Human Tissue Authority

The regulator for human tissue and organs

Updated guidance for Traceability standard T1(c)

Since the implementation of the updated Codes of Practice and licensing standards in April 2017, there has been an increase in the amount and severity of shortfalls identified during routine site visit inspections, particularly in the PM sector. We have identified that certain standards are consistently not being met by the majority of establishments inspected since April 2017. As a result, the HTA is undertaking some work, including a full review of the guidance that supports each of the licensing standards, initially focusing on those which have seen the most shortfalls. The ‘Traceability’ standard, T1(c) is one of those standards.

We hope that the updated guidance will help establishments to better understand what is required to meet the standards.

Traceability standard T1(c):

‘Three identifiers are used to identify bodies and tissue, (for example post mortem number, name, date of birth/death), including at least one being unique’
 

Previous guidance:

Identification details should not be written on bodies. Where bodies are moved off-site for contingency storage the DI should ensure that suitable systems are in place to identify same or similar names.


Updated guidance

Identification details should not be written on bodies or on the outside of body bags.

Bodies should be identified using three identifiers attached to the body that in combination uniquely identify them and can be checked:

  • against PM examination consent/authority documentation prior to evisceration;
     
  • against documentation brought by the funeral directors on release of a body, independent of any documentation generated by the mortuary. For example, the mortuary register, admission documentation or cremation forms;
     
  • with family members who visit the mortuary for viewings.

Where bodies are brought to the mortuary by the police or funeral directors with fewer than three identifiers (e.g. name and address), they should be requested to provide a third identifier.

Where it is discovered that there are fewer than three identifiers on a body, e.g. during daily checks, further enquiries should be made, e.g. with the police or relevant coroner’s office, to obtain the required number of identifiers. It is good practice to obtain this information in writing and keep it with the deceased’s mortuary record. A second wristband with the additional details may then be added to the body.

The mortuary register number can be used as a unique identifier while a body is in the care of the mortuary but should not be used as an identifier for release of a body to a funeral director, unless, this has been specifically provided by the establishment beforehand, for example, via a hospital release form.

If the mortuary register number has been written on the identification band of the body during admission checks, it may be used to locate a third identifier for the deceased in the mortuary register, for example, their address, if it is not already written on the identification band, or the notification of death card attached to the body.

The DI should consider options of how to obtain three identifiers from family members if they make an appointment and when they attend for viewings which can be checked against the identification on the body prior to the relatives viewing the deceased.

The DI should ensure that robust systems are in place to identify bodies with same and/or similar names, including those that are moved off site for contingency storage.

Audience: 
Sector: