Last updated on 03 Oct 2024
2023/24 review: Driving improvements within the post-mortem sector
Part of our role is to ensure post-mortem examinations are undertaken on suitable and licensed premises with appropriate consent or under the authority of the coroner. Given the complex system for managing the deceased, the scrutiny it receives and the sensitive subject matter, the post-mortem sector continues to be a high-risk sector.
In 2023/24, we took steps to improve practices at our licensed mortuaries and a large proportion of this work has focussed on improving mortuary security.
Previously, our approach involved clarifying our expectations of the post-mortem and anatomy sectors and conducting assessments to reinforce our standards. Last year, we moved to use our data and inspection methods to highlight common areas of non-compliance and take a targeted approach to improving compliance in the post-mortem sector.
“The inspectors were very transparent about what they were doing and why – I didn’t feel that there was any ulterior motive or attempt to ‘catch us out’ on anything. The advice and guidance was helpful and well considered.”
During the year, we conducted a data collection exercise to gain high-level insights on areas within the post-mortem sector. The results – alongside our shortfall and incident data, and the findings from the Phase 1 report of Sir Jonathan Michael’s independent inquiry into Fuller’s offending – confirmed further action was required to improve compliance with our security-related standards and in relation to contingency planning.
To raise awareness and vigilance of security in our licensed mortuaries, we hosted four webinars on security standards for Designated Individuals (DIs; who have a legal duty to ensure that our statutory and regulatory requirements are met). The webinars conveyed that DIs should have a well-rounded understanding of security arrangements in their mortuaries. This includes the importance of restricting, monitoring and auditing mortuary access. It also summarised the evidence we require to assure ourselves that security measures are in place to meet our standards and are suitably monitored.
“I thought this webinar was an excellent start and I liked the holistic approach to the topic backed up by data and clear explanations. I thought it worked very well.”
Given our incident data in the post-mortem sector, we also updated our HTARI guidance to improve the quality of information provided to us. This will enable us to understand what immediate steps an establishment has taken -both in response to the incident as well as to reduce the likelihood of the incident taking place in the future. The guidance also assists establishments in deciding whether an incident is reportable and ensures they are aware of our escalation processes.
Turning the lens on ourselves, we considered how we could improve our approach to assessing security-related standards in mortuaries and our expectations of licensed establishments. This includes how we assess that an establishment is assuring themselves that they are meeting the standards (for example, by carrying out routine audits of mortuary access, and reinforcing the importance of supervising all mortuary visitors).
We will continue to focus on driving improvements in mortuary security. To help do this, we will assess and engage with the sector and support the next phase of the independent inquiry into Fuller’s offending.
Changing requirements for bodies laid to rest at sea
At times, we use our expertise to assist change beyond our regulatory remit. This may be where we identify a problem or where we are asked for our advice or guidance. One example of this involved working with stakeholders to change requirements for bodies laid to rest at sea.
Occasionally, the deceased are laid to rest at sea. While weighted caskets are used, over time they can breach and bodies can wash ashore. When this occurs, the police and coroner may mount a suspicious death inquiry or cause distress to families of the deceased by asking them to identify body parts.
In a move to resolve this longstanding problem, the Marine Management Organisation led a working group that involved the HTA, the Senior Coroner for the Isle of Wight, National Crime Agency, Hampshire and Isle of Wight Constabulary and government departments. As a collective, we worked to change requirements and ensure that bodies laid to rest at The Needles site (off the Isle of Wight) from October 2023 have DNA extracted prior to being buried at sea. The DNA is subsequently held on a restricted access database for comparison to help match and identify any body parts found. Changing the burial at sea requirements ensured the wishes of those who seek a sea burial are respected. It also ensures families are not caused undue distress and that police and coroner resources may be allocated elsewhere.
Our role was important in bringing about this change. We advised on the necessary consent requirements to a group of funeral directors who have been authorised by government to obtain the relevant consent for tissue removal. While responsibility for obtaining consent continues to sit with the establishment carrying out the tissue removal, we will continue to offer our expertise by providing training on an annual basis and offering our guidance to the stakeholders involved.
Back to the 2023/24 review contents page