The HTA received 226 incident notifications in the year to 31 March 2018. Following the review of each incident by the HTA, 12 of these were categorised as near misses and 72 did not meet the definition of a HTARI, either because they did not fall within one of the reportable incident categories or because they were not of sufficient severity to warrant consideration by the HTA.
An example of an incident reported to the HTA as a reportable incident, but not classified as such by the HTA, is accidental damage to a body that happened as part of the care after death procedure on the ward. Whilst serious and warranting internal investigation, the matter falls outside the scope of HTA’s regulatory oversight.
Accidental damage and mistakes in identification of bodies (release, viewing or PM on the wrong body) are the two categories with the highest number of incidents reported in the year to 31 March 2018.
Nearly a third of all incidents reported to the HTA were not classed as reportable incidents for HTA purposes.
HTARIs reported by category
|HTARI classification||2017/18 total||2016/17 total|
|Accidental damage to a body||49||35|
|Discovery of an additional organ(s) in a body on evisceration for a second PM examination, or during the repatriation or embalming process||0||0|
|Disposal of retention of a whole fetus or fetal tissue (gestational age greater than 24 weeks) against the express wishes of the family||1||1|
|Disposal of retention of a whole fetus or fetal tissue (gestational age less than 24 weeks) against the express wishes of the family||3||3|
|Disposal or retention of an organ against the express wishes of the family||2||1|
|Discovery of an organ or tissue following PM examination and release of a body||6||5|
|Incident leading to the temporary unplanned closure of a mortuary resulting in an inability to deliver services||0||1|
|Loss of an organ||4||3|
|Major equipment failure||10||4|
|PM examination conducted was not in line with the consent given or the PM examination proceeded with inadequate consent||2||2|
|PM examination of the wrong body||3||3|
|Release of the wrong body||11||13|
|Removal of tissue from a body without authorisation or consent||2||3|
|Serious security breach||10||3|
|Viewing of the wrong body||9||9|
|PM cross-sectional imaging of the body of a deceased person included an invasive procedure for which consent had not been given||0||0|
|Any incident not listed here that could result in adverse publicity that may lead to damage in public confidence||30||24|
Whilst the ’Any other incident category’ captures a range of incidents, accidental damage represents the largest single identifiable share of incidents (49 out of 142, nearly 35%). These incidents occurred when bodies were being moved, for example, transferred into or out of refrigerated storage and during PM examination.
The next substantial category of HTARIs received in the year to 31 March 2018 is the ‘Any incident’ category, which accounted for 30 out of 142 (21%) of all reported incidents. A review of these incidents did not identify any recurring themes. The HTA continue to keep incidents reports in this category under review.
Errors in identification of bodies
Almost three quarters of incidents in which the wrong body was released to funeral directors involved bodies with the same and/or similar names. This reinforces the importance of having an effective system for dealing with bodies having the same and/or similar names and the value of using three identifiers, one being unique, for each body.