Detail about Mortuary services, workflow and outcomes

1. Dr. Sharad H. Gajuryal
Junior Resident,
MD(Hospital Administration)
BPKIHS

2.  Mortuary is an important integral part of every
hospital as it deals with the preservation of the
dead body so that the forensic clinicians &
pathologists may investigate the cause of death
and make scientific investigations.
 Bodies may be viewed and identified by
relatives and friends (unidentified body), and
bodies may be kept until burial can be arranged.

3.  The concept of "womb to tomb" in health care
of the population in our community health
literature clearly indicates that in health care
setup, part of doctor's duty is not only caring
for the living but also helping in arrange for
disposal of those patient who die.

4.  In general ,Mortuary complex consists of
Autopsy room/ postmortem room, and
preservation room for dead body before
disposal arrangement are made( Cold storage
room) and ancillary areas. Morgue is pre
dominantly used in Northern American English
while mortuary is more common in British
English.

5.  The term mortuary or morgue is usually not
mentioned infront of patient in the hospital,
instead ,euphemism "Rose cottage" is used in
British hospital to enable discussion infront of
patients, relatives and visitors in front of
them.

6.  From a practical angle , after the death of a
person, a number of procedures are to be
carried out under the generic term "Post
mortem care ". The body is washed carefully ,
the orifices are plugged, and the pads are kept
in certain areas to prevent bruising.
 These procedures not only reflects the
scientific requirement for keeping up dead
body before disposal but also reflects the
respect to the deceased one .

7.  In Hospital, the effect of death and look at
the dead body is great demoralizing factor for
the patients and visitors. Similarly, hospitals
and physicians prefer to project their success
rather than exhibit the dead body.
 So, it becomes essential for hospital
administration that a suitable provision shall
be made in an obscure place where the dead
body can be placed, pending final disposal or to
rule out the cause of death.

8.  A carefully planned mortuary complex is of
great benefit to all those who come in contact
with it. i.e police, doctors, medical students,
staffs and relatives of deceased.
 Provision of mortuary facilities and services in
a hospital also has an important bearings in
terms of public relation of the hospital.

9.  Lots of sentiments value are attached to the
dead body of the person with socio and medico
legal importance attached to the mortuary of
the hospital. Therefore, establishment and
proper management of mortuary is of
significance of every hospital.

10. 1. To preserve the dead body till the formalities of the
handing over of deacesed is completed.
2. To keep the dead body (unclaimed) till the relative
claim and take away for final disposal. Usually
unclaimed bodies are kept for 72 hours , and if not
cliamed till that period, disposal of dead body is done
as per existing policy of hospital and as per law of
land.
3. To receive and store dead body requiring postmortem
examination.
4. To carry out medico legal postmortem work.
5. To impart teaching programs for undergraduates and
post graduates.

11. The types of dead body preserved in the
mortuary can be classified as
1. Non medicolegal
Identified
Unknown
2. Medicolegal
Identified
Unknown

12.  Location : The location shoud be in obscure
place, in a separate building to where the
dead bodies can be transported
unobstructively. It should be easily accessible
from the wards, Emergency, ICU and OT and
pathology department

13.  Space Requirement : Depends uopn the size
and type of hospital and the workload.
Committee on Plan Project (COPP) has
recommended an area of 6-8 sq ft/bed as a
general guideline.

14.  Parking area & Covered Portico
 Reception & Waiting area
 Trolley area
 Storage Chamber
 Post mortem Room
 Office room for record keeping & Processing
 Doctors room
 Store room
 Room for technicians & attendants
 Changing room
 Toilets

15.  Parking with covered portico : Spacious
parking area with a covered area of about
18m2 for vehicles should be provided at
entrance to the body store as a protection in
wet weather and screen from adjoining area
with a exit to subsidiary road or parking area.

16.  Reception : A recption of the mortuary is the
place where the bodies are viewed and
documents checked. It should have easy
assecibility and approchable .

17.  Trolley area (3m2): A trolly bay is required to
keep the trolley fro transportation of dead
body.It should be nearby the reception.

18.  Waiting area: A waiting room of 12-15m2 is
recommended for the access to visitors and
relatives. It should be pleasantly furnished
with provision of WC and drinking water.
 In western countries viewing room(20m2) is
adjoined to waiting area to enable bodies to
be viewed by relatives. It is treated in such
way that it can be used by all regions and
denominations.

19. Storage chamber : (3m2)
 2 storage chamber- 50-100 bedded hospital
 3 storage chamber -200 bedded hospital
excluding any provision for special
circumstances like disaster, with some allowance
for epidemics and the possibility of major
accident (Putsep)
Space needed infront of cold chamber for
withdrawal of trays. It should have assess to
post-mortem room .

21.  Temperature for storage chamber :
 Negative temperature storage : (-15/-25DC) for
unclaimed body/cause of death not identified . At
this temperature, body is completely frozen and
decomposition is stopped. linen is adhered firmly
on tray.
 Positive temperature storage : (+2/+4) , it does
not prevent decomposition which continues at
slow rate . For bodies which are to be disposed
quickly and with no medicologal
disputes(preservation).

22.  Post mortem room : The post mortem room
is suggested to be treated like an operational
theater in all technicality. The major
difference between mortuary and OT is that in
operation theater, utmost care is needed to
prevent outside infection entering inside, and
in mortuary care is needed to ensure that
inside infection does not spread out.

23.  The room should have 2 or more postmortem
table.
 Upto 400 bedded hospital – 2 tables
 Additional 200 bedded- another 1 table
More than 4 autopsy table is not preferred.
 A two tabled room need about 40m2 area.
 About 15m2 area is needed for each extra
table
 The table are of procelain,fireclay or stainless
steel.Stainless steel is favored with

24.  Features of autopsy table :
 7 ft long and 3.6 ft wide
 Have horizontal false top supporting body
 Have a incline trupe-top for drainage
 Have either centered or foot drain.
 Recent addition is arrangement of air inlets
around the sites of it through which air
surrounding the body is sucked away thus
eliminating all smells.

26.  A cool spot light should be availlabe for use ,
eg for removing the brain.
 A wall mount xray view box is needed.
 Telephone should be arranged with due
consideration of contamination.
 Small steralizer should be available
 Shelf should be provided for formalin, saline
and other solution.
 Hose point should be available.

27.  Occasionally a so called foul room is
provided with tempreture of 10 degree C for
autopsy procedure for decomposed body.

28. The postmosterm room should
• Be Well ventilated, illuminated and cleaned to OT
standard.
• Be Flyproof, well lit
• Have proper instrument and specimen storing
cupboard
• Have heavy duty exhaust fan
• Have water impervious floor sloping to drain
• Have easily washable floors and walls
• Have proper infection control
• Have running cold and hot water
• Have facilities for collection of specimen
• Be hosed down from floor to ceiling with proper
drainage.

29.  Stores : Clean store for clean gown,
aprons,gloves, gumboots and towel ; Instrument
and equipment store for equipments, jars and
solutions; linen store for drapes, shroud, towel
etc.
 Consultant/Doctors room
 Changing room
 Sluice Room : for washing and disinfecting the
instruments
 Doctor’s office : For report writing
 Attendants room

30.  Floors : Floor should be RCC, hard and
durable & easily washable, nonslippary.
Should be of tiles or standard tarazzo to
which 3% copper may be added to act as
insect inhibitor.
 Walls : Washable ; with dadoing and
preferably of ceramic tiles.

31.  Window : If possible natural day light should
be used which provides adequate lighteing.
Window should be in north side.
 Doors : Should be wide enough for passage
of portable x-ray, Preferablt itshould be a
sliding door.

33.  Adequate supply of heat and cold water
 Safe drinking water facility
 Wash basin with soap seperately for the staffs
and visitors
 Fire fighiting system
 Sterilizer should be available
 Proper heating and ventilation
 Proper Drainage system

34.  Cold Chamber
 Autopsy Table
 Table ,Chair, Stools,File cabinets,Lockers
 Computer with printers
 Sterilizer
 Instrument cabinet
 Portable xray machine
 Spectrophotometer
 Fume chamber

35.  Weighing Machine
 Chromatography machine
 Essential instruments :
• Scissors
• Forceps
• Scalpels
• Brian knives and saw ( preferably electric saw)
• Occasionally a pair of bone forecep
 Embalming machine if facility available

36. i)Bleaching powder for cleaning mortuary table floors, etc.
ii) 2% Glutaraldehyde for cleaning instruments.
iii)Formative for sending specimens needing his to pathology.
iv)Rectified and Methylated spirit as preservative
vi)Common salt
vii)Sodium fluoride
viii) Potassium oxalate
ix) EDTA vials and tubes
x)Sterilized glass tubes (plain).
xi)Sterilized glass tubes with swabs
xii) Liquid paraffin
xiii)Sealing wax etc.
xiv)Big size envelops, plain papers etc.
(only 2/3rd of the specimen container is
Filled with solution)

37.  For specimen/ viscera examination ,
specimen are preserved in various viscera jars
consisting of saturated solution of salt
(stomach and liver/section of Both kidney),
fluoride (blood) and formaline for tissues.

38.  Embalming
 Exhumation
 Mummification

39.  The mass disaster plan must have a proper guideline
for proper identification, preservation and disposal of
the dead body taking into consideration all
medicolegal formalities. Ideally every victim who are
alive should be labeled by color coding system. These
are helpful in identifying and isolating case according
to seriousness of injuries to provide first-aid
meritwise.
 To take care of the dead bodies the disaster plan
must include setting up of temporary emergency
mortuary. The use of the hospital mortuary is not
recommended. There is rarely enough space, access
is difficult and it may hinder the accommodation of
hospital dead bodies.

40.  The medical man has an important role in the disaster
management. He may be involved in the following ways:
• Proper scientific numbering and tagging of the dead
bodies for future identification purpose by the relatives.
• Identification of body as far as possible by noting down
the identification features.
• Issuing of death certificates
• Conduction of medicolegal autopsy.
 In mass disaster, practically it becomes difficult to conduct
postmortems (unnatural death) due to high number of
cases. Therefore, the legal authority may waive of the
postmortems to minimize the inconvenience to the
relatives of the victims.

41. Medico legal Autopsy
Autopsy: Auto = Self
opis = View
Autopsy literally means to see for oneself.
It is non-medico legal.

42. Post-Mortem Examination:-
is a medico legal autopsy (Necropsy)
Necropsy Necros = dead
opis = view
or Post mortem examination:-
Post:- after
mortem:- death
So a medico legal autopsy means an
autopsy that is performed by a qualified
and registered Medical Officer specifically
to meet with certain requirements of law.

43. Precautions for Medico-legal autopsy or post
mortem.
1. Permission or authorization
2. Identification
3. Visit to scene of crime
4. History of the case
5. Examination
6. Verification of injuries noted by the police
7. Notes
8. Preservation of viscera and other tissues
9. List of articles.

44. Whenever a body is sent for autopsy it is always
accompanied by a
(a) Dead body challan
(b) An inquest report
In case of deaths from accidents and cases dying
in Hospitals
(c) The accident register
(d) Hospital case records are also sent.

45. Dead body challan :- is a requisition
submitted by the investigating police officer
to a medical man while handing over the
body for performing an autopsy. It contains:-
Name
Age
Sex
Religion of the deceased
Suspected cause of death
Purpose for which the body sent for post
morterm examination
Cont..

46.  Place from where body has come
 Name of person accompanying the body
for protection & identification
 The identification marks
 Time of dispatch
 Details of articles and clothing's
 Medical officer should note down the time
of arrival of the body in the mortuary and
time of post mortem.

47. An inquest report
is a report in which available history of the
case and the circumstances under which the
body was found or recovered are recorded.

48. Objectives of a medico-legal autopsy
1. To determine / find out the identity of a
person,
2. To determine the cause of death
Whether natural or unnatural,
if unnatural whether suicide , homicide or
accidental
If homicide Whether any trace of evidence has
been left by the accused on the victim
3. To determine the time since death.
4. In case of newly born infants to determine
the question of live birth and viability of the
child.

49. Instructions Regarding Deaths in the
Casualty
Patients who die in Casualty should be given
death certificates by the CMO or the Senior
Resident of the clinical unit.
The CMO should ensure that the body is sent
to the mortuary with due care and
consideration.
The CMO should make every effort to promptly
inform the relatives of the patient who dies in
the Casualty. When the relatives arrive in the
Casualty, the CMO should show due courtesy
and sympathy to them and help them in every
possible way in the disposal of the dead body.

50. Instructions regarding patients who are dead
on arrival at the Casualty
All cases “brought in dead”, and where the actual
cause of death is not known, should be handed
over the he police for suitable action.
(i) The name of such cases should be entered in
the Casualty attendance register along with all the
possible details about the dead person obtained
from the accompanying relatives whose name and
address should also be noted and recorded in the
remarks column of the register.

51. (ii) In case where death has occurred due to natural
causes and there is no suspicion of any foul play, the
dead bodies may be recorded with signatures of
relatives or attendants.
(iii) All other cases where death has occurred due to
accident, assault, burns, suicide, poison, rape or any
other causes where it is suspected that death has
not been due to natural causes, must be registered
as medico-legal cases (MLC) and the police
authorities informed accordingly.
(iv) In all the above cases, the out-patient paperwork
and the death reports duly completed, must be
forwarded to the M.S. for onward transmission tot he
Medical Records Section and New Delhi Municipal
Committee.

52. Instructions Regarding Medico-legal Cases
A medico-legal situation is defined as one where
there is an allegation, confession or suspicion of
causes attributing to body injury or danger to life.
The CMO is advised not to enter into any
arguments with the patient, relatives or attendants
regarding the medico-legal aspects of the case.
This problem must be left entirely to the Police
Constable on duty.
The Casualty Medical Officer’s foremost duty is to
render medical aid to the patient. All such cases
should be promptly entered in the bound medico-
legal case register available in the Casualty.
The CMO should see that the register pages have
been properly numbered
Contd..

53. Special emphasis should be given to clearly and
legibly entering the name, address, time of arrival
of the patient and to the cause and nature of
injury.
Signature should be in full with the name of CMO
given in capital letters.
At least two marks of identification should be
carefully entered.
A copy of the report should be handed over to the
Police and the register should be kept under lock
and key in the Casualty Department.
No person, including the Police officer, should
have access to the medico-legal record including
medico-legal register) without the written consent
of Medical Superintendent or any other officer
authorised by him.
contd...

54. All exhibits of legal importance (gastric lavage
etc.) should be immediately sealed and kept under
lock any key till delivered to the police and their
signatures obtained in the book.
In all medico-legal matters, where the CMO is in
need of expert advice, the faculty staff of the
Department of Forensic Medicine should be
contacted and proper guidance obtained.
Contd...

55. The following points may kindly be considered
while dealing with MLC cases:
(i) Each entry of identification data of patients in
the MLC register should be made by
the CMO and not by the Police Officer.
(ii) The MLC reports should be prepared by the
CMO’s/Residents and not by the Interns.
(iii) Nature of injuries should be recorded in every
MLC case.
(iv) The CMO should write his/her full name in
block letters along with the signature for
adequate identification.
Contd….

56. (vi) X-ray Department is requested to provide
the X-ray report within 48 hours.
(vii) Remarks of the specialists should be
entered in the MLC register and signed by
the specialist with his/her name clearly
written in block letters.
(viii) The Police Officer posted in the Casualty
should expedite the completion of all MLC
reports within 7 days.

57. THANK-YOU