Background Following bereavement, families can be left with unanswered questions or issues of concern. We piloted a bereavement service model which was consultant and governance-led with the aim to reduce complaints, reduce litigation, reduce coroners' inquests and support families.
Methods Following the death of a patient, the next of kin was sent an invitation. Those that responded were offered a 1-hour appointment with a consultant, senior sister and a member of the governance team. Notes were taken to track themes and feedback sheets were introduced to gauge the usefulness of the service to families.
Results Of 121 invitations sent out, 18 families (14.8%) used the service. Two families had already sought legal advice. Neither acted further. 44% said they would have made a complaint if the service had not been available. 78% stated that they had obtained closure.
Conclusion A bereavement service model which is consultant and governance led may reduce complaints and reduce litigation.
Statistics from Altmetric.com
Following the death of a loved one, families can be left feeling anxious, angry and isolated, particularly if the death is sudden or unexpected. Hospital-based bereavement services have been shown to improve coping, reduce isolation and enable families to feel cared for and supported.1
Formal support from health professionals positively influences the bereavement process.2 The ability to access timely and accurate information about the care given to a loved one impacts the grieving process. If caregivers are unable to access such information, the result can be feelings of abandonment and anger, which can extend long after the death of the patient.3 The ability to understand how the loss has occurred appears to reduce the risk of a prolonged and abnormal grief reaction in the bereaved. Families who seek support from hospital bereavement services do so because of clinical questions over the diagnosis, investigations, treatment and ‘what if’ scenarios, questions over the death certificate or postmortem, or because of quality of care issues such as issues around communication.4 5
There is evidence that if families are unable to obtain the answers they require or have their concerns addressed, they are more likely to make a complaint.6 Conversely, offering them the opportunity to have such concerns addressed or questions answered appears to lead to a reduction in complaints.6 Similarly, those that litigate following the death of a loved one often do so to obtain answers related the care their loved one received and to ensure that any issues related to quality of care are addressed to prevent similar incidents in future.7 8 Anecdotal evidence suggests that some coroners' inquests may be held for the same reasons. Coroners will call an inquest following surgery if the cause of death is ‘unknown’ or ‘unnatural’ and this is largely at the discretion of the coroner.9
There is evidence that bereavement services may also reduce the psychological burden on the family, including symptoms of anxiety and depression, post-traumatic stress disorder and prolonged grief reaction as well as reduce feelings of isolation and abandonment.1 10–12
Our study coincided with the publication of the UK’s National Guidance on Learning from Deaths which lays out the principles as to how NHS providers should engage with families and carers following the death of a patient.13
We hypothesised that a hospital bereavement service which was consultant and governance-led may therefore reduce complaints, coroners' inquests and the risk of litigation as well as reduce psychological morbidity associated with a difficult death. Our aim was to set up a service which would allow all clinical questions to be answered and all concerns related to quality of care or governance addressed as well as allow families to be supported.
We piloted the Bereavement Service over an 8-month period from May 2017 to January 2018 within the surgical directorate.
The service was initially piloted by the Governance Manager and the Consultant Surgeon with responsibility for governance, quality and safety in general surgery. The service was modified during the Pilot following feedback from families attending it, experience with the service and after discussion with the local Senior Coroner. Modifications meant that, following the pilot, the meeting is now run by a consultant with a subspecialty interest in the disease process that the patient died from and the matron responsible for the ward where the patient died. This means that specific detailed subspecialty questions can be answered by the consultant and any concerns related to care on the ward can be immediately dealt with by the matron. Training, in the form of a 1-hour session, is provided to all those who have agreed to assist with the service along with a written information guide as to how the service runs (online supplementary appendix 1). Minutes are taken by a member of the governance team resulting in a record of any agreed actions for the governance team and the family can reflect on the discussion. A feedback form was designed to ensure more structure to the feedback obtained from the families. In addition, there was a change to sending families invitations and information letters the next working day after the patient’s death rather than the following month. Meetings were expedited if the death was going to a coroner’s inquest to reduce the workload on the coroner’s office and ensure families were better prepared.
The resulting ‘Medway Model’ is shown in figure 1. The first working day after the death of a patient within surgery, the next-of-kin is sent an invitation letter and information sheet inviting them to the service (online supplementary appendix 2). There is no time limit on when families can respond. Those that respond attend for a 1-hour meeting. This meeting is semistructured—usually running in five parts. The first few minutes involve introductions, offering the family refreshment and explaining the role of service. The family are then encouraged to tell their story. Open questions are asked to help prompt this and issues that are raised are gently probed. In the third part, any specific questions that have been raised are then answered. Then any issues of concern are explored further. Finally, the meeting is concluded and any further action required is agreed. Anonymous feedback forms are given to the family with a stamped addressed envelope to return them in (online supplementary appendix 3). Minutes are taken from the meetings and the families are asked if they wish to have a copy. During the pilot, the main questions and concerns were noted at the end of each session, and from these, themes and trends were created. The deceased patient’s notes are present during the session to obtain answers to specific questions. Positive and negative feedback is fed back to the individuals, teams and wards involved in the patient care. Governance issues are taken up by the governance team. Clinical questions are answered by the Consultant. For any outstanding issues, these are investigated after the bereavement service and the families written to with the results, usually within 1 week of the bereavement meeting.
Over the 8-month pilot period, 121 invitations were sent out of which 18 families used the service (14.8%). Eighty-three per cent of these families had unanswered clinical questions and 78% had questions related to governance and quality of care. Twelve per cent had both. Figure 2 shows that the most common clinical themes relate to questions over the management or treatment, timing of investigations or treatment and whether earlier diagnosis or treatment could have saved their loved one's life. Figure 3 demonstrates that the most common issues of concern were the quality of nursing care, communication with and between health professionals and the need for reassurance that where the quality of care has not been felt to be ideal, that future patients will not experience the same.
One family had neither questions nor concerns but returned only to talk and give positive feedback. Analysis of the feedback forms received showed that 44% would have made a complaint if the service had not been available to obtain the answers they needed. Two families had already sought legal advice prior to attending the bereavement service and neither acted further. Seventy-eight per cent stated that they had obtained closure or answers, with the remaining 22% awaiting a further response as the specific information they had requested was not available at the meeting. Positive and negative feedback was given to individuals, wards and teams.
We found a bonus of the service was the ability to involve families in serious untoward incident investigations in keeping with best practice. Where the deaths were being investigated by the Trust as potentially avoidable, the bereavement service also ran as a Duty of Candour meeting and the concerns of the families were incorporated into the investigation process.
To date, no complaints have been received following the death of a patient in general surgery following the start of the service.
This study suggests that a bereavement service which is consultant and governance led and which aims to answer clinical questions and address concerns over the quality of care may reduce complaints and litigation as well as support families. Furthermore, it may reduce prolonged or abnormal grief reaction by allowing families to obtain closure following the death of a loved one.
Many other models of bereavement care do exist, but we are not aware of any other which are both governance and consultant led. Many other models appear to provide counselling or other psychological support, rather than specifically aim to reduce complaints, inquests and litigation through providing answers to questions or direct discussion about issues of governance. It is our view that families should not have to litigate or complain to get answers or raise concerns following the death of a loved one. They should have a right to access this through the hospital services.
Our experience of running the service is that a service such as this needs to be consultant led. This is primarily because the families that return to use the service tend to be those where the diagnosis or treatment and decision-making has been difficult. They often request and wish to speak to a consultant. Explaining exactly what was found on a CT scan, the details of the problems encountered during a tricky operation, the timing of investigations or whether a loved-one would still have died if they had attended hospital earlier, need a high level of specialist expertise. We found that a consultant general and colorectal surgeon was unable to answer the very specific and detailed questions asked by families related to vascular surgery, orthopaedic surgery, urological surgery or complex Intensive Care Unit (ITU) deaths and therefore subspecialty consultants were invited to participate in the service for these cases to answer specific questions related to these areas. Similarly, where there were concerns raised over the quality of care provided on the ward, families wished to speak to someone with direct responsibility for this. We found this was best provided by asking the matron in charge of the ward where the patient died to attend the meeting with the appropriate consultant.
Our findings fit with those of Parris et al 4 who described a consultant-led bereavement service for families of patients who died in the emergency department. They had a similar finding of 14% of families taking up the offer of a meeting.4 In this study, they waited 4–6 weeks before sending out the invitation. In the Medway Model, we started by sending out the invitations the month following the patient’s death but changed it to the next working day. This was for several reasons. First, we found that some bereaved families made a complaint to obtain answers to questions within the first 2–3 weeks following the bereavement and therefore, in order to avoid complaints, the invitation had to arrive before the complaint was put in. Second, discussion with our local senior coroner and a national coroner’s survey14 had suggested that our bereavement service could reduce the number and length of inquests performed as well as the workload on the coroner’s office, but only if we were able to offer families a meeting prior to the coroner’s inquest. Third, two of the families had already spent money on legal advice for questions that could be answered by the bereavement service and this could be avoided.
In conclusion, a consultant and governance-led bereavement service appears to provide answers to questions, allow families to obtain closure, provide feedback to individuals, wards and teams, reduce complaints, highlight issues of quality of care and may reduce the risk of litigation. We also found an additional use of the service for involving families in Serious Incident investigations. Further research is required to elucidate whether such a service, if rolled out nationally, would reduce the costs on the NHS from complaints and litigation.
Presented at The study was presented as a poster at the Confed conference in 2018, shortlisted for the HSJ Awards under Quality Improvement Initiative of the Year 2018 and nominated for the NHS70 Awards.
Correction notice This article has been corrected since it was published Online First. Apostrophes showing possession where originally omitted from the article.
Contributors CG, BS and LR-J conceived the idea for the service. All authors assisted with data collection. CG analysed the data. All authors contributed to the final manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.
If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.