Deceased should be given same care as the living, report claims
SERIOUS MISTAKES made in mortuaries – including identity mix-ups – might be avoided if the deceased received the sort of management standards given to the living, according to a new study.
Post-mortem examinations on the wrong body and even people being buried or cremated by the wrong family are some of the errors spotted by researchers who looked in to 132 incidents reported in England to a national NHS database between April 1, 2002 and March 31, 2013.
One of the most infamous cases was in Hull when it emerged that the body of Christopher Alder, who died in police custody in 1998, had not been buried as believed, but remained in the city’s mortuary more than a decade later.
The scandal was only revealed when a close friend of Grace Kamara, a 77-year-old Nigerian woman who died of natural causes, insisted on preparing her body for burial ahead of her funeral in November 2011, and was told it could not be found. A criminal inquiry by South Yorkshire Police, which failed to determine how the bodies were exchanged, established that Mrs Kamara had been buried in Mr Alder’s grave.
Weaknesses in or failures to
follow protocol and procedure, poor communication and informal working practices – all of which have been blamed in safety incidents involving living patients – were also found in the study in the Journal of the Royal Society of Medicine.
Among the incidents discovered by the researchers who looked at the storage, management or disposal of deceased patient remains were 25 errors in post-mortem examination, or examinations on the wrong body.
There were 31 incidents involving the disposal of bodies, including 25 bodies which were released to an undertaker by mistake, with nine buried or cremated by the wrong family.
They were 54 incidents linked to problems with the storage of bodies or body parts while 43 incidents concerned problems with the management of bodies.
Nearly a quarter of all reported incidents involved foetuses.
Scandals such as the removal and retention of organs from children who died between 1988 and 1996 at Alder Hey Children’s hospital centres in Liverpool show the public outrage when organisations fail to respect the dead.
The study points outs that “strictly speaking, a dead person cannot be harmed but civilised society expects that, after death, someone’s body will be accorded the same dignity and respect as during life”.
It concludes: “Serious incidents in the management of deceased patient remains have significant implications for families, hospitals and the health service more broadly. Safe mortuary care may be improved by applying lessons learned from existing patient safety work.”
Misidentification and cataloguing failures, problems in communication between the mortuary and other departments, poor written documentation, staff misconduct, refrigerator malfunctions, lack of leadership, fatigue and overwork and out-of-hours working were identified as some of the contributory factors.
Iain Yardley, lead author and a consultant paediatric and neonatal surgeon, added: “Serious incidents involving a dead body are uncommon. However, the findings of our study serve as a warning to those responsible for the management of mortuary services of the significant risks inherent in such services and the potentially devastating incidents that can occur if these risks are not mitigated and errors are allowed to go unchecked.”
Care may be improved by lessons from patient safety work. A report by the Royal Society of Medicine.