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

Standard 1: Leadership and governance

Standard statement

Each organisation demonstrates effective leadership and governance in the delivery and management of its mortuary service.

Rationale

Effective leadership and governance are critical to ensure that safe, person-centred and effective services are delivered to a high standard. Organisations that deliver high quality care and support have a responsibility and commitment to equity. People should have confidence that every organisation that provides care and assistance has high quality leadership and governance.^[19]

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. Separately, in Dundee, Police Scotland own and operate a mortuary which is staffed by the University of Dundee. The COPFS additionally has contracts with a number of mortuary services to provide forensic investigations.

Persons employed by those organisations include pathologists, anatomical pathology technologists, mortuary managers, clerical staff, porters and others required to deliver the service. Given the range of organisations and staff groups involved, it is essential that there is effective partnership working between the NHS, local authorities, universities, Police Scotland and COPFS.

While the statutory duties described above do not extend further than providing facilities and premises, a key component of the work carried out by all mortuary staff is care of the deceased, which is seen in essence as a continuation of clinical care, and supporting bereaved people in what can be a very distressing time. All organisations involved in the provision of mortuary services should ensure the safe accommodation and appropriate care of the deceaced and support for the bereaved.

The Scottish Health Planning Note 16-01 Mortuary and Post-Mortem Facilities: design and briefing guidance^[9] advises on how mortuary facilities can create a calm and supportive environment for people who have been bereaved. Continuous organisational self evaluation and reflective practice ensures people who experience mortuary services receive high quality care.

Criteria

1.1 Each organisation has effective management which includes:

• safe, effective and person-centred systems and procedures, and
• a designated lead professional (clinical or managerial) who is responsible and accountable for the quality of the service.

1.2 Each organisation ensures the delivery of a person-centred service which involves:

• mortuary staff routinely checking for recorded specific needs and wishes of the deceased and bereaved people and follow these respectfully
• equality policies, procedures and guidelines in place to address those needs and wishes, and
• an explanation being given when it is not possible to follow the wishes of either the deceased or bereaved due to a COPFS investigation.

1.3 Each organisation can demonstrate appropriate information is shared within and between agencies, in line with:

• professional confidentiality guidance
• legal requirements
• COPFS guidance^[20]
• UK General Data Protection Regulation (UK GDPR)^[21] and the Data Protection Act 2018^[21]
• Caldicott principles^[22]
• Access to Health Records Act 1990^[23]
• Health and Safety Executive (HSE) guidance^[24], and
• local and national data sharing protocols, policies and procedures.

1.4 Each organisation can demonstrate that it provides clear information about the service on the organisation's website and in its documents and leaflets. This information should be accessible to the public and professionals.

1.5 Each organisation can demonstrate implementation of the following relevant policies, procedures, guidance and standards:

• a multi-organisational approach to deliver person-centred care
• equality policies and information on rights in relation to people's protected characteristics
• updating, agreeing and monitoring contracts or service level agreements
• quality, monitoring, assurance and improvement, including review of feedback and relevant data and action taken as a result^[25]
• a point of contact for the mortuary service
• adoption of national documentation where available
• timely response to and learning from adverse events^[26], and
• complete and up to date risk assessments and standing operating procedures.

1.6 Each organisation demonstrates adherence to appropriate standards, and professional and organisational codes of conduct for all aspects of mortuary services, including:

• the Management of Hospital Post-Mortem Examinations,^[11] and
• those deaths that involve the police and COPFS.^{[20, 27]}

1.7 Each organisation ensures that its mortuary service adheres to all
relevant health and safety legislation and recommended professional obligations and practices.^{[11, 20, 25, 28]}

1.8 Each organisation can demonstrate that mortuary staff are provided with:

• regular training that is relevant to their setting, role and responsibilities
• continuing professional development, and
• provision for their wellbeing in line with the current organisational processes and practices.

1.9 Each organisation engages in partnership working with the organisations involved in delivering mortuary services. They should also, in partnership, review the services and undertake continuous improvement activities in response.

1.10 Each organisation ensures that the role of the mortuary service is understood by the wider staff group through providing information and training appropriate to roles, responsibilities and setting.

What does the standard mean for people using mortuary services?

• Everyone can be confident that when they die they will be treated with care and respect and their personal, spiritual, faith and cultural values, beliefs and identity will be taken into account, if known, and followed where possible.
• Everyone can be confident that the organisation has effective leadership and governance and that it promotes a culture committed to continuous improvement.
• All people who are bereaved will experience compassionate and respectful support from those involved in the mortuary service.
• All people who are bereaved have access to information about the mortuary service and will feel informed. They will be clear who to contact if they have a question or concern.
• In those deaths that involve COPFS and the police, people who are bereaved will be advised as fully as possible within the constraints of the legal system.
• In those deaths that involve COPFS and the police, people who are bereaved will be confident that all organisations will work together to deliver high quality and sensitive care, and that information will be shared and stored appropriately.

What does the standard mean for staff in the organisation?

• Mortuary staff have the policies, procedures and training to feel confident in their role and in how to respond to specific requirements of the deceased and people who are bereaved.
• All staff have information about mortuary services in their area. Where relevant to their role, staff have information about the funeral directors operating in their area.
• Where it is relevant to their role, all staff have an opportunity to visit the mortuary to learn more about the service.

What does the standard mean for the organisation?

Each organisation:

• complies with national and local policy, guidance and standards to support the mortuary service
• has policies, procedures and training in place to support staff
• seeks feedback on the service
• ensures mortuary staff have the necessary knowledge and skills, appropriate to their roles and responsibilities, to provide high quality care
• supports reflective practice for staff^{[29, 30]}
• offers ongoing assistance, training and continuing professional development opportunities to mortuary staff
• provides opportunities for multi-organisational and multidisciplinary discussions, meetings and training to encourage partnership working
• promotes information sharing where appropriate, and
• provides opportunities to relevant staff to learn more about the work of the mortuary service.

Practical examples of evidence of achievement (NOTE: this list is not exhaustive)

• Information is available to the public and other users in a range of formats and languages.
• Equality and diversity policies and procedures are in place and there is evidence of these being followed.
• Compliance reports relating to information sharing legislation, principles, policies and protocols.
• Current contracts with COPFS to deliver services.
• Audit and review reports against relevant guidance and standards.
• Improvement work, including action plans which demonstrate Healthcare Improvement Scotland Post-Mortem Examination Standards being implemented.
• Examples of joint working between staff from the relevant organisations.
• Feedback being sought and evidence of learning from the experiences of people who are bereaved.
• Procedures for adverse events and evidence of learning from the recommendations.
• Clear information on the roles and responsibilities of each organisation involved in the delivery of mortuary services e.g. NHS boards, COPFS, local authorities and Police Scotland will be shared with mortuary staff at induction.
• Staff training records.
• Staff visits to the mortuary as part of induction and professional development.
• United Kingdom Accreditation Service (UKAS) accreditation ISO 15189^[31] which includes mortuary services.
• Use of digital platforms to access recorded wishes of the deceased, where available.