Standards › Standard 10 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · HSP-SOP-005 · Version 1.0 · Approved by the ASF Expert Committee
Supports: Standard 10 (Hospice and Palliative Care), criterion 10.8
At a glance
- Families are offered follow-up after each death, within the set time.
- The offer and the answer are recorded (HSP-FRM-003).
- Families who accept are referred to a bereavement service.
- Follow-up is offered again if the family asks later.
- Stop and get help straight away if: a death is recorded with no bereavement offer to the family.
1. Purpose
To offer families help after a death and record the offer (10.8).
2. Scope
| Applies to | Clinical and support staff in the hospital |
| Locations | All wards, clinics and departments of the facility |
| When | Whenever the activity described is carried out |
| Does not apply to | Activities covered by another document listed in section 15 |
3. Definitions
| Term | Meaning |
|---|---|
| Clinical lead | The doctor or nurse in charge of the area at the time |
4. Background
Bereavement is a hard time for families, and some need help to cope. Offering follow-up after a death, and recording the offer, is a small act with a large effect.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Social worker or nurse | Makes the offer and refers | Nurse |
| Lead palliative clinician | Reviews the follow-up record | Clinician |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Records and forms named in this document | Current version | Checked before use |
7. Safety
- Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.
8. Before you start
- Confirm the forms and equipment named in this document are available and current.
9. Procedure
Step 1. Offer.
- Offer bereavement follow-up to the family within the set time after the death.
Key point: Offered after each death.
Step 2. Record.
- Record the offer and the answer on HSP-FRM-003.
Key point: Always recorded.
Step 3. Refer.
- Refer families who accept to a bereavement service.
Key point: Referred when accepted.
10. Decision points
- No decision points in this procedure.
11. Special situations
| Situation | Action |
|---|---|
| Out of hours | Follow the same steps. Use the on-call contact on the wall of the area. |
12. Escalation
- Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Deaths with a bereavement offer recorded | 100% | Monthly | Lead palliative clinician | Escalate to medical director |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Record named in this document | Patient record or the area file | the period set by the facility’s records policy years |
15. Training
- Staff are trained in this document at induction and refreshed each year, with a recorded competency check.
16. Related documents
| ID | Title | Use |
|---|---|---|
| HSP-FRM-003 | Family support and bereavement follow-up record | Record |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO Palliative Care fact sheet and the Lancet Commission on the Global Access to Palliative Care and Pain Relief (2017). |
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
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References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)