Human Tissue Authority

The regulator for human tissue and organs

Release of the wrong body incidents in the Post Mortem sector

Incidents or near-miss incidents – what we have learned:

Failure to meet the HTA standards can and has resulted in several incidents of release of the wrong body. Such incidents can have detrimental effects on families, staff and public confidence in the Post Mortem sector. Learning from these incidents is neccessary to improve services, maintain public confidence and protect the dignity of the deceased.

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.

For more information see our guidance on traceability procedures of the deceased.

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Last updated on: 13 Oct 2020