Root causes identified:
- Failure to check three points of identification on the body at the point of release, using fridge plates or whiteboards only to identify the deceased.
- Failure to implement a robust system for the same or similar named deceased, which includes considering contingency storage.
- Releasing deceased on internal paperwork after only receiving one or two identifiers from those collecting the deceased.
- Staff being distracted during release procedures or not fully participating in the release process.
- Bodies being released to those not authorised to collect the body or before the body has been authorised for release.
What should establishments do now to help mitigate risks:
- Review standard operating procedures for the admission and release of bodies. Consider whether changes to procedures have been made due to the current COVID-19 pandemic and if these changes have been documented.
- Read the Post mortem sector licensing standards and guidance document for further guidance.
- Ensure all staff are trained (including porters and others who assist in the mortuary) in the procedures they undertake.
- Ensure all staff are trained and competency assessed in the most current procedures regularly and by those suitably trained to do so.
- Review staff training and competency assessment records and ensure they are up-to-date, especially for any staff who have been absent or have not performed the procedure regularly.
- Perform regular process audits, including unannounced audits.
- Perform location and identification audits including bodies in long-term storage using three points of identification attached to the deceased. Correct any inconsistencies and add additional identifiers where required.
- Report any HTA reportable incidents (HTARIs) or near-miss incidents to the HTA within 5 working days of discovery.