Procedure for Preservation and Disposal of Dead Bodies in Hospital

The proper maintenance of the cold storage room is an important responsibility of the concerned hospital authority and the mortuary technician. The body should not be brought directly into the cold storage room of the mortuary. There should been open space outside the cold storage room, where the bodies can be brought in, to wait for preparation of the cold storage tray. The bodies should be brought to the morgue on stretcher and preferably be left on the stretcher in the cold room until disposed off.

Ideally, one body cabin is better than two or three bodies in one cabin which can lead to in-efficient working and occasionally to the confusion of one body with another. As a general rule, four cold storage cabins for each hundred beds in hospital is quite sufficient, excluding any provision for special circumstances like disaster, with some allowance for epidemics and the possibility of major accident. Within the cold storage area doors should be wide enough to allow easy entry and exit of corpses. The room should lead to the entrance area into the autopsy room. It is better to have a room with cold storage on each side, opening into a central wide area. Each cold storage door should bear a holder for an identification ticket. The name of the deceased should be written on a board on the wall of the room which lists each cold storage compartment. The temperature of the cold storage room must be kept at + 4 Degree Celsius.

It is the job of the technician to ensure that this temperature is maintained. It should not be allowed to fall bellow 0 Degree Celsius freezing point, because this will cause ice to form in the body tissues and the cells will be destroyed. Any subsequent microscopic examination of tissues that may be required after the autopsy will then be of little value. In case the body becomes frozen, there should be a boiler in the mortuary to provide hot water to defreeze the body. The frozen body become stiff and solidified and is difficult to conduct autopsy on it. To preserve the body for long periods, it must be deep-frozen. Therefore one compartment must be kept at-20 Degree Celsius. This is also helpful to store the decomposed body, which reduces the fowl smell. The body should not be put into this cabin until the autopsy has been carried out, the tissues taken for histological examination. Before a body is placed in the -20 Degree Celsius compartment, a linen sheet should cover the metal tray on which the body is to lie. If this is not done, the body may adhere firmly to the tray and be difficult to remove.

Disposal of a dead body

1. Death occurring in the Hospital

Once the death occurs in a hospital ward or casualty, the doctor (registered medical practitioner) who has attended the deceased in his last illness should issue the death certificate in a prescribed format issued by the government. Ideally there should be 4 to 5 copies of death certificate for non-medicolegal case and medicolegal case respectively

• for relative,
• for medical record,
• for municipal board for issue of formal death certificate,
• for autopsy request if required,
• for police, if M.L.C.

In AIIMS the death certificates are made in two copies for non-M.L.C. and in three copies for M.L.C. One copy is given to the relatives and one is retained by the hospital which is forwarded to municipal body. The third copy for M.L.C. is given to police. The doctor is legally bound to report all the medicolegal deaths to the nearest magistrate or police officer in the jurisdiction (S 29 Cr.P.C)8. All bodies (M.L.C. and non-M.L.C.) are kept in the mortuary cold storage till it is handed over to the relatives or the police. The doctor on duty or nurse on the behalf of the doctor should intimate the mortuary technician and send the body to mortuary along with a copy of death certificate. The body should be transported by stretcher. It should be covered by a shroud and then wrapped in a sheet. A standard label must be fixed to the winding cloth over the upper part of the body, so that when it is taken out of the mortuary cold storage room, head first identification is easy.

The death certificate and the label should be marked “M.L.C.” in bold letters for medicolegal cases. The label should have the following information on it: Patient’s name, address, the age and sex, hospital registration number, date and time of death and when the body was placed in the mortuary cold storage. The body should also have identity wrist bands, which serves as a ready means of identification.

The best label in a plastic waterproof type that clips on the patient’s wrist. It should carry as much information as possible, but should always include the patient’s full name, age and hospital registration number. The surname alone is inadequate. There maybe three or four corpses bearing the same surname in the mortuary at any one time. This can lead to serious confusion. As per Punjab police rules (25:37;5)7 in case of M.L.C. bodies it states that two police officer who have seen the dead body in the position in which it was found, and are competent to detect any attempt at substitution or tampering with the body or its coverings, shall accompany the body to the mortuary and remain in charge of it until examination is complete. If necessary an additional guard shall be supplied by the lines officer to place a sentry on the mortuary. The officer who have accompanied the body from the spot shall hand it over personally to the medical officer conducting the postmortem examination together with all reports and articles sent by the investigating officer to assist the examination and shall receive and convey to the investigating officer the postmortem report. This rule is followed in Delhi, Punjab, Haryana and Himachal Pradesh. Also the identification of the body is the duty of the relatives and the investigating officer. Further, Punjab police rule (25:37;6)7 states that as soon as the civil surgeon has intimated that his examination is complete, the police shall, unless they have received order from a competent authority to the contrary, hand over the body to the deceased relatives or friends. If there are no relatives or friends, or they decline to receive it, the police shall decide wherein the body to the buried or burnt according to the rules framed in this behalf by the district magistrate. The mortuary technician should also make sure that is identified beyond doubt by police and relatives before handing over the body to them. In case of Non-M.L.C. bodies it is kept at the risk of the relatives concerned. The hospital shall not be responsible for any decomposition or other physical changes in the body, which could happen due to sudden current failure or contamination with other bodies in spite of all precautions. The risk should be properly explained to the relatives.

2. Death occurring outside hospital

The non-M.L.C. bodies from outside maybe permitted to be kept in the mortuary for storage on the request of the relatives on the following conditions:

• Cold storage room must be in working condition.
• Space must be available for the body.
• Proper application along with a copy of death certificate, embalming certificate, if embalmed and no objection certificate from police.

The body shall be kept at the risk of the concerned relatives. In case of the M.L.C. the investigating officer should come with an application along with a copy of death certificate. As mentioned before the body shall be kept under the in charge of the police till the postmortem examination is conducted and handed over to the relatives. In AIIMS the permission for keeping the body is granted by resident doctor of forensic medicine during duty hours and by the duty officer in charge of the hospital administration after the duty hours. The body should be handed over to the police or relatives after proper identification.

3. Unclaimed body

The Punjab police rule (25:38)7 state that if a body is unidentified, the officer making the investigation shall record a careful description of it, giving all marks, peculiarities, deformities, other distinctive features and shall take the finger impressions. In addition to taking all other reasonable steps to secure identification he shall, if possible, have it photographed. In cases where such action appears desirable, a description should be published in the criminal intelligence Gazette. Unidentified body should be handed over to any charitable society which is willing to accept them, and if no such society comes forward, they should then be buried or burnt. In Delhi, the police sends telegram message called “Hue and cry notice’ to various police head quarters of the country. The “Hue and cry notice’ contained brief description of the identification features of the deceased. The body is preserved in the mortuary for 72 hours from the time telegram message is sent. If there is no one to claim the body after 72 hours the police is legally authorized to dispose off the body. But if the police think that the body maybe identified by the relatives, it should be preserved for longer time till relatives comes and claims the body. The expenditure on the disposal of body in unidentified case are born by the police department. This is applicable in medicolegal cases expired outside hospital or inside the hospital.

Again as per Punjab police rule (25:36)7 an investigating officer is empowered by law to waive off the postmortem in case he thinks that there is no foul play and death is due to natural cause. In Delhi the Assistant commissioner of police is authorized to waive off the postmortem on the recommendation of the investigating officer. However autopsy surgeon can recommend investigating officer for waiving off the case if he think it is a case of natural death, but the final authority rests with the Assistant commissioner of police.

In case of unclaimed bodies in hospital, died due to the natural cause, the hospital authority is lawfully in charge of the body. It should send telegram messages to whatever address is available. If the body is unclaimed after 72 hours, it is legally authorized to dispose off the body bearing it’s expenditure. As per human transplant act 1994, the hospital authority is authorized to give permission for removal of any human organ from the unclaimed body after 48 hours. However if the hospital has reason to believe that some near relative might object, the permission to remove the organ must not be given. The unclaimed M.L.C. bodies in hospital should be handed over to the police who shall dispose off the body after postmortem.

4. Embalmed body

The body taken for embalming should be identified properly beyond doubt and proper consent from a near relative or from the person in lawful possession of the dead body is necessary. It would also be accompanied by death certificate, postmortem certificate, if postmortem was done and no objection certificate from police. In foreign nationals, clearance from respective embassy is necessary. Embalming5 should not be done before autopsy (where autopsy is necessary) as it destroys the medicolegal evidence, especially in poisoning death, by hindering its detection’s in viscera. On completion of embalming, a certificate is issued by a competent authority (embalmer). This certificate is prerequisite for transportation of the body. Embalming is necessary to prevent putrefaction in case the relative wants to keep the body for longer time. In case of anatomical embalming it helps in the preservation and sterilization of the body besides making it suitable for dissection. It is not necessary to keep the embalmed body in the cold storage. Dehydration and hardening is a common complication in the embalmed bodies kept in the cold storage in a tropical country. For transporting the deal body, a watertight coffin is recommended by the railways and air service department.

5. Cadavers for anatomical dissection

The Anatomy Act 6 was enacted in 1949, which has been uniformly adopted in all states of the republic of India. It provides for the collection of a dead body for teaching purpose, only if death occurs in a state hospital or in a public place within the prescribed zone of medical institution, provided the police have declared a lapse of 48 hours that there are no claimants for the body and it could be used for medical purpose.

6. Pathological autopsy

It is also called clinical autopsy. Here the doctor seeks to learn the extent of the disease or cause of death for which they were treating the deceased patient. A proper consent from the near relative or in lawful possession of body is necessary. As mentioned before, any body kept for autopsy (clinical or medicolegal) should not be kept in a frozen cabin in the cold storage. It hinders the microscopic examination of tissue by destroying cells. Here it is important to mention that any sort of disrespect or unnecessary mutilation of dead body may amount to an offence under section 297 I.P.C.

7. Mass disaster

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 i.e. white strips for non-critical cases, yellow with blue strips for more serious cases and yellow with the red strips for emergency cases. 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. Air conditioned tents, which may be erected conveniently at any place may be considered at every 500 and above bedded hospital. 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. For example, in “Uphar tragedy”, where about 58 peoples died the postmortems was waived off by the Lieutenant Governor of Delhi. The emergency mortuary may be a tent house, which can be adapted as necessary, but its use depends very much on the weather. Briefly the temporary mortuary should have the following characteristics:

1. 1. Privacy
   2. Ease of access
   3. Entry of mortuary area
   4. Continuity and facility for:

• • Body storage
  • Primary reception area
  • Autopsy facility including recovery of clothes
  • Encoffining

V.Ancillary Services

1. 1. • Laying out

1. 1. • Examination of effects

References

1. Gresham, G.A. Postmortem procedures. World Medical publications Ltd. London. 1979: 16-28
2. Bernard Knight. Forensic Pathology. Arnold Publisher, London. 2nd edn, 1996:10
3. Polson, C.J. The essentials of Forensic medicine. Pergamon press, Oxford. 4th edn, 1985: 677-94
4. Parikh, C.K. Medicolegal Postmortems in India. Medical Publications, Bombay. 1985: 157-160
5. Ajmani, M.L. Embalming-Principles and legal aspects. Jaypee Publishers, 1998:81-91
6. Subrahmanyam, B.V. Modi’s medical jurisprudence and toxicology. Butterworths. 22nd edn, 724-27
7. Koshy, K. Punjab Police rules, vol III. The Bright law house. 1992: 1078-83
8. Sarkar, P.C. Criminal major acts. Orient law house, New Delhi. 6th edn, 1999
9. Manual for control of hospital associated infections. NACO, Ministry of health and family welfare, Govt. of India.

T. Millo, Arun Agnihotri¹,
Shakti Gupta²,
T.D. Dogra³

¹ Senior Demonstrators, Dept. of FMT, AIIMS

²Addl Prof. Dept. of Hosp. Admn., AIIMS

³Prof. and Head, Dept. of FMT, AIIMS

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