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Bereavement Questionnaire

At Sandwell and West Birmingham NHS trust we recognise the importance of monitoring the quality of the care we give to our patients in the final phase of their life.  If your loved one has died at our trust, and feel ready to share your experience please click on the button below to complete our bereavement survey.

Please remember this survey is completely voluntary, and it is very important you only complete this survey when you feel ready to do so.  We recognise that recalling memories and events around the time that your loved one died can raise difficult emotions.  If you would prefer to respond at a later date, even if it's some weeks or months following the bereavement, that's perfectly alright.

Please be assured that everything you tell us is in confidence (you are not required to provide any personal information).

Your responses and your comments will be collated along with those of other people and used to help to improve the care that seriously ill patients and their families receive in our services.
1.At which hospital was your loved one cared for?
2.Which ward was you loved one cared for on?
3.How many times had your loved one been an inpatient in hospital in the last 12 months of life before the final admission to hospital?
4.Within the hospital where did your loved one die?
5.What is the ethnic group of your loved one?
6.Did a member of staff at the hospital explain to your loved one that he/she was likely to die in the next few days?
7.Did the staff at the hospital involve your loved one in decisions about their care and treatment as much as he or she would have wanted to in the last 2 or 3 days of their life?
8.Did your loved one have an advance care plan in place prior to their last admission? An advance care plan could describe future treatment plans, the place they would prefer to be cared in, the use of life saving treatments, their values and beliefs and their end of life care wishes and goals.
9.How much do you agree or disagree with the following statements about the care received by your loved one during their last admission to hospital? Please select the most appropriate box.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
I felt that the people looking after him/her communicated sensitively.
I felt there was good coordination between different members of staff
I felt he/she was given sufficient pain relief
I felt he/she had adequate relief of symptoms other than pain (such as nausea, breathlessness or restlessness)
I felt that the staff at the hospital made a plan of care for him/her that took account of his or her individual requirements and wishes
I felt that he/she had support to drink or receive fluid if he or she wished
I felt that he/she had their emotional needs (eg feeling low, worried or anxious) met by staff
I felt that he/she had their spiritual, personal or religious beliefs taken into consideration by staff
I felt that he/she had a suitable environment with adequate peace and privacy in the last days and hours of their life
In the circumstances I felt that the hospital was the right place for him/her to die
10.Did a member of staff at the hospital explain to you that your loved one was likely to die in the next few days?
11.Did you receive timely communication to enable you to be with your loved one when he/she died (if you wished to)?
12.Did staff at the hospital involve you in decisions about your loved ones care and treatment as much as you wanted in the days before their death?
13.Were you given the name of the senior doctors and/or nurse responsible for his/her care?
14.How much do you agree or disagree with the following statements about the care received by your loved one during their last admission to hospital? Please select the most appropriate box.
Strongly disagree
Disagree
Neither Agree nor Disagree
Agree
Strongly Agree
I was communicated with in a sensitive way
I was asked about my needs
I was given enough emotional support by staff
I was given enough practical support by staff (for example help finding refreshments and parking arrangements)
I was offered enough support to meet my spiritual, cultural and/or religious needs
I was kept well informed and had enough opportunity to discuss my loved ones condition and treatment with staff
I was supported by the staff after my loved on had died
15.Overall how would you rate the care and support given by the hospital to your loved one during their final admission?
16.Overall how would you rate the care and support given by the hospital to YOU and other close relatives or friends during your loved ones final admission.
17.If you have any further comments or feedback about the care and support given to your loved one, or yourself and other close relatives and friends during this final admission, please detail below.
If you feel you are in need of support please contact our bereavement service on 0121 507 3216 or email: swbh.bereavementcare@nhs.net    
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