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MASS FATALITY PLANNING FOR THE UNKNOWN

Over recent years there seems to have been an increase in major incidents. Alongside a range of natural disasters... 

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... there has been a rise in hostile events in the developed world. With the UK terrorism threat currently classified as “severe”, Ishbel Gall and Alison Anderson explain how mortuaries plan for the unknown.

NHS and public mortuaries have, in the main, the capacity to deal with “business as usual” and winter pressures, but it doesn’t take much extra workload for capacity to be reached. Unfortunately, the deceased are spending longer in mortuaries due to factors including lack of pathologists and the cost of funerals, which is putting increasing pressure on available storage space.

Often it is hard for anatomical pathology technologists (APTs) to impress upon management just how unpredictable workload can be, as unlike many other professions, our clientele don’t adhere to any timetable and we must plan for the unexpected.

The challenges

Most mortuaries have well documented contingency plans for intensive mass fatality and disaster, and extensive (pandemic) events, with the two requiring slightly different approaches.

With extensive events, many areas of the country may be affected by excess deaths and storage may be an issue nationally, but there is not usually an impact on the post-mortem examination numbers, as the cause of death is known, or presumed.

National and local influenza pandemic planning has been high on the agenda for some time as it is seen to be one of the most likely potential threats to resilience.

Intensive incidents are usually localised in one area, so expertise can be brought in. More frequently, exercising of plans involves a presumed hostile element, where there may be more than one incident, in more than one location, and this means having to work round issues including staffing, equipment and other perceived resources. But each incident is different, so there can never be one overarching plan.

Contingency plans

When there is a major incident, the Home Office has National Emergency Mortuary Arrangements (NEMA) in place, this can provide body storage and a large mortuary facility that can be configured for up to 600 fatalities. This arrives “flat-packed” on several lorries, and needs utilities and a large area of fl at ground for assembly.

Finding a site can be problematic, as can deployment to remote or island sites. In July 2005, a temporary mortuary was set up in the grounds of the Honourable Artillery Company in central London, following the 7/7 bombings.

To date, this is the only time that the structure has been used in its entirety. The Home Office definition of mass fatality is: “Any incident where the number of fatalities is greater than normal local arrangements can manage.”

Incidents can be due to natural causes, such as the Boxing Day tsunami in 2004, transport incidents, hostile acts and industrial accidents. There is no one-plan-fits-all and when there is to be a criminal investigation, bodies may be fragmented, or there may be many unknown fatalities.

This greatly increases the numbers of people involved.

Public expectation

Due to advances in technology and the use of social media, there is increased pressure on staff to provide answers and identities very quickly. The public and media expect information immediately and even after single person incidents, it is common for the deceased to be named on social media before a formal identification.

This pressure should not colour judgement and procedures should be followed to ensure correct identification. Following an incident, one of the first decisions should be which mortuary is to be used, or if a temporary mortuary is needed. Except Scotland, other areas of the UK require an HTA licence before activation of any emergency mortuary.

This will not be granted until the HTA is satisfied that a suitable Designated Individual and Licence Holder are appointed and the premises are suitable. It may be that a current mortuary can be identified as suitable and if it meets the criteria, this should be the first preference.

Capacity and numbers

If there is to be a Disaster Victim Identification (DVI) investigation, this will involve a large number of police, as well as the APTs and pathologists and there may be a requirement for other forensic experts, such as forensic radiographers, odontologists and anthropologists.

Accommodating the numbers can prove challenging and NHS or local authority resilience teams should ensure that there are suitable car parking, rest areas and catering facilities available. It may be more feasible to arrange transport to get personnel to the mortuary as often parking space is at a premium.

Some NHS facilities have arrangements with their radiology departments to provide CT scanning as part of the DVI process and there should be a clearly identified route agreed with radiology, mortuary, facilities and police to ensure this can proceed as discreetly as possible. It may be deemed necessary to hire a portable scanner to be sited next to the mortuary facility.

Timescales

It can be difficult to estimate an incident timescale, which will depend upon the number of post-mortem tables and pathologists/APTs available. The nature of the incident and the condition of the fatalities also affects timescales – extreme fragmentation or burnt remains will present challenges.

Pathologists and APTs can be supplemented through mutual aid or national call-out lists. In a recent DVI exercise in Scotland, the UKDVI APT Response Team was “activated” and 21 APTs were available to deploy immediately, if they had been required.

It is important to draw up a realistic throughput plan (see Table 2) as there will be huge pressure in high profile events to identify the fatalities quickly. That said, the DVI process is time-consuming and should not be rushed.

The process involves the completion of Interpol Disaster Victim Identification Forms, which family liaison officers complete with the families of the “missing” and post-mortem forms, which are completed by the mortuary teams of the “unknown” fatalities.

The forms are then compared by a reconciliation team before being presented to the Identification Commission to authorise release of positive identification information to the next of kin. The decision on confirming identification is dependent on there being a primary identifier, such as dental records or DNA, supported by secondary identifier, such as jewellery or tattoos.

It should be noted that personal effects, including clothing and jewellery and other items, will need to be stored during the incident, possibly for a long period if there is to be a criminal investigation, and it is easy to underestimate the space required. The same amount of space is required by the DVI process as that to carry out the post-mortem examination.

Routine services

If an existing facility is a designated disaster mortuary (DDM), then there should be arrangements in place that will allow “business as usual”. Routine services should be provided with little disruption – a death can be as traumatic for the bereaved, whether natural or as the result of a mass fatality incident, and this should be taken into account when taking the decision to become a DDM.

At the forefront of any work within the mortuary is ensuring dignity and respect. Many issues, such as media policy, will already be in place through other local resilience plans, but it is important that all agencies which are potentially going to be involved in any emergency mortuary work together on planning and exercise that plan to ensure any issues are resolved before the plan is implemented.

The most important APT role, apart from facilitating the mortuary, is to ensure the deceased are treated with dignity and respect throughout the process and those conducting investigations treat them in the same way. As Charles Haddon-Cave QC said: “The care with which our dead are treated is a mark of how civilised a society we are.

Much goes on for understandable reasons behind closed doors. For this reason there is a special responsibility placed on those entrusted with this work and the authorities who supervise it to ensure that the bodies of the dead are treated with the utmost care and respect. That is what bereaved and loved ones are entitled to expect and what society at large demands.”

TEMPORARY MORTUARY

If a temporary mortuary is required, there are a few key points to be considered, location probably being one of the most important.

✔ The locus of the incident will affect the decision, but if a temporary facility is used, thought should be given to the building’s current use and how easy it will be to give the building back once the investigations have been completed.

✔ Access and egress, to afford privacy to the deceased and potentially any bereaved families. Staff should be considered in plans.

✔ Availability of equipment, PPE and other consumables.

✔ Access to utilities and secure communication channels.

✔ Security of the site.

Incident classification
Incident classification

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