advice to the Secretary of State

More information

Cord blood donation is a painless and free gesture, helping others and saving lives.

Cord blood donation is a painless and free gesture, helping others and saving lives. Cord blood donation is a painless and free gesture, helping others and saving lives. Cord blood, a bond for life. GRANDE CAUSE NATIONALE 2009 Donation for scientific research If your donation does not

More information

DOCUMENT CONTROL PAGE

DOCUMENT CONTROL PAGE Review Circulation Application Ratification Author Minor Amendment Supersedes Title DOCUMENT CONTROL PAGE Title: Directorate of Laboratory Medicine Sample Acceptance Policy Version: 009 Reference Number:

More information

Nursing Protocol for the Verification of Expected Death in the Community

Nursing Protocol for the Verification of Expected Death in the Community Nursing Protocol for the Verification of Expected Death in the Community 1.0 Introduction The intention of this policy is to support registered nurses in verifying expected death in the community for those

More information

IMS-ST-1.04 Document and Record Management. Prepared By: Jacqueline Raynes Print Date: 20/08/13 Version No: V01 Reviewed By: Jeff Innes

IMS-ST-1.04 Document and Record Management. Prepared By: Jacqueline Raynes Print Date: 20/08/13 Version No: V01 Reviewed By: Jeff Innes Integrated Management Standard 1.04 Document and Record Management Contents 1 Purpose... 2 2 Scope... 2 3 Standard... 2 3.1 OTML Documentation Overview... 2 3.2 Integrated Management System Documentation...

More information

National Hospitals Office Code of Practice for Healthcare Records Management

National Hospitals Office Code of Practice for Healthcare Records Management National Hospitals Office Code of Practice for Healthcare Records Management Part 5: Retention and Disposal Schedule Reader Information Directorate: National Hospitals Office (NHO) Title: NHO Code of Practice

More information

RD SOP17 Research data management and security

RD SOP17 Research data management and security RD SOP17 Research data management and security Version Number: V2 Name of originator/author: Dr Andy Mee, R&I Manager Name of responsible committee: R&I Committee Name of executive lead: Medical Director

More information

Policy for Screening Patients for MRSA Colonisation

Policy for Screening Patients for MRSA Colonisation Policy for Screening Patients for MRSA Colonisation To whom this document applies: All staff in Colchester Hospital University Foundation Trust screening Patients for MRSA Procedural Documents Approval

More information

MANAGEMENT OF POLICIES, PROCEDURES AND OTHER WRITTEN CONTROL DOCUMENTS

MANAGEMENT OF POLICIES, PROCEDURES AND OTHER WRITTEN CONTROL DOCUMENTS MANAGEMENT OF POLICIES, PROCEDURES AND OTHER WRITTEN CONTROL DOCUMENTS Document Reference No: Version No: 6 PtHB / CP 012 Issue Date: April 2015 Review Date: January 2018 Expiry Date: April 2018 Author:

More information

Medical Certificate of Cause of Death (MCCD) (Completion Of)

Medical Certificate of Cause of Death (MCCD) (Completion Of) This is an official Northern Trust policy and should not be edited in any way Medical Certificate of Cause of Death (MCCD) (Completion Of) Reference Number: NHSCT/12/492 Target audience: This applies to

More information

Rh D Immunoglobulin (Anti-D)

Rh D Immunoglobulin (Anti-D) Document Number PD2006_074 Rh D Immunoglobulin (Anti-D) Publication date 29-Aug-2006 Functional Sub group Clinical/ Patient Services - Maternity Clinical/ Patient Services - Medical Treatment Population

More information

Staff Resources Dying & Death in an Acute Hospital. End-of-Life Care Resources. Care After Death

Staff Resources Dying & Death in an Acute Hospital. End-of-Life Care Resources. Care After Death Staff Resources Dying & Death in an Acute Hospital End-of-Life Care Resources Care After Death The information below is from the Hospice Friendly Hospital Programme s Map for End-of-Life Care When a Patient

More information

Date 25/11/13 Our Ref 4191. I write in response to your request for information in relation procedures for pronouncing a patient dead.

Date 25/11/13 Our Ref 4191. I write in response to your request for information in relation procedures for pronouncing a patient dead. Lothian NHS Board Waverley Gate 2-4 Waterloo Place Edinburgh EH1 3EG Telephone 0131 536 9000 Fax 0131 536 9088 www.nhslothian.scot.nhs.uk Date 25/11/13 Our Ref 4191 Enquiries to Richard Mutch Extension

More information

2.3. The management in each HCF shall be responsible for ensuring good waste management practices in their premises.

2.3. The management in each HCF shall be responsible for ensuring good waste management practices in their premises. 1. PURPOSE Health-care activities lead to production of medical waste that may lead to adverse health effects. Most of this waste is not more dangerous than regular household waste. However, some types

More information

/ Clinical Waste & Offensive Waste Disposal Procedures

/ Clinical Waste & Offensive Waste Disposal Procedures / Clinical Waste & Offensive Waste Disposal Procedures Document Control Document Created by Last Updated by Shane McAteer 26/01/2011 Paul Monk 29/10/2013 1 Introduction This clinical and offensive waste

More information

Maternity Care Primary C-Section Rate Specifications 2014 (07/01/2013 to 06/30/2014 Dates of Service)

Maternity Care Primary C-Section Rate Specifications 2014 (07/01/2013 to 06/30/2014 Dates of Service) Summary of Changes Denominator Changes: Two additions were made to the denominator criteria. The denominator was changed to include patients who had: a vertex position delivery AND a term pregnancy of

More information

PLANNING FUTURE CARE. Wishes & Preferences for My Future Care. This Plan belongs to:

PLANNING FUTURE CARE. Wishes & Preferences for My Future Care. This Plan belongs to: PLANNING FUTURE CARE Wishes & Preferences for My Future Care This Plan belongs to: Planning Your Future Care What is this Plan for? This Care Plan is your opportunity to think ahead and write down what

More information

Help for Bereaved Parents

Help for Bereaved Parents Birmingham Women s NHS Foundation Trust Help for Bereaved Parents Author: Karen Henson Bereavement Service Manager Birmingham Women s NHS Foundation Trust Edgbaston, Birmingham B15 2TG Tel: 0121 472 1377

More information

School of Chemistry and Chemical Biology Hazardous Waste Management Plan

School of Chemistry and Chemical Biology Hazardous Waste Management Plan School of Chemistry and Chemical Biology Hazardous Waste Management Plan SOPs for the disposal of hazardous waste generated in the School of Chemistry and Chemical Biology Updated 29/11/12 Page 1 Contents:

More information

CCG: IG06: Records Management Policy and Strategy

CCG: IG06: Records Management Policy and Strategy Corporate CCG: IG06: Records Management Policy and Strategy Version Number Date Issued Review Date V3 08/01/2016 01/01/2018 Prepared By: Consultation Process: Senior Governance Manager, NECS CCG Head of

More information

Bereavement Policy. and End of Life Procedure. Documentation Control. Mortuary and Bereavement service, Child undertaken

Bereavement Policy. and End of Life Procedure. Documentation Control. Mortuary and Bereavement service, Child undertaken and End of Life Procedure Documentation Control Reference CL/CGP/076 Approving Body Directors Group Date Approved 26 Implementation date 26 Supersedes n/a Consultation Mortuary and Bereavement service,

More information

Policy & Guidance for the provision of Care & Respect in Death

Policy & Guidance for the provision of Care & Respect in Death Policy & Guidance for the provision of Care & Respect in Death Policy umber: 45 Version: 2.2 Category: Authorisation Committee: Clinical Date of Authorisation: September 2009 Ratification Committee: ursing

More information

Death Verification of Death and Medical Certificate of Cause of Death

Death Verification of Death and Medical Certificate of Cause of Death Policy Directive Ministry of Health, NSW 73 Miller Street North Sydney NSW 2060 Locked Mail Bag 961 North Sydney NSW 2059 Telephone (02) 9391 9000 Fax (02) 9391 9101 http://www.health.nsw.gov.au/policies/

More information

under the Licensed contains, relevant for use storage 14 May 2015 practices majority of the risk performed under

under the Licensed contains, relevant for use storage 14 May 2015 practices majority of the risk performed under Site visit inspectionn report on compliance with HTA minimum standards Central Mortuary, Birmingham HTA licensing number 12194 Licensed under the Human Tissue Act 2004 for the making of a post mortem examination;

More information

STANDARD OPERATING POLICY AND PROCEDURE

STANDARD OPERATING POLICY AND PROCEDURE STANDARD OPERATING POLICY AND PROCEDURE SUBJECT: Biospecimen Request and Release Policy Number: 500.0 Policy Date: 1/16/2009 Amendment Date: N/A Revision Date: 5-3-2010 I. INTRODUCTION AND PURPOSE The

More information

2013 No. 1629 CORONERS, ENGLAND AND WALES. The Coroners (Investigations) Regulations 2013

2013 No. 1629 CORONERS, ENGLAND AND WALES. The Coroners (Investigations) Regulations 2013 S T A T U T O R Y I N S T R U M E N T S 2013 No. 1629 CORONERS, ENGLAND AND WALES The Coroners (Investigations) Regulations 2013 Made - - - - 2nd July 2013 Laid before Parliament 4th July 2013 Coming into

More information

LiAiSON. Formaldehyde. In This Issue. How does Formaldehyde affect human health?

LiAiSON. Formaldehyde. In This Issue. How does Formaldehyde affect human health? LiAiSON OCTOBER Marwell Medical Newsletter Formaldehyde How does Formaldehyde affect human health? Formaldehyde is toxic by inhalation, by skin contact, and by swallowing. Breathing Formaldehyde vapours

More information

Guideline for staff involvement and responsibility with cord blood collection for stem cells (GL811)

Guideline for staff involvement and responsibility with cord blood collection for stem cells (GL811) Guideline for staff involvement and responsibility with cord blood collection for stem cells (GL811) Approval Approval Group Job Title, Chair of Committee Date Maternity & Children s Services Clinical

More information

RECORD KEEPING IN HEALTHCARE RECORDS POLICY

RECORD KEEPING IN HEALTHCARE RECORDS POLICY RECORD KEEPING IN HEALTHCARE RECORDS POLICY Version 6.0 Key Points The Policy provides a framework for the quality of the clinical record facilitates high quality, safe patient care and that subsequently

More information

Minutes of the HTA Histopathology Working Group

Minutes of the HTA Histopathology Working Group Minutes of the HTA Histopathology Working Group Date 24 October 2014 Venue Boardrooms 1 and 2 Human Tissue Authority Present Members HTA Ms Sarah Bedwell, Director of Regulation (SB) Ms Caroline Browne,

More information

The Newcastle upon Tyne Hospitals NHS Foundation Trust. Laundry Management Policy

The Newcastle upon Tyne Hospitals NHS Foundation Trust. Laundry Management Policy The Newcastle upon Tyne Hospitals NHS Foundation Trust Laundry Management Policy Version No.: 4.1 Effective From: 20 December 2013 Expiry Date: 31 December 2016 Date Ratified: 20 December 2013 Ratified

More information

2.1. Applicable areas: Royal Cornwall Hospitals Trust; Neonatal Unit and Delivery Suite

2.1. Applicable areas: Royal Cornwall Hospitals Trust; Neonatal Unit and Delivery Suite ADVANCED NEONATAL NURSE PRACTITIONERS (ANNPs) BLOOD COMPONENT AND BLOOD PRODUCT REQUESTING PROTOCOL NEONATAL CLINICAL GUIDELINE 1. Aim/Purpose of this Guideline 1.1 The purpose of this protocol is to guide

More information

Trust Guideline for the use of the Modified Early Obstetric Warning Score (MEOWS) in detecting the seriously ill and deteriorating woman.

Trust Guideline for the use of the Modified Early Obstetric Warning Score (MEOWS) in detecting the seriously ill and deteriorating woman. A clinical guideline recommended for use In: By: For: Key words: Written by: Supported by: Maternity Services. Obstetricians, Midwives and Midwifery Care Assistants. All women receiving care from maternity

More information

NHS. North Tees and Hartlepool. Practical help and advice after a death What do we do next? Information for relatives, carers and friends

NHS. North Tees and Hartlepool. Practical help and advice after a death What do we do next? Information for relatives, carers and friends North Tees and Hartlepool NHS Foundation Trust NHS Practical help and advice after a death What do we do next? Information for relatives, carers and friends We are sorry to hear that you have just learned

More information

MANAGEMENT OF MEDICAL GAS CYLINDERS AND MEDICAL PIPELINE SYSTEMS (MGPS) POLICY. Senior Managers Operational Group. staff)

MANAGEMENT OF MEDICAL GAS CYLINDERS AND MEDICAL PIPELINE SYSTEMS (MGPS) POLICY. Senior Managers Operational Group. staff) MANAGEMENT OF MEDICAL GAS CYLINDERS AND MEDICAL PIPELINE SYSTEMS (MGPS) POLICY Version: 3 Ratified by: Date ratified: December 2013 Title of originator/author: Title of responsible committee/group: Senior

More information

Control of Asbestos Policy

Control of Asbestos Policy Control of Asbestos Policy Version Number: V1D Name of originator/author: Estates Manager 0161 277 1235 Name of responsible committee: Estates and Facilities Committee Name of executive lead: Director

More information

Safe Blood Sampling Training Package

Safe Blood Sampling Training Package Better Blood Transfusion - Education Programme Safe Blood Sampling Training Package SBS Training Package version 2010 to SNBTS www.learnbloodtransfusion.org.uk Learning Outcomes Following this session

More information

ANNOTATED CODE OF MARYLAND HEALTH GENERAL TITLE 5 DEATH TITLE 5. DEATH. Subtitle 1. "Body" Defined. Subtitle 2. Determination of Death.

ANNOTATED CODE OF MARYLAND HEALTH GENERAL TITLE 5 DEATH TITLE 5. DEATH. Subtitle 1. Body Defined. Subtitle 2. Determination of Death. . 5-101. "Body" defined. Subtitle 1. "Body" Defined. Subtitle 2. Determination of Death. 5-201. Scope of subtitle. 5-202. Cessation of circulatory and respiratory or brain functions. 5-301. Definitions.

More information

INFORMATION AND ADVICE FOR BEREAVED FAMILIES AND FRIENDS

INFORMATION AND ADVICE FOR BEREAVED FAMILIES AND FRIENDS INFORMATION AND ADVICE FOR BEREAVED FAMILIES AND FRIENDS Bereavement Officer Patient Experience Team Warwick Hospital Lakin Road Warwick CV34 5BW Telephone 01926 495321 x 8131 What this booklet is for?

More information

Information Security Policy. Appendix B. Secure Transfer of Information

Information Security Policy. Appendix B. Secure Transfer of Information Information Security Policy Appendix B Secure Transfer of Information Author: Data Protection and Information Security Officer. Version: 0.7 Date: March 2008 Document Control Information Document ID Document

More information

Document Title: Trust Approval and Research Governance

Document Title: Trust Approval and Research Governance Document Title: Trust Approval and Research Governance Document Number: SOP034 Staff involved in development: Job titles only Document author/owner: Directorate: Department: For use by: RM&G Manager, R&D

More information

Hepatitis B Pathway stages to protection Actions, roles, responsibilities and standards

Hepatitis B Pathway stages to protection Actions, roles, responsibilities and standards Hepatitis B Pathway stages to protection Actions, roles, responsibilities and standards Start Pathway stages colour code: Action Midwifery role Risk areas Specialist services role Primary care role Paediatric

More information

Smart Use Inventory Management solution at the Royal Shrewsbury Hospital Pathology Service Delivery Unit

Smart Use Inventory Management solution at the Royal Shrewsbury Hospital Pathology Service Delivery Unit Smart Use Inventory Management solution at the Royal Shrewsbury Hospital Pathology Service Delivery Unit The Shrewsbury and Telford Hospital NHS Trust identifies efficiency savings, process improvements

More information

ABSTRACT LABOR AND DELIVERY

ABSTRACT LABOR AND DELIVERY ABSTRACT POLICY Prior to fetal viability, intentionally undertaking delivery of a fetus is the equivalent of abortion and is not permissible. After fetal viability has been reached, intentionally undertaking

More information

Data Protection Policy

Data Protection Policy Data Protection Policy Document Ref: DPA20100608-001 Version: 1.3 Classification: UNCLASSIFIED (IL 0) Status: ISSUED Prepared By: Ian Mason Effective From: 4 th January 2011 Contact: Governance Team ICT

More information

Domestic abuse in pregnancy guidelines (GL828)

Domestic abuse in pregnancy guidelines (GL828) Domestic abuse in pregnancy guidelines (GL828) Approval and Authorisation Approved by Job Title or Chair of Committee Date Maternity & Children s Services Clinical Governance Committee Chair, Maternity

More information

MEDICAL MALPRACTICE FOR INSTITUTIONS PROPOSAL FORM

MEDICAL MALPRACTICE FOR INSTITUTIONS PROPOSAL FORM MEDICAL MALPRACTICE FOR INSTITUTIONS PROPOSAL FORM (Hospital, Clinics, Nursing Homes etc ) PLEASE READ THESE GUDANCE TES BEFORE COMPLETING THE PROPOSAL FORM. WHERE FURTHER INFORMATION IS REQUIRED PLEASE

More information

Parent & Healthcare Professional Instructions for the collection of Maternal & Umbilical Cord Blood

Parent & Healthcare Professional Instructions for the collection of Maternal & Umbilical Cord Blood Parent & Healthcare Professional Instructions for the collection of Maternal & Umbilical Cord Blood 1 2 3 Contents List of Umbilical Cord Blood Collection Kit Thermally insulated transportation box - do

More information

Why the INFANT Study

Why the INFANT Study The INFANT Study A multi-centre Randomised Controlled Trial (RCT) of an intelligent system to support decision making in the management of labour using the CTG Why the INFANT Study INFANT stands for INtelligent

More information

What is a definition of risk?

What is a definition of risk? What is a definition of risk? Definition of Risk Risk is the probability or threat of any negative occurrence caused by internal or external vulnerabilities interfering with achieving objectives that may

More information

R&D Administration Manager. Research and Development. Research and Development

R&D Administration Manager. Research and Development. Research and Development Document Title: Document Number: Patient Recruitment SOP031 Staff involved in development: Job titles only Document author/owner: Directorate: Department: For use by: RM&G Manager, R&D Administration Manager,

More information

Essential Documentation and the Creation and Maintenance of Trial Master Files

Essential Documentation and the Creation and Maintenance of Trial Master Files This is a controlled document. The master document is posted on the JRCO website and any print-off of this document will be classed as uncontrolled. Researchers and their teams may print off this document

More information

Items from Appendix J of the Report on the Review of the Coroner Service not translatable into rules 39. Guidelines for Best Practice Notes 44

Items from Appendix J of the Report on the Review of the Coroner Service not translatable into rules 39. Guidelines for Best Practice Notes 44 Table of Contents Introduction, Establishment and Methodology 1 Coroners Rules - Part 1 Definition of Terms 3 - Part 2 Deaths Reported to Coroners 6 - Part 3 Post-mortem Examinations 8 - Part 4 Post-mortem

More information

Mother s blood test to check her unborn baby s blood group

Mother s blood test to check her unborn baby s blood group Mother s blood test to check her unborn baby s blood group This leaflet explains why it is important to have a blood test to check the baby s blood group, so that only those who need it, receive anti-d

More information

Procedure for Document Control and Management

Procedure for Document Control and Management Procedure for Document Control and Management 1.0 Purpose - This procedure provides requirements for the creation, revision, and control of quality documents used by State Crime Laboratory (Laboratory)

More information

What to do after a death at home

What to do after a death at home What to do after a death at home This booklet has been produced to help you to understand what you need to do when someone you have been caring for dies at home Acknowledgements Thank you to everyone who

More information

WASTE MANAGEMENT POLICY

WASTE MANAGEMENT POLICY WASTE MANAGEMENT POLICY Policy and Management Procedures for the disposal of clinical/healthcare and household/domestic waste Co-ordinator: Property & Environment Manager Reviewer: Healthcare Waste Committee

More information

My Future Care Plan. You can add to this as often as you like, and change your decisions at any time. This is YOUR plan.

My Future Care Plan. You can add to this as often as you like, and change your decisions at any time. This is YOUR plan. My Future Care Plan This plan is for you, to use to write down what you would like your friends, family/whanau, and health professionals caring for you to know. You can add to this as often as you like,

More information

CLINICAL GUIDELINE FOR VAGINAL BIRTH AFTER CAESAREAN SECTION (VBAC)

CLINICAL GUIDELINE FOR VAGINAL BIRTH AFTER CAESAREAN SECTION (VBAC) CLINICAL GUIDELINE FOR VAGINAL BIRTH AFTER CAESAREAN SECTION (VBAC) 1. Aim/Purpose of this Guideline 1.1. Due to a rise in the caesarean section rate there are increasing numbers of pregnant women who

More information

Standard Operating Procedure

Standard Operating Procedure Standard Operating Procedure Title: Waste Management of Medicines and other Pharmaceutical Products in the Community Setting Prepared by: Sam Durant Presented to: Care & Clinical Policies Date: 19 th March

More information

Title: Recording Patient and Specimen Information on the Inventory System. Version Approver: James Edwards Version Approval Date: 25/04/2012

Title: Recording Patient and Specimen Information on the Inventory System. Version Approver: James Edwards Version Approval Date: 25/04/2012 Title: Recording Patient and Specimen Information on the Inventory System Serial Number: OMB-LSOP 005 Version Number: 2.0 Version Approver: James Edwards Version Approval Date: 25/04/2012 Version Effective:

More information

Version: 5.0. Effective From: 28/11/2014

Version: 5.0. Effective From: 28/11/2014 Policy No: IC09 Version: 5.0 Name of Policy: Waste Disposal and Re cycling Policy Effective From: 28/11/2014 Date Ratified 17/10/2014 Ratified Infection Prevention & Control Committee Review Date 01/10/2016

More information

Professional Standards Authority and Human Tissue Authority

Professional Standards Authority and Human Tissue Authority Professional Standards Authority and Human Tissue Authority Notes of joint seminar on consent, 11 December 2012 The notes below summarise the case study discussions only. Case study 1 Qualifying Relationships

More information

Cord Blood - Public and Private Cord Blood Banking

Cord Blood - Public and Private Cord Blood Banking Policy Directive Ministry of Health, NSW 73 Miller Street North Sydney NSW 2060 Locked Mail Bag 961 North Sydney NSW 2059 Telephone (02) 9391 9000 Fax (02) 9391 9101 http://www.health.nsw.gov.au/policies/

More information

Clinical Audit Procedure for NHS-LA and CNST Casenote Audit

Clinical Audit Procedure for NHS-LA and CNST Casenote Audit Clinical Audit Procedure for NHS-LA and CNST Casenote Audit NHS Litigation Authority (NHS-LA) Risk Management Standards for Acute Trusts Pilot Clinical Negligence Scheme for Trusts (CNST) Maternity Clinical

More information

Standard Operating Procedures (SOP) Research and Development Office

Standard Operating Procedures (SOP) Research and Development Office Standard Operating Procedures (SOP) Research and Development Office Title of SOP: Undertaking Risk Assessment of a Research and Development Project SOP Number: 33 Version Number: 1.0 Supercedes: N/A Effective

More information

Aseptic Technique Policy and Procedure

Aseptic Technique Policy and Procedure Aseptic Technique Policy and Procedure Authorising Officer Tom Cahill, Deputy Chief Executive Signature of Authorising Officer: Version: V2 Ratified By: Risk Management and Patient Safety Group Date Ratified:

More information

Brighton and Sussex University Hospital NHS Trust

Brighton and Sussex University Hospital NHS Trust Brighton and Sussex University Hospital NHS Trust Year Ending 31 March 2013 Annual Audit Letter July 2013 Ernst & Young LLP Executive summary Ernst & Young LLP 1 More London Place London SE1 2AF Tel: +44

More information

South West Lincolnshire NHS Clinical Commissioning Group Business Continuity Policy

South West Lincolnshire NHS Clinical Commissioning Group Business Continuity Policy South West Lincolnshire NHS Clinical Commissioning Group Business Continuity Policy Reference No: CG 01 Version: Version 1 Approval date 18 December 2013 Date ratified: 18 December 2013 Name of Author

More information

CLP CLASSIFICATION, LABELLING AND PACKAGING REGULATION 1272/2008/EC

CLP CLASSIFICATION, LABELLING AND PACKAGING REGULATION 1272/2008/EC CLP CLASSIFICATION, LABELLING AND PACKAGING REGULATION 1272/2008/EC Objectives Bit of History. Where are we now? What does it mean to us? What will we see? What should we start to do now? Lets see why

More information

Subject Access Request Policy

Subject Access Request Policy Trust Policy Subject Access Request Policy Department / Service: Corporate Originator: Company Secretary Accountable Director: Director of Nursing Approved by: Information Governance Steering Group Trust

More information

INFORMATION GOVERNANCE POLICY

INFORMATION GOVERNANCE POLICY INFORMATION GOVERNANCE POLICY Name of Policy Author: Name of Review/Development Body: Ratification Body: Ruth Drewett Information Governance Steering Group Committee Trust Board : April 2015 Review date:

More information

CCG CO11 Moving and Handling Policy

CCG CO11 Moving and Handling Policy Corporate CCG CO11 Moving and Handling Policy Version Number Date Issued Review Date V2 06/11/2015 01/10/2017 Prepared By: Consultation Process: Formally Approved: 05/11/2015 Governance Manager, North

More information

CLINICAL AUDIT REPORT LABOUR WARD LOWER UMFOLOZI DISTRICT WAR MEMORIAL HOSPITAL

CLINICAL AUDIT REPORT LABOUR WARD LOWER UMFOLOZI DISTRICT WAR MEMORIAL HOSPITAL CLINICAL AUDIT REPORT LABOUR WARD LOWER UMFOLOZI DISTRICT WAR MEMORIAL HOSPITAL Dr A K M Hoque - Medical Manager Dr W Edelstein - Senior Specialist Perinatal mortality rate is a sensitive indicator used

More information

Division of Laboratory Medicine Department of Pathology and Laboratory Medicine Hospital of the University of Pennsylvania

Division of Laboratory Medicine Department of Pathology and Laboratory Medicine Hospital of the University of Pennsylvania Division of Laboratory Medicine Department of Pathology and Laboratory Medicine Hospital of the University of Pennsylvania General Laboratory Specimen Collection Guidelines The Laboratory will perform

More information

HOW YOU CAN OBTAIN ACCESS TO YOUR PERSONAL RECORDS Notes to accompany Application Form

HOW YOU CAN OBTAIN ACCESS TO YOUR PERSONAL RECORDS Notes to accompany Application Form HOW YOU CAN OBTAIN ACCESS TO YOUR PERSONAL RECORDS Notes to accompany Application Form Your right to request access to your personal records: The gives living individuals the right to request access to

More information

DATA MANAGEMENT IN CLINICAL TRIALS: GUIDELINES FOR RESEARCHERS

DATA MANAGEMENT IN CLINICAL TRIALS: GUIDELINES FOR RESEARCHERS Reference Number: UHB 139 Version Number: 2 Date of Next Review: 14 Apr 2018 Previous Trust/LHB Reference Number: N/A DATA MANAGEMENT IN CLINICAL TRIALS: GUIDELINES FOR RESEARCHERS Introduction and Aim

More information

Fetal and Perinatal Pathology Report of a Joint Working Party

Fetal and Perinatal Pathology Report of a Joint Working Party ROYAL COLLEGE OF OBSTETRICIANS AND GYNAECOLOGISTS AND ROYAL COLLEGE OF PATHOLOGISTS Fetal and Perinatal Pathology Report of a Joint Working Party Setting standards to improve women s health June 2001 ROYAL

More information

A guide to. Coroners and Inquests

A guide to. Coroners and Inquests A guide to Coroners and Inquests A guide to Coroners and Inquests Contents 1. What is a coroner? 3 2. What do coroners do? 4 3. What is the role of a coroner s officer? 4 4. Are all deaths reported to

More information

NHS Constitution Patient & Public Quarter 4 report 2011/12

NHS Constitution Patient & Public Quarter 4 report 2011/12 NHS Constitution Patient & Public Quarter 4 report 2011/12 1 Executive Summary The NHS Constitution was first published on 21 st January 2009. One of the primary aims of the Constitution is to set out

More information

SUBJECT ACCESS REQUEST PROCEDURE

SUBJECT ACCESS REQUEST PROCEDURE This document is uncontrolled once printed. Please check on the CCG s Intranet site for the most up to date version SUBJECT ACCESS REQUEST PROCEDURE DOCUMENT CONTROL Type of Document Document Title Description:

More information

Procedure for Non-Medical Staff who wish to Request MRI, Ultrasound and Imaging Examinations under IR(ME)R

Procedure for Non-Medical Staff who wish to Request MRI, Ultrasound and Imaging Examinations under IR(ME)R Procedure for Non-Medical Staff who wish to Request MRI, Ultrasound and Imaging V3.0 December 2013 Page 1 of 11 Table of Contents 1. Introduction... 3 2. Purpose of this Policy/Procedure... 3 3. Scope...

More information

Version 4 SPECIAL LEAVE POLICY. A Policy and procedure giving guidance on the Special Leave provisions within the Trust.

Version 4 SPECIAL LEAVE POLICY. A Policy and procedure giving guidance on the Special Leave provisions within the Trust. Version 4 SPECIAL LEAVE POLICY A Policy and procedure giving guidance on the Special Leave provisions within the Trust. Authorised by: TEG Date authorised: December 2005 Next review date: 30 April 2016

More information

The code: Standards of conduct, performance and ethics for nurses and midwives

The code: Standards of conduct, performance and ethics for nurses and midwives The code: Standards of conduct, performance and ethics for nurses and midwives We are the nursing and midwifery regulator for England, Wales, Scotland, Northern Ireland and the Islands. We exist to safeguard

More information

DONOR INFORMATION PACKET. Anatomical Board University of Central Florida College of Medicine

DONOR INFORMATION PACKET. Anatomical Board University of Central Florida College of Medicine DONOR INFORMATION PACKET Anatomical Board Orlando, Florida 32827 7408 407 266 1142 or 407 266 1131 www.med.ucf.edu/willedbody TABLE OF CONTENTS INSTRUCTIONS TO PERSONS INTERESTED IN DONATING THEIR BODIES

More information