(Fields marked with * are mandatory.)
 
Details of Child/Youth
Family Name: *
First Name(s):
Date of Birth:
 (DD/MM/YYYY) Date of Death: *  (DD/MM/YYYY)
Some families know their loved one's National Health Index (NHI) number, if so please include it here
NHI: e.g. ABC1234
Place of Death:
 Hospital  Home  Other
Hospital:
Address:
 
 
Relationship
1. What is your relationship to the child/youth concerned?
 
 Parent  Caregiver
 Family/whanau member  Spouse/partner
 Other (please describe): 
 
2. Please tell us below what you think are the important things that led to the death of your family member
 
The following questions ask you about specific areas of your experience that we are interested in and that may help improve things in the future.
 
Accessing Services prior to Death
For some accidents or illnesses getting help and accessing health/emergency services is important. The following questions ask if this help was available in your case.
 
3. Were you able to get the help you needed (such as, a doctor, nurse, counsellor, social worker, or other service provider) in a timely manner?
 
 Yes  No  Does not apply
  (please provide comment in the space below)
 
4. If you called for an ambulance, did it arrive quickly?
 
 Yes  No  Does not apply
  (please provide comment in the space below)
 
5. If you called a helpline, what helpline did you contact?
 
   Not Applicable
 
a. Was the advice and information given clear and helpful?
 
 Yes  No
 
(please provide comment in the space below)
 
6. If you called the police, did they assist you in getting the appropriate help?
 
 Yes  No  Does not apply
  (please provide comment in the space below)
 
7. Were there other people that you called on for help at that time?
 
 Yes  No  Does not apply
  Please state who you called on and whether it was helpful?
 
8. Was there hospital treatment relating to the death?
 
 Yes  No
 
During Treatment at Hospital
 
9.
Process and Timeliness (examples include: time taken to see a doctor, being transferred to a different ward, getting a test such as an x-ray)
 
a. Thinking about hospital processes and timeliness what do you think worked well?
 
b. What do you think could have been done better?
 
10.
Hospital Environment
 
a. Thinking about the hospital environment, in particular, whether it was child/youth friendly, what do you think worked well about the hospital environment?
 
b. What do you think could be done better?
 
11.
Medical knowledge and experience (eg. doctors)
 
a. Thinking about the treatment given by the medical staff to your loved one, what do you think worked well?
 
b. What do you think could have been done better?
 
12.
Nursing knowledge and experience
 
a. Thinking about the treatment given by the nursing staff to your loved one, what do you think worked well?
 
b. What do you think could have been done better?
 
13.
Hospital equipment
 
a. Thinking about the hospital equipment and how it was used on and by your loved one, what worked well?
 
b. What do you think could have been done better?
 
14.
Were you given clear information about what was happening?
 
 Yes  No
 
(please provide comment in the space below)
 
15.
If you had to make a decision regarding the care of your loved one, were you given sufficient time and information to make your decision?
 
 Yes  No  Does not apply
 
(please provide comment in the space below)
 
Treatment, Support, Intervention elsewhere (i.e. not in hospital)
If your loved one did not die in hospital please answer the questions below. The following questions ask you to identify the things that you felt worked well and the things that could be improved.
 
16. Who helped your loved one before they died? (Please tick the relevant boxes)
 
Ambulance Officer Doctor
Nurse Social Service Agency
Other  (friend, whanau member, social worker, agency, kaumatua), please describe below
 
Does not apply
 
17. Knowledge and experience of the people who helped you
 
a. Thinking about the help given to your loved one, what do you think worked well?
 
b. What do you think could have been done better?
 
18. Were you given clear information about what was happening?
 
 Yes  No
  (please provide comment in the space below)
 
19. If you had to make a decision regarding the care of your loved one, were you given sufficient time and information to make your decision?
 
 Yes  No  Does not apply
  (please provide comment in the space below)
 
After Death
Following the death, getting good support is important. We would like to know what support worked well for you and what could be improved.
 
20. Were you given clear information so you could understand why your loved one died?
 
 Yes  No  Does not apply
  (please provide comment in the space below)
 
21. Who provided support to you after the death? (Please tick the relevant boxes).
 
Doctors Nurses Funeral Director
Police Victim Support Social Workers
Other, please list:  
 
a. Describe the support received and whether it was helpful.
 
b. Was there any support that you did not get that would have been helpful for you?
 
22. Was your loved one treated with dignity after they died?
 
 Yes  No
  (please provide comment in the space below)
 
23. Was a post-mortem (autopsy) done?
 
 Yes  No
  a. Do you have any comments?
 
24. After the death of your loved one, did someone give you information about what happens next? For example: funeral director information, coroner processes (if relevant).
 
 Yes  No
  (please provide comment in the space below)
 
25. Who provided the follow up (like a visit, phone call, or letter) from the people who provided care for your loved one? (Please tick the relevant boxes below).
 
Paediatrician or child health service
General Practitioner (GP)
Victim Support
Church
School
Other, please list  
 None
 
a. What follow up was most helpful and why?
 
b. What could have been done better?
 
Prevention
For some causes of death there is information about how to prevent the death/illness/injury.
 
26. Did you receive any information about prevention? For example, by your doctor or maternity carer, social service agency, by pamphlets, by media advertisements, or by TV/radio programmes.
 
 No  Yes (please specify the type(s) of information received)
 
27.
If you answered yes to the question above, was the information clear and easy to understand?
 
 Yes  No
 
(please provide comment in the space below)
 
28. Have you any final comments you would like to make?
 
Permission to be contacted for clarification or further research (optional)
I consent to being contacted for clarification of my answers on this form.
I consent to being contacted about participating in future research.
Your name:
Your email:
Physical Address:
Contact phone no.:
(please specify when you would prefer to be contacted e.g. after working hours)
 
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