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We are very sorry for your recent loss and would like to offer our condolences at this difficult time. We appreciate that having been recently bereaved, this must be a very difficult time for you and your family but would be very grateful for any feedback which you can provide us about the care you and your relative or friend received leading up to and at the time of their death. This is very important to us as the feedback will help us to improve the care for future patients, their relatives and friends. We would be grateful if you could complete the questions below - you can do this anonymously if you prefer. If you would prefer to talk to someone, you can telephone our Nurse Specialist for End of Life Care on 0191 2829016 or 07714847426. Alternatively you could contact the Patient Advice and Liaison Service (PALS) on 0800 032 02 02

Please tick the box next to the relevant answer to each of the following questions:

Q.1
Hospital site your relative or friend died:

Q.2
Which ward were they a patient on?

Q.3
What date did your relative or friend die? Do not worry if you can't recall the exact date

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Q.4
Care
Excellent Good Fair Poor
Overall, how would you rate the care and support given by the hospital to the person who died during the final admission?
Overall, how would you rate the care and support given by the hospital to you and other close relatives or friends during the final admission?

Overall, how would you rate the care and support given by the hospital to the person who died during the final admission?

Overall, how would you rate the care and support given by the hospital to you and other close relatives or friends during the final admission?

Q.5
Comments:

Q.6
Staff
Yes No Not Sure
Staff involved me in my relative or friend’s care and I was given the opportunity to ask questions.
Staff provided me with spiritual/religious/cultural support to meet my needs. (E.g. offered support from an appropriate religious person? Were you asked about your visiting needs?
Staff supported my relative or friend’s emotional well being and treated them with respect and dignity
Staff supported my emotional well being and treated me with respect and dignity

Staff involved me in my relative or friend’s care and I was given the opportunity to ask questions.

Staff provided me with spiritual/religious/cultural support to meet my needs. (E.g. offered support from an appropriate religious person? Were you asked about your visiting needs?

Staff supported my relative or friend’s emotional well being and treated them with respect and dignity

Staff supported my emotional well being and treated me with respect and dignity

Q.7
Comments:

Q.8
Symptoms and Support
Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree Not applicable
The person was given enough pain relief.
The person had enough relief of symptoms other than pain (such as nausea, breathlessness, or restlessness).
Are you satisfied that your relative or friend had support to drink or receive fluid if they wished.

The person was given enough pain relief.

The person had enough relief of symptoms other than pain (such as nausea, breathlessness, or restlessness).

Are you satisfied that your relative or friend had support to drink or receive fluid if they wished.

Q.9
Comments:

Q.10
Options and Information
Yes No Not sure
Did your relative or friend have a conversations about where they would prefer to die during their last admission to hospital?
Were you given appropriate information on what to do following the death of your relative or friend? Including the leaflet “Information for the Bereaved.

Did your relative or friend have a conversations about where they would prefer to die during their last admission to hospital?

Were you given appropriate information on what to do following the death of your relative or friend? Including the leaflet “Information for the Bereaved.

Q.11
Comments:

Q.12
What did the person who died regard as their ethnicity?

Q.13
What do you regard as your ethnicity?

Please do not feel obliged to disclose the above if you would rather not.

Q.14
Can you think of anything that we could have done to improve your relative or friend's care? 

Q.15
If you would like to be contacted about this survey or have further feedback to provide, please provide your name and contact details below.

Thank you very much for taking the time to complete this survey. We value all feedback and will use this to improve our services where possible.

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