Lee Gibbs and Imogen Jones
A few months back, Gemma Norburn and I were prompted by the Brennan case to reflect on the relationship between the “economies of death” and “viewability”. There, we identified a domino effect, which we described as, “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 release and disposal of bodies, and therefore increased pressure on storage resources.” That system vitally included the capacity of funeral directors and crematoriums.
I’m now back in collaboration with Lee Gibbs, Mortuary Lead & Chief APT at Norfolk and Norwich University Hospitals NHS Foundation Trust. As a manager, Lee is confronted with not only the emotional burden of these delays, but also dealing with the technical administration of a mortuary. Lee has generously agreed to work with me to explain some of this detail and its impact. It is, inevitably, more complex that I ever imagined. With that in mind, here comes another mini-series, starting with the cause of delays. In Lee’s experience, the common causes of delays can be any number of individual reasons or more often a combination of several different issues. In this blog, we begin to explore these. To be clear, although this is written in my (Imogen’s) voice, it is very much a collaboration and many words are drafted by Lee.
- Treatment in hospital
We are all aware that that NHS is under immense pressure. Resources are limited and there are pinch points where the impact of this is amplified. These can include periods of staff shortage (e.g. bank holidays, Christmas/Easter, ongoing industrial action). In these circumstances fewer staff are available to care for patients and there may be increased discharges of palliative type patients. Moreover, like during covid, delayed treatments/operations and diagnoses all result in poorer treatment for the living, missed opportunities to improve patient care and more deaths. Thus, death rates are affected by resourcing, leading to an increase in the need for body storage.
- Doctors are still needed for death administration
Even if we assume that everyone who dies in periods of (even more) limited resource would have done at that time anyway, if the doctors are absent then they are unable to carry out essential administrative tasks following a death. This includes completing the Medical Certificate of Cause of Death (MCCD) and/or cremation form 4 (which is required for the release of a body). Given the impact of staff shortages on urgent care and waiting lists, it is easy to imagine that tasks such as this would not be prioritised.
In addition to the normal system of death certification, the relatively recent Medical Examiner (ME) system (which will be subject to statutory implementation and roll-out to all deaths from April 2024) introduces a further stage of review and therefore potential delay. The ME system relies on other doctors keeping accurate records and, where a death is not deemed to be reportable to the coroner, to promptly fill out the MCCD for review and authorisation by the ME. Of course, should the GP or ME decide that the death ought to be reported to the coroner, then there is a further delay because the case will then need to be reviewed by the coroner/coroner’s officers. In Lee’s experience, the Coroner’s referral and scrutiny/investigation can take a couple of days, after which a body might be released or going into the queue for further examination (i.e. a post-mortem).
- Coronial autopsies are private work
If the coroner decides that further investigation of a death by way of a post-mortem is required, then this needs to be actioned by a histopathologist. If the death has taken place in the hospital then the deceased will already be in the care of the mortuary. However, if the death took place in the community, the deceased will likely only be transferred to the mortuary once this decision has been taken. These need to be coordinated with the availability of pathologists to carry out the autopsies. Save a very few examples, the majority of pathologists who carry out coronial work do so in addition to their primary roles as hospital histopathologists. This is operationalised via time-shifting and is voluntary overtime. Depending on the number of pathologists available, their preferences and schedules, the delay for post-mortem could vary significantly.
It is well known that the national number of pathologists that perform post mortems has fallen, and that there is a brewing crisis in this regard. The reasons for this are varied and include removal from as essential training for histopathologists, respectively low rates of pay, the unpleasant nature of the work and work-life balance. In Norfolk (Lee’s area), six years ago there were 13 pathologists completing coronial postmortem work. This number is now reduced to five plus one that visits from London on an ad hoc basis. Most of these generally perform a maximum of four autopsies per session. To place this in context, at Lee’s mortuary, there is an average of 65/67 adult post mortems every month, plus another six to ten foetal cases on top of that. There are also occasional forensic cases on top of coronial cases.
This affects some geographical areas more than others, however. Lee explained that for Norfolk, ‘…the geographical location of the Trust combined with a lower-than-average agenda for change banding programme than its nearer London neighbours, means that we struggle to recruit trained pathologists. Those we’ve [the Trust] have recruited recently have opted not to do postmortems. Those that we’ve trained can find more money elsewhere, so we also struggle to retain pathologists. We also lose post mortem sessions when the pathologists are on leave, on sick leave, educational days or conflicting hospital work.’
- The demands of death investigation
Whilst tissue and organs can be taken without next-of-kin consent for the purpose of a medico-legal autopsy (i.e. under the Coroner’s authority, or in the case of suspicious deaths via the Police and Criminal Evidence Act 1984). They can be retained for as long as necessary for that investigation. In the case of homicides may be many years because of the possibility of appeals and so on. This does not only affect organs/tissue – in some forensic cases, the body itself may need to be retained for some time, especially where a second postmortem is expected (although this should not cause substantial delays if the Chief Coroner’s guidance is followed). At the time of writing, Lee has two such cases, one having been in his care for 399 days and the other 168 days.
As soon as tissue etc is not required for the investigation, the Human Tissue Act 2004 mandates that they cannot be retained without next of kin consent. Again, practice varies here – in some areas the coroner’s officers may talk to the bereaved, in others, a form may be emailed or posted. This then has to be returned to the coroner, who then communicates with the mortuary who log and give effect to the decision. This will clearly take time.
A further geographical lottery relates to the rate of inquest. If an inquest is required, many coroners will open and adjourn any inquests before they release the body. Again, taking Lee’s area: Norfolk, which is one of the largest coroner’s areas in the country, has an extremely high inquest rate (last year 20% of reported deaths went to inquest), as high as some of the busiest London Districts. Waiting for the coroner to go through this process therefore takes time with the result that in Lee’s mortuary, most coroners cases are in the mortuary’s care for seven to ten days prior to release.
Some (kinda) final (for now) thoughts
In this blog, we have set out the causes for delays and backlogs in the release of deceased bodies from mortuaries. What we have not addressed – yet – is the delays caused by the actions of next of kin and funeral directors following the ‘release’ of the body. We will turn to that in our next instalment, so until then….
Dead Bodies and the Law 