Title: Sensitive Handling, and Preparation for Disposal by Cremation, of Non Viable Foetal Remains

Transcription

1 Directorate of Pathology Page 1 of 5 Title: Sensitive Handling, and Preparation for Disposal by Cremation, of Non Viable Foetal Remains Version 1 Date of Original 2007 Issue CPA/HTA Standard F/ GQ1/GQ2/D1/D2 Review Interval Annual Author L Le Patourel Signature: L Lepatourel Authorised By H. Greenwood Signature: H. Greenwood Relevant Staff BMS / Trainee/MLA/MTO Groups Copy Master Location of Copies 1. Qpulse For manual document system record document history below. Review date Amendments Activated by:- Signature Distribution to locations Relevant safety data, COSHH and risk assessments: - Mark relevant procedures/policies VDU Lifting/Handling COSHH Spillage Disposal Sharps The above risk/safety assessments must be read and understood before carrying out this procedure. Details are recorded in the main text of the document. CPA Standard CROSS REFERENCES :- CPA Standard F2. HTA Standard Compliant

2 Directorate of Pathology Page 2 of 5 Sensitive Handling, and Preparation for Disposal by Cremation, of Non Viable Foetal Remains Risk factor 8 Standard Operating Procedure. A. Description of Procedure. This procedure effects the appropriate handling, recording and ultimately sensitive disposal of the following tissue types, taking into account any histology and/or cytogenetics testing that may be required. All such specimens are accompanied by a pink sensitive disposal request form: pregnancies of 16 weeks duration or less from MTOPs excluding therapeutic termination for foetal abnormality unidentified spontaneous loss at 16 weeks or less surgical samples at 16 weeks or less where foetal tissue may be present This procedure will be carried out in PL26 and B. Personnel/Training requirements. This procedure should only be carried out by trained personnel, ie BMS 1 upwards, MTO staff and suitably trained MLAs. Trainee staff may perform the procedure if supervised by a qualified member of staff and following the required in-house/cpsm blue book training procedures. C. Specimen Requirements Tissue samples may be received fixed in 10% buffered formalin or in a dry specimen pot, without fixative. D. Reagents The only reagent required is 10% buffered formalin, made up in-house from stock solution obtained from UHND (via Genta). It is stored in 5 litre bottles, located on top of the ventilated work bench, in.

3 Directorate of Pathology Page 3 of 5 E. Equipment ITEM Small minigrip bags Indelible marker pen Latex gloves Ventilated work bench Sieve Absorbent tissues Cremation office paperwork LOCATION Shelf, Specimen receipt bench PL26 PL26 F. Method/Procedure 1- Receipt of Samples It is expected that most samples will be sent directly to the laboratory, but any that are received in the Mortuary will be sent to the laboratory. All dry specimens containers are filled with formalin to fix the tissues. Specimens are transported to UHND for registration and sampling and/or storage as appropriate. 2- Preparation for disposal Specimens are returned from UHND in batches along with the sensitive disposal request forms. Each form and specimen is matched. Where histology has been performed the report date is checked on Winpath to ensure that they are retained for at least a further four weeks before disposal Where samples are for disposal only, the specimen is kept for four weeks from the date of the procedure given on the sensitive disposal request form. For all specimens the date received and by whom is entered on the results entry screen in Winpath. Using the indelible marker pen, the laboratory number and disposal date is written onto a separate minigrip bag for each specimen.

4 Directorate of Pathology Page 4 of 5 The formalin is separated from the specimen and drained to waste by sieving with copious running water. The retained tissue is wrapped in absorbent tissue then transferred to the minigrip bag. The sensitive disposal request forms are filed in date order and the packaged specimens placed in the ventilated store. The crematorium date is set as the last Wednesday of each month In preparation, the details of specimens eligible for disposal are added to a cumulative form provided by the crematorium, and the pink form kept to one side. When the cumulative form is full (ie: after 50 entries), a bag containing the related samples is sealed closed (batch). A matching batch number is assigned to the form and the bag. Batches of specimens (usually 2 or 3) are placed into a cardboard casket provided by the crematorium and sealed closed. Details of Cremation date and batch numbers are written on the outside. The caskets are stored in the ventilated cupboard in PL26 until the original paperwork including the cumulative form and official cremation request form are sent to the Crematorium Office.This must occur at least one week in advance of the next cremation date. A photocopy of the cumulative form is retained by the laboratory. The mortuary is informed of how many caskets need to be collected and a member of mortuary staff transfers them to the mortuary for collection. The sensitive disposal request forms are filed in the mortuary. One or two days before the cremation date, a representative from the Crematorium attends the Mortuary to pick up the batches ready for cremation, and signs them out. After cremation, attended by the Hospital Chaplain, a receipt for the batches sent and cremated is sent from the Crematorium Office to the laboratory, and disposal and batch details completed on Winpath. This is filed, with copies of other paperwork related to the batch, in a dedicated file in PL26. G. Health & Safety requirements. The health and safety issues around sensitive disposal are centred on leakage of formalin and/or biological material from the specimen pot. Staff should use the personal protective equipment provided. Hazard data sheets are available for formalin and staff are advised to thoroughly read the relevant sections before commencing procedure.

5 Directorate of Pathology Page 5 of 5 Hazard data sheets can be found in the filing system in PL26. The risk factor value for this procedure was calculated following the "Trusts guidelines" based upon the severity of the hazard and the probability of harm (HZ x Pr = Rf). Each step of the procedure is risk assessed using the above model and the risk value for the entire procedure is derived from the highest Step Rf.