Post mortem consent form

Post Mortem Consent Form
Patient no:
Name

First NameLast Name
Date of birth

MonthDayYear
Date
Date of death

MonthDayYear
Date
Gender

MaleFemale
How to fill in this form:
• Please show what you agree to by writing YES in the relevant boxes. Write NO where you do not agree.
• Record any variations, exceptions and special concerns in the Notes to the relevant section or in Section 5.
• Sign and date the form. The person taking consent will also sign and date it.
Changing your mind:
After you sign this form, there is a short time in which you can change your mind about anything you have agreed to.
If you want to change your mind, you must contact the hospital within 72 hours of signing the form.

Your decisions about a post mortem examination
A complete post mortem - This gives you the most information. It includes an external examination, examining the internal organs, examining small samples of tissue under a microscope, and taking x-rays and medical photographs. Tests may also be done for infection and other problems and the placenta may also be examined.
Complete Post Mortem
OR

A limited post mortem - This is likely to give less information than a complete post mortem.

A limited post mortem includes an external examination, examining the internal organs in the area(s) of the body that you agree to, examining small samples of tissue under a microscope, and taking x-rays and medical photographs. Tests may also be done for infection and other problems and the placenta may also be examined.
Limited post mortem
Please indicate what can be examined:
If other, please specify
OR

An external post mortem - This may not give any new information.

An external post mortem includes a careful examination of the outside of the body, x-rays and medical photographs.
Type a question

Section 2: Tissue samples

Only if you consent to a complete or limited post mortem
With your agreement, the tissue samples taken for examination under a microscope will be kept as part of the medical record (in small wax blocks and on glass slides). This is so that they can be re-examined to try to find out more if new tests or new information become available.
Tissue sample
If consent is not given, you must note below what should be done with the tissue samples. See Section 8, Item 6 for more information.

Section 3: Genetic testing
To examine the chromosomes or DNA for a possible genetic disorder or condition, the pathologist takes small samples of skin, other tissue and/or samples from the placenta (afterbirth).

With your agreement, this material will be kept as part of the medical record so that it can be reexamined to try to find out more if new tests or new information become available. This could be especially useful if you think you may have another baby in the future.
Genetic testing
Genetic material
Notes to Section 3 if required
Section 4:

Keeping tissue samples for training professionals and for research
Section 4 covers additional separate consent that you may decide to give. It will not affect what you have already agreed to above, what is done during the post mortem, or the information you get about your relative’s condition, but it may be helpful for others in the future.

With your agreement, the tissue samples may also be examined for quality assurance and audit of pathology services to ensure that high standards are maintained
Keeping tissue samples
Tissue samples, medical images and other information from the post mortem can be important for training health professionals. Identifying details are always removed when items are used for training.
Quality Assurance
Tissue samples, medical images and other relevant information from the post mortem can also be useful in research into different conditions and to try to prevent more deaths in the future. All research must be approved by a Research Ethics Committee.
Tissue sample record keeping
You can withdraw consent for any of the above at any time in the future. To do so, please contact the hospital and ask for the histopathology department

Section 5:

Any other requests or concerns
Section 6:

Patient/Parental consent (if applicable)
Patient Consent

I/We have been offered written information about post mortems.I/We understand the possible benefits of a post mortem.My/Our questions about post mortems have been answered.

Section 7:

Consent taker's statements
Consent statements

I have read the written information offered to the parents. I have checked the form and made sure that there is no missing or conflicting information.I have explained the time period within which parents can withdraw or change consent,and have entered the necessary information at the beginning of this form.I believe that the parent(s) has/have sufficient understanding of a post mortem and (if applicable) the options for what should be done with tissue and organs to give valid consent.I have recorded any variations, exceptions and special concerns.I have checked the form and made sure that there is no missing or conflicting information.I have explained the time period within which parents can withdraw or change consent,and have entered the necessary information at the beginning of this form.
Full Name

First NameLast Name
Signature

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Date

MonthDayYear
Date
Interpreter’s statement (if relevant)
Name

First NameLast Name
Signature

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Date

MonthDayYear
Date

Section 8:

Notes for the consent taker
Section 8: Notes for the consent taker

1. “Anyone seeking consent for hospital PM examinations should have relevant experience and a good understanding of the procedure. They should have been trained in dealing with bereavement and in the purpose and procedures of PM examinations and they should have witnessed a PM examination”.
2. Written information about post mortems should be offered to all patient relatives before you discuss the form with them.
3. If the parents have a specific request that you are not sure about, contact the pathologist before the form is completed.
4. Make sure that the patient relative(s) understand what to do if they change their minds. The post mortem should not begin unless this section is completed. It is your responsibility to ensure that, if the patient relative(s) change their minds, they will be able to contact the person or department entered on this form.
5. For a baby who was born dead at any gestation use the mother’s hospital number; for a baby who was born alive use the baby’s hospital number.
6. Sections 2 and 3: Tissue samples and genetic material If the patient relative(s) do not want tissue samples or genetic material kept as part of the medical record, explain the different options for disposal (below) and note their decisions in the relevant section. If disposal is requested, it will usually take place only after the full post mortem report has been completed. The options are: disposal by a specialist hospital contractor; release to a funeral director of the patient relatives choice for burial; or release to the patient relatives themselves. For health and safety reasons, blocks and slides cannot be cremated. Genetic material is normally incinerated.
7. Send the completed form to the relevant pathology department, offer a copy to the patient relative(s), and put a copy into the mother’s (for a stillbirth or miscarriage) or the baby’s (for a neonatal death) medical record.
8. Record in the clinical notes that a discussion about the post mortem examination has taken place, the outcome, and any additional important information.
9. Possible further examination of one or more organs. Very rarely, it may be recommended that an organ is kept for more detailed examination after the baby is released from the mortuary. In this case, further examination of organs for diagnostic purposes should be completed.
• If you already know that this is recommended, discuss it with the patient relatives and also explain how it might affect funeral arrangements.
• If the pathologist recommends further examination after the post mortem has begun, they will contact you or the unit. The patient relative(s) should then be contacted as soon as possible to discuss their wishes and to explain how keeping the organ might affect funeral arrangements. If they consent, further examination of organs for diagnostic purposes should be completed and copies distributed as above. A note should be added to the medical record that consent was given,
including how it was given (face-to-face, email, etc).
If samples should not be taken from any of these, please note this below.
Should be Empty:

Post Mortem Consent Form

Your decisions about a post mortem examination

Section 2: Tissue samples

Section 3: Genetic testing

Section 4:

Section 5:

Section 6:

Section 7:

Section 8: