Last updated on 23 Feb 2021

Guidance on traceability procedures of the deceased

The HTA traceability licensing standards aim to ensure that procedures to identify the deceased are robust. This is important to protect the dignity of the deceased.

T1(a): Bodies are tagged or labelled upon arrival at the mortuary.

T1(b): There is a system to track each body from admission to the mortuary to release for burial or cremation (for example, mortuary register, patient file, or transport records)

T1(c): Three identifiers are used to identify bodies and tissue (for example, post mortem number, name, date of birth or death), including at least one unique identifier.

T1(d): There is system for flagging up same or similar names of the deceased.

T1(e): Identity checks take place each time a body is moved whether inside the mortuary or from the mortuary to other premises.

When a body arrives into the mortuary

To meet HTA standards:

  • Check that bodies are labelled with three points of identification (ID)
  • Record the storage location of the deceased
  • Check for same or similar named deceased and implement systems
  • Audits of storage location are completed and recorded

Examples of good practice:

  • Conduct a two-person check of the condition of bodies and the ID of deceased
  • A unique mortuary identifier is assigned and attached to the body and used on all records for the deceased
  • Staff to sign to record the condition of bodies and  the identification check is completed and correct
  • Conduct daily body location audits

Examples of not achieving HTA standards:

  • Bodies are not labelled with three points of ID, the information provided is illegible or not attached to the body
  • Location of bodies is not recorded from the point of admission to release
  • Audit of body locations is not completed
  • Bodies with same or similar names are not identified and highlighted
  • Discrepancies with identifiers are not followed up and rectified
  • Deviations from standard operating procedures are not recorded

When a body leaves the mortuary

To meet HTA standards:

  • Check the ID attached to a body and match three points of ID provided by the person collecting the deceased
  • Check for same or similar named deceased and implement the systems
  • Complete mortuary records and record any deviations from standard operating procedures

Examples of good practice:

  • Conduct a two-person check of ID’s attached to the body and ensure they match three points of ID provided by the person collecting the body
  • Release form is completed by funeral director in discussion with the family.
  • Staff sign to record the condition of bodies and the identification check is completed and correct
  • Conducting daily body location audits.

Not achieving HTA standards:

  • Three points of ID attached to the body is not checked by staff against information provided by the person collecting the deceased
  • Person collecting the deceased does not provide three points of identification for the deceased. For example, only ‘green’ disposal form or name of deceased given. Body identification is checked against the establishment’s own documentation
  • Discrepancies between the IDs provided by the person collecting and those on body not resolved prior to release

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