Standards for mortuary services: guidance published by the Scottish Ministers, Police Scotland and the Crown Office and Procurator Fiscal Service

Introduction

Background

The Scottish Government and those organisations which operate mortuaries are committed to ensuring that care to all persons continues even after death. This care is delivered through the provision of high quality mortuary services. These services can be described as services which:

• carry out the temporary safe accommodation and preservation of people who have died until they can be collected for burial or cremation
• may support the carrying out of post-mortem examinations in order to investigate the cause of death and undertake relevant scientific investigations, and
• may support families and friends to view the person who has died either for purposes of identification or as part of the grieving process.

Following the campaign by the Whyte family and Richard Lochhead MSP, the Mortuary Review Group was established in 2016 by Aileen Campbell, then Minister for Public Health and Sport. The group's remit included clarifying the roles and responsibilities of mortuary services, in ensuring and monitoring that mortuary facilities met required standards. In 2018, the Scottish Government actioned the group's recommendation that Healthcare Improvement Scotland should develop national mortuary services standards, including for those facilities not provided by NHS boards. While the work of the group progressed during 2019, publication of these standards was delayed due to the COVID-19 pandemic.

These standards have been developed by Healthcare Improvement Scotland and partners to guide each organisation involved in the delivery of mortuary services to ensure national consistency in person-centred care for those who have died and the bereaved. To ensure the standards can be implemented by each of the organisations involved in delivering mortuary services, they have been published as guidance by the Scottish Ministers, the Crown Office and Procurator Fiscal Service and Police Scotland.

These standards apply to organisations which provide mortuary services in Scotland including:

• Local authorities
• NHS boards
• Police Scotland
• Crown Office and Procurator Fiscal Services (COPFS), and
• The University of Dundee.

Each of these organisations has agreed to the standards set out in this guidance, and has agreed to follow them as best practice in providing mortuary services.

Statistical overview of deaths in Scotland

In 2020, 64,093 people died in Scotland.^[1] The majority of deaths in Scotland are due to natural causes and in these cases the deceased either goes directly to a funeral home or stays in a mortuary until transfer can be arranged.

In the case of unexplained or accidental deaths, where COPFS is involved, the mortuary service supports the identification of the deceased and investigation into the cause of death. In 2020-21, 15,739 deaths were reported to COPFS.^[2] In 2020, there were 2,759 accidental deaths of which 679 occurred as a result of self‑harm, either intentional or of undetermined intent, and 47 as a result of assault.^[1] In 2020, 1,339 people died as a result of drug-related deaths.^[3]

The most recent national survey showed that in Scotland hospital post mortems were performed on 2% of deaths in hospital amounting to less than 500 hospital post mortems per annum.^[4]

Everyone will experience bereavement at some point in their lives. Stephen et al estimated in 2015 that for every death there are four bereaved people.^[5] Based on this metric and National Records of Scotland annual death rate, approximately 256,372 people were bereaved in 2020.^[1]

In the absence of official data on how many children and young people have lost a parent, the Childhood Bereavement Network used a range of sources to estimate childhood bereavement in 2015. Approximately 4,100 children and young people under the age of 18 in Scotland had been bereaved of a parent.^[6]

Mortuary services in Scotland

The delivery of mortuary services across Scotland is complex.

The Public Health etc. (Scotland) Act 2008^[7] places duties:

• on each local authority to provide premises and facilities for the reception and temporary storage of people who have died in the authority's area, and for the post-mortem examination of those people, as it considers appropriate
• on each health board ("NHS board") to provide premises and facilities for the reception and temporary storage of people who have died in a hospital in the board's area or whose bodies are brought to a hospital, and for the post-mortem examination of those people, as it considers appropriate

Local authorities and NHS boards must co-operate with one another in complying with these duties.

NHS boards in Scotland own and operate a number of mortuaries. State mortuaries are provided by local authorities in Aberdeen and Edinburgh. In Dundee, Police Scotland own and operate a mortuary which is staffed by the University of Dundee. The COPFS has contracts with a number of mortuary services to provide forensic investigations, which can lead to the deceased being transferred between geographical areas.

The mortuary staff and pathologists may be employed either by the NHS, the relevant local authority, or universities.

In addition to the statutory functions on NHS boards and local authorities outlined above, in practice the services offered by mortuaries go beyond that of providing appropriate accommodation for people who have died and the facilities for post-mortem examinations. In every case, it is the role of mortuary staff to ensure appropriate care of the deceased and, when required, mortuary staff will support people who are bereaved to view the deceased.

Not all mortuaries have facilities for carrying out post-mortem examinations. Those that have facilities for investigating the cause of a death by a post-mortem examination, carry this out either surgically or by 'view and grant'. In the future, it may be possible to carry this out using technologies such as CT and MRI scans or endoscopy. In the majority of cases, a post-mortem examination is undertaken at the instruction of the COPFS following, for example, an accident, suicide, drug overdose, assault or in unexplained circumstances. In such cases, the COPFS contracts a mortuary service to perform a post-mortem examination which contributes to the forensic investigations. The mortuary staff work with the COPFS and police to gather evidence and confirm identification.^[8]

Hospital post-mortem examinations can also be performed at the request of medical staff, following authorisation by the nearest relative, the family or the deceased prior to death.

Policy context

These standards should be read alongside relevant legislation such as sections 87 to 89 of the Public Health etc. (Scotland) Act 2008 as referred to above.

The standards are also designed to complement the following guidance and standards:

• Scottish Health Planning Note 16-01 Mortuary and Post-Mortem Facilities: design and briefing guidance^[9] provides detail and guidance on the facilities required to run mortuary services. For this reason, guidance on facilities have not been included within these standards.
• Shaping Bereavement Care: a framework for action on bereavement care in NHSScotland (2011)^[10] was published by the Scottish Government to assist NHS boards to develop and deliver quality bereavement care services.
• Healthcare Improvement Scotland Standards for the management of hospital post-mortem examinations^[11] details legislative updates and changes in service provision with regard to the Human Tissue (Scotland) Act 2006,^[12] Death Certification in Scotland^[13] and revised Guidance on the Disposal of Pregnancy Losses up to and including 23 Weeks and 6 Days Gestation.^[14]

Scope of the standards

The standards are expected to be used to guide the continuous improvement of the quality of mortuary services across Scotland. This guidance, as it is issued by the Scottish Ministers, COPFS and Police Scotland collectively, applies to mortuary services provided by:

• NHS
• local authorities
• funeral directors that have a service level agreement with a public organisation to provide a mortuary service
• mortuary staff employed by a university, and
• Police Scotland.

It is anticipated that hospitals and hospices which are run by the private or third sector will voluntarily adopt these standards to support their mortuary service delivery.

While mortuary services vary in size, service provision and staffing, all services should ensure that the deceased and the bereaved are placed at the heart of service delivery, within an overall context of public health, safety, security and sustainability.

The standards cover the following areas:

• leadership and governance
• dignified and respectful care of the deceased
• supporting the needs of people who are bereaved, and
• education, training and support for staff.

As outlined above, mortuary facilities are covered by Scottish Health Planning Note 16-01 Mortuary and post-Mortem Facilities: design and briefing guidance^[9] and therefore are not included in the standards.

Using the standards for self evaluation, assurance and improvement

All standards follow the same format which includes:

• a clear statement of the standard
• a rationale giving reasons why the standard is considered to be important
• a list of criteria describing the required structures, processes and outcomes
• what to expect if you are a person using a mortuary service
• what to expect if you are a member of staff, and
• what the standards mean for organisations, including examples of evidence of achievement.

The implementation and monitoring of these standards will be for local determination by relevant organisations and services.

Terminology

These standards, wherever possible, use generic terminology that can be applied across all settings, including mortuary services.

These terminology are:

• The deceased: the person who has died; in practice, when speaking to people about the person who has died, their name or relationship should be used for example, 'your husband', 'your mother'. This will ensure that services acknowledge the person who has died and their importance in their family and friends' lives.
• People who are bereaved/bereaved persons: Nearest relatives, family and friends of the deceased.
• Nearest relative: As next of kin is not defined in law, the term nearest relative is used. Nearest relative is a term used in the Burial and Cremation (Scotland) Act 2016 ("2016 Act")^[15] which states the nearest relative of an adult is the person who immediately before the adult's death was:

Their spouse or civil partner; living with the person as if married for a period of at least six months prior to death; their child; their parent; their sibling; their grandparent; their grandchild; their uncle or aunt; their cousin; their nephew or niece; long standing friend. The 2016 Act also contains definitions for the nearest relative of a child and of a stillborn baby.

• Deaths that involve the police (COPFS cases): Cases where the COPFS is involved and there is an investigation into the cause of death. This places legal responsabilities on the COPFS, Police Scotland and the forensic pathologists and scientists.
• Deaths that do not involve the police: Cases where there is no COPFS involvement. It should be noted that in cases where there is an unexpected or sudden death, it may begin as a COPFS case but change after initial investigation to an accidental death.
• Mortuary staff: Pathologists, anatomical pathology technologists, clerical staff, porters and other staff working directly with the mortuary.
• Organisation(s): All organisations employing mortuary staff such as the NHS, local authorities and universities. Also, in the case of those deaths that involve the policy (COPFS cases), the mortuary services are contracted by COPFS with involvement from Police Scotland.
• Viewing: This is a technical term relating to a time when family and friends of the deceased sit with the deceased within the mortuary. For many people, this is an important opportunity to spend time with the deceased. Mortuary staff will arrange and endeavor to support this opportunity for all who wish it.
• View and grant: A non-invasive procedure which involves an experienced pathologist externally examining the body of the deceased while considering the deceased's history and the event surrounding the death. The pathologist will confirm to the Procurator Fiscal if a surgical post-mortem examination is required where they are not in a position to certify the cause of death on the basis of a view and grant examination.
• Care After Death: The care given to a body after death. It is a process that demonstrates respect for the deceased and is focused on respecting their religious and cultural beleifs, as well as health and safety and legal requirements.^[16-18]