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TO BE COMPLETED IF MESOTHELIOMA IS DIAGNOSED OR SUSPECTED NOT TO BE RELEASED WITHOUT PATIENT/NEXT OF KIN S PERMISSION - PDF
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1 NOT TO BE RELEASED WITHOUT PATIENT/NEXT OF KIN S PERMISSION MESOTHELIOMA PRO FORMA PART 1 Patient held Record of Information - To be completed by patient/next of kin Demographic Particulars Name:.D.O.B: Age: CHI No:. Address:...Post Code: Phone No:. Marital Status: Occupation: When retired:. General Practitioner:. GP Address:. Tel No:. Consultant in Charge/Hospital at time of Diagnosis:. Next of Kin: Relationship to Patient:.. Address:.. Post Code:..Phone No:. Employer Information (Specify nature and content of asbestos exposure) To be completed by patient/next of kin Dates of Employment: Compensation Details To be completed by patient/next of kin Raised with DWP: Yes No Resolved with DWP: Yes No Date of Award from DWP:.. Court Action Raised: Yes No Status of Court Action: Interim Final Date of Court Award:. Asbestos Action Group (CAA or equivalent) involved: Yes No Solicitors content: Yes No 12 NOT TO BE RELEASED WITHOUT PATIENT/NEXT OF KIN S PERMISSION Attach Letter from Solicitor if relevant by patient/next of kin (see Appendix) 23 NOT TO BE RELEASED WITHOUT PATIENT/NEXT OF KIN S PERMISSION MESOTHELIOMA PRO FORMA PART 2 Patient held Record of Information To be completed by or on behalf of the Consultant in charge of the case History of Illness Date of Diagnosis of Mesothelioma:. Investigations performed Diagnostic hierarchy (1Low 4 High grade evidence) 1 Radiology:. 2 Cytology: Pleural/Peritoneal Aspirate Fine Needle Biopsy 3 Histology: Type of Biopsy: Core Closed Pleural VATS Pleural Open Peritoneal 4 Interpretation of results (including outcome of MDT discussion) Treatment: Smoker: Yes No How Long:. How Many: Pack Years:.. Referred to Asbestos Support/Action Group e.g. Clydeside Action on Asbestos or Asbestos Action Tayside: Yes No Other Asbestos Related Diseases: Please circle if applicable Pleural plaques, Pleural thickening, Asbestosis, Asbestos related lung cancer General Medical History: Completed at diagnosis by Hospital: Name of consultant in charge:... Signature:.. GMC Number:... Date: Contact Telephone Number (at Hospital) 34 NOT TO BE RELEASED WITHOUT PATIENT/NEXT OF KIN S PERMISSION Copies: GP Hospital (copy retained) Hospice (if appropriate) Notes Parts 1 and 2 should be in the Patient Held Record. The hospital should keep the copies of the documents in the hospital clinical records. The hospital should send copies to the GP, another hospital if relevant, and to the hospice if making a hospice referral. GPs should include the diagnosis and the existence of the Pro Forma in ECS, epcs and KIS. The patient/next of kin may provide the information in the Patient Held record to a preferred solicitor and a relevant Asbestos support/action group. 45 NOT TO BE RELEASED WITHOUT PF S PERMISSION MESOTHELIOMA PRO FORMA PART 3 Notification of Death to Procurator Fiscal (PF) Form to be completed by the doctor verifying death and the doctor notifying the PF Demographic Particulars Name of Deceased:. CHI No: Date of Death:. Time of Death (see MCCD guidance):.. Location of Death(e.g. own home): Current Location of body (e.g. hospital mortuary)... Specific religious/faith/cultural requirements (if known):.. Consultant/GP (if any) in charge at Time of Death (see guidance):... Contact Telephone number of Hospital/Hospice Consultant or GP:. Verification of Death: Hospital/Hospice/GP Practice: Name:.. Signature: Designation:.. GMC Number:. Date:.. Time: Work Contact Telephone Number:. PF Notification by Hospital/Hospice Doctor or GP: Willingness to Certify: Yes No Suggested Cause of Death Duration i) a... b... c... d... ii)... *NB This section will replicate the format of the new MCCD Name:.. Signature: Designation:.. GMC Number:. Date:... 56 NOT TO BE RELEASED WITHOUT PF S PERMISSION Work Contact Telephone Number:... 67 NOT TO BE RELEASED WITHOUT PF S PERMISSION Procurator Fiscal Decision to be completed by Procurator Fiscal Certificate accepted Yes No Post Mortem instructed Yes No Full Limited Name:.. Signature: Designation:.. Date:... Notes Copies of parts 1 and 2 with the completed Part 3 should be sent to the Procurator Fiscal by the notifying doctor. Copies of Parts 1, 2 and 3 should be retained in the deceased patient s clinical records. The completed part 3 returned to the notifying doctor, by the Procurator Fiscal with his/her decision, should be filed in the deceased patient s clinical records (electronic or paper) The hospital should keep the copies of the document in the hospital clinical records. The hospital should send copies to the GP, another hospital if relevant, and to the hospice if making a hospice referral. GPs should include the diagnosis and the existence of the Pro Forma in ECS, epcs and KIS. The patient/next of kin may provide the information in the Patient Held record to a preferred solicitor and a relevant Asbestos support/action group. 78 Guidance Notes for completion of Mesothelioma pro forma Background to PF involvement Exposure to asbestos is generally occupational but bystander exposure may also occur. As any asbestos contact may increase the risk of mesothelioma occurring, apportioning liability can be challenging. Obtaining an exposure history may be simple and straightforward in some cases, while in others it may be more complex. Mesothelioma caused by occupational exposure to asbestos is a well recognised condition and sufferers can claim compensation (Industrial Injuries Disablement Benefit). Stringent criteria must be fulfilled in order to establish the link between occupational exposure and mesothelioma and to this end the Procurator Fiscal (PF) is notified after the patient s death, both to elucidate the individual situation and for the common good. In a patient with known asbestos exposure, a diagnostic hierarchy exists: The diagnosis may be suspected from the clinical history. It is usually endorsed by radiological investigations. It is generally (but not always) confirmed by cytology or histology. o Sometimes pleural fluid analysis may suffice to establish the diagnosis. o A more invasive video assisted thorascopic surgical (VATS) biopsy would provide a more robust diagnosis but may be deferred if the patient is frail. In such circumstances, a diagnosis of probable mesothelioma may be made if there is a history of asbestos exposure, a typical clinical course and radiological evidence of pleural involvement. Evidence of Multi Disciplinary Team (MDT) discussion, providing a consensus opinion, lends considerable weight to the balance of probabilities of the likely diagnosis of mesothelioma. The provision of treatment according to guidelines for mesothelioma would be further confirmation of the diagnosis. Background to the use of the Pro Forma This pro forma has been devised to reduce distress caused to relatives when a patient with mesothelioma dies. It distils the information required by the Procurator Fiscal (detailed above) and obviates the need for relatives to be interviewed at a very stressful time for them. In practice the body is identified to the police officers (who are the PF s representatives) by clinical staff and the pro forma is handed to the police officers. Parts 1 and 2 will have been previously completed and Part 3 should be completed by the doctor reporting the death. The pro forma is then delivered to the PF by the police officers. The PF will decide if a PM is necessary on the basis of the interpretation of the information provided by the Pro Forma and other sources to the Procurator Fiscal.. Secure electronic delivery of the pro forma may be possible. The PF will return Form 3 with the decision regarding post mortem to the notifying doctor. This should be filed in the medical record (paper or electronic) of the deceased with parts 1 and 2. 89 If adequate information is available ante mortem and compensation has been obtained, a post mortem is not required. If compensation has not been obtained a post mortem is not required if a form (see Appendix) has been received from the patient s solicitor, confirming that adequate histology has been recovered. If histology is unavailable or inconclusive a post mortem will be necessary, but a limited post mortem may suffice. Of the Other Asbestos Related Diseases, currently compensation is available only for Asbestos related Lung Cancer. Organ / tissue donation Organ donation is seldom feasible in the palliative population but tissue donation may be possible. In the case of Mesothelioma organ donation and tissues such as heart valves, tendons and skin would not be possible, but donation of cornea would be possible. Unlike organs, tissues (corneas, tendons, heart valves) can be retrieved up to 24 hours after death but early retrieval optimises the quality of these tissues. All referrals should be discussed with The On call Transplant Co-ordinator via pager number or Ros O Sullivan, Transplant Coordinator, on mobile , WIG , Falkirk , E mail - Pro Forma The pro forma has 3 parts. Part 1 - Patient Health Record of Information This section should be completed by the patient/next of kin To confirm they are content, a confirmatory form (see Appendix) can be obtained by the patient/next of kin, from the patient s solicitors (via the relevant Asbestos Support/Action Group if necessary), if compensation has not been received by the patient. Such a letter from the solicitor may be attached to this section. Part 2 - Patient Health Record of Information This section should be completed by the Consultant in charge of the case at the time of diagnosis or by a nominated healthcare professional such as a another doctor or a Clinical Nurse Specialist, on behalf of the Consultant in charge.. Parts 1 and 2 These should be retained by the patient with copies in the hospital clinical records. Copies should be sent to the patient s GP, other relevant Hospital if required, and the Hospice if/when a Hospice referral is made. 910 GPs should record the diagnosis on the, Emergency Care Summary (ECS), electronic Palliative Care Summary (epcs), and (Key Information Summary) KIS. Patient/next of kin should be encouraged to send copies to their solicitor and the appropriate Asbestos Support/Action Group. Part 3 - Notification of Death to the Procurator Fiscal (PF) This document should be completed by the doctor who verified death and by the doctor notifying the PF of the death. Doctors should have regard to MCCD guidance. The PF may request additional clinical information from the notifying doctor as appropriate. Procedure Parts 1, 2 and 3 should be sent, with solicitors form if appropriate, to the Procurator Fiscal (PF) after the death of the patient, either electronically or via police officers. Copies should be held in the deceased patient s clinical records. The body should be identified to the attending police officers in case a Post Mortem is required. It should not be necessary for police officers to interview relatives. Clear arrangements should be made with the relevant undertaker or the family representative for collection of the death certificate. Any specific religious, faith or cultural requirements should be highlighted. Copies of parts 1, 2, and the returned part 3 should be retained in the deceased patient s record. Deaths which are notified to the Procurator Fiscal, (including people with or suspected of having Mesothelioma), will not be reviewed by the Medical Reviewer system under the Certification of Death (Scotland) Act11 Appendix Letter from Solicitor Solicitor s Name and Address Reference. NAME: ADDRESS: DATE OF BIRTH: DATE OF DEATH: 1. We act on behalf of 2. Sufficient histology has already been recovered. 3. A Post Mortem is not required. Signed:. Date:.. 11 Similar documents
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