Recommendations
Chapter 3. Handling of the organ retention
issue September 1999 to date
Recommendations
To prevent mishandling of this kind in the future we make the following
recommendations:
- Serious Incident Procedures should be developed and put in place.
- In the event of a serious incident the Chief Executive and
Trust Board shall devise a suitable Serious Incident Procedure
similar to those already in place for major disasters and review
it from time to time making any necessary alterations.
- When the procedure has been devised and prior to implementation
the NHS Executive Regional Office shall assess its suitability
and thereafter manage its performance, devising and instigating
any necessary alterations from time to time.
- In devising a Serious Incident Procedure the Chief Executive
and Trust Board shall consider the need for a serious incident
team independent of the hospital.
- In devising a Serious Incident Procedure the Chief Executive
and Trust Board shall consider the need for urgent professional
counselling:
- A proportion of individuals within any group is always likely
to require psychological support in the aftermath of disaster.
- An individual within the serious incident team shall be nominated
to take responsibility for the arrangements and the identification
of all those in need.
- Suitably trained practitioners shall provide the counselling.
- In devising a Serious Incident Procedure the Chief Executive
and Trust Board shall take advice from and where necessary include
within the serious incident team appropriate experts in bereavement,
pathological reactions to bereavement and therapy.
- The Chief Executive and Trust Board shall make available suitably
trained staff for implementing the Serious Incident Procedure.
- The Chief Executive and Trust Board shall inform all staff when
a Serious Incident Procedure is in force.
- The Chief Executive and Trust Board shall ensure the proper
debriefing and support of all staff associated with a serious
incident.
- Universities and other public bodies shall adopt compatible
procedures when acting in conjunction with an NHS serious incident.
Records should be reviewed and updated and an audit trail should
be developed and put in place.
- The Chief Executive and the Trust Board shall review and update
medical and pathology records to include, preferably on computer
and cross-referenced, the following information:
- name, medical record reference number and date of birth;
- date, place of death and death certificate;
- name and address of next of kin;
- whether Coroner's or hospital post mortem examination;
- date of consent for hospital post mortem examination;
- names of pathologist and those in attendance;
- post mortem examination reference number;
- date of examination;
- date of preliminary/final post mortem reports;
- date histology completed;
- record of specific instructions from the Coroner or clinicians;
- record of retained organs, samples, wax blocks, slides, photographs,
X-rays, date and method of dispersal or disposal;
- case notes;
- signed consent form;
- copy of any other relevant correspondence or notes;
- name and address of general practitioner;
- date post mortem report sent to general practitioner;
- record of communication of findings to the next of kin.
- University records shall provide a confidential audit trail
back to the clinical record.
- University records shall identify receipt, use, dispersal and
ultimate disposal of any organ or sample.
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