15 minute read
How many Covid deaths? Look in our fridges
from Booklaunch Issue 16
by Booklaunch
WHEN THIS IS OVER
REFLECTIONS ON AN UNEQUAL PANDEMIC
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Amy Cortvriend, Lucy Easthope, Jenny Edkins and Kandida Purnell (eds)
EDITOR’S NOTE
There was no one that the Covid-19 pandemic did not touch. In this book, academics, activists and artists come together to consider the experience of marginalised and minority groups, and to measure how unjust and uneven was the pandemic’s impact on the most vulnerable. They note how it brought out the good in many and the worst in others, and how it raised questions about what is truly important in our lives.
A MORTICIAN WRITES: For as long as I can remember, I’ve always wanted to work with the dead. I cannot explain what drew me to this line of work, and speaking to colleagues across this profession I can honestly say that very few of us can answer the question ‘why?’ A vocation, a calling— no one enters this line of work lightly. We are all individuals; there is no stereotypical mortuary professional (although with my all-black-everything attitude to clothing, multiple tattoos and piercings, I would say that I definitely look like what you would imagine a stereotypical mortuary dweller to look like).
As an ‘anatomical pathology technologist’ (APT), to give my full job title, I am responsible for the continued care of the deceased. I work in an NHS hospital but APTs also work in council/local authority-run public mortuaries. My job is to look after the adults and children who die in our hospital and local borough. We also provide post-mortem services for coroners from all over London, the southeast and as far afield as Hereford and Nottingham.
For APTs in general, our day-to-day job involves admitting and releasing deceased patients, assisting with post-mortem examinations and facilitating families visiting their loved ones, alongside the administration and maintenance of the mortuary environment. (CONTINUES AFTER COMMENTS)
READERS’ COMMENTS
Toni Haastrup, University of Stirling:
Andreas Papamichail, QMU London:
Yoav Galai, Royal Holloway, University of London:
Katharine Millar, LSE:
My job is gruelling and rewarding in equal measure, and for those of us who enter this career, it is usually a path we remain on for life. But I am not the sole authority on mortuary work, nor am I trained in emergency preparedness. However, I do believe I have something worthwhile to say on the lessons I have learned, and the lessons that we should take away from the pandemic as they relate to care of the deceased.
Business-as-usual to chaos
When news first started breaking about this new coronavirus with pandemic capabilities, I wasn’t worried. We are well versed in handling excess deaths—we do it every winter; but as the virus spread and death tolls were increasing across the world, we started to get concerned about our ability to cope with the projected death rates.
From mid-March, it was clear that this was on a scale we had never experienced before. We received out first COVID-19 patient in the mortuary on 14 March and less than three weeks later had reached capacity. Our day-to-day job became that of management of the deceased.
The increased death rate did not happen in a vacuum. Let’s say there is an expected death in a hospital, a death in which a medical certificate of cause of death (MCCD) can be issued without the need for a coroner or a post-mortem examination. The patient is brought down to the mortuary within four hours of death and placed in a fridge by two porters. They arrive maybe with some small items of personal property (jewellery, credit cards, religious tokens and so on).
The patient is then ‘checked in’ by a member of mortuary staff: three points of ID are put on two hospital wristbands, their property is accounted for, they are weighed and measured (in case of a post-mortem examination) and we look for evidence of any implanted devices, such as a pacemaker. We change their sheet and clean them up if needed. We then transfer this information onto our bespoke mortuary database. This will be very important later.
Meanwhile, the patient’s hospital notes and any other property is taken to the bereavement centre by a nurse or ward clerk where the bereavement staff input the patient’s details onto the database. They document the property and start to phone the wards to see if there is a doctor available to write the MCCD. The doctor has to come to the bereavement centre to do this. The family of the deceased get in touch and will be called when the MCCD is ready to be collected; we have a time frame of 48 hours for doctors to complete this paperwork. The family also collect the property of the deceased from the bereavement centre or is disposed of by the hospital, should the family not want it.
This is a basic run-through of what happens, but read it again and take note of how many people are involved and how much of this happens face to face. This is pre-COVID-19 and, of course, there are far more complicated deaths than this standard example, with families experiencing difficult emotions, some not speaking English as a first language or having specific religions or cultural needs.
Now imagine that process happening when the country is in lockdown, when people are not supposed to leave their homes, when doctors and nurses are overwhelmed on the wards and when the mortuary is receiving more and more patients.
During winter, excess deaths bring an increased volume of work but people can still attend the hospital and collect paperwork and property and register deaths. With COVID-19 and the lockdown, things ground to a halt. Legally, there was no way of registering a death remotely. Between the next of kin testing positive for COVID-19, or having to isolate because of their contact with someone with COVID-19, and the hospital shutting down to visitors, we were all stuck, waiting. The only thing moving was the dead and they were all coming our way
‘Not my problem’ becomes your problem
How to deal with the property of the deceased soon became a major issue. This was something that I had never really given a second thought about, as it wasn’t anything I ever saw: it was the bereavement office that dealt with it. As it turns out, people bring a lot of property to hospital with them: clothes, books, electronics, personal hygiene products and so much more. This property all needs to be returned to the family. With the death of a patient, these items are no longer just comfort items that make a lengthy hospital stay more pleasant; they are now the last link between the living and the dead.
Concerns about how long COVID-19 remained on surfaces (at this early stage in the pandemic, there were a lot of unknowns and uncertainties) meant there was an extra layer of complexity to contend with: how do we deal with property safely? A new process was created by those higher up the chain, involving ways of decontaminating, separating, documenting and tracking the property before it even reached us. I wish I could say it worked well. On paper it was easy, but practically … less so.
The most frequently recurring, contentious and infuriating aspect of the pandemic was the ‘property problem’, which really boiled down to communication problems among those who designed the new system, those whose job it was to use the new system and those whose job it was to implement and communicate these changes to all involved.
The mortuary was not responsible for any of these aspects, as this was about what happened to the property before it reached us. It just so happens that we were the ones who were at the end of the chain and spotted errors in the process, by when it was too late. The burden fell on us to fix the issues and we simply didn’t have the staff or capacity to deal with it alone.
Thankfully, redeployments were happening all over the NHS trust. With outpatient clinics and research departments on standstill, staff were available to work elsewhere. We were able to have a two-person team dedicated to dealing solely with property and it was a relief to have people who could focus their whole attention on this, coming up with systems and a database to document everything.
It was not an easy job, either practically and emotionally. These people were now responsible for contacting the families of the deceased and having conversations about what they wanted to do with the belongings their loved ones had left behind, packing it up and mailing it out. There was no training as such, and I cannot express enough how important this job was and how well they did it.
Trust your mortuary staff
National lockdown was announced on 23 March, quickly followed by the Coronavirus Act 2020’s receiving Royal Assent on 25 March. This was what we had been waiting for as this Act was effective at streamlining swift death certification and registration, but we were worried that it would not necessarily translate into the movement of deceased patients. Between the mortuary and bereavement staff, we predicted that families would be reluctant to book a funeral, given that restrictions meant that there could be no attendees. Seeing as the lockdown measures were going to be in place for three weeks, people would refrain from making arrangements until they could have the service they wanted. And if there is one thing the dead can do, it’s wait.
Three weeks is a bit long for a deceased person to stay in our care, but a couple of things were now becoming very evident. First, higher management had no idea how the mortuary worked on a day-to-day basis. Routine things such as the movement of the deceased, the hold-ups that can occur even with the introduction of online death registration (you cannot force people to make funeral arrangements), the lack of space at funeral directors’ premises—all of these we had to explain, it felt, on a near daily basis. Second, this lockdown was going to last a lot longer than three weeks.
We made our concerns clear from the start about our capacity: we needed more, and quickly. I remember vividly an almost comical exchange between my boss and local health and emergency planning leads about the number of COVID-19 positive patients in the mortuary. When we said that we were getting full and needed extra space urgently, we were met with disbelief. How could we be running out of space? There weren’t that many deaths, surely?
We sat open-mouthed, looking into the fridge room at our rapidly declining spaces: how could they not believe us? The answer was paperwork. Every death due to COVID19 had to be reported to NHS England, and this was done by filling in a paper form that then made its way up the chain. With the overwhelming demand on ward staff, there were delays in the forms leaving the wards.
On paper, there were few COVID-19 deaths. Our fridges told a different story. When patients die in hospital carrying infections such as hepatitis, HIV, tuberculosis and now COVID-19, they are placed in a specific, separate fridge bank, as more personal protection equipment (PPE) precautions are needed when handling the deceased. The separate fridge banks serve as an easy visual cue more than anything else. Contrary to belief, there is very little danger posed from the deceased in terms of infection transmission.
With COVID-19 deaths on the increase, the deceased were now placed wherever there was space. We made a note on the fridge doors if the deceased had COVID19—another easy visual cue for us and the portering staff who are responsible for transferring the deceased from the wards to us. A quick glance at our fridges showed the majority of our residents had had COVID-19.
From here began an eventual daily situation report (sitrep) meeting—virtual, of course—regarding mortuary issues: namely, capacity. It turns out there is quite a bit to consider when procuring extra mortuary space. Issues like security, ease of access and how public it would be all had to be weighed up.
During previous excess-death scenarios, we were fortunate enough not to have to use outside excess storage, as we could utilise the space at our (much smaller) satellite mortuary. Looking elsewhere meant there were cost and timing implications. Every mortuary in the country was looking at obtaining more space, and with few companies actually being able to provide such bespoke equipment, and with lead times increasing every day, a decision wasn’t made, and things were looking bleak.
London and national mortuary capacity databases were set up to enable the NHS and the government to monitor the situation. It was around this time that there were rumblings of large temporary mortuary facilities being put in place, quite separate from the Nightingale hospitals that were being built.
I received a phone call from someone in a council department who had been tasked with helping with the logistics of one such temporary mortuary facility that would be situated in Breakspear Crematorium, in the borough of Hillingdon. This was due to be operational only one week later and advice was wanted on how to keep track of the deceased moving in and out of the facility.
The specific question will be burned into my memory forever: ‘What system does the NHS use for keeping track of the deceased?’—as if such a system existed. I broke it to them: there wasn’t one. A brief silence was followed by a despondent, ‘Oh’.
I then explained how every mortuary uses a different system to track the deceased in its care, and that some may still use paper registers; that not everyone dies in a hospital, that our patients may arrive with us after dying at home. The, there’s the paperwork generated after you die in relation to burial and cremation, which is another matter altogether. This was clearly not the conversation the person on the end of the phone was hoping to have.
My boss had the pleasure of following up these conversations, and each email and phone call brought more bad news for the designers and disbelief from APTs that this was ever going to work.
Althugh our own temporary storage facilities were close to being built, the Breakspear facility would be operational first and a system for how to organise the transfer of the deceased seemed to have been ironed out. This was not without fault, was very labour-intensive for APTs and brought with it a lot of frustration and upset, but we really had no alternative but to use the facility as we had nowhere else.
This use of emergency mortuaries is the most difficult aspect to reflect on. APTs have high standards and expectations when it comes to management of the deceased; it is what we do on a daily basis, and to have this taken out of our control was very difficult to accept. APTs and funeral directors alike had an opinion on how this could have been done better and our picking apart of every perceived fault became a bonding activity. Because the deceased were still our responsibility, we felt comfortable passing judgement on those who dared enter our realm uninvited and uninitiated. It was an easy target and somewhere very tangible to direct our frustrations, but later on I would come to realise just what limited expertise the people in charge of setting these up had at their disposal.
By the time the first peak of COVID-19 seemed to be settling and we were moving into summer, things that had been strange and unfamiliar soon became routine. Our own onsite excess storage was up and running with no need to use the temporary mortuaries any further. Reporting systems for mortuary capacities were streamlined and reduced in frequency as mortuaries became less pressured for space. Knowledge about COVID-19 in general had advanced, in part because of the information that post-mortem examinations had yielded.
This information aided medicine in real time as the effects that COVID-19 and the current treatments were having was understood more, and the benefits to the living cannot be overstated. We were able to help other departments that were eagerly waiting to reopen their clinics as we were able to test various fluids and areas to see if COVID-19 was present and transmissible—things like orthopaedic surgery and ophthalmology—and guide risk assessments and PPE. This was down to the generosity of the families who consented for post-mortem examinations on their loved ones, and I cannot thank them enough …
WHEN THIS IS OVER
REFLECTIONS ON AN UNEQUAL PANDEMIC
AMY CORTVRIEND, LUCY EASTHOPE, JENNY EDKINS, KANDIDA PURNELL (EDS)
Policy Press, 208 pages, 14 March 2023, 9781447368069, RRP £14.99
Check our website for discount: www.booklaunch.london
