Mortuary review group: response

Executive Summary

Introduction

As part of the response to the campaign by the Whyte family and Richard Lochhead MSP to review the standard of all mortuaries across Scotland, the Minister for Public Health and Sport wrote to NHS Territorial Board Chief Executives on 14 October 2016 requesting they provide details of the mortuary facilities for which they are responsible, whether these comply with Mortuary Planning guidance and if not, the plans in place to address any issues identified ^[1] (see Annex A ).

The Minister also requested that Health Facilities Scotland review and refresh the 'Scottish Health Planning Note 20 - Facilities for Mortuary and Post-Mortem Room Services Design and briefing guidance' ( SHPN20), which was last updated in 2002.

In addition to the action outlined above, the Minister recognised that the provision of mortuary services would benefit from a wider review to clarify responsibilities and confirm that an appropriate standard of service is being provided. A Mortuary Review Group was subsequently formed and this report includes the recommendations from the group; the terms of reference for the group are contained in Annex B .

Key Recommendations from the Review Group

The Review Group make a number of detailed recommendations which are summarised below and which are detailed more fully in the body of the report, but the main conclusions of the group are:

Public services that provide post mortem examination should work towards the facilities being provided in Health Board ( NHS) facilities

There are only three non- NHS facilities that provide Crown Office and Procurator Fiscal ( COPFS) post mortem examinations - in Aberdeen, Dundee and Edinburgh and while all three facilities provide a high quality and appropriate service, the Review Group believes that these services should be provided by NHS Health Boards. This would ensure that consistent and well regulated standards are applied and that there is no ambiguity as to who is responsible for the service. Moving towards this position will be dependent on funding becoming available, but this is a long term vision which all relevant parties share. Until the LA/police mortuaries come under the control of the NHS, interim arrangements to monitor standards must be put in place.

Healthcare Improvement Scotland ( HIS) should be commissioned to develop national mortuary services standards, having regard to the NHS hospital post mortem standards and the SHPN 16-01 (revised HFS SPHN 20) advice.

HIS will be commissioned to develop appropriate mortuary services standards and NHS Boards will be monitored against them. HIS will also develop a quality framework and quality indicators, with a self-assessment tool, to enable self-assessment and external peer review of the quality of mortuary services.

Appropriate viewing facilities and environment must be provided at relevant venues. Not all facilities must be required to have all the services.

It is accepted that body viewing facilities will have different standards to facilities which are only used for body storage, but NHS Boards and Local Authorities need to ensure that appropriate viewing facilities are provided at agreed sites.

There must be an agreed protocol for raising concerns and complaints about any aspect of the mortuary service including a single point of contact for all complaints and concerns.

It was apparent that one of the main problems that the Whyte family had to contend with was that it was unclear as to who had overall responsibility for the service, so this recommendation addresses that issue.

Summary of Recommendations

A summary of the recommendations made by the group is noted below. Page 7 - 14 contain a more detailed narrative which contextualises each recommendation.

Roles and Responsibilities - Recommendations:

• Health Boards, Local Authorities, Police Scotland Crown Office and Procurator Fiscal Service ( COPFS) and Universities must provide clarity to their staff and the public about the components of the mortuary service and death investigation as appropriate, including who has the responsibility for which aspect of the service.
• The names and contact details of the individuals responsible for the mortuary facilities and for mortuary services must be known and accessible including establishing a single point of contact for any complaints.

Mortuary Provision - Recommendations:

• Public services that provide post mortem examination should work towards the facilities being provided in Health Board ( NHS) facilities, including those to be accessed by Crown Office and Procurator Fiscal Services - COPFS via agreements with Local Authorities.
• The capacity and capabilities of the service and facilities must be monitored.
• Health Boards and Local authorities must work with other partners within the Regional Resilience Groups to plan for normal and extensive events as part of their duties under the Public Health Act.

Contracts/ MOU (Memorandum of Understanding) between Partner public sector organisations - Recommendations:

• Contracts/ MOU between partners as required by the duties in the Public Health Act must be agreed, monitored and periodically reviewed.
• Compliance with the contract/ MOU must be monitored e.g. where a local authority discharges its statutory duty through the service and facility provision by the Health Board, then it is incumbent upon the Health Board to provide assurance to the Local Authority and COPFS, where relevant, that they are adhering to standards.
• There must be an agreed protocol for raising concerns and complaints about any aspect of the mortuary service including a single point of contact for all complaints and concerns.

Facilities - Recommendations:

• Appropriate viewing facilities and environment must be provided at relevant venues. Not all facilities must be required to have all the services.
• Compliance with the updated SHPN 16-01 (revised HFS SPHN 20) must be audited and monitored within the timescales agreed in the standards and explanations provided where the standards cannot be fully met.
• Where standards cannot be fully met, plans must be developed to address the gaps and these plans must be monitored.

Quality Improvement - Recommendations:

• Healthcare Improvement Scotland ( HIS) should be commissioned to develop national mortuary standards, having regard to the NHS hospital post mortem standards and the SHPN 16-01 (revised HFS SPHN 20) advice.
• HIS should also be asked to develop a quality framework and quality indicators, with a self-assessment tool, to enable self-assessment and external peer review of the quality of mortuary services (covers remit actions such as compliance with the Public Health Act, mortuary capacity, clarification of roles and responsibilities, etc.).