For many clients, issues may exist that are likely to make them more susceptible to experiencing difficulties during bereavement, with some being more at risk than others. This is often as a result of prior experiences of multiple losses and trauma in their lives. Furthermore, some research suggests that the death of people experiencing homelessness are more likely to be sudden and traumatic than the deaths of people who are housed. Such sudden or traumatic deaths can further intensify the grief reactions of others, particularly those close to the client who died.

Currently, in order to access most bereavement services, a person is required to agree to attend a number of sessions, refrain from drugs or alcohol during the sessions and be open to talking about their loss. This may be difficult for some people, probably those most in need of accessing bereavement support.

Grief is a natural process that takes time, and not every client will require formal bereavement support. However, if you are concerned about how a client is coping, at any stage before or after a loss, involve the client’s GP and/or members of the multi-agency team, as the client may benefit from more formal support. This may come from the GP, any psychologically based services if available, or from your local bereavement service.

Consider nominating staff members to ensure clients receive support over the days and short weeks after a death. This can provide a space for people to talk about their emotions and may help reduce the impact of the loss.

As a team you need permission to grieve, to be able to show and express emotions, and to be able to take care of your own needs in a way that is appropriate to you. Consider what is needed to support all members of the team, particularly in the initial days and weeks following a death. What actions might assist you and your team? Include opportunities for reflective practice, or counselling, and activities such as a shared meal.

Consider as a team how you want to acknowledge a death. This will also help to validate the importance of everyone’s life. Always involve clients in the planning of celebrations. Some clients may also have chosen to tell someone about the kind of celebration they would like once they are gone. Celebrations of life are often times when people reflect on their own wishes. This may be a good opportunity to explore with clients what these wishes may be.

There are some practical issues to consider following a death, which are considered throughout this section. The bereavement support activity sheet, and the “after a client has died” flowchart can help you here.

Depending on the nature and cause of death, a coroner’s investigation may take place before a funeral can be arranged.

If there is no next of kin, or means to pay for the funeral, a public health funeral can be arranged.

Many bereavement services have already begun to create initiatives to support people experiencing homelessness. Get in touch with your local bereavement service, invite them to your project, and explore together how they can support you and your clients. This can also enable them to understand more about the clients you work with, and how to overcome some of the challenges some clients experience in accessing bereavement support. It’s possible they may agree to provide support at the project.

The Cruse Bereavement Care website can help you find a bereavement service nearest to your project or service.

Grief following sudden or traumatic deaths

When someone we care about dies in a sudden, and/or traumatic situation the common grief reactions we are likely to experience can become more intense.

In this situation there is often no opportunity to prepare for the bereavement by saying goodbye, or completing unfinished business. This can mean additional difficulties may occur and the grief reactions outlined above may be more intense.Anticipatory grief

Anticipatory grief occurs while someone is still alive but clearly dying. It is a common grief reaction for people who are facing the imminent death of someone they love or care for.

It is also experienced by the person who is dying as they consider letting go of those they love, or are concerned about how loved ones will cope after their death. Anticipatory grief may not always occur. Nor does it make the grief reactions after death any shorter or less intense.

In contrast to losing someone from a sudden or traumatic death, when it is known that a person is dying, there is the opportunity to resolve unfinished business, to spend quality time with them and for personal growth while the person is still alive.

For some clients who are dying there are opportunities for the multi-agency team to plan their care with them, to try to ensure their wishes and concerns are known in the remaining time they have left. This can include reconnecting with family, or remaining at their project (with the right package of care) and managing any anxieties that arise.

When caring for a client who is approaching the end of life it’s also important to share with others how you feel you are coping, particularly if you notice yourself struggling with the normal routines of daily life. You may cope fine, perhaps having a good supportive network or belief system to help you manage, but knowing there are additional supports you can make use of can be helpful. We have a developed a Self-care toolkit which you may find useful.

Complicated grief

Complicated grief is where the usual responses to the death do not fade over time and impair or prevent us leading our normal lives.

This can include:

• Anger, irritation or episodes of rage.
• An inability to focus on anything but the death.
• Focusing intensely on reminders of the deceased, or an excessive avoidance of such reminders.
• Intense feelings of sadness, pain, detachment, sorrow, hopelessness, emptiness, low self-esteem, bitterness or longing for the deceased’s presence.
• Problems accepting the reality of the death.
• Self-destructive behaviour, such as alcohol or drug abuse.
• Suicidal thoughts or actions.

Considering many clients will have experienced multiple losses in their lives and/or have developed unhelpful coping strategies (such as using drugs and alcohol to block out strong grief reactions) they may be more vulnerable to complicated grief reactions. If you notice a client’s grief response remains the same or has intensified over time, discuss referral to the client’s local mental health team, or seek the advice of other specialists, such as counselling services or the Cruse Bereavement Care helpline.

• Shock and numbness – unable to believe what has happened.
• Physical sensations – Sleep problems, nausea, diarrhoea, loss of appetite, weight change, headaches, overall lack of energy, hyperactivity or underactivity, shortness of breath, feeling shaky, tearful.
• Anger – at what happened, at whoever allowed it to happen.
• Guilt – about what didn’t happen, of feeling responsible somehow? Questions may include ‘could we have prevented this?’, ‘if only we…’, ‘what if …’
• Blame – includes self-blame and blaming others. It is often perceived as a way of dealing with grief, but gives only temporary relief, and is viewed as a non-productive reaction
• Emotional reactions –  Sadness, difficulty concentrating or focusing, fear, (e.g.fear of losing control), relief, irritability, longing, forgetfulness, slowed thinking, loneliness or isolation, feeling overly sensitive or dependent on others, lacking initiative, lacking interest in things we previously enjoyed, questioning our spiritual or religious beliefs, anxiety and panic.
• Behavioural changes – Distraction, searching for the deceased (e.g. revisiting familiar places), needing to retell our story of how they died, not expressing feelings in order to protect others (putting on a brave face), withdrawing from our normal / usual social interactions, avoiding others, excitement or euphoria – rushing around, busying ourselves with practical tasks.
• Denial of emotions – i.e. ‘I’m not angry’, I’m not upset’.

• Consider clients as much as possible in the practical arrangements following a death.
• Identify clients early on who may potentially be at risk, and consider if additional support is needed, perhaps from the community mental health team or your local bereavement service, (if available).
• Consider nominating staff members to ensure clients can access some 1-to-1 support as early as possible following a death (if not before). This could provide a space for clients, if they wanted too, to talk about how they are coping. Support may be as simple as ‘checking in’ with clients, or offering reassurance, that in itself will help reduce the impact of the loss.
• Where possible, try to ensure those closest to the client who has died are notified before informing others. This may include partners, family, friends, roommates and peers. Then, as best you can, gather everyone else together to inform them of the death. Announcing a death on a noticeboard, with no other discussion with clients should be seen as an absolute last resort.
• Let clients know as much as you can (or are allowed to) about the cause of death. Where an inquest is being carried out it is important to keep clients informed, confidentiality permitting, of what is happening, particularly if it is likely to take some time for the coroner to reach their conclusions.
• Let others know when the deceased’s belongings are going to be removed from their room, or when someone else is about to move in.
• Consider as a team how to acknowledge a client’s death. For instance, placing a memorial book and a photograph of them in a communal area of the project, once everyone has been notified. This may feel hard, but it can be the first of many ways to celebrate the life of the person.
• Involve clients as much as possible in any further commemorations, celebrations of life or any funeral arrangements. Support those who may not wish to attend by helping them consider other ways of celebrating or marking the client’s life.
• The after a client has died’ flowchart along with the other information in this section provide practical key points to consider after a death. Particular attention needs to be given to the period immediately following a sudden death at the project. This is where grief reactions can be most heightened.

• Sudden and traumatic death – particularly if clients were present at the time.
• Prior experience of multiple losses and childhood trauma – many of which may be unresolved.
• Difficulty expressing feelings about a loss, or multiple losses.
• Using unhelpful (but often necessary) coping strategies such as alcohol and drugs to mask grief.
• Poor supportive networks – making it more difficult to give meaning to their grief.
• Living with high support needs – usually a mix of physical and mental health problems, and substance misuse.
• Unable to engage with or fit in with local bereavement service structures.

• Knowing that grief is a process that takes time
• Knowing that there is no right way to grieve.
• Knowing that the time we grieve is different for everyone
• Getting back to normal routines
• Helping clients accept that reactions to grief are normal
• Being with others – encouraging clients not to become too isolated
• Challenging irrational thoughts, e.g.feeling guilty when we shouldn’t
• Setting realistic goals with clients – knowing what may not happen
• Respecting their coping strategies and the choices they make, even when trying to encourage new ones.
• Supporting your local bereavement service to engage with you and clients.

• Look out for notable changes in clients following a death. Allow for the possibility that grief reactions may be intense or heightened in the coming hours and weeks following a death. For instance, increased levels of alcohol and substance use and/or heightened emotions such as shock, disbelief or anger.
• Honour and acknowledge clients’ experiences of the death. Support them to cope with their grief reactions, and bear in mind that grief reactions are normal and should gradually fade. If notable changes have not subsided in a few weeks, or you have significant concerns about a client, speak to their GP, and/or your local bereavement service for advice and support.
• Respect a client’s choice not to engage with services, but consider a multi-agency meeting. Together consider what you could offer the client that might help.
• Encourage clients to interact with others, or talk about their feelings.
• Continue to affirm and acknowledge the loss with clients months after a death, especially around significant events such as the clients first anniversary or their birthday for those closest to the client who died..
• Consider that many clients will need their coping strategies and defences to deal with their loss, however much we wish them to be different.
• Acknowledge that while strong emotions, such as anger and guilt can be normal grief reactions following a death, when projected onto another person (e.g. a keyworker or another client) it can be challenging. In such situations, it’s helpful to recognize these reactions as a person’s way of expressing their own internal feelings around the death. Explore these reactions with them, and discuss more beneficial ways in which to respond to the way they are feeling.

• What emotions and behaviours are considered normal grief responses in that person’s culture?
• What are their beliefs surrounding death?
• Who is expected to attend mourning ceremonies, and how are attendees expected to dress and act?
• Are gifts, flowers or other offerings expected?
• What special days or dates will be significant to the client?
• What types of verbal or written condolences are considered appropriate?

• Acknowledge that you may feel overwhelmed at times by the intensity of your feelings, but that these feelings are likely to be part of a natural process of grieving, and will eventually fade.
• As emotions are unpredictable in bereavement, you might feel ok to be at work and then suddenly find yourself struggling to cope. Each team member needs to have the permission to assess what’s best for them and to do what’s necessary to take care of themselves.
• Find a good listener – reach out to others that you feel safe with. Talk openly and honestly to them about how you might be feeling.
• Consider seeking bereavement support if needed, particularly if following a number of weeks you become stuck with difficult emotions or reactions.
• Acknowledge that there may be more than one loss present.
• Consider things that are nurturing and beneficial, particularly in the initial days and weeks following a death. The Self-care toolkit may help here

• Honour and acknowledge the differences that arise within the team in response to a client’s death, and how these responses vary overtime.
• Consider the different kinds of rapport you and others have had with the client who died, and how a close connection might impact differently on how someone responds to the death of a client.
• Explore opportunities to express emotions and concerns as a team, and do whats necessary to take care of each other.
• Consider what is needed to support all members of the team, particularly in the initial days and weeks following a death. What actions might assist you and your team? Include opportunities for reflective practice, or counselling, and activities such as a shared meal.

External bereavement support services could provide;

• Direct 1-to-1 and group support for clients and staff.
• A counsellor attending client and team meetings to talk specifically about loss and grief.
• Bereavement training for staff.
• Signposting clients to more specialist services, if needed.
• Providing general and specialist advice and information booklets about grief and loss.

• When a client dies in hospital and there is no next of kin or money to pay for the funeral, the hospital assumes responsibility. If the death occurred outside of hospital, the local authority within which the client resides will assume responsibility.
• The hospital or local authority need to establish whether there are funds, either from the client’s estate, or from family members, to contribute to funeral costs, and if not to begin making arrangements for a public health funeral.
• Arrangements will vary from area to area, but normally there is an arrangement between the hospital or local authority and a local funeral undertaker. The service is basic, but can include a celebrant-led service, which anyone can attend.
• Public health funerals are very basic and the burial or cremation times are normally the least popular, like early morning, which might make it difficult for some clients to attend.
• Contact the department within the Patient Advice and Liaison Service (PALS) section of the hospital or your local authority (as they vary) early following the death of a client. Try to get a contact name, and let them know about where the client was living. Inform them of the relationship between the client, you, the project and other clients, particularly if the client saw the project as their home and/or staff as next of kin. This helps them understand the significance of the relationship you all had with the deceased.
• Find out how you can be notified of the time and date of the funeral, and let the hospital or local authority know that you and potentially other clients would like to attend.
• If  a client made a verbal or written wish to be buried or cremated, let the service arranging the funeral know. This will normally be honoured, and where it is unknown, the type of burial or cremation that is carried out will vary in different hospitals and local authorities.
• It’s always helpful to have a good rapport with these services, particularly if your project has experienced numerous deaths. Otherwise it can be difficult to know when a client may be buried or cremated, and opportunities to attend the funeral may be missed.
• Where a postmortem is carried out, contact the coroner’s office to find out when the client’s body is being released to the hospital/local authority for burial or cremation. This is often where opportunities are missed to attend or participate in a funeral. Ask if they could notify you, or keep checking with them.
• Also, if the project would like to be involved directly in the funeral service, let the hospital or local authority know. This can include choosing the music, poetry or readings to have at the funeral. For more information on planning a funeral click here
• If a client had a particular faith, or may have preferred a non-religious service, let the hospital or local authority know.
• Though services are likely to be short, they can help to honour a client’s life.
• Encourage clients and others who knew the client to attend. For those unable to attend, try to arrange a celebration at the project.

• Planning a celebration or public health funeral together
• Sharing a meal
• Sharing stories about the deceased client at a client meeting or other group activity
• Planting a tree, creating a small garden, or erecting a bench
• Memory wall – possible commemorating all clients who have died in the project
• A celebration of life service – it can be religious, non-religious or humanistic, and held at the project or in the community.