Hi there,
The Fuller inquiry Phase 2 report landed with 75 recommendations and a stark conclusion: current arrangements for the care of people after death are “partial, ineffective and in some areas completely lacking.” It might be tempting to put in some new audit criteria, and keep on keeping on. But I was chatting to a friend about how we need to use our systems lens to examining the mortuary services. Side note – I was terrified the first time I had to go to a mortuary, I was quickly humbled by the compassionate nature of the teams working in that space. I’m really glad I took the time to learn about that service. It might feel intimidating to think about going to that space, but hopefully this will help you get a feel for what you might be looking for. And if you need support afterwards, then please seek some.
Fuller worked beyond his contracted hours, undertook unnecessary tasks, and operated in what the inquiry called an “uncontrolled environment.” To a human factors practitioner, these aren’t just procedural failures they’re signals of deeper systemic issues.
Taking a PSIRF and systems approach to understanding organisational risk from the Fuller report
The inquiry’s overarching recommendation is that there should be statutory regulation in place to protect the security and dignity of people after death, but regulation alone won’t solve this. What we need is a systematic approach to understanding our organisational risks, exactly the kind of thinking PSIRF encourages us to apply.
Using a SEIPS framework, we can ask the right questions about our own mortuary services:
Person factors: What staff training is in place around mortuary procedures? How is staff wellbeing being supported in what can be emotionally challenging work? What does sickness absence data tell you?
Task factors: What does the audit portfolio look like for mortuary services? Who reviews length of stay data (a key feature from the Fuller case)? Are barcode scanners for admission and discharge available and being used properly? Is there a consistent clinical record for each patient linked to the EPR? Are there patterns in who accesses the mortuary – any “frequent fliers” that warrant attention?
Technology and tools: What camera monitoring exists and when is CCTV actually reviewed? Is there independent oversight of this monitoring? What does access in and out look like? Is it properly controlled? What are the “norms” around access that have developed over time? Are there times when no mortuary staff are present? Where are the risk points for unauthorised access, and are these periods prioritised for any overview?
Environment: What access controls are in place? Do doors alarm if they don’t lock properly after exit? Is it clean? Are the norms of infection prevention and control in use? Is there a cleaning schedule, particularly for fridges in between patients. Is there any opportunity for contamination of staff from infectious agents?
Organisation: What do recent HTA assessments show, and what’s the action plan from these? Is there representation of mortuary issues in the incident reporting system? What quality assurance processes exist? What complaints data is available? Crucially, what internal and external oversight has there been?
How will you answer these questions?
I told you about my experience visiting the mortuary because that’s what I’d like you to do. Observations, walk through talk through, these are absolutely the methods we need to pull out of our toolbox for this one!
The Bigger Picture
The 75 recommendations include 19 for trusts and 25 for local authorities, focusing on access, dignity, security, and wider processes and procedures. These will undoubtedly improve physical security and oversight. But the human factors lessons go deeper.
This inquiry is ultimately about how we create and maintain cultures of safety, not just physical safety, but psychological safety that encourages speaking up, procedural safety that doesn’t allow normalised deviance, and organisational safety that maintains appropriate oversight without stifling trust.
Always happy to chat with anyone being asked to do some of this work or to share any further thoughts.
Thanks,
Lauren
