Analysis of the data we have collected has identified key themes and areas for improvement that the HTA will use to inform the sector through additional advice and guidance, some of which has been included in this document.
Data from compliance information indicates that bodies are being retained in mortuaries for longer, impacting on refrigerated storage, long-term body storage, and contingency capacity, which establishments have also highlighted as concerns on inspection.
The number and severity of shortfalls identified during site visit inspections has notably increased and appears to be only partly attributable to the revision of Standards that was introduced in April 2017, with the increase in number of shortfalls being most stark for certain specific standards. The details of and possible reasons for this are discussed further in this document.
Two issues that remain predominant among reported HTARIs include accidental damage to bodies and mistaken identification of bodies (resulting in release, viewing or PM examination of the wrong body). Accidental damage to bodies most commonly occurred during transfer into refrigerated storage, whereas bodies having same and/or similar names was a key factor in mistaken identification. Whilst these are not new issues, and were addressed in the revised standards and related guidance introduced in April 2017, this review gives additional insight into those that occur most commonly to help establishments recognise and address key risk factors.