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Selected Investigations Completed April - September 1998 > Part II, Case no. E.1173/97-98

Part II - Full Texts of Selected Investigations

Case No. E.1173/97-98 - Unsatisfactory mortuary arrangements

Matters considered: Trust staff did not contact the daughter of a woman before she died: failure to make proper arrangements for the woman's body to be stored

Complaint against: Central Nottinghamshire Healthcare NHS Trust

Complaint as put by Mr R and Mrs T

1 . The complaint put by Mr R's and Mrs T's solicitors was that in the early hours of Friday 25 July 1997 staff at the Mansfield Community Hospital (the hospital) contacted Mr R because his mother, Mrs S, was seriously ill. She died at 4.40 am. Mrs S's daughter, Mrs T, was not contacted by staff even though she had provided the hospital with her details. Undertakers contacted the hospital at around 2.45 pm on 25 July. However, although Mr R had signed a form allowing for the body to be released to the undertakers, staff failed to arrange for it to be transferred that day; they also failed to make proper arrangements for it to be held at the hospital. Arrangements were eventually made for the undertakers to collect the body on 26 July at 4.00 pm. On 28 July the undertakers told Mr R and Mrs T that due to the hospital's failure to arrange for the body to be appropriately collected and accommodated it was now inadvisable for them to view it. On 24 September the Trust's convener wrote to the solicitors informing them that he had refused a request which had been made by Mr R and Mrs T for their complaint to be considered by an independent review panel.

2. The complaints investigated were that:

1. in the early hours of 25 July 1997 staff failed to contact Mrs T and as a result she was not able to be present when her mother died; and
2. the Trust not only mishandled the release of Mrs S's body to the undertakers, but also failed to make adequate arrangements for it to be accommodated at the hospital.

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Investigation

3. The statement of complaint for the investigation was issued on 12 November 1997. The Trust's comments were obtained, and relevant papers, including Mrs S's medical records were examined. The Ombudsman's investigator took evidence from Mr R and Mrs T, staff from the Trust and a consultant pathologist (the pathologist) who worked for another Trust but performed post mortems for the Trust subject to complaint. Evidence was also taken from the undertakers who made the funeral arrangements for Mrs S (the undertakers) although their actions are not within the Ombudsman's jurisdiction. The abbreviations used in this report are listed in an annex.

Complaint (a)
Failure to contact Mrs T. Evidence from Mr R and Mrs T

4. Mr R told the investigator that on Friday 25 July at 3.00 am a nurse from the hospital telephoned and told him that his mother's condition was deteriorating. He arrived at the hospital shortly afterwards, and his mother died at about 4.40 am. Mrs T said that she was very upset that she had not also been told about her mother's deterioration and had, therefore, not been able to spend time with her in the last few minutes before she died. She could not understand why she had not been contacted. She had given her details to nursing staff; and although she could not remember the date, probably about a day or two before her mother's death she had specifically asked the nursing staff if she could be contacted if her mother's condition deteriorated.

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Local procedures

5. The Trust's death notification policy states that:

'The next of kin will be notified of an expected death by the Nurse in Charge of the ward or the patient's primary nurse. If the families/carers have expressed a wish to be present or notified, every effort must be made to contact them.

'It is essential that the wishes of the family/carers are documented in medical and nursing records in order for the identified instructions to be carried out. (For example, if death occurs in the night)'.

6. Mrs S was admitted to Holbeck Ward (the ward) at the hospital on 11 July 1997. The nurse with primary responsibility for her care (the first staff nurse) entered Mr R's name and telephone number in a section of the nursing notes headed 'Next of Kin' and added a note 'Family to be contacted at any time'. She entered Mrs T's name and telephone number in another section of the notes which is headed 'significant other'. There is no nursing note specifically recording that Mrs T had asked to be contacted if her mother's condition deteriorated.

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Evidence from Trust staff
The Trust's formal response

7. In the Trust's formal response to the statement of complaint the corporate affairs manager wrote:

'... Admission documentation identifies Mr R as being "next of kin" with Mrs T being identified as a "significant other". The Trust's normal practice in communicating with relatives is that such communication is undertaken via the identified next of kin other than when other family members are attending the ward. This ensures a constant line of communication and eliminates the risk of confusion that may arise from communicating with a wider family. This policy is being further reinforced by the Trust in ensuring that family members (particularly the next of kin) are aware of their responsibilities.

'... The prime purpose of identifying "significant others" is to ensure that should the next of kin not be contactable there are other communication options available to hospital staff should urgent contact with a family member be required. If the next of kin is contacted, it is considered to be that person's responsibility to communicate with the wider family and as such Mrs T was not contacted'.

8. The first staff nurse confirmed that she had entered information about Mr R and Mrs T in the nursing notes (paragraph 6). She thought that Mrs T had provided her details over the telephone. However, as far as the first staff nurse could recall, Mrs T did not ask to be contacted if her mother's condition deteriorated. Had she done so, the first staff nurse would have recorded that. The note 'Family to be contacted at any time' referred to Mr R, not to other members of Mrs S's family. Another staff nurse (the second staff nurse) said that she thought that she spoke to Mrs T on the telephone. She also could not remember her asking to be contacted if Mrs S's condition deteriorated.

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(Note: On 21 July the second staff nurse made an entry in the nursing notes which read '... Son has visited and daughter is also aware of how poorly her mother is ...')

9. The staff nurse in charge of the ward during the night of 24/25 July (the third staff nurse) said that the next of kin was considered by nursing staff as the first point of contact with a patient's family. As Mrs T's details were recorded in the 'significant other' section of the nursing notes she would only have been contacted if the next of kin had been unavailable. The third staff nurse could not recall being asked by Mrs T to contact her if Mrs S's condition deteriorated.

10 . The nurse manager for the hospital (the nurse manager) said that nurses had contacted Mr R in accordance with the Trust's death notification policy. They would have expected Mr R to contact Mrs T, but she did not think that had been explained to him. The Trust's death notification policy was incomplete in that it did not explain the respective responsibilities of staff and relatives. She was in the process of rewriting the policy to cover that point.

Comments of the Ombudsman's professional adviser

11. The Ombudsman's nursing adviser has stated that normal nursing practice when a patient's condition deteriorates would be to contact the nominated next of kin. She reviewed all the evidence obtained during this investigation; and in her opinion, the nurses acted reasonably and appropriately in contacting only Mr R during the early hours of 25 July.

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Findings (a)

12. Mrs T has said that probably about a day or two before her mother's death she asked the nursing staff if she could be contacted if her mother's condition deteriorated. The nurses interviewed in the course of this investigation could not remember her having made such a request, and there is no record of it in the nursing notes. Mr R was, however, recorded as the next of kin; and as such he was considered by the nurses to be the first point of contact if any information about his mother's condition needed to be passed on to other relatives. The nurse manager has said that although the nurses would have expected Mr R to contact Mrs T, she did not think that was explained to him. I note that the Trust are reviewing their death notification policy and I recommend that, in doing so, they clarify responsibility for notifying family members other than next of kin. However, I am satisfied that in the early hours of 25 July the nursing staff correctly implemented the policy as they saw it; and taking into account the advice from the Ombudsman's nursing adviser, I consider that they acted reasonably and appropriately. I do not, therefore, uphold the complaint as put.

Complaint (b)
Storage and release of Mrs S's body.

Evidence from Mr R and Mrs T

13. Mr R said that on 25 July at about 5.00 am, a porter told him and a nurse that Mrs S's frame was larger than could be accommodated in the refrigeration unit. At about the same time a doctor explained that the body could not be released until the coroner had been contacted. Mr R said that he wanted his mother's body to be taken to the undertakers as soon as possible and he gave hospital staff the undertaker's address. At about 11.00 am he returned to the hospital to collect a completed death certificate. When he did so, nothing was said to him about the problem of holding his mother's body in the hospital so he assumed that that had been resolved or that the hospital had been in touch with the undertakers. He delivered the certificate to the undertakers that afternoon. Mr R said that on the morning of Saturday 26 July a nurse contacted him to ask for the undertakers' details. He told her he had already given the details but repeated them. He understood that the undertakers collected his mother's body that afternoon. On Monday 28 July the undertakers advised him and Mrs T against viewing their mother's body as it had deteriorated because the hospital had failed to refrigerate it. They and their family were very upset about that.

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Evidence from the undertakers' staff

14. In a letter dated 29 July 1997 to Mr R the manager of the undertakers (the manager) wrote:

'... On Friday 25th July you called into [the undertakers'] office to make necessary Funeral Arrangements for your late Mother ...

'After you had left our office [my wife] telephoned [the hospital] at approximately 2.45 pm to obtain the size of deceased ... On contacting the Hospital, [my wife] was put through to the Portering Service's answerphone, where a message was left asking them to contact us with the appropriate size. We can confirm that when [this] office closed at 5.30 pm that evening, no reply had been received.

'On Saturday 26th July two telephone calls were received from [staff at the hospital]. The first being at approx 12.15 pm. The member of staff looking after this office took the message, but no further action was taken at this stage because we were slightly bemused as to why the removal of Mrs S had to be done during the weekend, when mortuary facilities were available within the Hospital.

'The second call was received at approximately 2-3 pm and was answered by a staff member at Head office. The appropriate removal staff were organised immediately and Mrs S was removed from [the hospital] at approximately 4 pm and brought to our premises ...'On arrival at [the hospital] our removal staff found that Mrs S was in the mortuary, but not in the cold room facility.

'Had we been informed on Friday [25 July] of the situation we could have acted sooner ...'

15. The manager said that when Mrs S's body was received by the undertakers on 26 July it was placed in their refrigeration unit. When he spoke to Mr R and Mrs T on 28 July he informed them that their mother's body had deteriorated to such a degree that it was inadvisable for them to view it.

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National guidance

16. In 1991 the Health Service Safety Commission issued a revised Code of Practice entitled 'Safe working and the prevention of infection in the mortuary and post-mortem room'. The Code stated that one of the functions of a mortuary was 'to prevent tissue decomposition while burial or cremation arrangements are under way ... bodies will normally be stored in cabinets at a reduced temperature (approx 4C) ...'

The Trust's formal response

17. In the Trust's formal response to the statement of complaint the corporate affairs manager wrote:

'... We have checked the dimensions of other fridge units in neighbouring hospitals and have identified that the dimensions of these units are approximately 4" wider than those at [the hospital] ... The incidence of bodies being too large to be accommodated is not known though it is recognised that such situations have previously arisen. Monitoring of the frequency of such occasions has been introduced in order to ascertain the scale of the issue and to determine whether a capital solution needs to be considered ...

'With regard to the circumstances of the release of Mrs S's body to the undertakers, it is accepted that errors were made by the Trust ...'... The nurse handing over the death certificate assumed that Mr R would notify the undertakers that the body was available for collection and advise of its present whereabouts. It is our understanding that Mr R attended the undertakers on the afternoon of the 25th but gave no indication of the body's unrefrigerated state, he being under the impression that the hospital would be separately contacting the undertakers. The undertakers consequently saw no urgency in removing the body. Reference has been made to a message left on the porters' answering machine by the undertakers. [The contractors providing the Trust's portering services (the contractors)] have investigated this issue. None of the portering staff on duty recall hearing a message about a body and there is no record of the alleged call as the machine records over all old messages each day.'The mortuary is in a separate block to the main hospital building and will only be attended for the purpose of moving a body either in or out. It was not until [7.30 am] on 26th July 1997 ... that enquiries identified that the body of the late Mrs S remained within the mortuary ... the undertakers ... collected the body at [4.00 pm].

'It is clearly the case that a communication breakdown occurred on this occasion resulting in very distressing consequences. The Trust gave an apology identifying the communication breakdown, in its letter dated 4th August addressed to Mrs T. Procedures had subsequently been reviewed and revised to ensure that the unfortunate series of events as described above cannot recur ...'

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Local procedures

18. The Trust had no mortuary procedure in place at the time of this incident. A procedure was drafted in September 1997 and brought into operation, with amendments, in December. The procedure states that when a patient's body cannot be refrigerated the porters must inform the nurse in charge of the ward of the problem. The ward nurse must 'use his/her judgement as to whether the problem is feasible and visit the mortuary with the porter if in doubt'. The ward nurse is then to inform the nurse co-ordinator that there is an unrefrigerated body in the mortuary and explain the situation to the relatives and request they ask the undertakers to collect the body as soon as possible, because it is not being stored in the mortuary refrigerator. Portering staff are to re-check that the unrefrigerated body has been removed within three hours of it arriving in the mortuary. If not, the porters are to contact the appropriate undertakers and request urgent collection. If the porters experience difficulty at that point they are to inform the nurse co-ordinator who will then contact the undertaker to request immediate collection of the body.

Documentary evidence

19. Mrs T made an oral complaint to the Trust on 28 July 1997. During the Trust's investigation of that complaint written statements were prepared during the next few days by the second staff nurse, who was on duty during the morning of 25 July, the third staff nurse, and another staff nurse (the fourth staff nurse) who was on duty during the morning of 26 July and who had also made a detailed note in the nursing records. Statements were also taken from three porters (the first, second and third porters). I set out below some key points:

The first porter's statement

'[The third staff nurse] phoned about 4.00 am [on 25 July] to ask me to go to assess a body on [the ward]. When I arrived at the ward [a staff nurse—the fifth staff nurse] was there with the son of the lady. I measured the body for size and I could see that she would not fit in the fridge. The size was written in our book and on the Notice of death ticket. Size was 5ft 7in and 28in wide.'The fridge size is 24" wide Tray 22" and 12" high. The staff nurse on duty asked me to go back and check again but I said that the fridge was not big enough.'The staff nurse told me she would contact the undertaker shortly for collection.'The ward generally contact the undertaker and I returned to duty. [The second porter] took over at 6.00am.'

The third staff nurse's statement

'On the death of Mrs S I spoke to [Mr R] explaining that his mother was a large lady and we had had difficulties previously placing these people in the mortuary under refrigeration circumstances and did he have a Funeral Director in mind because I would ask them to collect his mother. He said [the undertakers].'Then [the doctor] informed us that the Coroner was to be informed which meant the body could not be removed. [Mr R] was told of this by [the doctor] and [the fifth staff nurse] explained how Mrs S would be kept until 9.00 am when it would be determined whether or not the body could be released ...'

The second porter's statement

'Just after 6.00 am I went to [the ward] after [the first porter] told me that a body needed moving and the patient was moved on the bed with the help of a nurse to the mortuary. I had been told that the undertaker was being contacted later. I went off duty at 2.00 pm.'

The second staff nurse's statement

'On the morning of Friday 25th July [the third staff nurse] reported during hand over that Mrs S had died, her body was in the mortuary but had been left out of the fridge as she would not fit into it. [The third staff nurse] stated that she had informed the son ... and all that was now needed was for the doctor to complete the death certificate and speak to the coroner ... '[After the doctor had completed the certificate] I then telephoned the son who came to the ward to collect the death certificate and other documentation. After giving him the documentation and explaining where to take them, I assumed that the body could now be removed from the mortuary by the funeral directors who would have been informed by ... the son ...'Unfortunately I had not been told and did not know that I myself had to contact [the undertakers] for Mrs S to be taken from the mortuary. I had not seen any documentation which explained what to do when a body is not able to go into the fridge. As [the third staff nurse] had informed the next of kin about the situation I believed they would contact the funeral directors as soon as possible.'

The third porter's statement

'[The fourth staff nurse] contacted me on Sat at 7.30 am to ask if the body had been removed, I checked and it had not been which I told her. She said she would follow this up with the undertaker and ask the relatives to contact the undertaker.'

The fourth staff nurse's note in the nursing records

'On arriving on the ward for the morning of 26th shift I noticed that Mrs S's bed was not back on the ward. I contacted the porters to see if the bed was still over in the mortuary. [The third porter] went over and informed me that both the bed and Mrs S were still there. I contacted [Mr R] ... to see who was the funeral director in order for me to phone them. He said [the undertakers] and sounded surprised that his mum was still here. I contacted [the undertakers] and informed them that Mrs S needed to be taken to their chapel of rest as she had been here, not in the fridge, for 24 hrs now ... The boss was not available so they said they would get him to phone me back. By 1400 hrs no message was made so I again contacted [the undertakers]—the telephone went through to Nottingham—again message left there. I informed them that it was a necessity for Mrs S to be moved that afternoon. Information passed on to afternoon shift and I left duty.'

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Oral evidence

20. The third staff nurse said that although Mr R had given her the details of the undertakers she did not record them in the nursing notes because she was not sure whether he had discussed and agreed the funeral arrangements with other members of the family. She did not think she had explained at her handover to nurses on the early shift on 25 July who the undertakers were and what action staff should take.

21. The first staff nurse said that when she was on a late shift on the day that Mrs S died it did not appear significant that Mrs S's bed was missing. In retrospect, it should have occurred to her that there was a problem. She had taken no action because she assumed the matter was being dealt with.

22. The head porter said that there had been several other occasions when bodies had been left in the mortuary area unrefrigerated either because the body was too big to fit into the refrigerator or because it was full. He said he was familiar with the new mortuary procedure (paragraph 18) but was not confident he understood what the porters were expected to do if an unrefrigerated body remained in the mortuary after three hours. It had not previously been their responsibility to contact undertakers in such circumstances. As regards the message which the undertakers left on the portering service's answerphone (paragraph 14), the head porter said that the machine had not worked well in that each time a new call was received it would record over the previous message. That machine was no longer used.

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23. The nurse manager said it appeared that nurses had forgotten about Mrs S. They should have been more vigilant and realised earlier that her bed was missing from the ward. The Trust had introduced a mortuary procedure as a result of the problems which had occurred with Mrs S's body. She had asked ward managers to discuss with nurses how that procedure could be implemented. She had also discussed the details of the procedure with the area manager for the contractors and had asked him to train portering staff.

24. The hospital's general manager (the general manager) said that because of the seriousness of the events which had occurred in this case he had asked the contractors to perform a three month audit from December 1997 to February 1998 to look at incidents that occurred within the mortuary. He was interested specifically in whether there were occasions when a body could not be fitted in the refrigerator. Depending on what the audit revealed he might then consider buying a new refrigeration unit to improve the capacity of the mortuary.

25. The chief executive of the Trust said he accepted that the Trust had made a number of errors in the handling of Mrs S's body. He was deeply sorry for that. He was satisfied that the new mortuary procedure would prevent a recurrence. (Note: The chief executive later wrote to me stating '... the mortuary audit has been undertaken. In the three month audit period, no bodies were unable to be properly accommodated within the hospital's mortuary facility (total bodies during audit period: c90)).'

26. The pathologist said that it was undesirable for bodies to be left unrefrigerated for any length of time as that created a risk of deterioration and also carried health risks. The rate at which deterioration occurred would be affected by a number of factors. If a deceased patient had been obese or had suffered from diabetes (as in Mrs S's case) deterioration was likely to be accelerated. Storage of a body in a warm environment would also lead to accelerated deterioration. (Note: the Ombudsman's investigator visited the mortuary. He observed that it had no mechanical ventilation or air conditioning. I understand from information provided by the Meteorological Office that midday temperatures in the Nottinghamshire area on 25 and 26 July 1997 were in the range (21-23šC) .

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Findings (b)

27. If a body cannot be accommodated in a refrigeration unit in a hospital mortuary it is important that it should be moved quickly to refrigerated storage elsewhere. The pathologist's evidence indicates that there was a particular need to do so in Mrs S's case. The responsibility for arranging that rested with the hospital staff. However, there was no guidance at the time to help them in this. The porters thought that nurses would contact the undertakers. The nurses, in turn, assumed that Mr R would do so. However, in her statement (paragraph 19) the third staff nurse recorded that she told Mr R that she would ask the undertakers to collect the body. It is unsatisfactory that that was not properly noted in the nursing records. The breakdowns in communication in this case were compounded by a serious failure to monitor the action which needed to be taken. As a result, Mrs S's body was left unrefrigerated for over 30 hours in conditions which were likely to have been warm. That is totally unacceptable, and I understand fully the distress felt by Mrs S's relatives. I note that the Trust has since introduced a mortuary procedure, but the head porter's evidence (paragraph 22) suggests there could be some confusion as to how that should be implemented. I recommend that as a matter of urgency the Trust review the management of the mortuary and consider arranging for an individual to have responsibility for its operation. I also recommend that the mortuary procedure be revised so it is clear who is responsible for the specific aspects of the mortuary's operation, and that steps are taken to ensure the modified procedure is fully understood and implemented by staff. I uphold this complaint.

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Conclusion

28. I have set out my findings in paragraphs 12 and 27. The Trust have agreed to implement the recommendations in those paragraphs and have asked me to convey—as I do through this report—their apologies to Mr R and Mrs T for the shortcomings I have identified.

ANNEX TO E.1173/97-98

Schedule of abbreviations used in this report

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Last updated: 12 January 2006