This section is concerned with deaths in which criminal and forensic investigations play little or no part. The most extreme emergency of this type would probably be a pandemic such as the influenza pandemic for which Category 1 responders have been asked to prepare. Other emergencies requiring only limited post mortem forensic work would be those where sufficient evidence had already been collected or where the investigation focused on non-human aspects of the incident, e.g. natural disaster.
The remainder of this section will consider the management of the fatalities that are expected to result from an influenza pandemic, as a particular example of this type of incident.
Interest from Procurator Fiscal
The number of deaths requiring referral to the Procurator Fiscal during a pandemic will be affected by any changes to legislation and by derogations in force (see page 21). While the proportion of total deaths referred is likely to fall, the absolute number may not. The Crown Office Procurator Fiscal Service (COPFS) may consider criteria for referral of cases to them during a pandemic, the derogations relating to this and their own internal business continuity arrangements.
Pandemic Planning Assumptions and Context
In the National Risk Assessment, Pandemic Influenza is categorised as one of the highest risks in terms of its likelihood and impact. A comprehensive overview of pandemic influenza planning in the UK is given in UK Influenza Pandemic Preparedness Strategy; further references are given in Appendix 1.
The following points are of particular importance for mass fatalities planning.
- it is not possible to say with certainty what the clinical attack rates, case fatality rates, or duration of a pandemic will be; furthermore there may be significant local variation in the timing and intensity of its impact
- deaths rates may be higher in some age groups, e.g. the very old and very young, or young adults, but which groups will be most vulnerable is not known
- the pandemic may be spread over one or more waves, which could be weeks or months apart
- due to this uncertainty, local planning should be based on a reasonable worst case scenario
- the availability of staff and the provision of many services will be reduced during a pandemic. Arrangements that rely on overtime, agency or locum working may be particularly affected and cannot be regarded as robust
- arrangements relying on just-in-time delivery of supplies may be vulnerable.
Recommendations for Different Ways of Working
During a pandemic it is likely that changes to normal working practices will be needed by some or all of those agencies involved in the care and management of the deceased and the support of the bereaved. In all cases it is essential that any changes ensure the respectful treatment of the remains of the deceased and consideration for those who have suffered a bereavement. Although senior staff will determine what is done, how procedures are implemented will be very important. This will depend on operational staff, who may also be under considerable pressure. Planners and responders should consider how the quality of service and care of staff can be maintained under adverse circumstances such as these.
Mortuary Services Storage Capacity and Throughput
The following terms are used in this guidance:
Mortuary - a building where bodies are stored securely, often in refrigerated conditions, cared for by trained mortuary staff, and where additional mortuary services may be provided. These additional services may include autopsies, collection by undertakers and family viewing, and will require additional accommodation, staff and equipment.
Temporary Mortuary – this differs from a permanent mortuary only in that it is not a permanent structure. Some temporary mortuaries may not provide the full range of additional mortuary services (the NEMA are discussed on page 19).
Body Storage Facility - a location used for the long or short term secure storage of bodies under refrigerated or frozen conditions, either to supplement mortuary capacity or to support a temporary mortuary. Trained mortuary staff are not necessarily involved.
Throughput Capacity and Buffer Space
To respond effectively to the mortality rates of the reasonable worst case pandemic influenza planning assumptions, the throughput of mortuaries must be maximised. This will require an increase in all resources required to support a mortuary, including physical workspace. To manage the variable rates at which bodies may be transferred to and from mortuaries, the different amount of work needed for different cases and the activity of parallel teams of mortuary staff, capacity increase should include provision of additional short term “buffer” space. This is an area where bodies can be kept for up to 24 hours before or after mortuary procedures are carried out and can be thought of as a means of increasing the mortuary work- space. Unlike other forms of storage, it is a means to increase the rate and volume of work done, rather than deferring it to a later date.
Local planners and responders in agencies responsible for mortuary provision should ensure that arrangements are in place to increase both working capacity and throughput at short notice, by:
- ensuring that current staffing arrangements for all grades of staff are based on valid and sustainable assumptions
- modifying work patterns to increase working hours up to 24 hours/day and 7 days/week
- redeploying staff from other functions to work under the supervision of existing staff
- deferring any non-essential services and procedures
- identifying additional staff and training them for mortuary work or making them available for rapid orientation and induction (procedures and agreements for doing this will also be required)
- holding sufficient levels of equipment and consumables to support any required increase in levels of staffing and throughput (e.g. body bags) or pre-identifying suitable sources of supply
- conducting regular maintenance and inspection of equipment and having available back up equipment and spare parts
- developing management, communication and coordination arrangements for the required level of throughput, involving relevant partner organisations and responders as necessary
- considering how to achieve effective liaison between mortuaries, funeral directors and other agencies; or establishing an RRP sub-group to do so
- considering supplementary arrangements for the collection of the dead should undertakers be unable to collect bodies within the usual time (this is particularly relevant to care facilities which rely directly on undertakers)
- identifying accommodation within permanent buildings which can be used to expand mortuary workspace and provide buffer capacity.
In some situations, depending on local circumstance and the type of emergency, increasing throughput might not be sufficient to manage the number of deaths. Body storage might then be needed to defer mortuary, cremation, burial or other aspects of the care of the deceased.
When assessing proposals to combine increased throughput and body storage planners and responders should consider the additional demands made by a storage facility and possible effects on the bereaved. These include the additional work and costs of:
- placing bodies in storage
- recovering them from storage
- staffing and securing the place of storage
- administering the system.
The storage of bodies might also add to the distress of those who are grieving, particularly if their faith or culture requires prompt burial.
If the storage of bodies becomes necessary or is introduced in an attempt to defer some of the workload of the most severe days or weeks of a pandemic, those options not prepared in advance may present difficulties. Generally sourcing items from a third party at the time of a pandemic would involve additional risk due to the likely supply shortages. The creation of additional local “in house” body storage should therefore be considered.
Funeral Director Services
Achieving efficiencies in the time and staffing required for the work of funeral directors, while retaining the dignity and respect for the deceased and care for the bereaved, will be one of the most important elements in dealing successfully with excess deaths. The arrangements made following a person’s death for funeral
services and the burial or cremation of their remains are based on the customs and preferences of individuals and, to various extents, of the faith groups to which they belong. Many aspects of these arrangements are non-statutory and often commercial in nature. While the aim will be to maintain funeral services as near to normal as possible, it may become necessary to restrict the choices available in order to avoid delays affecting essential legal or health priorities.
Funeral directors will wish to provide the best possible service to their customers that are consistent with the commercial requirements of their businesses. The higher number of deaths will increase activity in this sector and creating additional capacity may be challenging.
Local planners should encourage Funeral Directors to consider the different ways of working listed below and take into account the degree to which they are able to implement these changes and the capacity levels that could be realistically achieved.
Capacity can be increased by considering:
- modifying normal work patterns by increasing working hours, introducing shift working, moving to seven day week operation
- employing extra staff to act under the supervision of existing staff
- re-evaluate staff roles to maintain only essential services and procedures e.g. the deceased are taken directly to the place where the funeral service will be held or to the place of burial or cremation, no car service is offered, the bereaved persons attending funerals are met there
- shorter services
- separation of the internment/cremation from the service which can be held later, particularly if there is advice against gatherings of people for reasons of health and wellbeing
- where several businesses are owned or networked, agreements to pool resources (e.g. reception staff, telephone operators, private ambulances) should be negotiated
- identify issues of resilience in the supply chain e.g. coffins
- working with other disciplines e.g. developing agreements to take on agreed non- technical duties at the chapel, crematorium, or cemetery, with a view to assisting cemeteries and crematoriums to deploy their own staff to other essential duties
- identifying additional vehicles and drivers for the transfer of bodies, particularly the uplift of bodies from dwelling homes and care homes.
Process can be streamlined by considering:
- working with local planners to establish ways to communicate and coordinate the use of available capacity
- limiting the choice of types and sizes of coffins offered, to ensure manufacturers can supply to demand
- the use of low bulk inner coffins, combined with a reusable exterior shell of a traditional design, or “cardboard” and “eco-friendly” types.
Local planners and responders should ensure arrangements take into account the use of particular or specialist funeral directors by some religious and ethnic groups.
Religious Services and Faith Communities
The Scottish Government will continue to liaise with representatives of different faith groups nationally, but Local Authorities should also facilitate engagement, where there are particular local issues. Representatives of faith communities and cultural groups will want to consider the impacts of a pandemic for the people they represent and to work with agencies that are planning for such an event.
Although many of the concerns of Scotland’s different cultural and religious groups will be similar in relation to mass fatality emergencies, there will be some areas where priorities and requirements will differ. Planners should therefore seek the views of local representatives and plan with these in mind. The following issues should be considered:
- whether the availability of celebrants for religious funeral services, or other staff, is likely to be a problem and how this could be addressed
- what might be done to increase the capacity to conduct services and rites
- whether the availability of specialised funeral director is likely to be a problem and how this could be addressed
- whether funerals could follow an alternative or simpler format, e.g. a shorter service at the crematorium or place of burial, with a memorial service at another venue (e.g. the home or place of worship)
- at which locations religious services and rites can take place (e.g. cemetery or crematorium chapel, chosen place of worship, home, or other setting)
- which elements of traditional funeral practices are most important and which could be modified, if necessary
- whether burial or cremation is preferred, whether this requirement is absolute, given the extraordinary circumstances of a pandemic, also whether there should be particular minimum or maximum periods of time between death and burial or cremation
- how these points will fit in with the different ways of working being implemented by the other organisations
- as it may not be possible to offer all the features of traditional rites and practices, planners should acknowledge this and prioritise those customs of greatest significance to the deceased and the bereaved.
Burial, Cremation and other types of funerals
Currently in Scotland, approximately 33% of people elect to be buried and 67% to be cremated. However, these preferences reflect the views of the elderly and may differ from those of the population who die during a pandemic or of particular local populations.
Cemeteries and crematoriums should aim for most burials and cremations to take place as soon as possible following death in order to minimise the impact on additional mortuary or funeral parlour storage capacity.
Estimates provided by the Federation of Burial and Cremation Authorities suggest that approximately 70 cremations per week can be provided for by a single cremator. Local planners should assess burial and cremation capacity in their area and ensure that the necessary arrangement and protocols exist so that this is maximised, taking into account the effects of implementing the different ways of working listed below:
- encourage private and public sector cemetery and crematorium operators to engage with planners to enable the implementation of necessary measures at short notice
- plan for and assess the capacity issues that are likely to result in future years from the rapid use of space.
It is recommended that managers of cremation and burial services explore the following different ways of working:
- extending opening hours and working days to cope with increased burials, cremations and absenteeism
- redeploying and licensing staff from other local authority functions as part of their BCM arrangements (while maintaining an awareness of necessary staffing levels for other essential LA functions, such as death registration)
- collaborative working with funeral director staff – allowing staff normally required for committals to be redeployed elsewhere
- ensuring that funeral directors and crematoriums are on the priority list for fuel –
- cremators and vehicles
- encouraging funeral services to be held in local places of worship
- introducing shorter time slots for committals
- providing graves in ways which allow interments to be undertaken more quickly, e.g. prior mechanical preparation of several graves and scheduling consecutive burials.
They should also:
- ensure regular maintenance and inspection of equipment is conducted and that back up equipment and replacement parts are available
- consider guidance in relation to pollution control requirements (Appendix 5 SGAQ01(09) Crematoria Standards in the Event of Mass Fatalities)
- discuss permitted hours of operation under their licence
- ensure that plant can be obtained and deployed at short notice for the mechanical excavation of graves.
The use of “common graves” could cause distress to those who have been bereaved and has limited practical benefits; their use is therefore discouraged. The term “common grave” is used here to mean an excavation of sufficient space to permit several separate individual burials. Usually these are prepared mechanically and the bodies interred are of unrelated people. While this might address difficulties due to shortage of land for burials or limits to how quickly traditional graves could be dug, it should be possible to anticipate these situations and find alternative ways to resolve them.
Place of Death and Uplift of Bodies
The higher mortality rates during a pandemic may lead to an increased proportion of
death occurring at peoples’ homes. This will require similar increases in:
- certification of deaths by primary care staff
- the need for immediate care for the bereaved at home
- the number of bodies to be transferred from dwelling houses to funeral parlours and mortuaries.
In addition to the guidance provided by the Chief Medical Officer on certification of death during an influenza pandemic, Local Authorities and NHS Boards should ensure there is clarity regarding the practical advice and care that the bereaved will require immediately following a death, particularly as this may differ from the provision in normal circumstances. This should include:
- assessment of health and social care needs of vulnerable individuals;
- advice about currently available funeral director services
- advice about current procedures for the registration of the death and the burial or cremation of the deceased
- the role of community health and social work services
- circumstances when the death has been identified by someone other than a general practitioner.
Local authority planners and responders should ensure that staff in care settings are prepared to support the bereaved and to work with NHS primary care staff and faith groups in relation to deaths in the community.
Funeral Directors will usually be called on to uplift bodies from homes but also from hospital mortuaries and directly from some hospital wards and care homes. Assessing, coordinating and implementing the uplift and transfer of bodies are considered on page 16.
Care of the Bereaved
Although of great importance, a detailed review of the psychological and emotional healthcare of the bereaved and the spiritual aspects of a mass fatalities emergency lie out with the scope of this document. Planners and responders should consider this as part of the integrated management of the emergency, taking into account the particular circumstances and cultural context of those affected. This should include consideration of the individual needs of those directly affected and the requirements of the wider public, both in the immediate aftermath and in the medium and long term. References to relevant information are given in Appendix 7 Further generic guidance on this part of the response is available in the Care for People Guidance and associated psychosocial supplement.
National Emergency Mortuary Arrangements (NEMA)
National Emergency Mortuary Arrangements are not intended for use for mass fatalities caused by a pandemic as the geographical and timing spread of deaths makes the use of such facilities impractical in a single location. Use of NEMA in other situations is discussed on page 19.
Coordination and Joint working
During an extensive mass fatalities emergency the effective use of resources and capacity in mortuaries, burial grounds and related services will be particularly important. Delays in these areas may result in backlogs which can lead to increased pressure on body storage facilities, compromise care of the living and add to the distress and long term ill effects on those who have been bereaved and on the wider society. It is recognised that the coordination of throughput and capacity over several weeks may be an unfamiliar challenge to those staff who are normally called upon to lead responses; it is therefore recommended that planners and responders consider how this will be carried out, with particular reference to:
- clarity of objective: the purposes of this process is to identify current and potential delays to the provision of mass fatality services and resolve these by redirecting demand for services, redirecting resources or recommending the commencement of different ways of working locally
- consideration of the establishment of a specialist Mass Fatalities Services Coordinating Group lead by a senior officer of the Local Authority (or other suitable person) to coordinate capacity management
- having an understanding of interdependences between services for managing mass fatalities
- identifying the minimum amount of data needed in order to coordinate the system
- how information about numbers of deaths and service capacity will be provided in a timely fashion, so that the minimum of additional demands are placed on those collecting it, and in what format this should be collected and how often. It will often be important to know the rate at which these services are able to work, as well as the amount of space available in their premises
- what the local thresholds for changes in working practices are and what options could be recommended locally at that stage
- how recommendations to respond in a particular way will be communicated
- how this role will relate to the provision of NRS data on deaths and predictions of future mortality and morbidity
- how this role will relate to those of operational managers of particular services and other Resilience Partnership command and control functions
- how this role will relate to derogation of legislation introduced by the Scottish and UK governments.