Guidance on Mortuary Audits

GQ2 (a) There is a documented schedule of audits. 

GQ2 (b) Audit findings document who is responsible for follow-up actions and the timeframe for completing these. 

GQ2 (c) Regular audits are carried out of tissue being stored so that staff are fully aware of what is held and why and to enable timely disposal of tissue where consent has not been given for continued retention.
 

Guidance for GQ2 states:

As a minimum, the schedule should include a range of vertical and horizontal audits checking compliance with documented procedures as outlined in standard GQ1a, the completion of records and traceability of bodies and tissue. Audits should include checking of CCTV as well as records of mortuary access. Audit findings should document who is responsible for follow-up actions and the timeframe for completing these. 

Staff should be made aware of the outcomes of audits and where improvements have been identified. Processes should be in place to ensure that feedback of audit findings to all staff takes place in a timely and appropriate manner to ensure up to date procedures are embedded and being followed.
 

• An audit schedule should be documented with a clear timetable of audits and persons responsible for their completion. Progress of the schedule, and any resulting actions, should be shared with staff via departmental and governance meetings.
• The scheduling of audits, and sample size, should be reflective and representative of the activity performed.
• Templates used for audit results should ensure any actions, persons responsible and completion timeframe is recorded.
• The schedule should contain a range of vertical audits, these help to identify procedural issues and mitigates risks associated with traceability and identification. These may include selecting a deceased’s file, and following the body’s identification checks through admission, viewing, post mortem and release.
• The schedule should contain a range of horizontal audits, these help identify systemic or common errors across multiple cases. This ensures compliance and highlights areas for improvement in record keeping and procedural consistency. These may include selecting a set number of a specific completed form or register entry.
• Audits, such as those for a specific procedure, may be completed the same time as other tasks to improve efficiency. For example, when auditing a specific procedure, the SOP review and staff competency assessment may be completed at the same time.
• Access audits should contain the use of CCTV, and where applicable, mortuary registers, signing in documentation, key logs, and swipe card usage. CCTV should also be audited at randomly selected times as part of the security audits.
• Audit of stored tissue should ensure traceability of all ongoing cases. The frequency of the audit should ensure timely retention, release or disposal of tissue following the coroner’s jurisdiction ending. The schedule should also contain an historical tissue audit to ensure all retained tissue has appropriate documented consent  for retention.