Lee Gibbs and Imogen Jones
In this third joint Lee-ogen piece, we are travelling full circle back to the elephant in the freezer – that is, the lack of them (freezers, not elephants). Recall that in Brennan, attention was drawn to HTA PFE2(c), which states ‘Storage for long-term storage of bodies and bariatric bodies is sufficient to meet needs.’ Previously, we outlined three possible responses to a demand for greater freezer capacity:
- Increase capacity
- Increase innovative use of technology
- Increase openness and understanding
All easier said than done. This blog draws on Lee’s considerable expertise as a mortuary manager to explore what might be involved in giving effect to suggestions 1 and 2 above.
When is sufficient insufficient?
Mortuary work is unpredictable, meaning that ‘sufficient’ is hard to define. We might want to assume, given HTA guidelines and the decision in Brennan, that if there is either not space to store the deceased following death or in order to adequately maintain their condition (i.e. to transfer to freezer storage within 30 days) then storage is not sufficient.
The cost of paying for and running storage that will not be used every day is not prohibitive, and the cost of rental storage is high. This means that, as the HTA notes, additional storage for periods of ‘excess’ death is expected to be operationalised via contingency agreements within Trusts (i.e. between different mortuaries). But what if, across a Trust, there still is not enough space? This suggests systemic capacity issues, albeit only seasonally/at times of unexpected crisis such as a mass fatality.
If we are not to rely on temporary additional storage via Nutwells, hired shipping container sized fridges and freezers and so on, then the reality is that more permanent capacity is required, despite the potential costs of this. These additional storage facilities may be difficult to place due a lack of available space or the mortuary being landlocked within the footprint of a hospital building. PFI buildings additionally have landlords and associated legal hoops to jump through to even place temporary units. Assuming additional capacity can be located nearby the main building, then transfer of the deceased will require further (or, indeed, ‘excess’) manual handling and carefully planned logistics operations to not cause further delays.
Who pays for buildings?
New buildings and facilities are expensive. They take time to plan and construct; in an era where public funds are stretched, demand outweighs resource. Mortuary services are not classed as frontline NHS departments, meaning that they may not be a priority until it is too late, fatal inadequacies being exposed in HTA inspections or emergencies such as pandemics. Indeed, COVID-19 demonstrated quite how ill-equipped current infrastructure is to cope with excess deaths in a manner which allows for timely disposal and maintains the dignity of the deceased.
In Norfolk, where Lee works, his mortuary operates as both a hospital and public mortuary. This means that the dead from the hospital, plus coroners patients from the community, are sent to the mortuary for storage and examination. This dual function results in negotiation regarding who is responsible for funding additional storage capacity when it is required. The Trust tend to see it as a Coroner problem, however as they are paying for the PM service, the Coroner considers it a Trust problem. This can result in a to-and-fro, whereby the buck is passed between the Coroner and the local Trust, never being resolved. These pressures mean that ad hoc solutions become semi-permanent, despite the fact that these would never be acceptable under guidelines for mortuary provision. For example, during COVID, Norfolk rented two external shipping container sized units with 40 spaces each. As of September 2023, both remain in situ. One has been purchased, the other is still rented. This model is specific to Norfolk – as with so many features of the coronial system, there is no national practice. However, the presence of car park shipping containers is all too familiar nationwide.
Of course, there are provisions for mass fatality events and private companies such as Kenyon exist to effectively take over mortuary handling processes in the event of a mass fatality event such as a plane crash. These extreme and unpredictable disasters arguably fall within a different category to annual winter excess deaths.
What about the private sector (i.e. in the funeral agencies)?
As we outlined in the previous blog, backlogs (leading to capacity pressures in public/NHS mortuaries) can be caused when there are delays in collection by funeral agencies. The funerary industry in England and Wales is currently unregulated (the situation is different in Scotland, and we discuss that below). There are two professional bodies, who funeral agencies can choose to join. These are the National Association of Funeral Directors (NAFD) and the National Society of Allied and Independent Funeral Directors (SAIF). There is also an Independent Funerals Standards Organisation (IFSO), which was setup by the NAFD but operates independently of it. Membership of these brings credibility and means committing to codes of conduct and an inspection scheme (although the only sanction is being removed from the relevant association). However, it is voluntary.
Because they are not regulated, the HTA requirements do not apply to the ‘post-release’ stage of the care of deceased bodies. This is a significant difference. For example, if an NHS mortuary experiences a trolley failure which results in the deceased being dropped to the floor, even if there is no damage to that patient, the mortuary are expected to: report it to the HTA via an official portal, investigate the incident, have a duty of candour conversation with the family, create recommendations of future mitigation and prove that they have implemented them within an expected and agreed timeframe. If the deceased is on the funeral agent’s trolley, handled by funeral agents outside of the confines of the mortuary threshold and it tips as they are loading the deceased, the HTA are not involved – they do not even expect it to be reported. This is not to suggest that funeral workers do not extend considerable care when handling the deceased but rather to highlight the differences in regulation and consequence.
That they are unregulated does not, of course, mean that standards are poor, but rather that there is no enforceable system of audit. The NAFD recognised this in their 2023 Report, ‘Picking Up the Pieces’ and are open to a system more akin to that being proposed for Scotland, where regulation has been provided for in legislation. In conversation with the NAFD following the 2023 publication, Imogen was informed that whilst freezer capacity in funeral agencies is necessarily limited, it is required frequently enough for many to have it. Best practice demands that, like public mortuaries, funeral directors should develop contingency arrangements with other providers. The NAFD recommends that their members adhere to the HTA guidance re moving to bodies to freezer storage. However, they accept that when capacity is reached it becomes very difficult to follow guidance to the letter.
Could technology be the answer?
The extent to which postmortem CT (PMCT) scanning can be used as a replacement for invasive autopsies is contested. There are pockets of extensive use, but there is no consistent practice or routine public funding for technology. In Imogen’s interviews, there was widespread support for the use of PMCT as an adjunct to traditional autopsies, but not as a panacea to replace them in all, or indeed, most coronial cases.
Even if PMCT were available and publicly funded in all areas, there is no reason to assume that this would address storage capacity. In an ideal world, following the Australian model, all coronial (and suspicious) cases would be routinely CT scanned in an onsite scanner, and this form part of both an evidence base for death investigations and as triage for informing what further investigations are required. Yet the infrastructure required to set up a routine PMCT offering would be huge (i.e. to have access to a scanner at or near each mortuary with capacity to deal with the dead). If shared with the living (with the dead being scanned outside of core hours, for example), issues of potential contamination and infestation caused by transporting disrupted or decomposed patients outside of the mortuary need to be addressed. The costs are such that, where PMCTs are currently offered, the scanning is commonly provided via the private company Digital Autopsy UK (formally known as iGene), with the bereaved often (although not always) footing the cost. This is not to mention the need to ensure pathologists are available to carry out external examinations (or to train others, such a APTs to do this), and to have access to sufficient radiographers to read and report on the scans.
Until resourcing hurdles are overcome, cases requiring a CT have to be moved to somewhere with this facility. This involves moving the body and potentially adds delays if an invasive PM is still then required. Any delays in this occurring may result in a reduction of overall PM findings/loss of pathology potentially. As Imogen identified in her blog ‘Autopsy Backlogs and the ‘Grief Crisis’ (June 2023), there is a shortage of pathologists willing to carry out coronial work. There is no reason to assume that there is a glut of radiologists in waiting to take on this additional work, or indeed that it would remove the need for pathologists where PMCT did not provide satisfactory outcomes. Absent national structural reform (with associated investment), the economies may simply not add up.
What to do?
This all sounds a bit miserable and, especially as we ramp up to winter, there is no doubt that capacity will be on the mind of mortuary managers. There are no easy answers and the ‘quick and dirty’ ones (such as additional ‘temporary’ storage) often run counter to deeply engrained (and important!) sense of what it is to treat the deceased, and bereaved, with dignity. The consequences of this are not only felt by the bereaved and reflected in the treatment of the deceased, but also leads to moral injury and harm to the wellbeing of APTs. We find ourselves back at the economies of death: until resourcing is properly addressed these issues will persist. None of this is new, yet as these issues become more widely acknowledged we can have hope that they will creep their way up the public – and political – agenda.
Dead Bodies and the Law 