Mortuaries

OVERVIEW

This document outlines the policy and service context and attempts to illustrate the desired planning principles and design considerations for mortuary services.

LEGISLATIVE CONTEXT

The following documents, as amended (though not an exhaustive list) pertain and contain an additional resource of information which would supplement and provide the basis of a design brief. A finer sense of standard operating procedures and legislative context is likely to inform and enhance the design process, so the professional teams are encouraged to use these as an additional resource:

• Births and Deaths Registration Act 1992. (c.51).Cape Town South Africa: Government Gazette.
• Criminal Procedure Act 1977.(c.51).Cape Town South Africa: Government Gazette.
• Department of Environmental Affairs and Development Planning Western Cape Province,2004. Western Cape health care waste management draft bill.(P.N.255/

2004). Province of Western Cape South Africa: Provincial Gazette.

• Department of Health (DoH),2013.Regulations relating to the management of human remains. (Government notice No.R.363 of the National Health Act,2003.(c.61).South Africa: DoH.
• Department of Public Works,2005.Space planning norms and standards for office accommodation used by organs of state. (Government notice 1665).Cape Town South Africa: Government Gazette.
• Health Professions Act of 1974. (c.56).Cape Town South Africa: Government Gazette.
• Inquests Act 1959.(c.58).Cape Town South Africa: Government Gazette.
• Municipal By-laws, as applicable
• National Archives of South Africa Act 1996. (c.42).Cape Town South Africa: Government Gazette.
• National Code of Guidelines for Forensic Pathology Practice in South Africa,20 Aug 2007
• National Environmental Management: Waste Act 2008. (c.59).Cape Town South Africa: Government Gazette.
• National Health Act 2003.(c.61).Cape Town South Africa: Government Gazette.
• Standard Operating Procedures, Forensic Pathology Service, PGWC DoH,2006
• U.S.Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention and National Institutes of Health,2007.Biosafety in microbiological and biomedical laboratories. (Fifth Edition)..Atlanta Georgia USA: U.S.Department of Health and Human Services.
• University of Pretoria (UP) in partnership with Southern African Legal Information Institute (SAFLII),2012.Regulations relating to the registration of microbiological laboratories and the acquisition, importation, handling, maintenance and supply of human pathogens.(Government notice No.R.178 of the National Health Act,2003.(c.61). Cape Town South Africa: Government Gazette.
• University of Pretoria (UP) in partnership with Southern African Legal Information Institute (SAFLII),2007.Regulations regarding the rendering of forensic pathology service.(Government notice No.R.636 of the National Health Act,2003.(c.61).Cape Town South Africa: Government Gazette.

Infection Prevention and Control Legislation

The National Infection Prevention and Control Policy and Strategy document makes specific reference to certain Acts and their relevant regulations, which bear relevance to the development and implementation of these health facility guidelines. These are:

• Constitution of the Republic of South Africa,1996. s.2,24,27,36&39.
• Department of Health,2003.Regulations relating to the application of the hazard analysis and critical control point system (HACCP system).(Government notice No.R.908 of the Foodstuffs, Cosmetics and Disinfectant Act,1972.(c.54)).Cape Town South Africa: Government Gazette.
• Department of Labour,2001.Regulations for hazardous biological agents. (Government notice No.R.1390 of the Occupational Health and Safety Act,1993.s.43).Pretoria South Africa: Government Gazette.
• The Environmental Conservation Act 1989. (c.73).Cape Town South Africa: Government Gazette.
• The Foodstuffs, Cosmetics and Disinfectants Act 1972. (c.45).Cape Town South Africa: Government Gazette.
• The Occupational Health and Safety Act 1993.s.8(1).Cape Town South Africa: Government Gazette.

Building Legislation

The following legislation and regulations impact and provide guidance on the provision and design of health care facilities as above:

• Building Regulations and Building Standards Act 1977.(c.103).Cape Town South Africa: Government Gazette.
• Promotion of Equality and Prevention of Unfair Discrimination Act,2000.(c.4).Cape Town South Africa: Government Gazette.
• South African Bureau of Standards (SABS),1986.SABS 1200 A-1986 Standardized specification for civil engineering construction.Pretoria South Africa: SABS Standards Division.
• South African Bureau of Standards (SABS),1992.SABS 0100-1 The structural use of concrete Part 1: Design.Pretoria South Africa: SABS Standards Division.
• South African Bureau of Standards (SABS),1992.SABS 0100-2 The structural use of concrete Part 2: Materials and execution of work.Pretoria South Africa: SABS Standards Division.
• South African Bureau of Standards (SABS),1993.SABS 0160 General procedures and loadings adopted in the design of buildings.Pretoria South Africa: SABS Standards Division.
• South African Bureau of Standards (SABS),2010.SANS 10400-A: 2010 The application of the national building regulations Part A: General principles and requirements.Pretoria South Africa: SABS Standards Division.
• The National Environmental Management Act 1998.(c.107). Cape Town South Africa: Government Gazette.

South African Building Practice Policy and Guidelines

• Department of Health (DoH),1980.Regulations governing private hospitals and unattached operating theatres. (Government notice No.R.158 of the Health Act,1971.(C.63).Cape Town South Africa: Government Gazette.
• The South African Pharmacy Council,2004.Good pharmacy practice.(Board notice 129).Cape Town South Africa: Government Gazette.

International Design Guidance

• American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE),1999.ANSI/ASHRAE standard 52.2-1999 Method of testing general ventilation air-cleaning devices for removal efficiency by particle size.Atlanta USA: ASHRAE.
• American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE),1989.ASHRAE standard 62 Ventilation for acceptable indoor air quality.Atlanta USA: ASHRAE.
• American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE),2003.HVAC design manual for hospitals and clinics.Atlanta USA: ASHRAE.
• American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE),2009.ANSI/ASHRAE/ASHE standard 170-2008 ventilation of health care facilities.Atlanta USA: ASHRAE.
• Chartered Institution of Building Services Engineers (CIBSE),1997.CIBSE applications manual AM10 natural ventilation in non-domestic buildings.London: CIBSE.
• Chartered Institution of Building Services Engineers (CIBSE),2000.CIBSE applications manual AM13 mixed-mode ventilation.London: CIBSE.
• Department of Health and Human Services (Center for Disease Control and Prevention),2003.Environmental control for tuberculosis: Basic upper-room ultraviolet germicidal irradiation guidelines for healthcare setting.USA: DHHS.
• QASA.“Know Your Rights” [Accessibility & the Built Environment]
• World Health Organisation (WHO),2009.WHO policy on TB infection control in health-care facilities, congregate settings and households.Geneva Switzerland: WHO.
• Guidance has also been provided by AIA (USA), NHS (UK), and Australian Health Facility Guidelines on Healthcare Building Design.Additional references can be sourced from www.tb-ipcp.co.za

Further reference material and precedent

• Australasian Health Infrastructure Alliance (AHIA),2007.Australasian health facility guidelines: Part B: Health facility briefing and planning.[online] New South Wales: AHIA.Available at: |AllItems.aspx Accessed 4 March 2014.
• Department of Public Works (DPW),1998.Fire security: A guide for architects. (Ref: F.P.O./G.61/3E).South Africa: DPW.
• Department of Public Works (DPW),1998.Standard specification for air-conditioning and ventilation installations. (PW 327).South Africa: DPW.
• Department of Public Works (DPW),2004.Standard electrical specifications. (PW 354).South Africa: DPW.
• NHS Estates,2001.Health Building Note (HBN) 20: Facilities for mortuary and post-mortem room services.Norwich England: The Stationery Office (TSO).
• South African Bureau of Standards (SABS),2013.CKS 336:2013 Mortuary trolleys.Pretoria South Africa: SABS Standards Division.

SERVICE CONTEXT

Service	District	Regional	Tertiary	Central	Specialised
Small (beds)	50-150	Min 300	Min 400	-	-
Medium (beds)	150-300	-	-	-	-
Large (beds)	300-600	Max 800	Max 800	Max 1200	Max 600
Training	Where practical	Where practical	Optional	Yes. (Attached to medical school)
Conduct research				Yes
Mortuary
Short-term stay (+2˚C)	Yes	Yes	Yes	Yes
Long-term stay (-20˚C)	Yes	Yes	Yes	Yes
Autopsies (20°C -21°C)	Yes	Yes	Yes	Yes	Yes

For the determination of capacity requirements of mortuaries refer to the recommendations further on in this guide. This guidance document relates to mortuaries located within and serving hospitals, with respect to persons that die due to natural causes in that hospital.
This guidance excludes mortuaries dealing exclusively with cases that require medico-legal investigation of deaths from unnatural causes. Post mortems conducted in hospital mortuaries should be limited to conducting investigations and procedures where no medico-legal investigation is required and death from natural causes is suspected. Hospital deaths from natural causes and those suspected to be of unnatural cases should not be managed in the same facility unless the hospital mortuary is equipped to comply with the specific staffing infrastructure and operational requirements as they relate to the legislated forensic pathology services mandates, etc.
The requirements for forensic-pathology service mortuaries are not exhaustively detailed in this document. It is also noted that some hospitals may opt to contract out the removal and storage of decedents to private undertakers and these hospitals may require only the minimum in terms of refrigerated body storage.

PLANNING AND DESIGN

Introduction

All state-run mortuary facilities fall within the domain of the Department of Health, both National and Provincial; and in an effort to provide engineers and architects who are required to either design new facilities or upgrade existing facilities, this document provides the minimum standards necessary to comply with existing legislation.
This document will provide designers of this type of facility with guidelines as to what is required in terms of the following:

• Type of service and package of care being provided
• Mortality rate
• Access and egress
• Discreet management of human remains
• Size and dimensions of the actual facility
• Positioning of mortuaries within hospitals
• Finishes of surfaces in these facilities
• Water-supply requirements
• Drainage requirements
• Electrical supply and lighting requirements
• Installation requirements for equipment and services
• Body-storage requirements
• Body-handling facilities
• Body-holding areas
• Body-viewing area
• Autopsy equipment (tables)
• Air conditioning and ventilation requirements (for infection and indoor air quality control)
• Security of the facility
  

In addition to the items listed above, it is also necessary to consider the needs of visitors to these facilities, particularly those wishing to, or who are required to, identify bodies. In line with this, it is also necessary to take the handling of bodies into consideration as it pertains to issues of patient dignity.
Forensic pathology mortuaries are not exhaustively described in this document, although the majority of hospital mortuaries do have basic facilities for general autopsies that are not medico-legal in nature. A forensic pathology service mortuary has laboratory facilities attached, as well as legislated operational requirements that are outside the scope of regular mortuaries found in hospitals. It should be noted that there are a number of principles that hold true for both hospital and forensic pathology mortuaries.
Compliance with the requirements of the Occupational Health and Safety Act (Act 85 of 1993 as amended) are to be complied with at all times during the design of a mortuary.

LOCATION OF THE MORTUARY AND ACCESS ROUTES

The position of the mortuary in a hospital should be such that the mortuary is easily accessible to mortuary staff and related service providers without presenting either aesthetic, emotional or ethical problems for unrelated hospital staff, patients or visitors. Visitors to the mortuary, however, should be provided with clear and direct access to the mortuary upon arrival at the hospital, without having to travel unnecessarily through hospital departments.
Where bodies are moved into or out of the mortuary, they should not be moved through general public-access areas. Appropriate routes would include technical service or goods corridors and through the hospital’s support services yard.
Special considerations should be given to plans for contingency access to the mortuary in the event of case-load surges, which may result from disasters.
Bodies should not be held for any period in any locations between the body-holding rooms within clinical areas and the mortuary.
Where a mortuary unit is used jointly between the hospital and the local authority it is beneficial for the mortuary to be in a building separate from the main hospital building.
The delivery of bodies to the mortuary and their subsequent removal from the facility is to be such that it is carried out in a manner that is not visible to the general public, preferably in a covered and enclosed area.
While siting and access are important aspects when locating a mortuary, it is also important to provide the mortuary with pleasant surroundings in order to promote the dignity of those working in or visiting the mortuary.

FACILITY CAPACITY

The layout and size of a mortuary is largely determined by the number of bodies stored and whether body storage needs to be in cabinets or in refrigerated rooms.
In order to determine the storage capacity of a hospital mortuary, it is recommended that historical data, where available, should be used. In the South African context, it is suggested that a storage capacity of between 5 and 10 bodies per 100 beds should be used. This varies with the rural or urban location of the facility. This capacity should not take into account the need to store bodies from deaths which are not hospital-related, typically motor-vehicle accident deaths and deaths from criminal activity. Requirements for contingency storage capacity related to disaster management should be considered. The body storage capacity required can be estimated on the basis of the number of deaths per year in the hospital, the length of time of holding and the required body store occupancy rate.

The number of body trays can be calculated from the equation:

BT=(D×S)/(365×R)

Where:
BT = Number of body trays
D = Number of deaths per year requiring body trays
S = Average length of stay (in days)
R = Required body tray occupancy rate

Example

The number of body trays required in a hospital that records 800 deaths per year (not necessarily all within the hospital per se but including bodies delivered to the hospital), with the average length of time that a body remains in the mortuary being 8 days and with a body tray occupancy rate of 80%. BT = (D x S) / (365 x R) = (800 x 8) / (365 x 0.8) = 6400 / 292 = 21.92 With body cabinets generally having a storage capacity of three bodies per cabinet the calculated required capacity should be rounded up to the nearest multiple of three and as such in the above example 8 cabinets would be required.

The estimated storage capacity for bodies in a mortuary could be confounded by a number of local factors, such as:

• Mortality rate from natural causes.
• Mortality rate from infectious disease.(Highly contagious disease deaths require special storage facilities.)

Where the hospital is expected to place the body in cold storage until collection by forensic pathology services, the following additional factors should be considered with respect to numbers of unnatural deaths (accidental, suicidal, homicidal, unknown and procedure-related deaths) anticipated at any particular hospital, including:

• Mortality rate from foul play (homicide) or suicide
• Mortality rate from traffic or other accidents
• Mortality rate from procedure-related deaths
• Mortality rates from sudden, unexpected or unexplained deaths