Planning and designing of modern mortuary complex in tertiary care Singh Sanju*, Dr., Sinha U.S.†, Dr., Kapoor A.K.§, Dr., Verma S.K.¶, Dr., Singh Dalbir**, Dr., Sharma Susheel†, *Department of Hospital Administration, A.I.I.M.S., New Delhi. †Department of Forensic Medicine and Toxicology, M.L.N Medical College, Allahabad. §Department of Pharmacology, M.L.N Medical College, Allahabad. ¶Department of Forensic Medicine and Toxicology, U.C.M.S, Delhi. **Department of Forensic Medicine and Toxicology, PGI, Chandigarh. |
INTRODUCTION Rapid modernization and exponential sophistication have take place over the last century in the field of medical sciences but a lot is desired for those who dead and need to be laid to rest with peace, dignity and respect. The importance of proper decent facilities and services of modern postmortem complex will play a vital role and Yeoman services to the harassed layman. So that even the most reluctant mortuary visitor would not mind entering the complex. They will dispel the atmosphere of dislike, fear and hatred presently prevailing in majority of the so-called postmortem building in major part of the country. |
Top Mortuary Services and Concept Of Modern Mortuary Complex Mortuary is the place where dead bodies are kept before burial/cremation, whereas Morgue is a place where dead bodies are kept in the refrigerated body store and examined in the post mortem room. |
The mortuaries have long been neglected and are generally located in a far-off isolated corner of the hospital with primitive facilities for body preservation and autopsy. Instead of becoming a pulsating enquiry center of modern medicine, it has remained a dead house. It is pathetic to note that even in most of the medical colleges in state like UP, mortuary services are in pitiable situation and there is no denial they need immediate attention and redressal. The concept of a modern mortuary in a hospital, regards the mortuary as a culturally sensitive area in terms of public relation of the hospital. While considering the support and utility services of a hospital, the role and importance of mortuary services cannot be over emphasized. The concept of health of the population from “womb to tomb” in the community health care clearly indicates that in a health care set up, a doctor's duty is not only caring for the living but also in helping to arrange for the disposal of those patients who die. However, many of our heath care professionals are less adopted at this duty. |
From a practical angle, following death of a person, a number of procedures are to be carried out under the generic term “Post Mortem care”. The body is washed carefully, the orifices are plugged and protected and pads are applied to certain areas to prevent bruising. The rationale for these actions is generally presented as “showing respect for the deceased”. Respect is not the only reason for these procedures, but there is a scientific requirement for proper upkeep of the body till it is disposed off. When body is required to be preserved for sometime and then is dissected to find out the cause of death. This is called an autopsy or post-mortem examination in laymen's terminology. This examination is conducted to find out the cause of death may be for legal or scientific requirement depending on the circumstances leading to the death. The area where such procedure is carried out is called a Mortuary (Or Post-Mortem/Autopsy Room). On certain occasions, the body is also required to be preserved, till disposal arrangement is made either by the relative of the patients or the hospital authority. This place of preservation is called cold storage room and the entire area is called a “Mortuary Complex”. |
Top Importance of Mortuary Services The subject of disposal off the dead is hedged around by religious, social and cultural beliefs and practices. Whatever these may be, it is necessary to provide within the hospital or its precinct, a place to which a dead body can be moved quietly and discretely, so that other patients are not upset. It is also necessary to see that the body can later be removed from the hospital for burial or cremation by an exit away from the common view of patients and others in the hospital. |
Sanctity of the ‘dead’ is a universal concept and is intimately related to the cultural background of the community. Therefore, facilities for safe custody of dead bodies before and after post-mortem are to be provided accordingly. The responsibility of the hospital, to preserve the bodies until handing over to relatives, needs to be stressed. Thus, a requirement of a proper cold storage is important. The added responsibility of hospital authorities is to see that no mix up occurs and the particular body is handed over to its rightful heir/relatives for the last rites. In government hospitals the bodies of medico-legal cases are handed over to the police personnel for post-mortem if required and bodies are never directly handed over to relatives. |
Role and Functions of the Hospital: It is the duty of the hospital to provide mortuary facilities for the dead bodies. When death occurs in wards, the body is immediately shifted to mortuary unit and other formalities of the hospital are completed. The mortuary broadly serves the following purposes: |
To keep the dead till the relatives claim and take over the body for disposal. |
To keep unclaimed bodies until disposal (burial or cremation) is arranged by the hospital authorities. |
To allow viewing and identification by relatives, police and other people. |
To receive dead bodies requiring pathological post-mortems pending final disposal. |
To receive dead bodies brought to the hospital for medicolegal post-mortem work and store in the mortuary pending further disposal. |
For teaching the undergraduates as well as post-graduates. |
Ideally as per the sub-committee report (Bureau of Police Research and Development) of 1975, which has been accepted in principle by the government, no teaching hospital should have more than 500 autopsies in a year otherwise teaching activities suffer. It may be mentioned that at MLN Medical College, Allahabad, a total of 2436 autopsies were performed during the year 2005 far more than accepted norm. Moreover, in criminal case no. 214 DB of 1997, Hon'ble Justice Amar Dutt and Justice Kiran Anand Lall on 23.10.2005 have passed orders for ways and means to facilitate better conduction of post-mortems plus medicolegal work and obtaining rich information for ultimate evaluation of the issues and maintenance of mortuary, availability of space and provision for proper implements plus chemicals. |
The division Bench has observed that orders be served to the States of Punjab and Haryana and Union Territory of Chandigarh for necessary compliance in respect to improvement of the facilities mentioned in the judgment for conducting post-mortem and medico legal examination in these states. The court has also observed, “It may be appropriate if the concerned state communicates the steps taken by it to the sister States so that they do not lag behind.” |
Staffing: The requirement of staff in the mortuary differs from place to place and depends on the type of work undertaken, the quantum of work and the type of institute whether teaching or non teaching hospitals. Unfortunately, Forensic Medicine departments of most of the state medical college are understaffed and even MCI norms are not followed. |
The sub-committee report (Bureau of Police Research and Development of 1975) laid down the following staffing pattern and this has been accepted in principle by the government. |
For initial 100 autopsies per year Specialists-Two (as one specialist is likely to be busy in other important work, teaching work, in court attendance, or if he falls sick, it is necessary to have two specialists). Post mortem technician-One. Post mortem Assistant-One. Clerk/Steno-One. Chowkidar- One. Peon-One Sweeper/Morgue attendants-4 (Three sweepers for shift duty round the clock and one as a reliever).
For every additional 100 autopsies per year, following additional staff is required Specialist - One. Post mortem assistant - One. Technician - One (for teaching institutions). Technical assistant - (300–500 autopsies/yr)-One,(>500 autopsies/yr)-Two. Photographer - One. Dark room attendant- One (on big centers, personnel for photographic work)
The sub-committee notes that in teaching institutions, two senior staff members should not be counted while assessing the total number of staff required as they will be busy in discharging their administrative, teaching and research guidance work. Since the sweepers are the only officials available all the time in the mortuary, they should be re-designated as morgue attendant and should at least be matriculate who can read and write English language. This is important to ensure that bodies are not wrongly delivered and to differentiate between MLC and non-MLC bodies so that MLC body is not released without post mortem. To maintain records, a record clerk should also be posted in each mortuary complex. Planning Consideration: The location of the mortuary and autopsy room for obvious reason is always a problem and preferred to be in an obscure place. This is normally because both hospitals authorities and physicians by and large prefer to project their successes rather than exhibit the dead body, which apparently indicate their failure. This mind set requires to be changed and mortuary complex must be situated at a reasonable vicinity to the main hospital complex so that it is not only convenient to the hospital staff but also to relatives, police and other officials who are required to visit mortuary very frequently. It is also important for the security reasons that mortuary complex is near to the main hospital building. Location: The mortuary should be located in a separate building near the pathology laboratory on the ground floor, easily accessible from the wards, accident and emergency departments and operation theatres, in an area with ample natural light through windows; the widows of the principal rooms should preferably be on the northern side. It should be located in one wing of the hospital preferably away from the general traffic routes used by the public. It must have a separate entrance and exist for relatives. The area for the functional purpose in the mortuary can be divided into various segments. These can, broadly, be mentioned as under. Top Physical Facilities Area and Space Requirement The access to the unit should have a covered area along with parking space for vehicles leading to the mortuary complex. This acts as a protection in wet weather and as a screen from adjoining areas. It is also desirable to have an exit to a subsidiary road and nearby car park. |
The mortuary and post mortem unit should consist of: |
Reception and Waiting area Cold room for body preservation Post mortem room Ancillary areas: Like consultant's room, conference room, prayer room, toilet and other facilities for the staff and the visitors, trolley bay comp, stores, etc.
A. Reception and Waiting Area: (Size 240 sq. ft.) It is the place where the body is received and documents are verified and checked. It is essential that this particular area be at a prominent place for easy accessibility. It should be easily approachable and due care should be taken to shield if from OPD/ward block areas of the hospital. This area should be gently illuminated, warm and have comfortable chairs. It should be pleasantly and soberly furnished and decorated with plants and pictures, which would create a pleasant atmosphere, as the last impression of the relatives receiving the deceased is one of quite dignity in death. This area can also be used as prayer area where relatives and friends of all religion may like to offer prayer. A lavatory also must be provided with and kept scrupulously clean. The Hon'ble High Court as cited above has also directed for provision of a waiting hall for attendants, police with provisions for a central platform. |
B. Cold Room for Body Preservation: (Size sufficient to accommodate 50 bodies). It is the place where all the bodies including hospital dead will be transferred and kept prior to post mortem/autopsy or cremation. It is very essential to have an adequate cold room or sufficient number of refrigerators for storing the dead bodies, viscera etc. so that the putrefaction changes are kept to the minimum and to preserve the normal appearance of the body as far as possible till the final disposal. The court order has also made provision of a cold chamber depending upon number of bodies. |
The number of bodies to be accommodated will depend upon the size and type of hospital, but for preliminary planning purposes an estimate of three percent of the hospital bed holding may be taken. |
It is desirable, rather it is essential, that the body racks should be refrigerated, as it is not always possible to know how long a body will have to remain here. The chambers should be about 6 ft. wide, 8 ft. 9 inches deep and 6’fit high in which six bodies may be stored in two sets of three tiers. Cabinet doors should open through 1800 to allow the attendants to approach either side of the trolley. Depending on the layout, a depth of 18 ft. for the body store is usually satisfactory. Space is needed in front of the cold chambers for the withdrawal of trays and for working space for the morgue attendants. |
A/C Plant Room: Where more then twelve bodies are to be stored, a separate plant room 25–30 sq. ft. may be required, immediately adjacent to the body storeroom. Access for maintenance should be arranged externally so that it is unnecessary to enter the building. |
C.Post Mortem Room: (size 30’ × 20) This is a room where the body is investigated and dissected, so the room, like an operation theatre must be kept clean to protect the doctors and staff from bacterial contamination. Two tables or 400 sq. ft. are required for every 450 hospital deaths (probably one third of the total hospital death only will be examined). However, Hon'ble Court has provided that autopsy complex should have an autopsy room (approx. 400 sq. meter area) with washing and drainage facilities mortuary tables should be (preferably of stainless steel with arrangements for allowing free drainage of a constant flow of water from top to bottom). |
Requirement: i) Large windows of frosted glass. ii) Adequate water supply (including sinks) iii) Fluorescent lighting/good concentrated lighting over tables. There should be fluorescent lights with at least one having tilting mechanism. iv) Fans. v) Autopsy table of stainless steel. vi) Built in cupboards for keeping instruments and equipments. vii) Water-impervious floors sloping to a drain viii) Tiled walls so that the whole room can be easily washed. ix) Suitably covered junctions between the walls and floors. x) Two sinks for clean and dirty work. xi) Writing desk and chairs. xii) Shelving for jars (and tanks under) for depositing the immediate specimens. xiii) Space for mortuary trolley. xiv) Testing bench, accommodating scales, gas, and light with blackboard on wall behind. xv) Trolleys for shifting dead bodies and adequate furniture. |
The autopsy room in a teaching hospital should have space for students/doctors/nurses to observe autopsies. Tiered benches at the sides of the room for observers to visualize and avoid interference. The room should be so arranged that the pathologist/forensic medicine doctor might work at two or more tables. However, in smaller hospitals one table will normally be enough but area recommended should be large enough for the installation of a second table if required i.e. About 150. sq. ft. of space will be needed for each additional table. |
Ancillary areas: in order to achieve adequate results and provide basic necessities for those working in the mortuary, the following areas should be planned and provided in the mortuary complex: |
Consultant Room: Size 100 sq. ft. This is the place where the doctor and police fulfill legal formalities and where the post-mortem/death reports are generally written or dictate on telephone or recorded on tape during the course of an autopsy. It may also be used for discussion with members of the clinical staff. Changing Room: Two separate male and female changing rooms are required for the doctors and other clinical staff to change before entering the post-mortem room. There should be separate lockers for personal clothes and for post mortem room gowns, aprons and boots. Further, changing space or second changing rooms are also needed where there are both male and female doctors. Ante Room: A small lobby is needed for discarding soiled garments and bots before the doctors and clinical staff returns to the changing room. Consultant lavatory: Size 160sq.ft. One separate male and female W.C. lavatory, basin and a shower cubicle are needed. Room for the mortuary supervisor. Mortuary attendant's and cleaner's room: Size 100-150sq.ft. This is the place required for the attendants assisting the doctors in post-mortem to change before entering the post-mortem gowns aprons and boots. There should be separate lockers for personal clothes and for post-mortem gowns, aprons and boots. A table will be required for keeping the records of arrival and the removal of bodies, viewing periods etc. and for other official documents. One or two mortuary attendants will be employed whose duty, among other things, will be to transport bodies from the sickrooms to the mortuary. The Court has directed that efforts be made to have full time mortuary staff. Attendant lavatory: Size 80 sq. ft. A W.C. and washbasin will be necessary together with a shower cubicle. Trolley bay: A bay is required for the two mortuary trolleys (the elevating trolley and the covered type collecting trolley). Stores: Three small stores may be required (size 30-40sq.ft. each). Clean Store: For clean gowns, aprons, rubber gloves, gumboots, towels etc. It should be adjacent to consultant room and outside post-mortem room. Instruments and Equipment Stores: Required to hold the reserve stock instruments, unused specimen jars, chemical solutions, the electric resecting saw, the portable trolley, mounted spot light, etc. this should open directly in the post-mortem room. Chemical Store: Where chemical solutions for preserving the viscera and specimen jars and packing material are kept.
Sluice Room: (Size 50–75 sq.ft.) To be provided for the through cleansing of all instruments and equipments, also for the disposal of unrequited matter which does not warrant removal to the destructor. Requirements: Slop sink with hot and cold water connected to the soil drain Slab required for washing of bowls and instruments, Cupboards for cleaning material, Glass Shelving, Washable floor and walls. Specimen Room: (Size 120 Sq. ft.) This should be provided in which body tissues may be stored (in jars tanks of formal in) prior to their removal to the department of histology for microscopic pathological examination or permanent preservation. Viewing Room:(180–120 sq.ft) This should be designed as a small chapel, which will be used by relatives of the deceased. This chapel must not be cramped, as space is necessary for turning body trolleys, coffins, etc. Requirement for specific religious denominations must be ascertained at the outset as the requirements and accommodation will vary. Bier Room: This room should be free of hangings and drapes and the furnishing should be capable of being easily, cleaned and disinfected. Relatives and visitors will not be allowed in this room. It may, therefore, be smaller than the main viewing room. Undertakers vestibule: (Size 150sq.ft.) The setting of the mortuary may sometimes require a lobby for use as an anti-room to prevent direct observation into the body store. This lobby might also conveniently provide working space for the undertakers’ assistance and could contain writing top and table. Foresaid Radiology Section: The Hon'ble court has directed that initially arrangements may be made for conduction of X-ray though portable machines and facilities of view box for viewing X-ray films. Forensic Photography Section: Having facilities for photography. The division bench of the court has observed, there is no denying the fact that “scaled colour- photography’ and sketching on the pictorial chart/Traumagram will be highly informative and aiding better interpretation. Furthermore photo documentation can be very useful as an adjunct to hand written records and sketches. Medical Observation Room: (Size 70–150 sq.ft.) It is a room that allows clinical staff to attend autopsy without changing. It may be in form of gallery or room, separated from the postmortem room by a full-length glass-viewing panel above worktop height, would allow adequate observation and discussion. Doctors Room: This room is required for writing of reports. It may be used for discussion with members of the clinical staff, so the size and dimension of the room should be adequately planned.
Engineering and special services: Engineering services should be designed and installed so as to enable easy maintenance, minimum interruption of services and disturbance to the working of the mortuary while repair and maintenance are being carried out. |
Top Miscellaneous Floors: Should be hard and durable. It should be made from material, which is moisture resistant and can be easily cleaned. Floor ducts and trenches should be avoided in the post-mortem room and body storeroom. The junction between the walls and floors should be suitably covered. Walls: The walls of mortuary should be thick, durable and permanent. The walls should be fitted with tiles making it impermeable and washable. Ceilings: The ceilings of the mortuary should be made of material that can be easily cleaned. Principal rooms height of ceiling not less than 12 ft. and Ancillary rooms height of ceiling not exceeding 10 ft. Doors: Wide doors (double or sliding) should be provided to allow easy passage of trolleys and equipments in the post-mortem room. Windows: The mortuary should have sufficient natural light. Windows preferably on the northern side should be provided wherever possible. Windows of the principal rooms should have opaque glass and be fitted with external fly proof screens. Windows sills should be at least 5 ft. above the floor. Corridors: The corridors of the mortuary limit should be wide to allow passage of trolleys. (Not less than 8 ft.). Lighting: The light fittings should be designed to avoid glare, and should be easy to clean and maintain. In the mortuary either tungsten or fluorescent lighting can be used. Switches in the wet areas should be hose-proof. Special lighting should be provided in the post-mortem room to ensure adequate illumination of post-mortem tables and dissection benches. Heating and Ventilation: The heating requirement of the mortuary unit can be met by conventional heat radiators/convectors, which can be mounted on the walls. The temperature required in the mortuary should be 10–18°C. Natural ventilation by fly-proof screen windows and fresh air inlet grills should be adequate except in the post-mortem room where a mechanical exhaust system is necessary. Fans should be of the variable speed type designed to produce 10 air changes per hour. Hot and cold water supply: Hot and cold water be required to the sinks, washbasins and showers. Post mortem tables should be fitted with individual/water hoses. Water suction pumps should not be used. Floor service ducts should be avoided Drinking water tap taken directly from the mains should be provided at different locations. With All taps in the working area should be of the elbow operate type in the mortuary complex. Communication: Communication has to be very good for one person to control the area efficiently. There should be provision of both internal as well as external telephone lines as the forensic expert would always be communicating between the department and mortuary, other hospital areas and mortuary as well as police and public agencies. A public address system is also desirable. Air conditioning: The entire mortuary complex should be air conditioned with a separate system for the autopsy room to prevent foul air permeating the rest of the area. No air should be recirculated in the mortuary in order to ensure a clean air environment. However, in view of financial constraints, a system that does not re-circulate air is recommended. Safety: The complex should be fitted with emergency lighting, fire sprinklers and smoke/thermal detector in all rooms. A fire alarm system with blue/red beacon light with hooter should be installed. Fire exit routes should be clearly identifiable, well illuminated and earmarked with red point. Refrigeration: The temperature of cold rooms is to be maintained between 5.5°C to 6.5°C, thermostat control will be required for each cold chamber. Facilities to be provided to enable the chambers, which, are not in use to be switched off.
Equipments The equipments required in mortuary vary widely. Only those equipments that are of certain significance related to the mortuary complex are listed as under: (as per the recommendation of Survey Committee Report on Medico-legal Practices in India, 1964) |
Basin E. I 12” -2 Weighing machines 3 No. For weighing bodies, organs and foetus with top loading tray up to 500 gram and up to 5kg. Platform scale for weighing the whole body -1 Balance to weight 100gms to 10 kg -1 Balance to weigh 0.2 gms to 10gms -1
Cutting instruments-stainless steel: Skull cutter (electrical) -1 Organ knife 10’ blade, solid forged -1 Organ knife 6” blade, solid forged -1 Caltin solid forged - Cartilage knife 5–1/2” blade solid forged -2 Rib cutter Cartilage knife 4” blade/solid forged -2 Brain knife 10” blade, solid forged -1 Resection knife 3” blade, solid forged -2 Scalpels, BP Handle with blades -1 Set Bistoury, probe pointed solid forged -1
Scissors (stainless steel) Scissors; blunt sharp 8” -1 Scissors; blunt/sharp 6” -1 Scissors; dissecting 5” with one probe point for coronary artery 1 Scissors; bowel, Bernard 11” -
Forceps (stainless steel) Bone cutting forceps 10” straight -1 Bone cutting forceps 10” angled -1 Rib-shears 9–1/2” -1 Dissecting forceps 6” -1 Dissecting forceps 8” -1 Dissecting forceps 10” -1 Toothed and un-toothed forceps -6 each
Post-mortem Scissors: Saw, Bernard 11” stainless steel Blade -1 Saw, Bernard 9” stainless steel Blade -1
Straight and curved Enterotome, viscrotome - 1 each Miscellaneous: Coronet stainless steel -1 Needles, post-mortem half curved & double curved -1 dozen Probes silver with eye 10” -1 Chisel, straight 3/4 ” blade -2 Chisel, spine with locating point (stainless steel) -1 Gouge, 3/4” blade, stainless steel -1 Hammer with wrench stainless steel -1 Measures 12” stainless steel -1 Mallet, boxwood with metal bands -1 Small table 20” × 24” × 12” for dissection of organs -1 Measuring jug (one litre) -1 Metal/steel scale -2 Magnifying glass -3 Instrument trolley -3 Cabinet -1 Wooden boards -3 Rubber gloves -Adequate quantity Aprons -Adequate quantity
This list covers almost the entire range of equipments for pos-mortem examination. However the following additions are also recommended by some of the authorities: Suction Pump & Aspirators -1 each Body Scale - 1 Repairing materials like: Thread white, cotton wool (absorbent), wool waste, a variety of discarded clothes, malleable wire, Polythene bags, Gloves, Masks, and Aprons etc. Plastic Bins: For fixing large specimens.
Top Chemical and Articles Discussion Working in mortuary should be smooth and without significant problems. The area should be pleasant and not the usual mortuary atmosphere of fear and dislike. The aim should be of having maximum ease of handling the bodies by maintaining hygiene with colour coded areas and special flooring, air flow and exhausts to eliminate odours, pleasant meaning facilities, relative facilities and good communications by installing intercoms and thus allowing for a good workflow patterns. The key factor which would influence the successful outcome of the project would be close interaction of forensic and pathology staff, architects, engineers and builders. It is interesting to note that court has observed for better condition of post-mortems plus medicolegal works the doctors dealing with post-mortems have adequate exposure with the subject of forensic medicine and that periodic refresher courses are arranged. |
Top Conclusion In tune with the trend in the country in Allahabad also workload of Medico-legal postmortem is increasing at a rapid pace and the mortuary is a neglected lot and the condition is worse since basic facilities like regular electric supply and water for cleaning dead bodies is not available. Due to lack of facilities there are chances of producing post mortem artifacts and missing out valuable findings. Provisions of mortuary facilities and services in a tertiary care hospital have an important bearing in terms of public relation of the hospital. Any shortcoming in the form of delay, inadvertent disrespect or negligence to the dead may bring a bad name to the hospital. Improper identification and wrong handing over the body due to procedural lapse or casual approach by the worker in the hospital may have far reaching implications. |
In a tertiary care hospital we must also take into consideration that spiritual and religious needs are an important part of caring in totally respond to these needs, the hospitals should offer the Chaplaincy services. This service should be available to people of all faiths and religions. |
It is, therefore, very important to have proper facilities laid down and frame procedural guidelines to give best of the services, if the image of the hospital is to be kept high in the eyes of the community to which it is serving. |
Top Figures | : Space requirement varies from hospital to hospital depending upon the workload, level of care it provides and jurisdiction of medical autopsies.
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| | : Proposed Plan for a Mortuary Complex
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Table | : Hon'ble Court has directed the provisions for following chemical articles.
| | i) | Bleaching powder for cleaning mortuary table floors, etc. | | | ii) | 2% Glutaraldehyde for cleaning instruments. | | | iii) | Formative for sending specimens needing his to pathology. | | | iv) | Rectified and Methylated spirit | as preservative | | | v) | Thymol crystals | | vi) | Common salt | | vii) | Sodium fluoride | | | viii) | Potassium oxalate | | | ix) | EDTA vials and tubes | | | x) | Sterilized glass tubes (plain). | | | xi) | Sterilized glass tubes with swabs | | | xii) | Liquid paraffin | | | xiii) | Sealing wax etc. | | | xiv) | Big size envelops, plain papers etc. | |
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