Mortuary Orientation Programme (Epsom Site)

This orientation programme is intended for members of the portering staff who will be required to undertake the transfer of deceased patients from hospital wards and departments to the mortuary on the Epsom Hospital site. If you work cross-site, you will also need to undertake the training for the St Helier Hospital site.

All staff have a responsibility to ensure that deceased patients are treated with dignity and respect at all times and that the security of the mortuary facility is maintained.

This programme gives a detailed overview of your role in transferring and admitting patients from wards and departments to the mortuary facility. It is important that you raise any concerns or questions you may have with the mortuary staff at the earliest possible opportunity.

If, once you have completed this programme, you feel you would benefit from a one-to-one training session, please contact the Mortuary Manager to make an appointment.

A booklet is also available, upon request, for you to refer to in the future. Please contact the Epsom Hospital Mortuary Manager if you would like to see the latest version.

Some Important Information

Electronic Devices

Cameras and Mobile Phones

Cameras, mobile telephones and any other device capable of recording are strictly prohibited from use in the mortuary without the expressed permission of the mortuary manager.

Confidentiality

You are expected to observe the same level of confidentiality with regard to your mortuary duties as you are with all of your other duties.

How Many Porters Does It Take?

Two Porters Are Required

In order to provide a safe, dignified and respectful service, two porters are ALWAYS required to transfer and admit a deceased patient to the mortuary.

No exceptions - ALWAYS TWO.

Accidents and Incidents

If an Accident or Incident Occurs

Report it without delay.

  • Contact your General Manager;
  • Contact the Mortuary Services Manager;
  • Contact the Clinical Site Manager.

Do Not Be Afraid to Report Incidents and Accidents

The Trust has a statutory duty to report any incidents and accidents to the Human Tissue Authority. In many cases we can learn from incidents and accidents, so they should not be regarded as something that should be covered up.

Access to the Mortuary

Access To The Mortuary

NO ONE is allowed access to the mortuary when the mortuary staff are off duty. The only exceptions are:

  • The emergency services (including resuscitation teams and Clinical Site Managers) attending an emergency;
  • Nurses or Clinical Site Managers conducting viewings;
  • Clinical Site Managers who have spoken to the on-call mortuary staff member and require access to the mortuary.
  • Portering staff engaged in transferring and admitting a patient to the mortuary.

Do Not Use The Deep-Freeze Units

If there are no other spaces - DO NOT use the freezer. Call the on-call mortuary technician for advice.

What would you do if your mobile telephone rang whilst you were admitting a deceased patient to the mortuary?

  • Do not answer it. I would return the call after I have completed the task and left the mortuary.
  • Answer it. It may be urgent.

You are walking along the corridor when you are approached by a doctor (who you know). He asks if you can open the mortuary door so he can examine the body of a patient you admitted to the mortuary about an hour ago. What would you do?

  • Explain that you cannot allow access to the mortuary when the mortuary staff are not on duty and advise the doctor to contact the on-call member of mortuary staff.
  • You know the doctor, and know they can be trusted. Let them in and ask them to complete the visitors book, and assist them to remove the body from the cold store.

You are working a very busy shift, and you are short staffed due to sickness. You receive a request to transfer a deceased patient from a ward to the mortuary. There are no other portering staff available at the present time. What should you do?

  • Carry out the transfer by yourself. It will be half an hour before anyone can help, and the patient is physically very small. You can handle the task on your own.
  • Wait until another member of portering staff is available, and carry out the transfer then. A mortuary transfer is always a two-person task, with no exceptions.

Admitting a Deceased Patient to the Mortuary

Admitting a Body to the Mortuary

When you are requested to admit a body to the mortuary

You will need the following equipment:

  • The mortuary concealment trolley;
  • Disposable gloves

Make your way to the mortuary and collect the equipment. Any additional Personal Protective Equipment can be supplied (as necessary) by the ward or department from where the deceased is being collected.

Remove the deceased from the ward or department according to the training provided by your employer.

Reminder...



Remember to collect the patient notes before you leave the ward

Admitting a Body to the Mortuary - Upon Arrival at the Mortuary

  • Locate an unoccupied cold store space - look at the whiteboard to see where they are;
  • Move the hydraulic trolley to the door of the cold store and raise it to the level of the unoccupied space;
  • Lock the wheels of the trolley;
  • One porter removes the tray from the cold store and onto the roller top of the hydraulic trolley - the other watches to ensure that if a problem occurs they can warn their colleague immediately.

Using the Hydraulic Trolley

  1. Unlock the wheels (if necessary)
  2. Pull the tray out of the store by approx 12" and align the trolley.
  3. Lock the wheels.
  4. Raise the trolley bed.
  5. Remove the tray.
  6. Slide tray all the way to the end of the roller bed.
  7. Engage the safety pin.
  8. Pull trolley away from cold store and close the door.
  9. Lock the wheels.

Reverse these steps to load the cold store.

When the trolley has a patient on it, do not raise the tray above the level of your waist when moving it. This ensures that the load is not top-heavy, reducing the likelihood of the trolley tipping over.

Admitting a Body to the Mortuary - Transferring the Deceased

  • Unlock the trolley wheels and move the trolley away from the cold store;
  • Adjust the height of the trolley to the height of the concealment trolley;
  • Lock the wheels on both the concealment trolley and the cold store hydraulic trolley.
  • Laterally slide the patient from the concealment trolley to the cold store tray, as per your manual handling training, taking care not to hit the head of the deceased on any edge or surface.

Very Important:

Ensure that the body is centred on the cold store tray. Ensure the arms of the deceased lie within the outer edges of the tray, and that there is sufficient clearance above the body to ensure that they will not touch the tray above.

If there is insufficient space, transfer the deceased to a larger sized tray. If no tray is available, contact the mortuary staff immediately for advice (via switchboard if out of hours).

Place the Deceased into the Cold Store

  • Keep the level of the body tray NO HIGHER THAN YOUR WAIST - this ensures the trolley will not tip when moved;
  • Unlock the wheels;
  • Move the trolley to the cold store, ensure there is a sufficient gap at the foot end to avoid the tray making contact with any other patient in the cold store and door furniture;
  • Lock the wheels of the trolley;
  • Adjust the height of the trolley bed to the level of the cold store space;
  • Carefully slide the tray into the cold store.
  • Remember to watch out for problems at all times and stop immediately if anything is an issue.
  • Close the cold store door and ensure the latch is engaged;
  • Store the hydraulic trolley and concealment trolley ready for use.

Door Safety Reminder

Remember - One porter operates the hydraulic trolley, the other observes to make sure there are no problems.

Admitting a Body to the Mortuary - IMPORTANT REMINDERS

  • One porter operates the trolley, the other observes for any problems and stops the operating porter immediately if a problem develops;
  • Pay particular attention to door locks - the tray can become wedged under, or rest on,  them and will tip;
  • Ensure the door of the cold store is closed properly and the latch is firmly engaged.

Admission of Babies from Maternity and Delivery Suite

All perinatal cases are admitted to the mortuary in the burgundy baby carrier located in the entrance lobby of the mortuary

  • Remember to collect the paperwork from the ward with the baby;
  • Place the baby into space G3 unless otherwise instructed (remove the baby from the carrier);
  • Write the details of the baby in the admission book, as per usual.

Place the paperwork that accompanies the deceased with the patient in the cold store.

Returning Babies to the Ward for Viewings

If you are requested to take a baby back up to the ward...

  • Transfer the baby back to the ward in the baby carrier.
  • Complete the perinatal internal transfer book (located above the admission book in the mortuary);
  • Return the baby to the mortuary in the baby carrier when requested to do so;
  • Record the return in the perinatal internal transfer book.

The Baby Carrier...


  • The baby carrier is NOT to be left on the ward for any reason. 

  • Return it to the mortuary after EVERY use.

How many porters are required to admit a body to the mortuary?

  • 1
  • 3
  • 2
  • 4

When moving the hydraulic trolley with a deceased patient on it, what is the maximum height the roller bed should be?

  • Head height
  • Chest height
  • Waist Height

It is out of normal working hours. You are admitting a patient to the mortuary. They are wider than any of the cold store spaces available. What should you do?

  • Squeeze the body into the available space.
  • Leave them on the concealment trolley and leave it for the mortuary staff to deal with when they come into work.
  • Call the on-call mortuary technician for advice.

Completing the Paperwork and Whiteboard

Completing the Admissions Register

  • Write the details of the deceased into the mortuary admissions register.
  • If you make an error, cross it through with a single line and make a fresh entry.

Completing the Whiteboard

Write the name and ward of the deceased on the whiteboard

  • Make the entry in the box corresponding to the cold store where you placed the deceased.
  • Write in RED

Place the notes in the box

  • Place the patient notes folder in the green box to the right of the mortuary admission register.

If you make a mistake in the mortuary admissions register, what should you do?

  • Use Tipex to blank out the mistake and write over the top of it.
  • Cross through the mistake with a single line and make a new entry.
  • Scribble out the mistake and make a new entry.

Where do you put the patient notes when you have written details in the admissions book?

  • In the green box to the right of the admissions book.
  • In the cold store with the deceased.
  • On the side, next to the admissions book.

What colour pen do you use to write a new admission on the mortuary whiteboard?

  • Black
  • Green
  • Red
  • Blue

Viewing Requests

Ward Viewings

When You Receive a Viewing Request

Sometimes relatives of a deceased patient will ask them to view them out of normal working hours.

Portering staff ARE NOT responsible for conducting viewings. This is the role of the Clinical Site Manager or ward staff.

Portering staff are solely responsible for moving the deceased from the cold store to the viewing room. All other tasks are the responsibility of the CSM or Ward Staff.

The Procedure

Placing a deceased patient into the mortuary viewing room

  • Locate the deceased in the cold store - look at the whiteboard;
  • Remove the deceased from the cold store (as per earlier instructions);
  • Transfer the deceased (and tray) onto the roller trolley located in the viewing room - remember to LOCK THE WHEELS (this is VERY important);
  • Place the deceased into the viewing room;
  • Contact the ward (if the CSM or Nurse is not already present) and inform them that the deceased is ready to be prepared for the viewing;
  • Wait for the arrival of the staff member. 
  • ENSURE THAT THEY COMPLETE A VIEWING RECORD FORM (located outside the viewing room on the green trolley).



Important Reminders Regarding Viewings

  • If there are any discrepancies with the identification of the deceased - THE VIEWING MUST NOT GO AHEAD until the CSM or Senior Ward Sister has addressed the problem;
  • Place the deceased back into the cold store when the viewing has finished.
  • Ensure the mortuary entry points are locked when you leave.

Contacting Mortuary Staff

Need Advice? Have a Problem?

A member of mortuary staff is available at all times, if you need to speak to them.

  • Contact switchboard and ask the operator to contact the on-call mortuary technician for the site you are working.

Bariatric Patients

Who are Bariatric Patients?

bariatrics

[bar-ee-a-triks] noun1.a branch of medicine that deals with the control and treatment of obesity and allied diseases.


There are patients whose physical size present challenges to providing a safe and dignified transfer from the ward to the mortuary. For this reason, the mortuary has additional equipment available to ensure that the portering staff can provide a safe and dignified transfer, and the mortuary staff can store the deceased in a manner which is also dignified and respectful.

The correct and appropriate use of this equipment helps to minimise the risk of injury or accident to those removing the deceased from the ward or department.

Details of the procedure are given on the next few pages.

Before you attempt to transfer the deceased

Be guided by the nursing staff

The ward staff have nursed the patient for a period of time - be guided by their advice.

If you are not sure how to proceed - seek advice from your manager, and if necessary visit the ward to assess the physical size of the deceased - this saves you taking the concealment trolley to the ward and having to take it back to the mortuary if you need to transfer the deceased on their bed.

Equipment Required

If the deceased will not safely transfer to the concealment trolley, you will need to transfer them to the mortuary on their hospital bed.

The mortuary has special bed covers for use in these instances.


The covers are located in the cold store room, in the equipment trolley under the area where the mortuary admission register is located (see picture, left).

How to use the Bed Covers

There are two sizes of bed cover

Standard and Large. The standard sized cover is usually sufficient to cover a standard bariatric bed.

This is how the cover is applied to the bed:

1. Attach the strap

There is a red strap in the pocket of the bed over. Attach this to the side rails of the bed, or the head and foot board. This lifts the cover off of the deceased.

2. Apply the bed cover

Ensure that the whole bed is covered (as above), and that there are no gaps around the outside.

Upon Arrival at the Mortuary

Do nothing - assess your next action:

  1. Assess whether the deceased can be safely transferred to, and accommodated in the cold store.

If the deceased cannot be accommodated in the cold store, or you are not sure - STOP!

Contact the on-call mortuary technician (as detailed earlier) and seek advice at once.

Contact the on-call technician as a matter of urgency.

Place the deceased in a private area of the cold store room and cover them completely with a sheet or blanket.

Preserving the dignity of the patient is your priority until the mortuary staff arrive to take over.

Returning the Bed to the Ward

The Bed Stays in the Mortuary...

Until such times as the deceased is either transferred to the cold store OR until the deceased is collected by the funeral director.

Any enquiries from ward staff regarding the return of the bed should be referred to the mortuary staff.

Hygiene and Security

Before you leave the mortuary

Wash your hands before you resume your normal duties

There are advice posters on the walls around the department.

Hand sanitiser is freely available at all points of exit.

Biohazard Spill Kits

Blood Spill Kit

Urine and Vomit Spill Kit

Biohazard spill kits are available in the cold store room. Each kit contains instructions for use - please read them before use. Report the use of the kit to the mortuary staff.

Use the correct kit for the correct type of spill.

Security

Lock the doors and turn out the lights...

Ensure the cold store door is closed and the latch engaged.

Turn the lights off.

Close the cold store room door.

Make sure the code locks are cleared down.

The doors are locked.

Any doors that are left unlocked (cold store, entry and exit points etc) will be reported as Datix incidents

Reporting Incidents and Accidents

Reportable Incidents

Despite Our Best Efforts, Things Can Go Wrong...

It is an unfortunate fact that incidents and accidents do happen from time to time, despite our best efforts to ensure that they don't.

By ensuring you following the guidance in this training and also by observing best manual handling practice etc., you can ensure that the likelihood of an accident happening is kept to a minimum.

So, what type of incidents are reportable?

Accidental Damage To A Body

If you accidentally damage a body, report it immediately.

This applies to incidents within the mortuary - if the incident occurs on the ward or on the way to the mortuary - report it immediately to your general manager and the Clinical Site Manager on duty.

Unauthorised Access to the Mortuary

This may be a member of the public, a relative of the deceased or member of staff who has not been granted permission to have access to the mortuary.

Report these incidents immediately to security, the on-call mortuary manager, your general manager and the Clinical Site Manager on duty.

Viewing the Wrong Body

If a family view the wrong body out of hours, this must be reported immediately to the on-call mortuary manager, your general manager and the Clinical Site Manager on duty.

These examples are not all...

This small list is just an example of what is reportable. If you are in doubt, make a report in any case - it can always be disregarded once the circumstances have been evaluated.

The Mortuary is Governed By Specific Laws

The mortuary is governed by the Human Tissue Act and is licenced and regulated by the Human Tissue Authority. Therefore, there is a LEGAL duty for the Trust to report incidents which affect the safe operation and running of the facility. Reporting incidents is not voluntary - it is a legal requirement.

How To Report Incidents

Reporting Procedure

When an incident occurs within the mortuary you must inform the following people immediately:

  • The on-call mortuary manager
  • The duty clinical site manager
  • Your general manager

You may also need to inform

  • Security
  • The Police

You may also need to report the incident via Datix and/or your employers incident reporting system - your manager will be able to advise you.

Unsure What to Do?

Not Sure If You Should Report Something?

If you are unsure if you should make a report or not - it's simple:

Make a report

If it's not needed, it can be disregarded at a later stage.

End of Programme Assessment

Before you Start...

If you feel you would benefit from a practical training session, please contact the Mortuary Manager to make arrangements.

How much respect should you give to a deceased patient?

Choose one answer.

  • Exactly the same amount of respect I would give to any other patient.
  • Not much respect, they've died.
  • It depends on who's around.

You are placing a deceased patient into the cold store when your mobile telephone rings. What would you do?

Choose one answer.

  • Stop what you are doing and answer the call. Your colleague can complete the task.
  • Ignore the call and return it when you have completed the task and have left the mortuary.
  • Complete your task and return the call before you leave the mortuary.
  • Leave the mortuary and take the call and complete the task when you return.

How many porters are required at all times when transferring and admitting a patient to the mortuary?

Choose one answer.

  • 1
  • 2
  • 3
  • 4

You have been asked to transfer a baby from the maternity unit to the mortuary. What do you need to do?

Choose all options that are correct.

  • Telephone the on-call mortuary technician.
  • Collect the baby carrier from the mortuary.
  • Collect the notes and paperwork when you collect the baby.
  • Place the baby, in the carrier, into the cold store.
  • Book the admission into the mortuary admissions book.
  • Place the baby into a free perinatal cold store space.
  • Write the name of the baby on the whiteboard in red.

You arrive on the ward to transfer a patient to the mortuary. The patient is physically very large and has been nursed on a bariatric bed. Which of the following statements are True and False?

Choose one answer

  • Call for more staff and force the patient into the trolley.
  • Tell the nurse in charge of the ward to contact the Clinical Site Manager. Return the trolley to the mortuary and await further instructions.
  • Call the on-call mortuary technician and ask that they attend the hospital to assist you transfer the body.
  • Return the concealment trolley to the mortuary, collect the bed cover, return to the ward and remove the patient on the bed - fully covered.

You are transferring a patient from the concealment trolley and the cold store tray. You forgot to lock the wheels, and the patient falls between the two trolleys to the ground. What do you do?

Choose one answer.

  • Lift the patient from the floor onto the tray and proceed as normal.
  • Assess whether the body has been damaged. Lift the patient from the floor to the tray and proceed as normal.
  • Assess whether the body has been damaged, lift the patient onto the tray, place them in the cold store, and contact the mortuary manager, clinical site manager and your general manager immediately to report the incident.

You admit a bariatric patient to the mortuary. You assess that the patient is physically too large to transfer into a cold store space. What things do you need to do?

Choose two answers.

  • Call the on-call mortuary technician at once and inform them of the situation.
  • Place the patient, on the bed, in the corner of the room - covered with a blanket or sheet to maintain their dignity.
  • Call your general manager to request extra staff to assist you in placing the deceased into the cold store.

You are requested to take a baby back to the maternity unit for a viewing. Where would you record that you have made this transfer?

Choose one answer.

  • The perinatal internal transfer book
  • The mortuary admission register
  • On a piece of paper, and leave it near the admission register for the mortuary staff to see when they return to work

Select the potential hazards to watch for when loading a tray into the cold store

Choose as many answers as you think correct.

  • Other bodies in the cold store
  • Door latches
  • Other protruding door fittings

Which of the following statements is true?

Choose which of the following is TRUE

  • Doctors and nurses are allowed access to the mortuary to look at notes without the permission of the mortuary staff.
  • Clinical Site Managers and Ward Staff are allowed access to the mortuary to facilitate viewings of patients in the mortuary viewing room.
  • Family and friends of deceased patients are allowed access to the cold store room to say "goodbye" to their loved one.

When moving the hydraulic lifting trolley with a patient on a tray, what is the highest level the tray should be at?

Choose one answer.

  • Waist height
  • Shoulder height
  • Level with the top cold store tray

You have removed a bariatric patient from a ward on their own bed. What actions should you take when you arrive at the mortuary?

  • Place the body into the cold store, even though you need to apply considerable effort to make them fit, and they are wedged into the space.
  • Call the on-call mortuary technician via switchboard, inform them of the situation, leave the deceased covered on the bed in an area that affords privacy and await the arrival of the mortuary staff to deal with the situation.
  • Leave the deceased on the bed covered in an area that affords privacy and let the mortuary staff deal with them in the morning.