Last updated on 21 Jun 2023

Accidental damage to a body incidents in the post-mortem sector

Damage to a body that has the potential to cause distress to the family or may lead to damage in public confidence must be reported to the HTA. Incidents in this category include damage to a body during post-mortem examination, for example during evisceration or reconstruction of a body. Near-miss incidents should be reported to the HTA.

 

HTARI and Near- miss Incidents

Between 1st April 2022 to 31st March 2023, we received a total of 100 notifications of incidents relating to accidental damage to body. 87 of these were deemed to be Incidents or Near-misses. Incidents in this HTARI category are the most frequently received notifications.

We have reviewed the common themes and the staff groups involved in incidents involving accidental damage to a body.

 

Breakdown of Staff Groups Involved in all reported incidents

The accidental damage incidents referred to above involved 160 members of staff which is broken down below. 4 of those incidents were attributable to equipment failure and some incidents involved more than one staff group.

  • APTs- 41%
  • Porters- 19%
  • Funeral Directors- 14%
  • Ward Staff including maternity staff- 5%
  • Pathologists- 7%
  • Equipment Failure- 2%
  • Other Staff (bereavement/care after death teams, trainee APT, trainee pathologist, mortuary assistant, locum mortuary assistant.)- 12%

Types of Incidents that should be reported

Actual or potential damage to a body caused by:

  • Dropping the body during transfer
  • Equipment failure causing the body to fall
  • Damage due to poor selection of fridge space- injury to elbows, or facial injury
  • Damage due to poor preparation of the body during last offices
  • Conditional changes due to capacity issues and availability of freezer spaces or storage suitable for bariatric bodies
  • Injury/damage sustained during Post Mortem examinations and the reconstruction process. For example, button hole injuries

Actions to take to mitigate further risks

Investigation reports should reflect consideration of the following:

  • Checking staff competency and training is up to date
  • Retraining of staff and re assessment of staff competency
  • Reviewing and amending SOPs and Risk Assessments
  • Equipment checks: is equipment serviced and fit for purpose? Are staff aware of maximum weight limits for equipment?
  • Reviewing and updating training programmes and competency assessments to reflect changes in practice.
  • Learning from incidents- meetings with wider staff teams and external stakeholders to share information and learning- sharing with regional forums including resilience and winter pressures groups.
  • The availability and appropriateness of equipment eg bull nosed scalpel blades, fine gauged sutures.
  • Consideration of Duty of Candour requirement.

When not to report

Examples of incidents that are not HTARIs

  • Damage to a body on a ward (unless the ward is covered by the HTA licence – for example, a maternity ward – in which case, the incident should be reported to the HTA);
  • Damage to a body when the body is in the care of funeral directors in an area not covered by the HTA licence, for example in the loading area outside the mortuary.
  • Damage to a body during post-mortem cross-sectional imaging (for example, damage caused when the arms of the body are raised to prepare the body for the scanning procedure).
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Case Studies

Accidental damage sustained during Post Mortem Examination

Button hole injury sustained. Investigation concluded there was no pre mortem damage to tissue- this procedure was carried out by a locum APT who had received training and been signed off as competent. The establishment undertook a training session and competency checks for all staff. SOPs and risk assessments were reviewed and updated to reflect the use of bull nosed scalpels where there was an identified risk of injury due to pre mortem tissue damage.

Accidental damage sustained during fridge selection

Body of the deceased received a head injury due to selection of an inappropriately sized fridge space- this was carried out by porters who had received training and been assessed as competent. Training content and SOP reviewed by the establishment and all staff involved in the transfer of the deceased received updated training and competency assessments. Additional guidance given by the HTA included the use of visual aids/information posters on the body storage doors to assist porters when selecting an appropriately sized fridge space.

Accidental damage sustained during transfer

 Wheels of a mortuary trolley became trapped resulting in the trolley falling with the body of the deceased attached during transfer into the care of a Funeral Director. This occurred on licensed premises. The establishment shared the incident with the funeral director managers, additional signage was placed in the area where the incident occurred warning of the risk of the trolley wheels becoming trapped and the equipment within the establishment was checked for faults.

Where third party training is identified as a root cause of these incident types, the HTA would expect this to be offered.

Accidental damage sustained during storage

 The body of a deceased deteriorated to an unviewable state whilst in storage. This was due to lack of freezer capacity to provide long term storage. The establishment escalated the lack of freezer capacity through the management structure and the risks were added to the risk register. The SOPs and risk assessment were updated to reflect earlier identification of bodies potentially needing long term storage.

Where insufficient staffing levels are identified as a root cause of accidental damage to a body, establishments may consider the cross training of support staff to assist in mortuary duties such as administration tasks and condition checking. Establishments are further advised to escalate significant risks relating to staff levels to incorporate them into the Trust’s organisational risk register.

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Relevant standards

GQ1(a) Documented policies and SOPs cover all mortuary/laboratory procedures relevant to the licensed activity, take account of relevant Health and Safety legislation and guidance and, where applicable, reflect guidance from RCPath

GQ1(c) Procedures on body storage prevent practices that disregard the dignity of the deceased.

GQ3(a) All staff who are involved in mortuary duties are appropriately trained/qualified or supervised.

GQ3(c) Staff are assessed as competent for the tasks they perform

GQ3(g) Visiting / external staff are appropriately trained and receive an induction which includes the establishment’s policies and procedures.

GQ5(a) Staff know how to identify and report incidents, including those that must be reported to the HTA.

PFE2(a) Storage arrangements ensure the dignity of the deceased.

PFE2(c) Storage for long-term storage of bodies and bariatric bodies is sufficient to meet needs.

PFE3(b) Equipment is appropriate for the management of bariatric bodies.

Guidance on Body Storage

Our guidance on body storage include recommendations on condition checking to include the documentation and recording of condition checks.  

Read the guidance on body storage

Example standard operating procedure

An example of an SOP used for monitoring the care of the deceased can be found here