A BODY GOES MISSING AT THE MORGUE!!

Last week, news stations were awash with the story of the missing body of a child that was discovered during the burial date. It is a nightmare for any hospital administration for several reasons: 

1. Burial is usually an emotive issue already, hence dealing with the family is already a difficult task
2. The challenge with keeping this within the family since the funeral arrangements (going on for days to weeks) are public affairs
3. The issue becomes a two family affair, meaning you have to create another family crisis and then try to solve them
4. The likelihood that the missing body may have been buried in a faraway location,
5. The possibility that the body was cremated hence there is no body to retrieve.
6.  The legal, police and public health processes that need to take place to handle the matter, among others 

As a medical director, I have witnessed my own share of bodies released to the wrong family and know too well the PR headache that this is. I share my experience below. 

So, what should a medical director do when a body is reported missing from the funeral home? 

Immediate: 

1. Meet the family and apologize
2. Identify the real owners: The easiest root is to reach to previous families that have carried similar bodies (age group) in the duration the body in question was in the morgue. Ask the most likely family to come and confirm the body in the morgue is theirs. 
3. Organize the switch:
   1. Record an OB at the police station (DCI)
   2. The two concerned family reps and the Mortuary/Hospital rep swear an affidavit under a lawyer. Use the OB and the affidavit to apply for court order for exhumation under a certificate of urgency. 
   3. The hospital provides transport and manpower for exhumation. Police escort the vehicle and staff for the exhumation. The affected family may wish to have this done under cover, it good to reach out to a few village leaders to make this happen, besides notifying the assistant chief of the goings on. 
   4. The body is carried back to the mortuary and the family identifies it correctly. It is cleaned and dressed and dispatched to the correct family. It may happen on the same day of funeral if events have gone as quickly as possible, otherwise the buria may have to be post poned. It is always good to work with the local burial committee chair to manage the community expectations and explain delays or postponements

Root Cause Analysis: 

After dispensing with the matter and surviving whatever public backlash ( wish you don’t get this known publicly), it is important to get to the internal processes/systems audit via a root cause analysis (RCA). 

1. Medical director/administrator/Quality Manager conducts a root cause analysis. It is important to make this objective and system focused, asking all the ‘Why’s and coming up with corrective action plans. 
2. The corrective Action- Give yourselves time to quickly implement the changes while the issue is fresh in the minds. Training/refresher or change of SOPs is best applicable at this stage. Document any training and have the relevant staff sign off against the training
3. Do monitoring and evaluation meetings at least fortnightly and at most monthly to ensure that all the corrective actions have been enforced and communicated to all staff. 

The Disciplinary Process:

While the culture of safety through finding fault with system, not individual, is the hallmark of quality and safety improvement, there are moments where institutional disciplinary processes have to be followed. The only way to maintain that judicious balance between a culture of safety and individual accountability is to ensure the RCA is done before the disciplinary process, however obvious a disciplinary process looks. In instances where there is an obvious negligence from the side of the staff, then it is important the formal disciplinary process is carried out 

1. The mortuary in-charge or the nurse covering or other relevant manager must fill an incident form or write a report indicating all the details including the staff involved. The incident report should include findings from the RCA if it is delayed. 
2. The statement by staff- if the incident was written immediately after the event, then a request for a statement should capture RCA findings. The staff involved is asked to write a statement in light of the incident. 
3. After the statement, a show-cause letter is written to the culpable staff outlining the specific areas of focus.  After the staff responds to the show cause, then based on the circumstances and the HR policy, you may proceed to issue a caution letter, a warning letter or organize a disciplinary hearing on the matter. The final disciplinary verdict is then communicated to the staff and their in-charge and captured in the personnel file.  

Common Root Causes

From experience, the common route causes are:

1. Poor (or lack of) SOPs, 
2. Inadequate capacity by staff, 
3. Inadequate supervision and policy enforcement- often, managers focus on the living and, though clear on the organogram, the morgue matters are rarely top priority.