Human Tissue Authority

The regulator for human tissue and organs

Part 3 - HTA Reportable Incidents (HTARIs) 2017-2018

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.

Advice: Before reporting an incident to the HTA, please refer to the guidance on the website here  to help assess whether an incident is a HTARI. If further advice is required, please contact the HTA on 020 7269 1900 or email enquiries@hta.gov.uk 

 

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
Total 142 110

Accidental Damage

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.

Advice: Establishments should ensure that only staff who are trained and signed-off as competent in the transfer and movement of bodies, including in and out of the body store, undertake this activity. The training should also include information on how to recognise bodies that may not fit easily into standard fridge spaces, such as patients who have unusual body morphology.

 

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.

Advice: Establishments should check both forenames and surnames (and similar sounding as well as spelling of names) when identifying whether they have bodies with same and/or similar names.

Establishments should have a consistent approach to recording names (including on temporary records, such as white boards or fridge doors), for example, being consistent about the sequence of names (forename, surname or surname, forename) and this should be clearly visible to anyone completing or using this information. This mitigates the risk of confusion where a forename could also be a surname, for example Martin Thomas and Thomas Martin.
Last updated on: 29 May 2019