Release of the wrong body incidents in the Post Mortem sector

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Failure to meet our standards can and has resulted in several incidents of release of the wrong body. The data above confirms that we have received notification of 66 incidents of release of the wrong body since April 2017.

These incidents are deeply distressing to the families of the deceased who are already going through a grieving process. These incidents are also damaging to public confidence. Learning from these incidents is necessary to improve services, maintain public confidence and protect the dignity of the deceased, and will help us in our aim of reducing the number of these types of incidents to zero.

We have reviewed the common themes that emerge from the various incidents reported to us under the category of “release of the wrong body.

Incidents or near-miss incidents – what we have learned
  • Releasing deceased on internal mortuary paperwork after only receiving one or two identifiers from those collecting the deceased. Our guidance suggests a minimum of three identifiers should be used.
  • Releasing a body using information on the ‘green certificate’ – this form does not detail three robust identifiers of the deceased. Age is not considered to be a robust identifier.
  • Failure to check three points of identification on the body at the point of release, using names on fridge plates or whiteboards only to identify the deceased which may be inaccurate.
  • Failure to implement a robust system for the same or similar named deceased, which includes considering deceased located in contingency storage.
  • Staff distractions during release procedures or not fully participating in the release process.
  • Bodies being released to those not authorised to collect the body or before the body has been authorised for release by a Coroner or before the medical certificate of cause of death has been issued.
Root causes identified
  • Review standard operating procedures for the admission and release of bodies. Consider whether changes to procedures have been made due to the current COVID-19 pandemic and if these changes have been documented.
  • Read the Post-Mortem sector licensing standards and guidance document for further guidance.  
  • Ensure all staff are trained (including porters and others who assist in the mortuary) in the procedures they undertake.
  • Ensure all staff are trained and competency assessed in the most current procedures regularly and by those suitably trained to do so.
  • Review staff training and competency assessment records and ensure they are up-to-date, especially for any staff who have been absent or have not performed the procedure regularly.
  • Perform regular process audits, including unannounced audits.
  • Perform location and identification audits including bodies in long-term storage using three points of identification attached to the deceased. Correct any inconsistencies and add additional identifiers where required.
  • Report any HTA reportable incidents (HTARIs) or near-miss incidents to the HTA within 5 working days of discovery.
What should establishments do now to help mitigate risks

Our Code B Post-Mortem Examination and Guidance includes mandatory traceability standards and associated guidance to ensure robust traceability of the deceased whilst in mortuary storage and during procedures which directly involve identification checks to be performed. The relevant standards and guidance include:

T1c) Three identifiers are used to identify bodies and tissue, (for example post mortem number, name, date of birth/death), including at least one unique identifier. 

Guidance: This licensing standard aims to ensure that identification procedures are robust. Any deviation from documented procedures should be considered on a case-by-case basis, escalated internally (for example, to the mortuary manager) and documented.

Bodies should be identified using a minimum of three identifiers attached to the body that can be used to check the identification of the deceased. Age is not considered to be robust as an identifier; date of birth should be used wherever possible.  Where there are fewer than three identifiers on a body, enquiries should be made to obtain a minimum of three identifiers, wherever possible.

In cases where the identity of the deceased is unknown, information such as mortuary register number, date of admission to the mortuary and place of death may be used, whilst enquiries are ongoing. It is good practice to obtain this information in writing and keep it with the deceased’s mortuary record. The additional identifiers should be added to existing or additional identification bands on the body.

If the mortuary register number has been written on the identification band of the body, it may be used to locate a third identifier for the deceased recorded in the mortuary register or other mortuary documentation.

Identification for release from the mortuary:

A minimum of three identifiers on the body should be checked against documentation brought by the funeral directors. The mortuary register number can be used as a unique identifier while a body is in the care of the mortuary but should not be used as an identifier for release of a body to a funeral director, unless it has been specifically provided by the establishment beforehand (for example, on a hospital release form).

T1d) There is system for flagging up same or similar names of the deceased. 

Guidance: This should consider the sound and spelling of forenames and surnames. The system should include bodies that are moved off site for contingency storage, where they may be returned to the establishment.


Relevant Standards and Guidance
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