When Things Go Wrong!

1. When Things Go Wrong! Terry Johnson Mortuary Manager Hull & East Yorkshire Hospitals NHS Trust

2. Overview • Outline of the incident • Procedures in place at the time • What went wrong? • What action was taken? • The procedure now. • Lessons learnt.

3. The Incident • On 27th October 2008 a member of my staff released a deceased baby to a local funeral director following presentation of Coroner’s ‘A’ Form No 36491. • The brain had been retained at PM for examination by our Neuropathologist. • Following a call from the laboratory it became apparent that the brain was still at the mortuary awaiting collection prior to examination. • I then discovered that the deceased had been released to the funeral director about 20 minutes beforehand.

4. Procedures in Place at the Time • On completion of the PM the pathologist completes a Tissue Retention Form (TRF) which is faxed through to the Coroner’s Office. • The Coroner’s officer’s contact the family to establish their wishes regarding any retained tissues. • The TRF is updated with their wishes and faxed back to the mortuary.(this can take some time)

5. Procedures in Place at the Time • Mortuary staff complete a Specimen Log Form that provides a means of tracking samples/specimens. • All paperwork had been completed appropriately. • In cases were whole organs had been removed it is usual for relatives to ask that they be returned to the body. Especially Brain/residual tissue) • An agreement was in place with the Coroner that papers for release would not be issued until he had received confirmation from the mortuary that the organ had been returned.

6. What went wrong? • Mortuary staff is instructed not to release the deceased without proper and appropriate authorisation. The Coroner’s ‘A’ or ‘E’ form were both deemed as appropriate. This had been stipulated due to previous incident. • The whole incident therefore hinges around the fact that release paperwork had been issued. • The number of the ‘A’ Form had been recorded in the mortuary register.

7. What went wrong? • When a brain has been retained at PM our standard practice is to leave it fixing for 24hrs before transfer to Neuropathology. • In this case the brain required a slightly longer period of fixing because of its condition. • On releasing the patient mortuary staff checked the register and admission form for patient property but did not look at the attached Specimen Log Form. Working on the assumption papers released therefore clear. • They had no reason to check the Log Form because the funeral director had the release papers issued by the Coroner.

8. What went wrong? • Investigation had revealed all mortuary staff and two Coroner’s Officers were operating the system that we thought was in place while two other Coroner’s Officers were not. • This raised the question “Why were two Coroner’s Officers doing something different”? • The answer – ‘Procedures not documented’

9. What action was taken • Meeting held with the Coroner on 5th November 2008 at which the incident was reviewed. • The need to document procedures between the mortuary and the Coroner’s Office was discussed and agreed. • Coroner agreed to use our Specimen Log form in future and that the mortuary would manage the process.

10. What action was taken • The following SOPs were reviewed and amended: • MO/HR/018, MO/HR/026, MO/HR/027, MO/HR/031, MO/HR/039, MO/HR/042, MO/HR/050 and MO/009. • When any material is to be returned to the body the name of the deceased and mortuary ID number is written on the day board in the reception office so all are aware. The mortuary staff asked for this.

11. The Procedure Now • TRF and Specimen Log Form completed by circulator before leaving the PM room. • TRF faxed through to Coroner’s Office. • Circulator updates the computer database and puts details on day board in reception. • When TRF is returned the whole process is managed by the mortuary who distribute copies to those that need them.

12. The Procedure Now • Tissues/Organs are transferred to the lab using the Specimen log for signatures. • When a funeral director arrives to pick up the deceased the first thing the mortuary staff check is the day board. • As a second check they examine the patient file and if there is a specimen log form they read it and then take the appropriate action.

13. The Procedure Now • If we have tissues/organs that are to be returned to the body mortuary staff will refuse release to funeral directors no matter what paperwork they produce.

14. Lessons Learnt • No matter how good a system you think you have in place it can go badly wrong. • Its often difficult to see a potential problem when you are so familiar with your own systems. • The agreement that we thought we had with the Coroner had not been adequately documented thus problems were bound to develop over time. • HTA inspection is perhaps the most useful audit that we have.

15. Working together; building confidencePost mortem sector conference Wednesday 21 October 2009