Health and Safety Issues in New Zealand ... - Business.govt.nz

Health and Safety 

Issues in New 

Zealand Mortuaries 

An Audit of Health and Safety Facilities and 

Procedures in New Zealand Mortuaries 

carried out by the Occupational Safety and 

Health Service of the Department of Labour 

during February and March 1998 

OCCUPATIONAL SAFETY 

& HEALTH SERVICE 

DEPARTMENT OF 

LABOUR 

TE TARI MAHI

Published by the Occupational Safety and Health Service 

Department of Labour 

Wellington 

New Zealand 

May 1998 

ISBN 0-477-03615-5 

Price: $20 (incl.GST) 

P309-001/150

Contents 

Executive Summary................................................................................................ 4 

Acknowledgements ................................................................................................ 5 

Introduction ............................................................................................................ 6 

Relevance of the Health and Safety in Employment Act ..................................... 7 

Hazard Identification and Risk Control ................................................................ 8 

Standards Applied .................................................................................................. 9 

Methods .................................................................................................................. 11 

Audit Findings: 

Institution A .................................................................................................. 12 

Institution B .................................................................................................. 14 

Institution C .................................................................................................. 16 

Institution D.................................................................................................. 18 

Institution E .................................................................................................. 20 

Institution F .................................................................................................. 22 

Institution G.................................................................................................. 24 

Institution H.................................................................................................. 26 

Institution I ................................................................................................... 28 

Institution J ................................................................................................... 30 

Institution K .................................................................................................. 32 

Institution L................................................................................................... 34 

Institution M ................................................................................................. 36 

Institution N .................................................................................................. 38 

Institution O ................................................................................................. 40 

Institution P .................................................................................................. 42 

Discussion .............................................................................................................. 44 

OSH Actions ........................................................................................................... 46 

References .............................................................................................................. 47 

Appendix 1: OSH Audit Tool ................................................................................ 48 

Appendix 2: Generic Recommendations for Suitable Personal 

Protection ............................................................................................................... 51

Executive Summary 

This audit arose after the Occupational Safety and Health Service of the Department of 

Labour (OSH) received several complaints from pathologists and mortuary technicians 

throughout the country. They were concerned that their working conditions were 

exposing them to potentially lethal infections. In particular, the complaints identified 

the following problems: 

• Unsuitable and antiquated premises; 

• Absent, inadequate or inoperative ventilation; 

• Haphazard control of visitors/observers; 

• Variable standards of workplace procedures; 

• Variable standards of employee (medical) monitoring. 

Key findings of this audit were: 

• OSH was unable to find specific international standards for mortuaries. What 

information is available comes from several sources, predominantly the UK Health 

Services Advisory Committee. 

• Seven institutions have what OSH has described as suitable basic facilities and 

workplace procedures to carry out non-high-risk autopsies. 

• Eight institutions do not meet these basic standards. OSH has written letters to 

the relevant managers detailing the improvements it sees as necessary to meet 

these basic standards. Most of these required improvements are not, in 

themselves, expensive and should be coupled with work practice changes. 

• One institution (Christchurch Hospital) has mortuary facilities that are deemed 

suitable for “high-risk” procedures. Some alteration in work practices are 

suggested. At least two other institutions could meet this standard with some 

minor alterations. 

• OSH will encourage the mortuary owners, the employers of mortuary staff and 

the New Zealand Committee of the Royal College of Pathologists of Australasia 

(RCPA) to formulate and adopt national standards. These standards should 

reflect environmental requirements, suitable work practices and protocols for the 

monitoring of staff. As such, these protocols could be used for ongoing 

accreditation of facilities. 

4 

Health and Safety Issues in New Zealand Mortuaries

Acknowledgements 

This project arose because of industry concerns expressed to OSH about working 

standards. 

OSH departmental medical practitioners, occupational hygienists and occupational 

health nurses carried out these audits as an addition to their normal duties. I would 

like to thank them for their prompt attention to this project and the quality of their 

work. 

I would also like to thank the facility managers, pathologists and mortuary technicians 

who welcomed and co-operated fully with this audit. They provided many valuable 

suggestions and comments, as did the New Zealand Committee of the Royal College of 

Pathologists of Australasia. 

I trust this project will result in agreed standards for this industry, monitored and 

updated by the industry itself, thus ensuring that there are zero deaths or illnesses 

arising from this essential service. 

R J M Hill 

General Manager 

Occupational Safety and Health Service 

Department of Labour 

Health and Safety Issues in New Zealand Mortuaries 5

Introduction 

Autopsies, tissue harvesting and the environment that they occur in are a specialised 

and unusual area to consider the application of the Health and Safety in Employment 

Act (HSE Act). Although in terms of usual industrial activities the risks faced occur 

relatively infrequently, this service is a vital part of New Zealand’s medical, educational 

and forensic services and will remain so. It is clear historically that pathologists and 

mortuary attendants are at increased risks from this aspect of their occupation 1 . OSH 

has audited the control measures to the risks posed by both standard and high-risk 

autopsies using the traditional health and safety hierarchy, which is unusual for this 

industry. 

There are many cultural and emotional issues, as well as infection control and 

occupational health and safety considerations in this industry. 

Because of the geographically widespread distribution of mortuaries, and the need for 

some sharing of expertise in difficult or unusual cases, OSH elected to make this a 

national project so as to ensure the application of uniform standards during the audit 

and the delivery of uniform advice to employers. 

6 


Relevance of the Health and Safety in Employment Act 

The empowerment of the HSE Act in April 1993 fulfilled the vision of Robens, 

enunciated in 1972 in the United Kingdom, by bringing the health and safety aspects 

of all places of work under one legislative umbrella (HSE Act) and under the 

supervision of one Authority (OSH). 

The HSE Act has two broad principles. It encourages excellence in health and safety 

management and requires compliance with minimum standards. (Section 5) 

The principal duties and requirements of the HSE Act are set out as follows: 

• In essence, “managers must manage”. Employers are required to ensure the 

safety of employees at work by adopting a systems approach to identifying 

hazards, assessing which are significant hazards, i.e. those hazards that can result 

in ‘serious harm’ as defined in Schedule 1 of the HSE Act, and control these 

hazards by means of an hierarchy of measures. (Section 6, Section 7) 

• This hierarchy requires that employers consider eliminating the hazard, isolating 

the hazard if elimination is unreasonable and impracticable, and minimising the 

hazard if elimination or isolation is unreasonable or impracticable. Minimisation 

itself contains an hierarchy of controls, starting with engineering controls and last 

of all considering the use of personal protection. (Section 8, Section 9, Section 10) 

• Included in the Act is the requirement of communication with employees 

(concerning the identified hazards and the appropriate control measures), the 

requirement for training and supervision, and of ongoing monitoring (of the 

hazards, the control measures and the employees’ health status). (Section 11, 

Section 12, Section 13) 

• Standards are developed in conjunction with employers and employees or 

adopted from overseas where they are applicable. 

• The HSE Act contains clauses (Sections 15, 16 and 19) which apply to people 

other than employers and employees who may be exposed to risk from the 

places of work. 

• The requirements of the HSE Act are tempered by the requirement that the 

employer has to take “all practicable steps” (Section 6). The consideration of “all 

practicable steps” includes what other facilities have achieved in the way of risk 

control and what is accepted “best practice”. 

It is the Courts that establish the parameters of the HSE Act (e.g. what constitutes 

serious harm, what are “all practicable steps”, etc.) Until the Courts determine these 

steps, it is OSH’s function to explore issues with employers and employees and 

develop practical guidelines to address issues as they arise. 

It is OSH’s view that the mortuary falls under the jurisdiction of the HSE Act, that 

pathologists and mortuary technicians are at risk of suffering “serious harm”, as are 

visitors to the mortuary such as medical students, and the sections of the Act dealing 

with communication and monitoring are of relevance. 


Hazard Identification and Risk Control 

A very brief summary of the hazards faced and potential illness is presented below. 

This list is not exhaustive but is used to illustrate the discussion about risk control 

options that follows. These risks arise during autopsy procedures or during tissue 

harvesting for transplant/research procedures. 

1. Blood/body fluid transmission 

such as occurs with fluid splashes, needlestick and sharp instrument incidents. Such 

incidents expose the recipient to the risk of transmission of Hepatitis B Virus (HBV), 

Hepatitis C Virus (HCV), Human Immunodeficiency Virus (HIV), Creutzfeldt Jacob 

Disease (CJD), the viral haemorrhagic diseases and other viral, subviral and bacterial 

illnesses. 

2. Aerosolisation of blood/body fluids 

such as occurs with bone sawing, sectioning of fresh lungs, etc. These exposures may 

increase the risk of the diseases outlined above but are especially applicable to 

tuberculosis (Tb). 

It is of note that all the diseases mentioned above, including multidrug resistant Tb, are 

incurable and are either fatal or potentially fatal. 

3. Chemical issues 

Some facilities use chemicals as part of their procedures. Complaints would suggest 

that inadequate information, storage and handling procedures are in place to protect 

employees. 

4. Manual handling issues 

Some cases constitute a manual handling hazard. 

8 


Standards Applied 

Facility and Procedural Requirements 

The procedural requirements are largely drawn from the Safety in Health Service 

Laboratories Series Safe Working and the Prevention of Infection in the Mortuary and 

Post-Mortem Room 2 , the Health Building Note 20 3 and the CDC publication for Tb 

control 4 . These documents recommend: 

• Risk assessment. 

• Immunisations and baseline measurements of antibody status of exposed staff. 

• The provision of “clean, transition and dirty” areas within the mortuary. The 

traffic flow within the mortuary should restrict opportunities to move haphazardly 

from one area to another. 

• A dedicated supply and extraction ventilation plant for “dirty” areas. This 

extraction should be from ceiling entry to floor exit (i.e. so as to direct air flow 

from the breathing zone of the pathologist across the case to the extraction grill). 

• Provision of local ventilation extraction for bandsaws /bonesaws. 

• The appointment of a “safety supervisor”. 

• Adequate staff induction and ongoing training. 

• Appropriate personal protective equipment. 

• Special procedures for “high-risk” cases. 

• Appropriate waste disposal facilities. 

• Properly designed areas for demonstrating a case to observers, students, etc. 

It should be noted that these recommendations are made for standard (i.e. Hazard 

Groups 1 and 2 — not high-risk) autopsies. The Advisory Committee on Dangerous 

Pathogens 7 categorises pathogens by hazard group, viz: 

Hazard Group 1 

An organism that is most unlikely to cause human disease. 


An organism that may cause human disease and which might be an hazard to 

laboratory workers but is unlikely to spread to the community. Laboratory exposure 

rarely produces infection and effective prophylaxis or effective treatment is usually 

available. 


An organism that may cause severe human disease and present a serious hazard to 

laboratory workers. It may present a risk of spread to the community but there is 

usually effective prophylaxis or treatment available. 


An organism that may cause severe human disease and is a serious hazard to 

laboratory workers. It may present a high risk of spread to the community and there 

is usually no effective prophylaxis or treatment. 


The diseases mentioned on page 8 all fall into Hazard Groups 3 and 4, and for the 

purposes of this document “High-Risk” autopsies are those which involve Group 3 or 4 

agents. 

Guidelines for carrying out post-mortem procedures on known or suspected CJD 

patients exist 5 . The Australian CJD Guidelines 6 recommend “referral centres” for such 

autopsies to ensure procedural expertise. 

It is OSH’s view that the most “risky” autopsies are those cases where undiagnosed Tb, 

HIV or HBV are present. The doctrine of “standard precautions” practised in clinical 

medicine recommends that all cases be treated as infectious unless definite clinical 

evidence exists to the contrary, and this doctrine has application in this industry. 

10 


Methods 

A list of mortuaries in its area was obtained by each OSH branch and supplemented 

with a list provided by the RCPA. Appointments were made with the pathologists, 

head technician and mortuary manager, and an audit carried out using the audit tool in 

Appendix 1. Where necessary, letters to the manager were written detailing what 

improvements should be carried out in OSH’s view and follow-up visits planned. 

The information has been collated and this report produced. It contains, in summary 

form, an assessment of each facility and an outline of the improvements required. 


Audit Findings: Institution A 

Audit Requirement Meets Basic Standards Meets High-Risk Standards 

Hazard identification 

Meets all requirements 

Regular induction and staff training 


Chemical hazard information 

communicated to staff 


“Public safety” policies for visitors 


Risk control: 

Carries out risk assessment 


Minimises risk by engineering controls 

Ventilation controls: 

Mortuary at negative pressure 


Achieves 12 air changes/hour 


Ventilation does not recirculate 


Guarding and extraction on saws to 

control aerosolisation No guarding or extraction Meets all requirements 

Manual handling issues 


Minimises risk by use of personal protection: 

Impermeable clothes 


Adequate footwear 


Face splash guards routinely used 


Double-gloved 


Adequate respiratory protection 


Appropriate isolated clean facilities 


Minimises risk by means of appropriate 

immunisations for staff: 

BCG/Baseline Mantoux 


Hepatitis B Virus Antibodies (HBV Abs) 


Monitoring of control measures: 

Environmental monitoring 

Not performed 

Personal monitoring (Tb Mantoux status, 

HBV Abs etc.) 


Safe disposal of high-risk wastes 


Facility suitable for use 

(auditor’s summation) 


Work practices suitable 



12 


Comments on Institution A 

• Meets the requirements for basic facilities. 

• With the addition of bone saw guarding and band saw guarding, this institution 

would be suitably equipped to carry out high-risk procedures. This can be 

achieved by fitting the saws with a small capture hood and providing suitable 

suction by means of an industrial-quality vacuum cleaner fitted with a HEPA filter. 

Similar units are used in orthopaedic plaster rooms. 


Institution B 

Audit Requirement Meets Basic Standards Meets High-Risk Standard 






Risk control: 


Minimises risk by engineering 

controls 





Guarding and extraction 

on saws to control aerosolisation 


Minimises risk by use of personal 

protection: 




Double-gloved 






Hepatitis B Virus Antibodies 

(HBV Abs) 



Personal monitoring (Tb Mantoux 

status, HBV Abs etc.) 






Inadequate —no regular 

training or retraining 

(little staff turnover) 

Inadequate 

Meets standards 


Absent 

Inadequate 

Absent 

Absent 


Inadequate standard 

Meets standard 


Inadequate 

Inadequate standard 

Minimal facilities 




An old building which is now 

unsuitable for its use 

Does not meet basic facility 

requirements 

Some work practice 

changes suggested 


Absent 

14 


Comments on Institution B 

• Does not meet the basic facility standards required by OSH. 

• Cases recognised as “high-risk” should be transferred to a neighbouring facility 

with appropriate facilities. 

• OSH would recommend that changes to work practices be instituted even though 

the staff have worked in this environment for many years. 

• Some immediate upgrading to facilities is recommended. They include: 

1. Ensuring at least 6 air changes per hour (preferably 12). 

2. The provision of local exhaust hoods for saws (this can be achieved by 

fitting the saws with a small capture hood and providing suitable suction by 

means of an industrial quality vacuum cleaner fitted with a HEPA filter.) 

Similar units are used in orthopaedic plaster rooms. 

3. The use of appropriate personal protection (splash guards etc.). 

• OSH has written requiring improvements. 


Institution C 







Risk control: 







Guarding and extraction on saws 

to control aerosolisation 



protection: 




Double-gloved 







(HBV Abs 










Inadequate 

Inadequate 

Inadequate 

Inadequate 

Partially meets standards 

Not checked for 4 years 


Inadequate 

Partially present 

Inadequate 










— some monitoring required 

Does not meet standards 

Some improvements required 

Inadequate 

16 


Comments on Institution C 

• This unit meets the standard required of a basic facility. A protocol is in place to 

transfer high-risk cases to a neighbouring facility. 

• The following recommendations were made: 

1. A written hazard identification is required. 

2. Written control measures (for police, visitor, etc.) including policies on body 

fluid spills, chemicals (preparation of formalin solutions in appropriate 

areas) and manual handling policies is suggested. 

3. Some engineering changes to the unit’s ventilation exhaust system are 

required. 

4. The ventilation system’s efficiency should regularly be checked for 

operational integrity, 

5. Provision of exhaust ventilation on bone saws (this can be achieved by 

fitting the saws with a small capture hood and providing suitable suction by 

means of an industrial quality vacuum cleaner fitted with a HEPA filter. 

Similar units are used in orthopaedic plaster rooms). 


Institution D 







Risk control: 


No “stand alone” hazard ID. 

Has “Telarc” operations and 

procedures manual 

Inadequate 

done on an “as needs” basis 

Inadequate 

None on site but available nearby 


Inadequate 

Some informal procedures 



Mortuary at negative pressure Meets standards Meets standards 

Achieves 12 air changes/hour Meets standards (almost) Meets standards (almost) 

Ventilation does not recirculate No information 


control aerosolisation 

Inadequate 




protection: 


No information 



Face splash guards routinely used No information 

Double-gloved 

Not routinely 


Inadequate 

Appropriate isolated clean facilities Confusion between clean and 

dirty areas 




Subcontractor staff 

Hepatitis B Virus Antibodies (HBV Abs) Unclear if protocols followed 







Safe disposal of high-risk wastes No information 


Needs some redesign to meet 


clean/dirty separations 



Needs formalisation of procedures 

and improvements in personal 

protection 

18 


Comments on Institution D 

• This unit meets the standards required of basic facilities. It has decided to 

transport “high-risk” cases to a neighbouring facility. 

• A more formal risk assessment would be desirable. Some protocols could be 

formalised, although they are essentially present in other forms. 

• Some redesign of the facility’s internal traffic flows would enhance health and 

safety procedures. 

• There is potential for confusion between the duties of the principal contractor 

(the CHE) and subcontractors (who provide the mortuary technical staff). OSH 

would view the principal contractor as being responsible for ensuring the 

subcontractor carries out the correct protocols — in this case, the appropriate 

immunisations of exposed staff. 

• Some improvements in personal protection are suggested (See appendix 2). 


Institution E 




Regular induction and staff training Inadequate 



Inadequate 

“Public safety” policies for visitors Inadequate 

Risk control: 

Carries out risk assessment Informal Inadequate 



Mortuary at negative pressure Inadequate Air leaks throughout building 



Ventilation does not recirculate Not certain 



Inadequate 




protection: 





Face splash guards routinely used Inadequate 

Double-gloved 

Occasionally 

Adequate respiratory protection Inadequate 

Appropriate isolated clean facilities Inadequate 






(HBV Abs) 



Environmental monitoring Not undertaken 





Inadequate 


auditor’s summation) 

Unsuitable 



Unsuitable 

20 


Comments on Institution E 

• This institution does not meet the standards required of a basic facility. The 

mortuary area is perforated by a lift which traverses all floors of the building, four 

of which are used by different departments. The lift acts as a giant pump to 

disperse air throughout the building. 

• Work practice reforms were about to be implemented at the time of the first OSH 

audit. These reforms were completed shortly after but the items were included in 

the improvements required by OSH. The work practices in existence had 

negative implications for infection control procedures. 

• The facility is totally unsuitable in its current state for high-risk cases, or as a 

teaching venue for students. At the time of the audit, its “control” procedures for 

ingress and egress from the autopsy suite were nonexistent. 

• It is acknowledged that considerable work practice improvements have already 

occurred. It is OSH’s view that the autopsy suite in its current state is completely 

unsuitable and major modifications need to be undertaken. Currently risks are 

controlled by the use of upgraded personal protection. If the institution does not 

address engineering controls, improvement and stop notices may have to be 

contemplated. 


Institution F 




None 

None 




Risk control: 







Guarding on saws to control 

aerosolisation 



protection: 




Double-gloved 







(HBV Abs) 










None 

None 

Absent 

Absent 

Absent 

Absent 

Absent 

Inadequate 





Inadequate 

Absent 

Some aspects present 


Absent 


Not suitable 

Inadequate 

Inadequate 

22 


Comments on Institution F 

• This institution does not meet the engineering standards required for basic 

autopsy facilities nor are its work practices ideal. 

• A letter from the Departmental Medical Practitioner (DMP) requiring 

improvements has been issued. 

• Some issues exist between the primary and secondary contractors. The HSE Act 

make all parties in the contractor/subcontractor chain responsible for health and 

safety in the workplace. 


Institution G 






Risk control: 











protection: 




Double-gloved 






Hepatitis B Virus Antibodies (HBV Abs) 










Meets standards but requires 

upgrading 







Absent 

Inadequate 

Absent 

Absent 





Available 

Available 

Inadequate 




None 


Needs improvements 


Inadequate 

24 


Comments on Institution G 

• This facility meets basic standards. 

• The engineering controls should be improved by the addition of a basic 

ventilation unit. 

• Work practices and traffic flow could be improved. 


Institution H 




Regular induction and staff training Absent 




“Public safety” policies for visitors Inadequate 

Risk control: 

Carries out risk assessment Meets standards 



Mortuary at negative pressure Probably 

Achieves 12 air changes/hour Exceeds standards Meets standards 

Ventilation does not recirculate Meets standards Meets standards 



Inadequate 


Inadequate 


protection: 





Face splash guards routinely used Not used 

Double-gloved 


Adequate respiratory protection Meets standards 

Appropriate isolated clean facilities Inadequate 






(HBV Abs) 



Environmental monitoring Meets standards 





Inadequate 



Suitable as a basic facility 




26 


Comments on Institution H 

• This institution meets the standards required of a basic facility and has elected 

not to carry out high-risk autopsies. 

• Its engineering facilities are on the whole good. 

• There are some improvements to be made in work practices and procedures. 


Institution I 







Risk Control: 










Minimises risk by use of 

personal protection: 



face splash guards routinely used 

Double-gloved 







(HBV Abs) 










Absent 

Absent 

Absent 

Absent 

Absent 

Absent 

Absent 


Absent 

Absent 


Absent 

Available 


Inadequate 

Absent 



Absent 


Unsuitable 

Inadequate 

Absent 

28 


Comments on Institution I 

• This institution lacks suitable facilities. It does not meet the standards required of 

a basic facility. 

• Considerable improvements in work practices and procedures are required to 

achieve compliance with the HSE Act. The DMP has outlined required 

improvements. 


Institution J 







Risk control: 


Inadequate 

No ongoing standards 

No evidence to support this 

happening 


Inadequate. Not done by unit 

exposed to risk. 










to control aerosolisation No guarding or extraction Meets standards 




protection: 







Double-gloved 


Adequate respiratory protection ? Inadequate 







Hepatitis B Virus Antibodies (HBV Abs) Meets standards 


Environmental monitoring Carried out 





Inadequate 


(auditor’s summation) Meets basic standards Almost meets high-risk standards 


Some discrepancy between 

statements and actions. For 

example a bicycle was stored in 

the “clean” autopsy area but 

presumably this belonged to the 

last case as no owner could be 

found! 

30 


Comments on Institution J 

• This facility meets the requirements of a basic facility. 

• It would meet “high-risk” specifications with some work practice and procedural 

modifications. 


Institution K 







Risk control: 











protection: 




Double-gloved 







(HBV Abs) 










Inadequate 

Present but not specific to risks 

faced 


Inadequate Unclear whether these 

are adhered to 

Yes — informal 

Absent — exhaust duct sealed 

Comments on Institution K 

• This facility does not meet the standards required of a basic facility. An 

improvement in its engineering controls, particularly the ventilation, is required. 

• Some improvements in workplace practices and procedures have been identified 

and conveyed to the management of the facility by the DMP. 

• From an OSH point of view, it must be queried whether cases should be 

transferred to a neighbouring, better equipped facility, even if the pathologist has 

to travel to perform autopsies. 


Institution L 







Risk control: 


Needs to be updated to reflect 

new facilities 

Induction and training should include 

all staff including pathologists 

Included in H&S manual? 

Needs more specific emphasis 

Inadequate 

All treated as high-risk 

Minimises risk by engineering controls New facility Does not have a separate area 

suitable for Hazard Group 4 cases 


Mortuary at negative pressure Designed, not checked Needs checking before used as a 

high-risk facility 

Achieves 12 air changes/hour Designed — not checked 

Ventilation does not recirculate Designed — not checked 







protection: 

Impermeable clothes Meets standards Meets required standards for PPE 



Face splash guards routinely used Meets standards 

Double-gloved 


Adequate respiratory protection Meets standards 

Appropriate isolated clean facilities Meets standards 






(HBV Abs) 



Environmental monitoring Needs to be undertaken 










Suitable for high-risk facility if 

provision could be made for a 

separate area (some security 

concerns under review) 

Suitable for high-risk facility 

34 


Comments on Institution L 

• This unit would be suitable to be used for high-risk cases if provision for a 

separate area could be made, or the current general facility could be screened 

off. 

• OSH suggested some relatively minor procedural improvements. A new and 

impressive facility. 


Institution M 







Risk control: 











protection: 




Double-gloved 







(HBV Abs) 











Available 

On a case by case basis. ? Needs 

more formal approach 

Inadequate 


Extensive documentation 



Exceeds standards 

Exceeds standards 












Exceeds basic standards and attains 

excellence 

Exceeds basic standards and attains 

excellence 

36 


Comments on Institution M 

• This facility meets the standards required to safely undertake high-risk cases. This 

is an excellent institution. 

• The only improvement suggested by the OSH auditors was the provision of local 

exhaust on the band and bone saws. 

• Some minor improvements in work practices were suggested. 


Institution N 







Risk control: 











protection: 




Double-gloved 







(HBV Abs) 










Inadequate 

Absent 

Absent 

Absent 

Absent 

Inadequate 

6 air changes per hour 

(not tested) 

Not well maintained 

? No power tools used 






Not used 

Not used 



Inadequate 



Inadequate facility for 

basic autopsies 

Inadequate standards 

38 


Comments on Institution N 

• This institution does not meet the standards required of basic facilities. 

• It should redesign/upgrade the facility and its work practices or transfer autopsies 

to a neighbouring facility with suitable facilities. 

• Current facilities and work practices expose staff (and the public?) to an 

unacceptable risk. 

• The OSH DMP has notified management of required improvements. 


Institution O 







Risk control: 











protection: 




Double-gloved 







(HBV Abs) 










Absent 

Absent 

Absent 


Absent 

Inadequate 

Inadequate 


Absent 






Needs improvements 

Absent 



Not undertaken 

Absent 


Does not meet basic facility standards 

and needs immediate improvement 

Does not meet basic facility standards 

and needs immediate improvement 

40 


Comments on Institution O 


• It should redesign/upgrade the facility and its work practices or transfer 

autopsies to a neighbouring facility with suitable facilities. 

• Current facilities and work practices expose staff (and the public?) to an 




Institution P 







Risk control: 











protection: 




Double-gloved 







(HBV Abs) 










Inadequate 

Minimal 

Inadequate 

Inadequate 

Absent 

Absent 

Inadequate — does not achieve 

6 changes/hour 

Totally inadequate 

Some guarding — no local 

exhaust ventilation 

Inadequate 



Inadequate 

Inadequate 

Inadequate 

Completely inadequate 



Absent 


Inadequate 

This facility is totally inadequate 

and does not meet standards 

Work practices are to some 

extent determined by the 

environment and are inadequate 

42 


Comments on Institution P 


• It should redesign/upgrade the facility and its work practices or transfer autopsies 

to a neighbouring facility with suitable facilities. 

• Current facilities and work practices expose staff (and ? the public) to an 




Discussion 

Only one institution met the facility and work practice standards required of a 

mortuary carrying out high-risk procedures. 

Eight institutions do not meet the standards required of a basic facility and require 

immediate improvement. OSH departmental medical practitioners (DMPs) have 

written letters to the managers outlining the sorts of improvements required to 

achieve compliance. 

Seven other facilities required engineering improvements of changes in work practices 

to achieve compliance with the HSE Act to meet the standards of a “basic facility” that 

OSH would see as the minimum for “standard” autopsies. 

OSH developed the “standards” for this audit from international documents. Although 

the risks of an autopsy are relatively low, they are potentially fatal and OSH feels that, 

given the presence of these international recommendations, New Zealand institutions 

must meet this standard. 

It is OSH’s view that elimination of these risks is not practicable. 

Isolation (of the high-risk cases) does seem a practical option for some institutions 

and, in OSH’s view, should be considered if the cost of upgrading a local facility is 

excessive. Isolating the risk to well-maintained, suitable facilities with well-trained 

staff not only decreases the health and safety risk but must have important benefits 

for quality control issues. Isolation is, however, complicated by forensic and cultural 

issues. 

Minimisation will remain the risk control mechanism of choice for most institutions. It 

is vital, however, that institutions accept that some investment in engineering 

solutions is necessary, particularly ventilation, and that strict adherence to work 

practices, however familiar, is required. It is OSH’s recommendation that the 

following principles apply to any mortuary facility: 

1. That an “autopsy manager” (circulator) with responsibility for the health and 

safety aspects (as well as the quality control, professional standards, etc.) be 

appointed for each case. This person has the authority to set the health and 

safety standards for that case, including the ability to stop or decline the case if 

necessary. The pathologist would seem the logical choice. 

2. That the autopsy facility be purpose-designed and kept abreast of new or 

changing recommendations in the future. 

3. That each facility have clearly demarcated “dirty”, “transition” and “clean” areas. 

Changing, rest and eating areas are confined to the clean area, as are storage and 

other general use areas. 

4. That the “dirty” area of the mortuary complex be at a negative air pressure to the 

rest of the facility and that there be at least 6 air changes per hour in this area. 

OSH’s preference is for 12 air changes per hour 4 . The air flow should be from 

ceiling entry to floor exit. 

5. That the air from the “dirty” area of the complex be either vented directly to the 

exterior (but not into surrounding buildings) or to the atmosphere via an HEPA 

filter. The air should not be recirculated. 

44 


6. That “risk assessment” occurs on each case to determine the possibility of the 

case fitting the “high-risk” category. These assessments will be far from perfect, 

particularly in forensic cases, but in OSH’s view is an important procedural step 

to take. All cases where details are unknown should be treated as high-risk if 

the principles of “standard precautions” are to apply. The risk assessment 

should be the function of the “autopsy manager” rather than delegated to ward 

staff. 

7. That all bone saws/band saws be provided with local exhaust systems (see 

Appendix 2). Some institutions have minimised this hazard by encasing the 

skull in a plastic bag (as per CJD recommendations). 

8. That suitable personal protective equipment be worn during procedures. 

Suggestions are made in Appendix 2. There is no room for personal choice by 

staff if PPE is the control mechanism of choice. 

9. That all staff working in the mortuary complex be immunised (or have natural 

antibodies) against Hepatitis B Virus. OSH encourages mortuary employees to 

have had a BCG vaccination 8 . 

10. That an active treatment and follow-up system exists for staff who suffer 

occupational exposures to HBV, HCV, Tb, HIV, etc. 


OSH Actions 

1. Letters detailing improvements required have been issued by the DMPs to the 

managers of each mortuary where this has proved necessary. 

2. A follow-up audit will occur within a 3-month period. 

3. If important issues are not being addressed, and the health and safety of those 

employed to work in that particular mortuary is at risk, then Improvement/ 

Prohibition Notices for certain procedures will be issued under Sections 39 and 41 

of the Health and Safety in Employment Act. 

4. OSH will work with the RCPA to develop a “best practice” guideline for this 

industry. 

5. OSH recommendations for suitable PPE are included in Appendix 2. 

46 


References 

1. Lunn J, Mayho V. Incidence of pulmonary tuberculosis by occupation of hospital 

employees in the National Health Service in England and Wales 1980-84, Journal 

of the Society of Occupational Medicine 1989, 39: 30-2. 

2. Safe Working and the Prevention of Infection in the Mortuary and Post-Mortem 

Room, Health Services Advisory Committee, Safety in Health Service Laboratories, 

HSE Library and Information Services, UK, 1991. 

3. Health Building Note 20, Mortuary and Post-Mortem Room, NHS Estates, HMSO, 

ISBN 0 11 321400 6, 1991. 

4. Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in 

Health Care Facilities, US Department of Health and Human Services, Public 

Health Service, Centers for Disease Control and Prevention (CDC), 1994, October, 

43: RR-13. 

5. Bell J E, Ironside J W. How to tackle a possible Creutzfeldt-Jakob Disease 

necropsy, Journal of Clinical Pathology, 1993, 46: 193–7. 

6. Creutzfeldt-Jakob Disease and other Human Transmissible Spongiform 

Encephalopathies: Guidelines on Patient Management and Infection Control, 

National Health and Medical Research Council, Australia, 1995. 

7. Precautions for Work with Human and Animal Transmissible Spongiform 

Encephalopathies, Advisory Committee on Dangerous Pathogens, HMSO, 

ISBN 0 11 321805 2, 1994. 

8. Guidelines for Tuberculosis Control in New Zealand 1996, Public Health Policy 

and Regulation Section, Public Health Group, Ministry of Health, ISBN 0-478- 

09467-1, 1996. 


Appendix 1: OSH Audit Tool 

Health and Safety Audit Mortuary Facilities of ................................................... Institution 

This audit tool is designed to achieve a uniform measure of compliance across New Zealand with the relevant 

standards to control health and safety risks in this industry. The relevant standards are enclosed. You are asked to 

grade the facility. Occasionally you will have to estimate or undertake measurements (e.g. airflow) but the employer 

(the facility owner) should have been monitoring these control measures already. Testing reports from reputable 

laboratories are, of course, adequate. 

High-risk facilities are suitable to examine cases of CJD, HIV/AIDS, multi-drug resistant Tb, etc. Score each item on 

the tool out of 10, i.e. Absent = 0, Some aspects present = 5, Present = 10. 

Each section is categorised as follows: (Acceptable high-risk facility score = xx, Acceptable Basic facility score = 

yy). High-risk facilities must achieve a “high-risk pass” in Sections 3, 4, 5, 6 and 8). 

Make an evaluation of the suitability of this facility to continue operating. This will not be binding or acted on 

immediately but will act as a starting point for information for the employer. 

Minimum Standards Observed Measures and Facilities Your Evaluation 

Absent Some Aspects Present 

(0) Present (5) (10) 

1. Has written hazard ID including: 

(a) Acknowledgement of air borne 

infectious agents. 

(b) Acknowledgement of blood/body 

fluid infectious agents. 

(c) Acknowledgement of manual and 

chemical hazards. 

High-risk facility = 20/30 

Basic facility = 15/30 

2 Has regular induction and staff 

training procedure (both 

pathologists and mortuary 

assistants) which explain the 

potential hazards faced and 

control measures used. 



3 Has a policy in place to protect 

mortuary “visitors” (e.g. routine 

use of respiratory protection, etc). 

High-risk facility must have = 10/10 

Basic facility = preferable but not necessary 

48 




(0) Present (5) (10) 

4. Carries out risk assessment of 

each case to determine whether 

“high-risk” or not. Risk assessment 

parameters are written down 

and uniformly applied to each case. 



5. Has ensured appropriate staff 

immunisations (HBV and BCG). 



6. Engineering controls: 

Mortuary area is at negative 

pressure to surroundings. 

Mortuary area has 6 air changes per 

hour. (Basic facilities must have.) 

OR 

Mortuary area has ≥ 12 air 

changes per hour. (High-risk 

facilities must have.) 

Ventilation exhausts directly to 

exterior. (No recirculation.) 

(preferable - HEPA probably ok 

though = 5) 

Ventilation is checked regularly. 

Appropriate drainage systems in 

place. 

Machines guarded to prevent trauma/ 

aerosol formation (e.g. band saws). 



7. Appropriate facilities/systems in 

place to address manual handling 

issues. 

Appropriate information available 

concerning chemicals used, spills 

procedures, etc. 

Security considered as a hazard. 






(0) Present (5) (10) 

8. Use of personal protection: 

Impermeable clothes used. 

Footwear provides adequate cover 

against scalpel/needle drop. 

Face splash guards readily 

available. 

Double-gloved. 

Respiratory protection adequate 

and used. 

Appropriate isolation facilities for 

personal clothes/showers, etc. 



9. Has appropriate follow-up and 

monitoring procedures for Tb 

contact, blood/body fluid 

incidents, etc. 


Basic facility must have = 10/10 

10. Other issues noted during 

your audit: 

THIS FACILITY MEETS THE STANDARDS 

REQUIRED FOR HIGH-RISK AUTOPSIES 

THIS FACILITY MEETS THE BASIC 

STANDARDS FOR NON-HIGH-RISK 

AUTOPSIES ONLY 

THIS FACILITY IS UNSAFE AND 

REQUIRES IMPROVEMENTS BEFORE 

AUTOPSIES SHOULD BE CARRIED OUT 

Name: ....................................................................................... Date: .......... / .......... / .......... 

50 


Appendix 2: Generic Recommendations for Suitable Personal 

Protection 

• Routine use of face shields is recommended during procedures likely to cause 

aerosolisation or body fluid splash. 

• Double-gloving is recommended as a routine practice. 

• Use of disposable, passive (negative-pressure) respiratory protection (preferably 

HEPA filter) is recommended as routine during procedures likely to cause 

aerosolisation or body fluid splash, or when fresh lungs are being sectioned. 

Examples of suitable masks (taken from the 3M range as an example, other 

manufacturers have similar products) are: 

1. 3M 1860 (95% efficient with < 10 % leakage). 

2. 3M 8822 (contains an exhalation valve which improves comfort). 

3. 3M 9970 (HEPA with exhalation valve) — the preferred routine choice. 

• High-risk cases would require full-face mask, positive-pressure, air purifying 

respirator using a P3 particulate filter full facepiece. 

• All people closely involved in the autopsy should be wearing impermeable 

clothing and stout safety boots. The current practice of wearing heavy-duty 

gumboots is acceptable. 

• High-risk cases should be clothed in an impermeable (preferably disposable) 

“immersion” suit. 

• Visitors/observers/students should either be separated from the autopsy by means 

of a viewing room (with separate ventilation) or be provided with the same 

degree of protection that other people closely involved with the autopsy are 

wearing.

Health and Safety Issues in New Zealand ... - Business.govt.nz

Create successful ePaper yourself

Delete template?

Save as template?