MORGUE

AMMENDMENT SHEET

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 1. FUNCTION:

To preserve the bodies of the deceased (expired in the hospital) till they are

taken by the relatives

2. OBJECTIVE:

 To ensure the temperature of the freezer is maintained at optimum

 To ensure the identity of the deceased while receiving and handing over the

body

2. INSTRUMENTS/MATERIALS REQUIRED:

Freezers, Registers

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 4. STANDARD OPERATING PROCEDURE

4.1 Preparation of the Body:

 The declaration of death is done by the concerned doctors’ team in front of

the relatives of the deceased as per the protocol.

 Death care is given in the Unit itself by the senior nurses on duty and it is

packed as per the protocol.

 An identification paper, which has details like name, age, time of declaration

of death and place from which the he / she is hailing from and stuck on the

body. The MSW ensures that this is properly done.

 The nurse enters all the details of the body like name, age, time of death and

place in the Death Register which is maintained in the ICU, first and second

floor Ward. She signs in it. She also takes signature from the Medico Social

Worker or the Manager on Duty in the same register. She also enters the

details of the items and documents that are handed over to the relatives and

gets their signature in the Handing over Register.

 Infected bodies are labeled as per infection control colour coding.

4.2 Policy for handling cadavers and Disinfection in the morgue.

 All personnel involved in mortuary practice should follow standard

precautions.
 The mortuary is thoroughly cleaned every morning. Walls, floors, tables&
racks should be disinfected with 1% sodium hypochlorite solution.
 Cadaver is washed with tap water and then with 1% sodium hypochlorite
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 solution. Nose and mouth should be plugged with cotton swab soaked with
appropriate dilution.
 Cadaver is then put in a plastic bag for handing over to the relatives to avoid
dissemination of infections. The relatives or attendants receiving the body
should be informed about the safe method of handling and cremation of the
body.
 All clothes used for known infective cases should be disposed off by
incineration.
 The tables and floors should be carefully wiped out with a 1% hypochlorite
to remove bloodstains, body, fluids followed by cleaning with soap and
water.
 Aluminium and stainless steel instruments should be decontaminated with
2% Lysoformin solution. After 4 hours, the instruments are washed and
autoclaved, and are then reusable.

 After handling the cadavers, the staff must wash their hands thoroughly with
soap and water.
 Plastic apron, plastic shoe cover, gloves, plastic cap and mask used by the
staff must be discarded in a plastic bag. Tie the bag properly and send it for
incineration.
 The pajama, shirt and cotton gown worn inside the above plastic apron
should be soaked in sodium hypochlorite solution and washed with water,
and then sent for autoclaving.

4.3. Counseling of the patient relatives

 Counsel the relatives of the deceased, which is done by the Medico Social
Worker.
 Ask them to collect the death certificate from the Bommasandra Panchayat
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 Office.

 Prepare the death report, which will have three copies. One copy is retained
in the hospital, one is issued to the local Panchayat and the third copy is
handed over to the relatives.

4.4 Shifting of the body:

4.3.1 for local shifting:

 Arrange for a vehicle to shift the body as per relatives’ request, which is done
either by the MSW or the Travel desk.
 Hand over the death summary and death report to the relatives and shift the
body.

4.4.2 For out station:

 Once the packing is over shift the body to the cold room if the agency’s
ambulance has not arrived. Then hand over the body to the relatives to shift
into the agency’s ambulance.
 Incase the ambulance arrives immediately after the packing is over, hand
over the body to the relatives so that the body is shifted into the vehicle. This
agency does the embalming of the body, completes other formalities and
places the body in the coffin if the relatives are willing to take the body on the
same or next day. Then the body is placed in the Cargo till the time of the
departure of the flight.
 Receive the body after embalming if it has to be preserved in the cold room
(especially in cases of body being taken to far off places or abroad) after
proper and adequate labeling of the freezer. The label should contain details
like name, age, time of declaration of death etc.

Then make necessary arrangements for the shift of the body depending on

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 the time and date of departure.
 In this case, all the rest of the formalities like cargo permission, police
clearances, tickets clearance etc is done by the same outsourced agency.

4.5 Processing the Death Report:

 Three copies of Death Report are generated by the senior nurse. A copy in
Pink is given to the Patient Relatives along with the Death Summary & the
Dead Body.
 The other two are filed in the Patient File, out of which, a copy in Yellow is
sent to the Panchayat and a copy in Green is retained in the File.

4.6 Unclaimed Bodies:

 If in case any dead body is not claimed by relatives, Medico Social Workers
will search for the relatives.
 Even after 48 hours of search, if failed to trace them or contact them, inform
the Police.
 The body will be handed over to the Police for further action.

4.7 Handing over the body

 After death declaration by Doctor patient relatives are counseled by MSW.
 The body is packed carefully and is sent to Mortuary department along with
all records.

 The body is handed over to the relatives in the presence of Nurses and MSW.
 The housekeeping staffs in turn shift the body to the vehicle.

4.8 Morgue Keys:

 The morgue is under lock and key. The keys are available with the
Housekeeping staff who is exclusively posted in Morgue between 8:00 am till
6:00 pm.
 He hands over the key to the MSW on duty at 6:00 pm and the same is

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 available with them till 8:00 pm.
 The key will be with the MOD between 8:00 pm till 8:00 am the next day.

4.9 Maintenance of the freezers:

 In case of leakages from any of the freezers, contact the maintenance
department for repair.
 Monitor the temperature of the freezer at the optimum level and record the
same in ht form of graphs.

4.10 Medico Legal Cases (MLC)

 For all MLC cases at the time of admission and death, MRD informs police.
 Deceased body is handed over to the police by MSW in presence of relatives

PRECAUTIONS IF ANY:
 To ensure that proper identification of the body is done before handing over
to the relatives

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 ANNEXURE I

Protocol for body identification

 The body comes down to mortuary area after the completion of
formalities from the wards/ I T Us.
 The body may be identified by the relatives down in the mortuary
 The concerned Nurse verify the death report/ summary/label on the
body before handing over to the relatives
 Nurses will counter check the same with the M S W/ M O D
 Then the nurse will open the face and shows to the relatives
 Then face is covered and shifted to the vehicle

Protocol for counseling the patient relatives

Counsel the relatives of the deceased is done during the day by the MSW and at
night by the M O D

Protocol followed to shift the body to the mortuary

 Once the packing is over the body is shifted in the closed trolley to the
cold room
 No body will be retain in the unit due to delay of finance clearance
 In case any delay in vehicle the body can be kept in the mortuary with the M
S W/ M O D approval

Protocol for Medico legal cases

 For all medico legal cases at the time of admission and death MRD at
daytime and MOD in the night inform the police station.
 Body is handed over to police by MSW or MOD in the presence of
relatives.

Protocol for embalming the body

 Once the relatives decided to take the body by flight MSW/ MOD inform the
reception.

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  Reception arrange with the out source to do the Embalming / coffin box
/ police clearance/ Cargo clearance.
 Local patient requesting for embalming the same procedure followed but
after embalming the body is handed over to the relatives.
 If there is a delay in cargo clearance the body is brought back to the
morgue and taken after the clearance.

Infection control protocol for Mortuary

 The floor and the walls of the mortuary cleaned with bacillo floor twice
every day.
 The trolley and the freezer trolley cleaned with isopropyl alcohol after
removing the dead body.

 Any body fluid spill on the trolley and in the freezer compartment or on
the floor has to be soaked with sodium hypochoride and subsequently
mopped with linen and the same is discarded
 The trolley inside the freezer has to be cleaned with sodium hypochrloride
 All the above procedures have to be performed with a mask and heavy
duty glove.
 The expected temperature ranges between 36 F to 47 F, 2 C to 8 C

Procedure for Death certificate coordination

 Death report is written by the concerned doctor

 The nurse and MOD / MSW is the coordinator to organize the report
o Pink Form– patient relative
o Yellow Form- Panchyat
o Blue Form – patient file
 The yellow form is handed over to the Panchyat by the MRD
 Then the certificate is issued by the Panchyat

Special protocol for overseas patient

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  The same is followed like other deceased person

 The passport is collected and handed over to the travel desk to arrange for
embalming / police clearance / embassy clearance/ visa extension if
required/ foreign registration office permission/ custom clearance/ coffin
packing
 After embalming any delay in flight booking the body is brought back to the
morgue and the body is sent back after the final clearance from the
hospital.

Out source transport for contact

 The contact number of the outsource is available in the travel desk (NCH)
during day time
 Ext: _________.
 Night contact no: _______________________
 Outsource contact no: ________________ Ambulance Service: _____________________
 This is coordinated by MSW/ MOD
 The same policy used in the ambulance break down while carrying the
patients.

Protocol for transferring the body for autopsy

For all the medical legal cases at the time of admission and death, MRD will
inform police. In case of death, the body will be handed over to the police
department after taking their signature, PC no. And discharge summary if
required. They in term receive and shift the body to the district hospital for
autopsy, later handed over to the relatives.

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