Journal of the Royal Society of Medicine
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Biography Historical Article
John Shaw Billings: creator of Index Medicus and medical visionary.
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Objectives To describe serious incidents occurring in the management of patient remains after their death. Design Incidents occurring after patient deaths were analysed using content analysis to determine what happened, why it happened and the outcome. Setting The Strategic Executive Information System database of serious incidents requiring investigation occurring in the National Health Service in England. ⋯ The reported underlying causes were similar to those known to be associated with safety incidents occurring before death and included weaknesses in or failures to follow protocol and procedure, poor communication and informal working practices. Conclusions Serious incidents in the management of deceased patient remains have significant implications for families, hospitals and the health service more broadly. Safe mortuary care may be improved by applying lessons learned from existing patient safety work.