Policy Type: CLINICAL

Definition: POLICY
Owner Group: Professional Services

INFECTION CONTROL POLICY

Section 3.11 – Handling of Infectious Diseased Persons/Last Offices

Application:
Applicable to: ALL STAFF MEMBERS
Communication Method: TRUST INTRANET, SPECIALIST TRAINING
Consequence of Non-Adherence: Failure to prevent cross infection and
contamination

Approvals:
Approval Body: Clinical Quality and Risk Management Group

Date Approved: 18th November 2006

Implementation Date: 18th November 2006
Review Date: 18th November 2008

Source & Version:

Version: 1
Trust Policy No.: 135
Policy Owner: DIRECTOR OF INFECTION PREVENTION and
CONTROL

Birmingham East and North Primary Care Trust Infection Control Policy and Procedure Manual 2002
Last Offices Section 3.11
Updated March 2004
HANDLING OF INFECTIOUS DISEASED PERSONS/
LAST OFFICES
NOTE: This policy is applicable only until care of the deceased is with the
undertaker.

INTRODUCTION

A body is no more infectious following death than during life. Staff performing last
offices for a patient with any infectious disease should following the routine
procedures, taking the same precautions as when the patient was alive. A small
number of bodies may present an infection hazard. These bodies must be placed in a
cadaver bag. Other bodies which may require a cadaver bag are those with
excessive body fluid leakage.

AIM

The purpose of this policy is to:

 Minimise the risk of infection to staff and other persons who may be required, as
part of their job, to handle infectious or potentially infectious bodies.

 Provide guidelines for staff as to the risk to relatives of viewing any infectious body.

 Recognise the sensitivity of bereaved relatives and friends.

 Protect staff and undertakers involved in handling the infectious and leaking body
by use of a cadaver bag of acceptable standard and give appropriate information.

NB. Cadaver bags are available from the mortuary. Wards/departments should not
purchase their own supplies as the associated paperwork required is issued by
the mortuary with each bag.

RELIGIOUS BELIEFS

Death customs differ in different cultures and religions, of which health care staff
should be aware. No assumption should be made as practice may vary within the
same cultural and religious practices. Relatives should be asked about any restriction
before the body preparation is commenced. Gloves should be worn as an immediate
measure as some religions forbid strangers from touching a body with bare hands. If
customs and religious rites require to be performed on a body requiring a cadaver
bag, these should be carried out under controlled conditions PRIOR to placing the
body in the cadaver bag.

The Trust's Control of Infection Committee is aware of the apprehension of some staff
and the distress that can be caused to some relatives by the use of a cadaver bag.

Birmingham East and North Primary Care Trust Infection Control Policy and Procedure Manual 2002
Last Offices Section 3.11
Updated March 2004
However, the Health & Safety At Work Act 1974 places a responsibility on all
employees to ensure that the health, safety and welfare of others is addressed. Staff
should appreciate this requirement and most relatives will respond appropriately if the
need for a cadaver bag is dealt with in a sympathetic manner.

The decision to place a body in a cadaver bag will only be made following discussion
between senior medical and nursing staff, assisted, if required, by the infection control
doctor/infection control nurse. Unless there are overriding reasons, the circumstances
and diseases requiring the use of a cadaver bag, as described in this policy, will be
adhered to.

DISEASE REQUIRING THE USE OF A CADAVER BAG

(More in-depth information is available in Appendix 1)

Patients identified as having the following infections must be placed in a bag:

Common

 Hepatitis B or C
 HIV/AIDS
 CJD
 Invasive Group A streptococcal infection
 Diarrhoea and vomiting, including Salmonella, Campylobacter, SRSV, Shigella
 Tuberculosis
 Meningococcal meningitis/septicaemia
 Typhoid fever/paratyphoid fever

Rare

 Anthrax
 Plague
 Yellow Fever
 Viral Haemorrhagic Fever
 Diphtheria

Other infections - obtain advice from the Infection Control Team.

NB. Patients with MRSA or routine infections such as chest infections DO NOT
require the use of a cadaver bag.

The use of a cadaver bag may also need to be considered if leakage and discharge of
body fluids is anticipated, despite dressings, including:

1. Wound drainage areas.

2. External bleeding, particularly from intravenous and central venous puncture
sites.
3. Gangrenous limbs and infected amputation sites.
4. Large pressure sores.

Birmingham East and North Primary Care Trust Infection Control Policy and Procedure Manual 2002
Last Offices Section 3.11
Updated March 2004
5. Areas of large skin harvesting.
6. Burns.
7. Trauma.

A form must be completed to identify the reasons for use of a cadaver bag - see
Appendix 2. The use of the cadaver bag should not exclude measures to prevent
leakage.

ROLES OF INDIVIDUALS

Nursing Staff

 All relevant information is made available to porters, mortuary staff, pathologists,

undertakers and relatives that they may take appropriate action to avoid acquiring
infection themselves (see policy below).

 Porters specifically require Information on whether a patient has been placed in a

bag for infection or leakage as it affects the area of the Mortuary into which the
body is placed.

 The same procedural precautions should be used for relatives and ministers of
religion in the viewing of bodies on the ward as are in force for visitors prior to
death.

 Where possible, staff should consult relatives about any restrictions before body
preparation is commenced on the ward. If relatives make requests that could result
in non-adherence of this policy, advice of a senior member of the medical staff
should be sought. Further advice may be obtained from the Clinical Microbiologist
or Infection Control Nurse, and out-of-hours the Clinical Microbiologist via the QEH
switchboard.

 Relatives must be told in a sensitive way that the body will be placed in a cadaver
bag on the ward. Staff should be sensitive to the distress the use of a cadaver bag
can cause relatives.

 If relatives wish to see the body prior to placing in a cadaver bag they should only
be allowed to do so following discussion with a member of the medical staff or
senior nursing staff, who will inform them of the risk of infection to themselves.
Relatives may view the body but should be discouraged from contact, especially
kissing the body - the risk implications of this practice should be made clear to
them.

 The relatives may be given permission to carry out ritual preparation of the body in
the ward under supervision, observing universal precautions.

 The body should be laid out and washed in the normal manner according to cultural
needs. Further details are available in the Nexus file. Nurses/staff should wear
disposable gloves and a plastic apron. All drains, catheters, intravenous lines etc

Birmingham East and North Primary Care Trust Infection Control Policy and Procedure Manual 2002
Last Offices Section 3.11
Updated March 2004
 should be removed unless the case has been referred to the Coroner or medical
staff request the lines to be left in. All vascular access (eg drains and line sites) or
wound sites should be totally occluded USING MINIMUM PADDING REQUIRED
AND WATERPROOF TAPE (eg SLEEK) TO OCCLUDE PADDING AND TO
PREVENT LEAKAGE.

 The body should be placed in a shroud. A sheet should NOT be used. Continence
pads must be placed in the bag if leakage is anticipated.

 The use of sheet to cover the bag once closed will help to prevent cadaver bag
damage/tears and assist with the manual handling of the patient.

 The body should be placed in a cadaver bag (head placed at zip end) which must
be sealed. Infant, child and adult bags are available.

 A patient identify form/'Notification of Death' form should be completed, and for

bodies in a cadaver bag this form/'Notification' should also be marked 'DANGER
OF INFECTION' or 'BODY LEAKAGE' as appropriate. This form MUST be inserted
in the cadaver bag pocket (not on the body).

 Cadaver bag form must also be completed and placed in cadaver bag pocket.

 The patient's notes must be sealed in an envelope before leaving the ward.

 The porters must be informed when requesting that the body is moved:

(a) That a cadaver bag has been used.

(b) Whether it has been used for infection control purposes or leakage of fluids.
PATIENT DIAGNOSIS MUST NOT BE REVEALED.

 Patient linen should be treated as infected (see Linen Policy).

 Terminal cleaning of the area and equipment should be undertaken (see Isolation
and Domestic Cleaning Policy).

 All items of a disposable nature should be discarded according to the Waste Policy.

 Contaminated non-disposable items should be placed in a biohazard autoclavable

bag and sealed. This should be sent to CSSU in accordance with procedure.

 Dressing trolleys should be wiped down with hot, soapy water and wiped with 70%
alcohol.

Medical Staff

Medical staff must:

Birmingham East and North Primary Care Trust Infection Control Policy and Procedure Manual 2002
Last Offices Section 3.11
Updated March 2004
 Seek advice from the Infection Control Team as to the requirements for the use of
body bags in individual cases with a known or suspected infectious disease.

 Advise relatives who may wish to see the body before it is placed in the cadaver
bag of the potential risk of infection to themselves and the appropriate measures to
be taken when viewing the body.

 Advise relatives if the body has been placed in a cadaver bag for conditions other
than an infectious disease, thereby allowing subsequent viewing if requested.

 Complete the 'Notification of Death' form fully if it has not previously been
completed by the nurse.

 Complete the Cadaver Bag Information Form (Appendix 2) and send this form with
the body to the mortuary.

 When seeking permission for a hospital post-mortem examination on a body known

or suspected of having an infectious condition:

(a) Discuss with pathologists whether the post-mortem is necessary or practical.

(b) Be aware of cultural considerations (it would be seen to be inappropriate to

request a hospital post-mortem on Jewish or Muslim persons for example).

 If it should only subsequently become known that the patient was suffering from an
infectious disease, inform the pathologist and senior mortuary staff as appropriate.

 If there is doubt as to the diagnosis and an infectious disease is suspected, seek

further advice from the Control of Infection Doctor/Consultant Microbiologist.

Portering Staff

 Porters will be notified by a ward that a body in a cadaver bag is ready for
transportation to the mortuary and whether the bag has been used for ‘leakage or
infection.’

 It is the responsibility of portering staff to remove all bodies, whether infectious or

not, to the mortuary.

NB. The medical or nursing staff will have made the body safe for handling by the
porters.

 The porters should wear a plastic apron and gloves for moving the body from the
bed to the mortuary trolley if it is in a cadaver bag. The gloves and apron should
be discarded into the ward yellow clinical waste bag. Hands should be washed
before leaving the ward.

 Gloves are not required when transferring the trolley to the mortuary.

Birmingham East and North Primary Care Trust Infection Control Policy and Procedure Manual 2002
Last Offices Section 3.11
Updated March 2004
 Non-sterile gloves and plastic apron should be worn before putting the body into
the body store and are available within the Mortuary.

 Porters must handle and transport all bodies in a manner so as to avoid leakage of
biological fluids from the body during transit to the mortuary and when
subsequently being placed in the body refrigerator.

 The body may be removed from the ward to the mortuary in the usual manner. No
protective clothing is required for the transportation of the body to the mortuary.

 In the mortuary the body should be placed in the infectious bodies store. If
unavailable, the body should be placed on the lowest available shelf. Portering
staff should not remove infectious bodies from the body store - this is the
responsibility of mortuary staff/G grade on-call in conjunction with the on-call
Microbiologist.

 Porters must highlight to mortuary technician’s requirements to clean and disinfect

as appropriate any equipment found to be contaminated by body fluids as a result
of transporting the non-infectious body to the mortuary. Any equipment
associated with infected bodies must be cleaned and disinfected irrespective
of being soiled or not.

 The body trolley will require cleaning after transportation of a non-infected body if
leakage of body fluids has occurred. A spillage procedure will be found with the
appropriate materials in the body store area (see Appendix 3).

 Gloves and apron must be removed and be placed into the clinical waste bag
provided.

 Hands should be washed with soap and water before returning to other duties.

 Porters should complete the body depository book.

Birmingham East and North Primary Care Trust Infection Control Policy and Procedure Manual 2002
Last Offices Section 3.11
Updated March 2004
Mortuary Staff

 Bodies on which a post-mortem examination has not been carried out but which
are known to be infectious should be contained in a cadaver bag, which should be
accompanied by the cadaver bag pocket information form (Appendix 2). Patient
identification details/'Notification of Death' form and 'Use of a Cadaver Bag' form
should be enclosed in the cadaver bag pocket.

 Depending upon the nature of the infectious disease suffered in life, the body may
be removed from the cadaver bag for medical reasons on the advice of medical
staff (see guidelines). In conjunction with the Infection Control Team where
necessary.

 When handling a cadaver bag mortuary staff should wear a plastic apron and
disposable gloves.

 If a post-mortem examination is carried out the body should, after reconstruction,

be placed in a fresh cadaver bag and patient identification details/'Notification of
Death' form should accompany the bag in the pocket.

 If the relatives ask to see a body, confirmation that they have been informed of the
infectious condition of the body by medical or nursing staff at ward level should be
ascertained. If this has not been done, the relatives should be referred back to the
ward for information. If the relatives have been informed of the infection risk then
the mortuary staff should inform the relatives of any restrictions to the viewing of
the body and the reasons for these restrictions. After viewing, the relatives may be
asked to wash their hands.

 After viewing by the relatives the cadaver bag should be re-sealed, checking for
leakage onto the surrounding area. If this has occurred it should be cleared up
using the mortuary spillage policy.

 Any soiled linen should be treated as infectious and sent to the laundry (see Linen
Policy).

 Any disposable personal protective equipment should be treated as clinical waste

and disposed of accordingly (see Waste Policy).

 Cleaning and disinfection of body fluid spillage in the body refrigerators/ mortuary
must be undertaken as soon as possible (see Appendix 3).

 Replenish appropriate supplies including disinfectants, protective clothing and

cleaning materials required in the body store or mortuary.

 Contact the Consultant Microbiologist if further information is required concerning

the infectious nature of the deceased person.

Birmingham East and North Primary Care Trust Infection Control Policy and Procedure Manual 2002
Last Offices Section 3.11
Updated March 2004
 Inform the undertakers dealing with the body of the reason for the use of the
cadaver bag, ie leakage or route of spread of infection, having due regard for
patient confidentiality.

 Ensure that a cadaver bag patient information form has been completed by the
medical staff involved with the case (see Appendix 2). A copy must be sent with
the body to the undertakers.

 Be responsible for the accurate completion of the Register of Death and use of the
'Infected Body' stamp if appropriate.

 Provide general advice, if requested by the undertakers, on the handling of the

infectious body, and ensure that the form 'Guidance for Funeral Directors,
Cemetary and Crematorium Staff on Handling the Deceased' is given to the
undertakers (Appendix 4). Due care to confidentiality must be given.

 If the undertakers require specific information/advice concerning handling of the

body they should be referred to the Consultant in Communicable Disease Control.

 Inform the undertakers or other appropriate persons (eg CCDC/ICT) in the event of
an infectious disease being identified subsequent to release of the body from the
mortuary.

Histopathologists

Histopathologists have a responsibility:

 Not to put themselves, mortuary, and any other staff attending the post-mortem, at
risk of acquiring infection as a result of their actions by the use of risk assessment
and appropriate post-mortems only.

 If there is doubt as to the diagnosis and an infectious disease is suspected, to seek

further information/advice from medical staff responsible for the patient and/or the
Infection Control Doctor/Clinical Microbiologist.

 If at post-mortem or following histological examination an infectious disease is

identified, or suspected, to contact the Infection Control Doctor/Clinical
Microbiologist.

 To seek advice from a Consultant Histopathologist if a post-mortem examination is

to be carried out on a body deemed to be infectious.

 To seek advice from the Infection Control Doctor/Clinical Microbiologist where the
risk of infection is thought to be great but a post-mortem is essential.

 To refer to the guidance relating to post-mortem examinations (Appendix 5).

Birmingham East and North Primary Care Trust Infection Control Policy and Procedure Manual 2002
Last Offices Section 3.11
Updated March 2004
Infection Control Team/On-Call Clinical Microbiologist (Out of Hours)

It is the responsibility of the appropriate member of the Infection Control Team (ICT)
to ensure that:

 Medical staff and nurses are advised of the requirement for use of a cadaver bag if
a patient suffering from any of the diseases listed in the policy is likely to die whilst
still infectious.

 The ICT will notify the Ward Senior Nurse of appropriate procedures if a laboratory
result indicates that a patient has an infectious disease which requires the use of a
cadaver bag.

 If a team member is notified by the Microbiology Laboratory or any other diagnostic

pathology laboratory, or other source, of a result indicating that a patient who is
known to have died earlier of an infectious disease which would have required the
use of a cadaver bag, the member must inform:

(a) The mortuary staff.

(b) The ward nursing staff. )
(c) The deceased's medical team. ) if appropriate
(d) The Occupational Health Department. )
(e) The duty Clinical Microbiologist, who will inform the CCDC.

Undertakers

 This procedure has been formulated to comply with current information from the
Department of Health, the Consultant in Communicable Disease Control (CCDC)
and the Birmingham Specialist Community NHS Trust Policy for the Handling of
Infectious Deceased Persons.

 If in a cadaver bag, care should be exercised in handling the body.

 A leak-proof coffin must be used to collect an infectious body from the hospital
mortuary.

 Advice on how to deal with any case should be obtained from the CCDC.

 Any body in a cadaver bag despatched to an undertaker by Birmingham East and

North Primary Care Trust should be accompanied by the appropriate form 'Use of a
Cadaver Bag'.

 Personal protective equipment (gloves and plastic apron) is available in the

mortuary and will be offered if required.

 If approached by relatives who request to view the body, but the body has not left
the hospital, they should be advised to contact the ward nursing or medical staff
before visiting the Chapel of Rest so that the nature of the illness and any
precautions necessary may be given to them.

Birmingham East and North Primary Care Trust Infection Control Policy and Procedure Manual 2002
Last Offices Section 3.11
Updated March 2004
 Certain diseases present a hazard to undertakers who perform embalming. Advice
should be sought from the CCDC.

Consultant in Communicable Disease (CCDC)

The CCDC has responsibility for:

 Advising on the infection control aspects, handling, viewing and religious practices
associated with bodies in all community premises outside the hospital.

 Liaising with the hospital Infection Control Doctor, if necessary, concerning infection
control aspects of dealing with infectious bodies, in particular rare diseases.

 Advising undertakers on policies and safe working practices.

VIEWING OF PATIENTS IN THE MORTUARY

Viewing during normal hours

 Request should be made by nursing staff/bereavement officer as normal to

mortuary staff.

 Viewing time will be advised by mortuary staff depending on circumstances.

Viewing out of normal hours

 A body placed in a cadaver bag for an infectious disease may only be viewed
out of hours after liaison with the Senior Nurse in charge and on-call
Microbiologist who will undertake a risk assessment.

 The senior nurse on-call, in conjunction with the porters, will arrange the viewing
where appropriate.

Guidance for all viewing

 Bereaved relatives must be accompanied to the Chapel of Rest to view the

deceased.

 A member of staff must stay in the vicinity of the viewing to supervise and support if
necessary.

 Handwashing should be offered to the relatives following viewing if necessary or

requested.

APPENDIX 1

Birmingham East and North Primary Care Trust Infection Control Policy and Procedure Manual 2002
Last Offices Section 3.11
Updated March 2004
DISEASES REQUIRING THE USE OF A CADAVER BAG FOR REMOVAL OF
BODY FROM WARD TO MORTUARY

Diseases are divided into two groups compatible with risk:

Group 1: Place in a cadaver bag; viewing on ward acceptable for medical

reasons or by relative if supervised by qualified staff. In general,
precautions for relatives should be no more stringent after death than
before.

Group 2: Place in a cadaver bag, which should not then be opened.

INFECTION GROUP 1 GROUP 2

Hepatitis B, C, non-A, non-B  (B)
1
HIV/AIDS  (B )
4
Transmissible spongiform  (N )
encephalopathies
(eg, Creutzfeldt-Jakob Disease)
Invasive Group A streptococcal 
infection
Anthrax (rare) 
Plague (rare) 
Rabies (rare) 
Smallpox 
Viral Haemorrhagic Fever 
Yellow Fever (rare) 
Typhus 
1
Typhoid Fever  (I/B )
1
Paratyphoid Fever  (I/B )
1
Cholera  (I/B )
1
Dysentery  (I/B )
1
Food poisoning  (I/B )
Tuberculosis  (B)
Meningococcal meningitis or  (L)
septicaemia
Diphtheria  (L)
3
Relapsing fever ( )
Brucellosis 

KEY:

 = selected group B = blood risk N = neurological risk

I = intestinal risk L = lung risk

1 A body bag is recommended to contain any leakage during transport. The body can be
removed from the bag for viewing.
2 A mask should be worn by staff if the body is removed from bag or bag opened.
3 A body bag is only necessary if the louse vector is present.
4 Viewing of the body PRIOR to post-mortem is acceptable.

APPENDIX 2

Birmingham East and North Primary Care Trust Infection Control Policy and Procedure Manual 2002
Last Offices Section 3.11
Updated March 2004
 Cadaver Bag No.

FORM TO BE COMPLETED BY MEDICAL PRACTITIONER OR

NOMINATED REPRESENTATIVE FOR DECEASED PATIENTS
REQUIRING A CADAVER BAG

THIS FORM MUST ACCOMPANY BODY TO MORTUARY

1. Name of Deceased: ...................................... Ward: ............... Reg No: ..............

2. The deceased had or is suspected of having an infection (detailed Yes/No

below). (If "No", question 3 must be answered.)
If "Yes", please tick type of infection: tick
(a) Bloodborne (eg HIV, HepB, HepC, meningococcal septicaemia) 
(b) Wound (eg invasive GpA, beta-haemolytic streptococcus) 
(c) Respiratory infection (eg open pulmonary TB, meningococcal 
meningitis)
(d) Gastrointestinal infection (Shigella, Salmonella, Campylobacter, 
viral diarrhoea, E. coli 0157)
(e) Neurological infection (eg CJD) 
(f) PUO and/or jaundice returned from abroad, or undiagnosed 
jaundice in UK
Specify: ................................................................................................
Note: Pneumonia, chest infection (other than (c) above) and
MRSA do not require use of a cadaver bag.

3. The deceased requires a cadaver bag for reasons other than infection, 
eg leakage, skin harvest, major burn/trauma, organ donation.

Please state: .........................................................................................

Signed: ............................................ Print Name: ..............................

(Medical Practitioner or nominated person)

Designation: ..........................................................................................

Date: ...............................................

Enquiries
Any queries prior to placing body in cadaver bag should be referred to Infection Control
Team or on-call Microbiologist out-of-hours.
Following removal of the body from the hospital, enquiries concerning infection should be
addressed to the CCDC for your area. The Environmental Services Department or local
hospital have the appropriate numbers. For Birmingham: telephone 0121-695-2350
(office hours), 0121-766 6611 (out-of-hours).

Birmingham East and North Primary Care Trust Infection Control Policy and Procedure Manual 2002
Last Offices Section 3.11
Updated March 2004
 APPENDIX 3

PROCEDURE FOR DEALING WITH SPILLAGE FROM INFECTED OR NON-

INFECTED BODIES

The equipment for this procedures includes:

1. Yellow clinical waste bag (in foot-operated pedal bin).

2. Disposable paper towels (minimum one roll).
3. Disinfectant - Sanichlor (1.8g tablets 0 1 tub).
4. Sanichlor granules (1 shaker pack).
5. Buckets x 2 (1 double domestic type).
6. Disposable cloths.
7. Full length plastic aprons (in dispenser).
8. Disposable gloves (1 box - medium size).
9. Full arm length veterinary examination gloves.
10. Overshoes.
11. Visor to BS2092 Grade 1.
12. 70% alcohol hand gel.
13. Disposable scoops.
14. Mop with disposable head.
15. Decontamination cards.

These items will be stored in the mortuary and should be replenished as required by
the mortuary technicians.

Birmingham East and North Primary Care Trust Infection Control Policy and Procedure Manual 2002
Last Offices Section 3.11
Updated March 2004
STAFF HEALTH

NB. Remember that hypochlorite is corrosive to skin, eyes and other

mucous membranes. In case of a spillage onto skin/mucous
membrane, wash immediately with water and report accident.

A porter should collect from the supplies cupboard and put on:

(a) Full length plastic apron.

(b) Overshoes.
(c) Full arm length gloves over which are worn two pairs of disposable
gloves.
(d) Visor.

The following items should then be collected from the cupboard:

(a) Disposable paper towels.

(b) Disinfectant (Sanichlor tablets and granules), buckets and mop.
(c) Disposable cloths.

Birmingham East and North Primary Care Trust Infection Control Policy and Procedure Manual 2002
Last Offices Section 3.11
Updated March 2004
 Appendix 3 (continued)

PROCEDURE FOR MAKING UP A HYPOCHLORITE SOLUTION

Hypochlorite solutions are not very stable and thus when required should be
made up fresh using effervescent Sanichlor tablets.

The Sanichlor solution required in this procedure should be made up at

10,000ppm or 1,000ppm available chlorine. The solutions should be
prepared as follows:

10,000ppm = 1x1.8g Sanichlor tablet in 100ml water

for blood/body fluid spillages

1,000ppm = 1x1.8g Sanichlor tablet in one litre (1,000ml) or

water
for surface cleaning

1. Add the appropriate number of Sanichlor tablets to the Sanichlor

plastic bottle.

2. Add most of the required volume of water (tepid not hot).

3. Allow to effervesce and dissolve over two minutes.

4. Make up to volume with water.

5. Replace cap tightly and gently swill the bottle to mix.

6. Transfer solution to bucket.

7. Prepare a second bucket to contain hot water and detergent.

NB.  Wash hypochlorite off metallic equipment with detergent and hot water,
and dry.
 Where possible, ensure good ventilation when using chlorine solutions.
 Do not mix chlorine solutions with any other chemical product or urine.
 Do not use hot water to make up solution

Birmingham East and North Primary Care Trust Infection Control Policy and Procedure Manual 2002
Last Offices Section 3.11
Updated March 2004
 Appendix 3 (continued)

PROCEDURE FOR CLEANING UP A SPILLAGE

1. Put on protective clothing.

2. Either:

(a)  Sprinkle Sanichlor granules liberally over the spillage,

ensuring complete coverage. Leave for at least two
minutes. Do not leave unattended.

 Scoop debris into yellow clinical waste bag.

 Wipe up remaining granules with a damp paper towel

soaked in hypochlorite solution previously prepared. Never
return used cloths to the hypchlorite solution.

 Wipe the inside, outside and handles of the body trolley and
any other areas soiled by spillage with the hypchlorite
solution.

or:

(b)  Mop up the spillage (if large) with hypochlorite 10,000ppm.

NB. If an individual spills pack is available, i.e. Haz-tabs, then follow

instructions on outside of the pack.

3. Remove outer gloves, discarding to a yellow waste bag.

4. Wipe the inside, outside and handles of the trolley and any other areas
cleaned with hypochlorite, with detergent and hot water.

5. Dry off the trolley with disposable paper towels or cloths, discarding
thse into the yellow waste bag.

6. Remove visor. Wipe over with detergent and hot water.

7. Discard unused hypochlorite and hot water and detergent solutions to

the drain.

8. Discard mop head to yellow waste bag.

9. Rinse out buckets.

Birmingham East and North Primary Care Trust Infection Control Policy and Procedure Manual 2002
Last Offices Section 3.11
Updated March 2004
10. Remove overshoes with gloved hands, taking care to avoid
contamination with the shoes, and discard overshoes to a yellow waste
bag.

11. Remove the apron and outer gloves, and discard to a yellow waste
bag.

12. Remove the yellow waste bag from the pedal bin.

13. Remove arm length gloves and discard to a yellow waste bag.

14. Seal the yellow waste bag and date the pre-labelled bag tie in
accordance with the Trust Waste Policy.

15. Leave the yellow waste bag for removal by the mortuary staff.

16. Return unused and non-disposable items to store.

17. Wash hands thoroughly with soap and water. Dry hands, discarding
paper towels into yellow waste bag.

18. Complete the cleaning procedure card and leave on the mortuary desk.

Birmingham East and North Primary Care Trust Infection Control Policy and Procedure Manual 2002
Last Offices Section 3.11
Updated March 2004
 APPENDIX 4

Part 6: Information for Cemetery & Crematoria Staff Birmingham East and North Primary Care
Please tear off this section and send with the “DISPOSAL CERTIFICATE or Trust
CORONER’S AUTHORITY” to the cemetery or crematorium

Guidance for Funeral Directors,

MORTUARY NUMBER: ………………………………………………..
Cemetery & Crematoria Staff on
or
Handling the Deceased
NAME OF DECEASED: ……………………………………………….. (This form must accompany the body to the funeral directors)

Please print clearly and use biro or waterproof ink

 Body has been embalmed YES/NO

 Body is in a cadaver bag YES/NO Part 1: Mortuary Number: ……. …………………………

Name of Deceased: …………………………………………

Mortuary address:

Birmingham East and North Primary Care Trust Infection Control Policy and Procedure Manual 2002
Last Offices Section 3.11
Updated March 2004

Section 2.26
Part 2: Body Bag to be used because of: Circle:
Part 5: Safety Instructions:
1. An infection as follows:
Strict adherence to precautions here is essential
Airborne infection Yes/No
Universal Precautions:
Blood borne infection Yes/No
 No smoking, eating or drinking in work rooms
Gastro-intestinal infection Yes/No
 Wear protective clothing which should include an apron and gloves
 Cover existing cuts and wounds with waterproof dressings
Neurological infection Yes/No
 Thoroughly wash hands after every procedure
Leakage Yes/No  Keep movement of the patients body and chest to a minimum

2. Other reason (please specify) ………………………………….
………………………………………………………………………
Part 3: Body Preparation
 Body can be removed from bag for hygienic preparation
 Bag should not be opened. Unsuitable for embalming under any Yes/No
circumstances (e.g. Neurological infection or Invasive Group A
streptococci infection)
Advice for undertakers on embalming is available via the CCDC. Embalmers
National guidance should be followed.
Accidents:
Cuts, stabs, pricks and wounds are made to bleed, then thoroughly
washed, treated with tincture or iodine or 70% alcohol and a waterproof
Circle: dressing applied. Splashes to eyes should be washed immediately with
saline/tap water.
Yes/No
*REPORT AN ACCIDENT TO appropriate HOSPITAL CASUALTY
OHD IMMEDIATELY
Where there is a risk of splashing blood or any other body fluid:
Wear waterproof full length apron, latex/vinyl gloves, boots and face
protection.
Cover existing cuts and wounds with waterproof dressing.

Birmingham East and North Primary Care Trust Infection Control Policy and Procedure Manual 2002
Last Offices Section 3.11
Updated March 2004

Section 2.26
Part 4: Final Presentation For Further Advice:

Circle: Useful Contact: Consultant in Communicable Disease Control,

Birmingham Health Authority, St Chad’s Court, 213 Hagley Road,
 Body can be viewed Yes/No Edgbaston, Birmingham B16 9RG

Tel: Office Hours: (0121) 695 2351

Out-of-Hours (0121) 766 6611 & ask for on-call Public Health
Physician

Birmingham East and North Primary Care Trust Infection Control Policy and Procedure Manual 2002
Last Offices Section 3.11
Updated March 2004

Section 2.26
 APPENDIX 5

GUIDANCE RELATING TO POST-MORTEM EXAMINATIONS

Certain diseases present hazards to mortuary staff and histopathologists.

The following action is to be taken by medical staff in certain groups for
specific conditions:

1. Conditions which require a test for hepatitis viruses to be carried out

before a post-mortem examination will be performed by the pathology
staff, ie:

(a) Jaundice of unknown aetiology.

(b) Acute or chronic bronchitis.
(c) Hepatoma.

2. Conditions which require a test for HIV* to be performed before a post-

mortem examination will be considered by the pathology staff, ie:

(a) Drug addicts.

(b) Promiscuous homosexual or bisexual males.
(c) Haemophiliacs whose HIV status is unknown.
(d) Persons who have been resident in high risk areas.
(e) Persons having symptoms or signs suggestive of AIDS or AIDS-
related complex.
(f) Consorts of the above.

*Consent, together with counselling, for HIV testing needs to be obtained

from next of kin.

3. Conditions in which pathologists reserve the right to refuse to do post-

mortem examinations, ie:

(a) Hepatitis B, C and D.

(b) AIDS/HIV positive.
(c) Creuztfeldt-Jakob Disease.

Histopathologists should follow the guidance on the safety aspects and

precautions to be taken on bodies which have an infectious disease, as
referred to in 'Safe Working and the Prevention of Infection in the Mortuary
and PM Room'(1).

Birmingham East and North Primary Care Trust

Handling of Infectious Deceased Persons/Last Offices
REFERENCES

1. Health Services Committee: Safe Working and the Prevention of

Infection in the Mortuary and Post-Mortem Room. HMSO 1991.

2. Ayliffe GAJ, Lowberry EJL, Geddes AM, Williams JD. Control of

Hospital Infection. Published: Chapman and Hall Medical; 3rd edition.

3. Advisory Committee on Dangerous Pathogens: HIV - the causative

agent of AIDS and related conditions. January 1990; second revision.

4. CMO: Information for Undertakers - Infectious Diseases. PL/CMO

88(8). March 1998.

5. DH/DE: Guidance to Local Authorities and Regional Districk Health

Authorities: Communicable Disease Control. HSG(93)56.

6. DH. Code of Practice for the Prevention of Infection in Clinical

Laboratories and Post-Mortem Rooms. HMSO 1978.

7. Advisory Committee on Dangerous Pathogens: Categorisation of

Pathogens According to Hazard and Categories of Containment. 2nd
edition; 1990.

Birmingham East and North Primary Care Trust

Handling of Infectious Deceased Persons/Last Offices