Mortuary
	Post-Mortem Examinations Hospital/Couseuted post-mortmen examinations. Advice on Coroner/Medico-Legal post mortem examinations Advice on Death Certificate Advice on Certifying Death in a Patient with Health Care Associated Infection Guidelines for Managing Deaths due to Infection

Who carries out the post-mortem examination?

Medico-legal or coroner post-mortem examinations

The senior coroner for Northern Ireland is Mr. John L. Leckey. There are two deputy coroners, Mr Brian Sherrard and Ms Suzanne Armstrong.

The coroner will order a post-mortem examination under certain circumstances. These include where:

If any of these circumstances apply, the coroner must be informed. (The Consultant in charge of the patients care must also be informed). It is not usually necessary to immediately report the death of a patient who dies in hospital during the night unless the death is associated with homicide or there is need to obtain consent from the coroner for harvesting of organs for transplantation.

For further information on informing the Coroner about certain categories, see this power point presentation. (The Coroners Service for Northern Ireland)

The telephone number of the Coroner’s office is 0289044680 and it is open from 8. 30am until 5pm. Out side of these hours it is possible to leave a message.

If a death is to be referred to the coroner, it is important that relatives are not asked for consent. Relatives cannot legally withold consent for a post-mortem examination which has been ordered by the coroner but they should be given oral and written information about why the coroner has ordered the examination and what is the likely outcome. They should be informed of when and where the examination will take place ( Most coroner post-mortem examinations on adult patients take place in the City of Belfast Mortuary, Foster Green Hospital and most coroner post-mortem examinations on children take place in the Mortuary at the Royal Hospitals Belfast) . They should also be informed that that a Coroners Liaison Officer will contact them after the post-mortem examination has taken place to let them know the outcome and also to make arrangements with them regarding any tissue samples which might have been retained for further examination.

It is necessary to provide a written clinical summary for the pathologist. This should be prepared by a consultant or experienced registrar and not delegated to a junior member of staff. It should be sent to the mortuary with the body of the deceased. The Mortuary Technicians will arrange transfer of the body of the deceased to the appropriate PM facility.

The Hospital, or consented post-mortem examination.

These examinations are requested by doctors or relatives and are carried out to obtain detailed information about the patients illness, to monitor disease progression, assess the response to treatment and to establish the cause of death.

When are post-mortem examinations carried out?

Post-mortem examinations are carried out as soon as possible, having regard for relatives who have to make funeral arrangements. However the pathologists other work commitments have to be taken into consideration and it is important therefore that relatives are not promised a particular time for release of the body from the mortuary until the post-mortem arrangements have been made with the pathologist and mortuary technicians.

There is an on-call service for post-mortem examinations at the weekend and during public holidays. The appropriate pathologist can be contacted through the mortuary technician on-call who, in turn, can be contacted by the switchboard at Craigavon Area Hospital.

There is a mortuary technician available in the Craigavon Area Hospital Mortuary from 9 am – 6pm and in the Daisy Hill Hospital Mortuary from 12 pm – 6.30 pm, on weekdays. Outside these hours, the mortuary technician on-call can be contacted via the hospital switchboard. The mortuary technicians are a valuable source of advice on matters concerning post-mortem arrangements, transportation of bodies and funeral arrangements.

Obtaining consent for a hospital post-mortem examination

The decision to ask for a hospital post-mortem examination should be taken by a senior member of the clinical team who was looking after the patient. The Consultant of that team must always be informed (and should also be informed before any notification to the Coroner)

Oral and written consent must be obtained from the next of kin, using the correct consent form, appropriate for adults, child or infants/fetuses. The next of kin should also be given the appropriate information leaflets which explain about the different types of post-mortem examination, and which are available on all wards. If the deceased had no living relative, consent may be given by the Chief Executive of the hospital or his deputy.

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Possible contraindications to a post-mortem examination

1) Patients known or suspected to have a potentially dangerous infection

If a patient has died from a suspected or known potentially dangerous infection, regardless of whether or not a post mortem examination is to be carried out, this information should be made available to any personnel involved in removal of the body from the ward to the Mortuary, and to the Mortuary Technicians. The body should be placed and sealed in a body bag before removal from the ward. The patients relatives should also be informed. Under these circumstances, embalming procedures may be contra-indicated.

The pathologist will assess the possible risks to himself and to the Mortuary Staff of carrying out the examination, versus the potential benefits of an examination.

2) Radioactive hazards

In addition to some potentially dangerous infections, post-mortem examination should not be carried out on patients who have recently received radioactive materials as part of their investigations or treatment. Advice on individual cases should be obtained from a consultant pathologist before seeking consent for post-mortem examination from relatives.

Patients who die in the community

General practitioners who wish to have a consented post mortem examination on a patient who has died at home should contact one of the pathologists directly. The pathologist will fax a consent form for completion by the next of kin and also a written information leaflet for them to help inform their decision to consent.

The body will be transferred to the Mortuary at the Craigavon Area Hospital by a funeral director, whose expenses will be paid by the hospital.

Paediatric and Perinatal Post-Mortem Examinations

Post-mortem examinations on fetuses, greater than 12 weeks size, stillborn infants, perinatal deaths and child deaths are carried out by the Regional Paediatric Pathologists, at the Mortuary of the Royal Hospitals, Belfast. Remember that a ‘child’ is defined as up to the age of 18 years. Remember also to use the correct consent form. There are forms for 1) ‘A baby’, i.e. fetus of greater than 12 weeks gestation up to and including babies of 28 days, and 2) A child’.

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If any examination of a formed fetus is to be carried out, fully informed oral and written consent must be obtained from the parents, no matter how small the fetus is. There are consent forms specific for fetuses less than 12 weeks size (product of conception) and fetuses greater than 12 weeks size.

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Advice on the Certification of Death.

Advice and instruction on the completion of a medical certificate of the cause of death is given in the four pink pages at the beginning of the Death Certificate Book. Some points are reproduced below. Advice may also be obtained from the website of the Office for National Statistics at www.statistics.gov.uk.

Death certification serves a number of functions.

The death certificate must be given and signed by a medical practitioner who was in attendance during the last illness of the deceased and who attended the deceased within 28 days of death.

If a death is to be reported to the Coroner, a medical certificate of the cause of death must not be issued. For deaths which should be referred to the coroner, see section on Coroner’s or medico-legal post-mortem examinations.

Doctors are expected to state the cause of death to the best of their belief. They are not expected to be infallible.

The certificate is divided into two sections, I and II. In ‘I’ should be entered the immediate cause of death and any diseases which lead up to it (if there were any), the latter being stated in time order backwards from the immediate to the antecedent causes. In ‘II’ should be entered conditions which were not in the chain of pathological events which lead to the immediate cause of death but which nonetheless contributed to the fatal outcome.

Do not certify deaths as due to failure of any organ without specifying the disease or condition that led to the organ failure.

Consider whether the essential features of the deceased’s terminal illness cannot be stated as a single cause.

Where possible state whether the condition was acute or chronic.

For deaths due to cancer, the primary site of origin and histological type should be stated where known.

Try to avoid the term ‘Cerebrovascular accident'. State infarct, haemorrhage or embolic if known.

If the patient had diabetes, state whether type 1 or type 2 and if it was the underlying cause of death, state the complication or consequence which lead to death.

If death was due to infection, specify the infecting organism, the source or route of infection and the manifestation or body site, e.g. pneumonia, septicaemia.

Do not use abbreviations.

Remember panels A and B on the back of the certificate. Panel A relates to cases where further information is likely to emerge, e.g. following a post-mortem examination.
Panel B refers to deaths where the deceased was either pregnant or within 4 weeks of delivery at the time of death. ( When pregnancy, parturition or miscarriage was in any way contributory to death, this should be mentioned in the front of the certificate. Panel B does not take the place of such a mention.)

It is ultimately the responsibility of the consultant in charge of the patient’s care to ensure that the death is properly certified. It is good practice to take advice from him on what to enter on the death certificate.

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Advice on Certifying Death in a Patient with a Health Care Associated Infection.

It is a matter for your clinical judgment whether a condition the patient had at death, or in the preceding period, contributed to their death, and so whether it should be included on the MCCD. Where infection does follow treatment, including surgery, radiotherapy, antineoplastic, immunosuppressive, antibiotic or other drug treatment for another disease, remember to specify the treatment and the disease for which it was given.

If a health care associated infection was part of the sequence leading to death, it should be in part 1 of the certificate, and you should include all the conditions in the sequence of events back to the original disease being treated.

Examples

Example

C. difficile Associated Deaths

Junior Doctors in HSC Trusts should where possible discuss with a Consultant before completing the death certificate for a patient who has had C. difficile associated diarrhea and has died to ensure that the death certification is completed accurately to reflect all the contributing causes.


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Guidelines for Managing Deaths due to Infection.

Mortuary staff, members of the ambulance service and Funeral Director staff need to know if a body which they are to handle is either known or suspected to be infectious, and understand the requirements of relevant standard operating procedures. The information that needs to be given will not be the precise identity of a particular infectious agent, but should warn of any potential for transmission by inoculation, inhalation or hand to mouth contact.

It is the job of the Mortuary staff to present the body of the deceased in an aesthetically acceptable state for the bereaved to pay their last respects and to proceed with their funeral arrangements. Preparation of the body will routinely involve what is called ‘hygienic preparation’ but may also involve embalming. As a general rule, standard infection control procedures will be continued after death as in life. If however the deceased had or was suspected to have had a potentially dangerous infection, these procedures may be contraindicated.

If the deceased died because of an infection, or if an infection was not the direct cause of death but contributed to it, this will be stated on the Death Certificate. However for certain infections, it is important that relevant information is included on the Mortuary Form which is attached to the body sheet or bag of the deceased. This informs the Mortuary staff of what precautions they need to take. This information also need to be passed on to the Funeral Director, so the Mortuary technician will ask the doctor who signed the Death Certificate to also complete a ‘Mortuary Infection Control Notification Sheet’.

The most common infections for which Mortuary staff and Funeral Directors require notification are listed below.
Please note that this does not include infection due to MRSA or Clostridium difficile.

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