Background Following a cluster of complaints relating to care after death, our incident reporting process identified that poor documentation may have led to miscommunication and that the processes for documenting essential information after the death of a patient were not always being followed.

Aim The aim of this audit was to establish whether there was a true problem with documentation, to identify possible causes and methods of improvement.

Methods All deaths (58) on the IPU between 1 May 2010 and 31 July 2010 were identified from the electronic notes. The auditor reviewed each individual case record focusing on the ‘windows’ which should be completed when a patient dies. These include documentation of: the medical certificate of cause of death (which generates a notification letter for the GP), completion of cremation papers, verification of death (VOED) and details of the bereavement meeting.

Discussion Although documentation was generally good, there were significant omissions. For all deaths no indication was given as to whether the notification letter should be sent to other health professionals. Evidence of completion of cremation papers was only available for one patient. VOED was documented in 93% of cases although the documentation of who was present at the time of death was not always specific. There was evidence of a bereavement meeting after 39 deaths.

Actions Recommendations were put into place to improve documentation including teaching to clinical staff and updated guidance on care after death. A re-audit was completed in 2011 (1/1/11–31/3/11, 59 deaths) with an improvement in most areas. There was over 90% evidence of completion of cremation papers. An indication of whether the notification letter should be sent to others was present in almost half of cases. There was evidence of a bereavement meeting after 52 deaths. There is an on-going programme of audit in this area.