Nurses staffing the busy accident and emergency unit of Belfast's City Hospital have, on their own initiative, set up a support service for the many bereaved relatives suffering the trauma of a totally unexpected death in the family. And in the process, they have found that they, too, have become better able to cope with the stress of losing people in their care.

Their unit handled almost 56,000 casualties last year, ranging from from a simple cut incurred in the kitchen to critical injuries suffered in a terrorist bombing or gun attack.

'We felt we were not caring for the bereaved as we should, that we were shying away from it and that we were inadequate,' Senior Sister Doreen Patton says. The upshot was the formation almost a year ago of the department's own bereavement support group.

Its primary purpose is to help relatives to cope with the initial shock of bereavement and to reach, through proper grief, an acceptance of the death. Their initial research established that, in the UK, little work has been done in this field: only two hospitals in mainland Britain are known to offer similar help. Counsellors from Cruse, the

bereavement support service, advised the unit's staff on relatives' reactions to sudden death.

'We were warned that there is often a lot of anger at the time of death, that it could be directed towards us and that it was not to be taken personally,' the sister says. 'And we were told how we could help people with the different stages of grieving.

'Take a young man going to work at 8am. He says goodbye to his wife, but maybe they've had a row and haven't yet made it up. Then he's killed on the way home. That wife needs to know: did he suffer? Was he conscious when he came in? Did he leave any message? Did he say anything?

'These are the questions that were being left unanswered: the details of what happened here. Did they suffer - and what did we do? It's the sort of thing which tends to stay in the mind and doesn't allow the bereaved to grieve.'

In the initial shock the immediate relatives are often unable to take anything in. But later, in the quiet of her own home after the flood of mourners has gone, a bereaved wife, say, has time to reflect and wonder what happened.

Relatives are now offered a telephone call or a home visit by a named nurse, about a week to 10 days after the death, when such questions can be answered. Normally two nurses are sent, but, if the contact call indicates that questions of a medical nature may be asked, a nurse and junior doctor go out.

In only about one-third of cases is the offer of a home visit taken up, most often in cases of the traumatic death of young and healthy people.

'With the old and ill, the bereaved tend not to request a visit,' Sister Patton says. 'They are more prepared. They knew their relative was ill, and they more easily come to terms with sudden, even accidental, death.'

Before the group began to operate in October last year, costings were made of all the deaths in the casualty department that year. The number, 18, was suprisingly low for its huge intake and, because the hospital serves a geographically tight catchment area, the predicted cost of the new service was small in NHS terms.

'We estimated it at pounds 650 a year in travel costs and staff time,' the sister says. 'We told the board that we could cover it with efficiency savings, so no new money was needed.'

A nurse is allocated to look after the bereaved the minute they arrive at the unit, and often before the death has occurred. Relatives are strongly encouraged to view the body. The nurse will accompany them, but leaves them alone to say their goodbyes, an important factor in the acceptance of the unexpected death. 'It is also important that they should see and touch the body, and we never cover up a body entirely, leaving an arm extended from the sheet so that they can hold a hand,' she says.

A staff member has donated a crib, which is used in the particularly traumatic event of a baby's or young child's sudden death. 'If you leave a young child lying on a big trolley it is so cold and clinical that it would stick in the parents' minds for a long, long time,' Sister Patton says. 'We use the crib in such cases, and offer the relatives a photograph, which they usually accept.'

All the 50-plus nursing staff of the casualty unit are involved in the support group's work. 'It is very, very important that we care for the carers, too,' their senior sister says. 'We have confidential counselling, but we also put big emphasis on group discussion, involving junior medical staff as well. Staff find they can help each other by talking over how they feel about a death.

'And one thing that we make very clear is that there is no harm in crying. It is not a sign of being a bad nurse.'

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