Columbia, South Carolina


TO:                All Organizational Components

SUBJECT:   Inpatient Facilities Procedures for Patient Deaths

I. Purpose

To outline SCDMH procedures for the reports for patient deaths, scheduling of autopsies and release of remains.

II. Initial Report of Death and Notifications

A. The physician who pronounces the death is responsible for notifying the coroner and completing confirmation of telephone report to coroner of patient death (Form AS-117).

B. Medical staff at the facility where the patient died are responsible for notification'of next-of-kin and, when appropriate, endeavoring to obtain authorization for an autopsy from the patient's next-of-kin (paragraph V., infra). After notification of the coroner and the family of the patient's death, the physician designated by the facility where the patient died shall make the determination as to whether to contact one or more organ procurement agencies, and document the patient's medical record accordingly (paragraph VI., infra).

C. Nursing Service or other responsible personnel are responsible for notifying SCSH A&D Office at 734-6552 of all SCDMH deaths so that SCSH will have information to provide to hospital and funeral home personnel and for completion of removal permit.

1. SCSH A&D Clerk will complete the Form R-19, "Report of Death and Autopsy for SCDMH Patients."

2. Additional information such as funeral home specified by family, or progress of autopsy permission, shall be telephoned to SCSH A&D Personnel as it becomes available.

III. Death Certificate Certification at Time of Death

A. In accordance with DHEC Regulation 61-19, Section 18 (a), a death certificate shall be filed with the county registrar of the county in which the death occurred within five (5) days after such death. In order to expedite the filing of the death certificate, Section 20 of Reg. 61-19 allows institutions to assist in the preparation of certificates. The signature of the physician may be obtained and the medical certification completed immediately after death. The partially completed certificate, identified by the name of the decedent and the completed medical certification, is to be presented to the funeral home director or person acting as such when the body is released.

B. Nursing Service personnel shall supply the pronouncing physician with the Death Certificate Form (670) and may assist in the preparation of the death certificate by placing the full name of the decedent in the space provided.

C. The attending physician shall certify the cause of death and sign the certificate. When the attending physician is unavailable to certify to the cause of death, another physician on duty may certify to only the fact of death by completing the appropriate items on the death certificate. In such cases, the funeral home director is responsible for obtaining the cause of death information and certifier's signature from the attending physician, medical examiner or coroner.

D. If the cause of death is unknown to the attending physician, medical examiner or coroner pending an autopsy or further investigation, "Pending" should be entered in the appropriate blank. The attending physician, medical examiner or coroner will be provided with a Supplemental Report of Cause of Death (DHEC Form 627) to be completed when determination can be made.

IV. Preparation of Remains

The Nursing Service of each facility shall develop a procedural policy for the preparation, tagging and removal of the body and the completion and distribution of required documents.

V. Autopsies

A. It is the policy of the Department of Mental Health to obtain autopsies, if proper approval can be obtained, in cases in which death is unexpected and the cause of death is subject to question. If the coroner does not authorize an autopsy, the physician should endeavor to obtain authorization for an autopsy from the patient's next-of-kin. If permission is obtained, it should be reduced to writing on SCDMH Form M-106 "Autopsy Authorization" or by means of a telegram. Such documentation shall be filed in the medical record of the facility where the patient died.

B. Autopsies are performed by a pathologist contracted by the Department of Mental Health.

C. Arrangements for autopsy and transportation of remains shall be made by the facility where the patient died. I

1. items needed prior to transportation of remains:

a. Current Psychiatric/Medical Record

b. Copy of Report of Death

c. Copy of M-104, Disposition of Remains

d. Original and two copies of Permission for Autopsy

2. The facility shall arrange for the transportation of remains and above listed items. (It is not necessary to place the remains in Ensor Morgue prior to transporting the body to the contracting medical facility for an autopsy if all administrative requirements listed above are complete.)

3. The facility where the patient died will notify the contracting medical facility that the remains are being sent for an autopsy.

4. The contracting medical facility will accept remains on any day and at any hour; however, the autopsy may not be performed until the next working day.

5. Upon completion of the autopsy, the contracting medical facility will notify the funeral home. If no funeral home has been designated, the facility shall arrange for transportation of the remains to Ensor Morgue.

6. The medical record and other documentation will be returned to the patient's facility with the provisional autopsy report (usually within a few days). -

VI. Donation of Organs

In the event that a patient dies, or is dying in a SCDMH hospital in circumstances which give rise to a reasonable medical belief that the patient meets the medical criteria for organ or tissue donation, the designated physician shall make a determination as to whether the Organ Procurement Agency, Red Cross, and/or the Lions Eye Bank should be contacted to pursue donation authorization from the family. If it is determined that the decedent is a potential organ, tissue or eye donor, the attending or on-call physician shall document in the patient's medical record:

(1) if the appropriate procurement agency is not contacted or if the family is not approached to request donation authorization, the underlying reasons; or

(2) if a procurement agency is contacted or the family is approached, the disposition. [Note: the appropriate procurement agency is responsible for notifying the hospital of the ultimate disposition.]

If a procurement agency determines that the decedent is a suitable potential donor, the agency will contact the family to obtain such authorizations as are necessary for donation. If authorization is obtained, the agency will arrange to transport the remains to a medical facility for donor surgery.

All physicians on the hospital staff shall be made aware of this procedure at least annually.

VII. Donation of Body

Prior to death a patient may have signed an agreement with either the Medical University of South Carolina (MUSC) in Charleston, or the USC Medical College in Columbia, for the donation of his/her body at time of death. Agreements for the donation of a body must be made prior to death; therefore, no agreements are initiated by either MUSC or the USC Medical College at the request of a next-of-kin at the time of a patient's death.

When a donor patient dies the facility where the patient died follows the same procedure outlined previously in this directive with the addition of calling the Anatomy Department of the institution (MUSC or USC Medical College) with whom the patient had the agreement and communicating required information.

VIII. Deposit and Removal of Bodies from Ensor Morgue

A. BMC laboratory personnel are responsible for the physical upkeep and maintenance of the morgue. The SCSH Admission and Disposition Office is responsible for the admission and disposition of all remains that pass through the morgue. This will include all paperwork, acceptance, and releasing of remains.

B. A key to the morgue is kept in the SCSH A&D Office and is to be given to the transporter of the body when the body is brought to the morgue. The ambulance driver is to bring the Identification Tag and Certificate of Death accompanying the body to the SCSH A&D Office.

C. SCSH A&D Personnel must complete a Removal Permit for all SCDMH bodies housed at the Ensor Morgue.

1. Blank Removal Permits are supplied by DHEC in numerical order. Permits are to be voided if a mistake is made or a permit is not completed for.any reason.

2. All information must be completed. Information can be obtained from the Death Report and from the funeral home representative picking up the body.

3. The funeral home representative signs the middle copy and keeps the top copy.

4. The release of a body to either MUSC or USC Medical College, for donation, shall be handled in the same way as releasing a body to a funeral home.

5. A body that is released from the contracting facility because of an autopsy must still have the removal permit completed at SCSH prior to being picked up from the contracting facility.

D. Disposition of Remains (Form M-104) is completed for all bodies.

1. The funeral home representative completes the top portion, specifying which family member authorized the body to be picked up.

2. The employee who actually accompanies the representative to the morgue completes the next portion, certifying that the body was released. All funeral home representatives must be accompanied to Ensor Morgue by an employee who will return the completed M-104 to SCSH A&D Office upon release.

3. The release of a body to either MUSC or USC Medical College for donation shall be handled in the same way as releasing a body to a funeral home.

E. After the body is released, the following documents are forwarded as specified:

1. Death Report, pink copy of the Removal Permit, Tags and Disposition of Remains are forwarded to the Medical Records Department of the home facility.

2.  The yellow copy of the Removal Permit is forwarded to Richland County Health Department.

3. The death certificate will accompany the body. It is the responsibility of the facility where the patient died to complete and to forward the death certificate with the body.

IX. Unclaimed Bodies

Unclaimed bodies will be handled by the home facility to include documentation, coordination with the contracting funeral home, interment and completion of Certificate of Death. Funerals shall be arranged in accordance with SCDMH Directive No. 689-86, "Funeral Policies and Procedures."

X. Facilities Outside Columbia

SCDMH facilities located outside the Columbia area shall develop facility procedures on patient deaths. These procedures shall be submitted to the Division of Clinical Services for review and approval.

This directive rescinds and supersedes SCDMH Directive 744-90.


                                                                                        Joseph J. Bevilacqua
                                                                                                     Joseph J. Bevilacqua, Ph.D.
                                                                                       State Commissioner of Mental Health

December 13 , 1991