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24.11.17

Errors in mortuary can be avoided with better procedures, study says

Mortuary staff should learn from procedures used to protect living patients in order to prevent serious errors, a study has recommended.

The study, published in the Journal of the Royal Society of Medicine, analysed 132 incidents in the NHS between 2002 and 2013.

Incidents included the release of the wrong body for burial or cremation, incorrect storage of bodies, and postmortem examinations carried out on the wrong body.

Almost a quarter of the incidents reported involved fetuses - a highly emotive area.

“A hospital board and its senior executives cannot promote their values in this regard if they fail parents by presiding over incidents in the management of the bodies of their precious children,” the report warns.

Whilst the authors of the study accept that a dead person cannot be harmed, it argues that: “a civilised society expects that, after death, someone’s body will be accorded the same dignity and respect as during life,” and that errors cause: “emotional upset” to families, and can leave them “devastated.”

When healthcare institutes are considered to have failed to respect the dead, it is often met with public outrage - a notable example being the Alder Hey Children’s Hospital organ retention scandal, where between 1988 and 1996 children’s organs were removed and stored for a number of years without the families’ permission or knowledge.

The report found that whilst serious incidents involving dead bodies are uncommon, it identified failure to follow standard identification procedures and poor communication between departments as the most common causes of incidents.

Misconduct of staff was found to be a direct cause of seven confidentiality incidents.

The authors described the resemblance between the incidents occurring to patients before death and those afterwards as “striking,” with similar themes, such as documentation and patient identification, patient accident, infrastructure, and treatment.

Therefore, the study recommends that mortuary services adopt systems that have been shown to be successful in other healthcare areas, in order to minimise the risk of serious incidents affecting dead bodies and their grieving families.

Lead author of the paper, Iain Yardley, a consultant paediatric and neonatal surgeon at Evelina London Children’s Hospital, said: “Serious incidents involving a dead body are uncommon.

“However, the findings of our study serve as a warning to those responsible for the management of mortuary services of the significant risks inherent in such services and the potentially devastating incidents that can occur if these risks are not mitigated and errors are allowed to go unchecked.”

Top image: MariusFM77

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