Veiwabilty pt 3: economies of death

With Gamma Norburn, APT

In the first two blogs in what is becoming a mini-series, we considered the issues highlighted by the recent legal cases which engaged and combined the concepts of ‘viewability’ and ‘dignity’. Against the backdrop of a legal dispute, we see the danger legal process’ tendency to ask very narrow questions, framed as they are to ‘win’ or ‘lose’ on one or several legal points. Whilst providing space to hear, and give legitimacy to, the voices of victims, this approach can also leave the professions involved feeling attacked by unwarranted generalisations. Thus, in the second blog we saw the juxtaposition of the failings of care in Brennan (and other cases) with the evidence from my research, and Gemma’s experience, that in many mortuaries practice is shaped by a profound culture and sense of moral duty with care for the deceased and bereaved at their centre.

Brennan, and any similar cases, involved a serious failure of process. Those processes – largely set out in HTA Guidelines – may be intended to ensure that the dignity of the deceased is protected, but they are only guidelines and exist against a backdrop of finite – often stretched – resources. Resources here means both physical ones such as storage capacity (i.e. the number of freezer spaces that exist) and the availability of relevant personnel to give effect to the multifarious demands of dealing with the dead.

In this blog, we think about that process and the pressure points within it. In doing so, we highlight two key points:

1. That mortuaries are part of a wider process and depend on others within that to be able to discharge their obligations as might be envisaged by the HTA and/or the bereaved.
2. That death care is rarely immune from the pressures of finance – hence our initial labelling of this blog as ‘The economies of death’.

Types of Storage

Brennan turned on the failure to move the body to freezer storage within a reasonable timeframe, leading to significant deterioration of the body such that it was not ‘viewable’ by the family (for what this means, see (inset link to blog 1). The HTA ‘Guidelines’ suggest that this should take place within 30 days, but this is just a guideline – a body may deteriorate before then. The elephant in the room is this: most storage is refrigeration, not freezer space. Again, if we look to the HTA, we see that standard PFE2(c) states ‘Storage for long-term storage of bodies and bariatric bodies is sufficient to meet needs.’ The question this poses is, of course, what is ‘sufficient’? The HTA would expect there to have been an assessment on the amount of freezers required. As was explained to me by an HTA inspector, this varies considerably across mortuaries – what is ‘sufficient’ in a small hospital with 5 spaces is vastly different to a large Trust with 160 spaces. The HTA would only assess against this standard and not whether there was, at any given point in time, actually sufficient freezer capacity. They key for compliance is in the planning, not the provision for any individual.

Against the backdrop of recent delays caused by winter excess deaths and indeed COVID19, it is all too easy to see that what is ‘sufficient’ is not only geographically but also temporarily varied. This is where money matters – space costs money, facilities cost money, and resources (such as electricity) cost money. These are all increasingly finite, especially in the public sector. We are at a point of crisis, with risings costs, public sector discontentment (as demonstrated by widespread industrial action) and social fractures. It is simply not affordable to provide year round freezer storage capacities, contingencies or otherwise, such that there would be ‘sufficient’ such storage in the event of increased storage demand.

It is useful to explore this via the extreme of a mass fatality event. These unpredictable events such as a terrorism bombing or disaster are predictable in the sense that they will always happen at some point, but are unpredictable in the sense of when and at what scale. In these events, emergency storage in the form of Nutwell refrigerators is often used (also we have recently often seen the use of refrigerated shipping containers). But they are just that – refrigerators. Better than open air, but they will not stop the decomposition seen in Brennan.

One answer to this must be – why not just release the bodies within 30 days? As with so much, easier said than done – and we address this now.

The Delay Domino Effect

Hospital and Council mortuaries may be publicly funded, but the next stages of body disposal rarely are. Funeral Directors, Crematoriums and Graveyards (even if technically council owned) are businesses. They depend on profit margins and must respond to this. They also have limited capacities – limited storage, limited slots, limited furnaces and so on. This all means that if they are ‘full’ there will be delays, and they are under no obligation to reduce the burden this causes on public mortuaries who are at, or exceeding, capacity for any type of storage.

We therefore see a domino effect – where one part of the system is unable to cope with demand, this triggers a chain reaction whereby others are overburdened. The consequence of this is delayed released and disposal of bodies, and therefore increased pressure on storage resources.  This in turn increases costs, and is likely to intensify the grieving process in which disposal is so important.

What can be done?

There are three key ways that we might want to address the issues outlined above. Each begins with ‘increase’…

1. Increase capacity

Contingency arrangements may go some way to dealing with periods of excess death, but they are often less than ideal – temporary storage, or bodies being stored some distance from the bereaved. And this nearly always takes the form of refrigeration so will not arrest decomposition. One way around this is to increase capacity. During COVID, where need was demonstrated, grants were provided for increased provision. Whilst some of this has now been dismantled, some also remains. This goes to show that capacity can be increased, but clearly this comes with significant costs and lead in times. The same goes for disposal technologies (primarily crematoriums) – additional facilities can be funded and planned, but the lead in times mean that this needs to be done well before the immediate pressures are experienced.  

• Increase innovative use of technology

Technology may not be a panacea, but it can help. This might be new disposal technologies or thinking about alternative means of dealing with excess death, for example, electronically chipping remains for later identification and disposal. Clearly the way that we care for and dispose of the dead is a matter of both cultural and individual norms and expectations. It is not therefore as simple as just solving the problem by change. Nevertheless, technological innovation can, and should, be explored. We cannot know what contribution it might make, or how acceptable it could be, without first testing this.

• Increase openness/understanding

Here we can the real elephant in the room. If expectations (by the public, politicians and so on) are unrealistic then there is likely to be unrest and additional trauma. These expectations might, non-exhaustively, relate to: the time that a body can be released in, the way that bodies might look after a period of storage, the disruption done by post-mortems (whether in terms of the evisceration/removal of organs or in speeding up deterioration), what can meaningfully be recovered post disaster and so on.

One way around this is to be more open and to manage expectations. Doing this would involve some difficult conversations, but would also enable the bereaved to make choices based on accurate information. We would posit that the damage caused by feeling misled or let down is far greater than that of the anger and trauma that can accompany the alternative.

This last point is crucial therefore – other than training, this is a quick win. More than that it is one which is grounded in respect for both the bereaved and the deceased. It recognises that a perfect process does not exist, but that by invoking humane values and practices we can at least mitigate against some of the negatives of that.