Specialist Paediatric Palliative Care Clinical Advisory Service

Patient Death Summary

The following patient was discussed at the Clinical Advisory Service (CAS) MDT on the date stated. For any questions, please contact the CAS team on – clinicaladvisoryservice@chas.org.uk

PATIENT INFORMATION
First Name	Click or tap here to enter text.	CAS Chair	Choose an item.
Surname	Click or tap here to enter text.	Lead Consultant	Click or tap here to enter text.
DOB	Click or tap to enter a date.	Disease directed teams	Click or tap here to enter text.
CHI Number	Click or tap here to enter text.	Nursing teams	Click or tap here to enter text.
Ethnicity	Choose an item.	CHAS Key Worker	Click or tap here to enter text.
Resident Health Board at time of death	Choose an item.	Date of MDT	Click or tap to enter a date.

CLINICAL INFORMATION – BACKGROUND
Diagnosis Click or tap here to enter text.
Date of death	Click or tap to enter a date.	Time of death	Click or tap here to enter text.
Place of death	Choose an item.	Expected death	Choose an item.
Categorisation of death	Choose an item.	Police Occurrence Marker / Ambulance Alert Deactivated	Choose an item.
CYPADM	Click or tap to enter a date.	ACP	Click or tap to enter a date.
Co-ordinated by	Click or tap here to enter text.	SMP	Click or tap to enter a date.
Completed by	Click or tap here to enter text.

NARRATIVE SUMMARY OF END-OF-LIFE CARE
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CLINICAL ADVISORY SERVICE INVOLVEMENT
Date of referral	Click or tap to enter a date.	Reason for referral	Choose an item.
MDT attendance	Choose an item.	No of MDTs	Click or tap here to enter text.
On-call activated	Choose an item.	On-call Utilised	Choose an item.
Please provide details	Click or tap here to enter text.
Any key learning or adverse events?	Choose an item.	If learning or adverse events, is there a plan in place to review? And who is responsible?	Click or tap here to enter text.

DEATH CERTIFICATION
Death certificate issued	Choose an item.	Completed by	Click or tap here to enter text.
Referred to Procurator Fiscal	Choose an item.	Postmortem	Choose an item.
Registered cause of death
1a	Click or tap here to enter text.	1d	Click or tap here to enter text.
1b	Click or tap here to enter text.	1e	Click or tap here to enter text.
1c	Click or tap here to enter text.	2	Click or tap here to enter text.

KEY LEARNING POINTS
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COMMUNICATION AROUND FAMILY WISHES – PREFERRED PLACE OF DEATH (PPOD)
PPOD discussion offered	Choose an item.	PPOD discussion undertaken by	Click or tap here to enter text.
What were the last stated preferences	Click or tap here to enter text.
Agreed preference	Click or tap here to enter text.
Did preference change?	Choose an item.
Preference comments	Click or tap here to enter text.

SYMPTOM MANAGEMENT MEDICATIONS AT END-OF-LIFE CARE
Weight (kg)	Click or tap here to enter text.	Did the CYP require symptomatic medication in last 72 hours of life	Choose an item.
LIST OF MEDICATIONS REQUIRED IN LAST 72 HOURS OF LIFE (INCLUDING DOSE INCREMENTS)
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Comments
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POST DEATH CARE
Discussion about post-death care offered	Choose an item.	Family preference	Choose an item.
Was preference achieved	Choose an item.	Comments	Click or tap here to enter text.

SAFEGUARDING INFORMATION
Was the CYP on the Child Protection register?	Choose an item.	Was the CYP a looked after or in receipt of aftercare or continuing care at the time of death?	Choose an item.
Was the case open to social work?	Choose an item.	Mental health service involvement	Choose an item.

BEREAVEMENT/SPIRITUAL CARE FOLLOW UP
Team leading	Click or tap here to enter text.	Family contact	Click or tap here to enter text.
Bereavement referral offered	Choose an item.	Health board responsible for CDR review	Choose an item.

FAMILY/SIBLING SUPPORT FOLLOW UP
Team leading	Click or tap here to enter text.	Family contact	Click or tap here to enter text.

CHILD DEATH REVIEW
Health board responsible for CDR review	Choose an item.	Date of CDR if known	Click or tap to enter a date.

OUTSTANDING ACTIONS /RECOMMENDATIONS
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Update written by	Click or tap here to enter text.	Date	Click or tap to enter a date.
Checked in MDT by	Click or tap here to enter text.	Date	Click or tap to enter a date.