Guidance

Guidance for care of the deceased with suspected or confirmed coronavirus (COVID-19)

Updated 14 March 2022

This guidance was withdrawn on 1 April 2022

This guidance has been superseded by Health and Safety Executive’s guidance on handling the deceased with suspected or confirmed COVID-19.

Who this guidance is for

This guidance contains information for:

• members of the public who identify a death outside of a healthcare setting
• first responders managing a death in the community
• general practitioners (GPs) managing a death outside of a healthcare setting
• staff in adult social care and residential settings including care homes and hospices
• funeral directors and others managing a death in the community
• staff and appropriately trained volunteers^† who manage deceased people suspected or confirmed as infected with coronavirus (COVID-19) including:
  • coroners
  • mortuary operators
  • pathologists and anatomical pathology technologists
  • medical practitioners
  • funeral directors and embalmers
• those who are participating in or supporting faith and belief practices that involve close contact with the deceased
• those involved in the transport of the deceased

† In some communities, deceased bodies are cared for by appropriately trained volunteers. If you are a volunteer with an underlying condition that puts you at higher risk of severe illness if infected with COVID-19, you should consider seeking advice from your health professional on whether you should provide care for the deceased.

Where there has been a death in secondary care, healthcare workers should follow the recommendations in UK infection prevention and control (IPC) guidance.

Main messages

This guidance is of a general nature and should be treated as a guide. In the event of conflict between any applicable legislation (including the health and safety legislation) and this guidance, the applicable legislation shall prevail. The guidance remains under review and may be updated in line with the changing situation as required.

This guidance is designed for people who may be involved in managing the body of a deceased person during the COVID-19 pandemic. This includes deaths where COVID-19 infection was present.

It has been developed to ensure that:

• the deceased are treated with sensitivity, dignity and respect
• people who come into contact with the deceased or who work in services providing care for the deceased are protected from infection

There is separate guidance for funerals or commemorative events in England during the coronavirus pandemic.

Those who come into close contact (less than 2 metres) with the deceased should assume that COVID-19 infection may be present and take account of the precautions described in this guidance.

Those handling bodies of the deceased should be aware that there is likely to be a continuing risk of infection from body fluids and tissues where COVID-19 infection is suspected or confirmed. Although the risk of infectious transmission is lower than for living patients, action should be taken to mitigate that risk. Standard infection control precautions (SICPs) and transmission-based precautions (TBPs) should be used to ensure safe ways of working when handling the deceased, these include additional precautions for aerosol-generating procedures (AGPs).

Where alternative causes of death are clearly known and features are solely consistent with that known cause, care of the deceased should follow usual management practices.

This guidance should be read in conjunction with:

• Health and Safety Executive (HSE) guidance: Managing infection risks when handling the deceased, which, whilst not specific to COVID-19, details the standard infection control precautions and transmission-based precautions that should be followed by all those handling the deceased
• Royal College of Pathologists (RCPath) and Association of Anatomical Pathology Technology (AAPT) guidance Transmission-based precautions: Guidance for care of deceased during COVID-19 pandemic, which details the Personal Protective Equipment (PPE) required for TBPs that should be used by any professional involved in the care of the deceased during the COVID-19 pandemic

This guidance has been developed in consultation with the Health and Safety Executive, the advisory group for the management of the deceased (Deceased Management Advisory Group), which represents the funeral, cremation and burial sector and representatives of faith communities.

Sharing information

It is critical that all clinical and non-clinical professionals handling the deceased are informed if the deceased presents an infection hazard so that they follow the appropriate infection control guidance, particularly with regard to AGPs which may be undertaken by a funeral director and others.

This information must be handled sensitively and shared only with those who need it to carry out an appropriate risk assessment and to enable appropriate precautions to be taken. While it is not essential to provide the specific details of the infectious agent, the information should include the detail of likely routes of transmission to ensure that adequate precautions may be taken.

This approach is supported by General Medical Council (GMC) guidance on Managing and protecting personal information which states that ‘disclosure is justified in the public interest to protect others from a risk of death or serious harm’.

HSE guidance also advises that where there is a known or suspected risk of infection, sufficient information must be provided to enable people handling the deceased to supplement the SICPs with appropriate additional precautions to minimise exposure.

Members of the public who identify a death outside of a healthcare setting

If you are a member of the public or a family member and you come into contact with a person who has died, including a loved one, please follow this advice:

• try not to touch the deceased person
• if there has been contact with the deceased, wash your hands with soap and water for 20 seconds
• move to at least 2 metres away or to another room, in order to be able to maintain a distance from the deceased
• if indoors, let fresh air in by opening windows if possible
• call the deceased person’s GP (if the GP is not available you will be connected to the out of hours service) or call NHS 111 for further advice
• if the death was unexpected and you have not been engaging with the healthcare system regarding the patient’s condition prior to the death, please call 999 and explain the situation
• use the guidance on cleaning in non-healthcare settings for managing the deceased’s laundry and waste

First responders managing a death in the community

If you are responding to a 999 call-out and are entering a home to assess whether a death has occurred, you should:

• on entry to the home, wash your hands with soap and water for 20 seconds. Where facilities to wash hands are not available, hand sanitiser should be used
• advise others not to enter the room in order to maintain at least 2 metres distance from the deceased
• stay at least 2 metres away from other household members, who may be in their self-isolation or quarantine period
• if indoors, let fresh air in by opening windows if possible
• wear PPE as indicated in COVID-19: guidance for first responders if you are required to assess for signs of life

Among first responders, ambulance staff and paramedics have different requirements for PPE as they may be required to perform AGPs. Additional specific guidance on PPE is available for ambulance staff and paramedics.

See Coronavirus (COVID-19): verifying death in times of emergency.

You should notify those who are handling the deceased when a death is either suspected or confirmed to be COVID-19 related. Sharing this information will enable correct management of the infection risk.

GPs managing a death outside of a healthcare setting

If you are a GP and are verifying death and/or certifying the cause of death of a patient with suspected or confirmed COVID-19 outside a healthcare setting:

• on entry to the home, wash your hands with soap and water for 20 seconds. Where facilities to wash hands are not available, hand sanitiser should be used
• stay at least 2 metres away from other household members, who may be in their self-isolation or quarantine period
• advise others not to enter the room in order to maintain at least 2 metres distance from the deceased
• if indoors, let fresh air in by opening windows if possible
• wear PPE as indicated in Table 2. PPE requirements for care of the deceased in non-clinical settings

GPs should notify those who are handling the deceased when a death is suspected or confirmed to be COVID-19 related as required. This information will enable correct management of the infection risk.

Staff in adult social care and residential care settings including care homes and hospices

If a resident or client dies with suspected or confirmed COVID-19 in an adult social care or residential care setting where you are a member of staff:

• make sure that all residents maintain a distance of at least 2 metres or are in another room from the deceased person
• avoid all non-essential contact with the deceased to minimise risk of exposure
• if you need to provide care for the deceased, this should be kept to a minimum and correct PPE should be used as indicated in the guidance on how to work safely in care homes
• you should follow the usual processes for dealing with a death in your setting, ensuring that infection prevention and control measures are implemented

You should notify those who are handling the deceased when a death is either suspected or confirmed to be COVID-19 related. Sharing this information will enable correct management of the infection risk.

Funeral directors managing a death in the community

Funeral directors, in addition to faith and belief representatives, will often be the primary support to households in the immediate period after a death, including attending the home to collect and transfer the deceased. Where possible, support and advice should be provided over the phone. If you are required to meet with the bereaved but will not make direct contact with the deceased, it is advised that you:

• maintain a safe distance (at least 2 metres) from the bereaved and other members of the household, who may be in their self-isolation or quarantine period
• wash your hands with soap and water for 20 seconds on entry to the home and again when leaving the property – where facilities to wash hands are not available, hand sanitiser should be used
• avoid touching your eyes, nose or mouth
• wear a face covering, especially in crowded and enclosed spaces. It is important to use face coverings properly and wash your hands before putting them on and before and after taking them off
• ask if windows and/or vents may be opened to ventilate the room

This advice should be followed for all deaths in the community, including if someone in the household is symptomatic or self-isolating, or if the household is isolating.

If you are required to have close contact with the deceased, for example, to move them, the following precautions should be taken:

• PPE should be worn as described in Table 2
• to be able to maintain 2 metres distance from the deceased person, and other household members if they are self-isolating or in quarantine, household members should be asked to leave the room containing the deceased, including any room that the deceased will travel through as they are moved from the premises
• placing a barrier, such as a cloth or mask, over the mouth of the deceased when moving them may prevent the release of droplets from the respiratory tract
• body bags are not essential although it is recognised that they are used routinely, as part of usual safe ways of working, to prevent leakage affecting the immediate environment and to help maintain dignity, including during repeated movement
• body bags are recommended where capacity in the usual management processes for the deceased is exceeded and management and/or transport of the deceased is being undertaken by individuals who may not be familiar with safe ways of working and appropriate use of PPE
• cloth wrappings (shrouds or wraps) and coffins may be used to manage the risk of contact transmission but are not a replacement for body bags in situations where they are recommended
• wipe down the external surface of the body bag or coffin with a combined detergent disinfectant solution as normally used within mortuary practice. Follow manufacturer’s instructions for dilution, combination, application and contact times for all detergents and disinfectants
• if body bags are used for cremation, they must not contain any PVC or any highly chlorinated materials

Guidance for staff who manage the deceased

This includes mortuary staff, pathologists, anatomical pathology technologists, funeral directors and embalmers and appropriately trained volunteers.

Any member of staff who develops symptoms of COVID-19 (a new continuous cough, a high temperature, or a loss of, or change in, their normal sense of taste or smell) should be advised to follow the guidance for people with COVID-19 and their contacts.

If the member of staff is a recent close contact or lives in a household where someone else has symptoms of COVID-19, or has tested positive for COVID-19, they should follow the advice in the relevant section in the guidance for people with COVID-19 and their contacts.

If you are working with the deceased, including in temporary mortuaries, you should follow Working safely during coronavirus (COVID-19) guidance.

Following a risk assessment of potential post-mortem risk pathways, this guidance has been developed with specific reference to the SICPs and TBPs set out in the HSE guidance on managing infection risks when handling the deceased.

The HSE guidance provides advice on the risks of infection from work activities involved with handling the deceased. It also provides guidance for those involved in funeral services, including embalmers, and those involved in the exhumation of human remains.

It covers the safe handling, storage and examination of bodies in hospitals, mortuaries and post-mortem rooms. HSE guidance is not specific to COVID-19 but the SICPs and TBPs described are sufficient for managing the risk with additional precautions taken for AGPs.

Characteristics of the virus that causes COVID-19

The exact duration that SARS-CoV-2 virus (the coronavirus that causes COVID-19) can remain infectious in body fluids and tissues in a deceased body is unknown and will depend on several factors. Residual hazard of infection from COVID-19 may arise from:

• droplet generation emanating from the deceased during their care
• post-mortem examination or implant removal involving the use of power tools, which is a risk for aerosol generation
• direct contact with contaminated material such as soiled clothing or bedding from the deceased and the surrounding environment

Placing a barrier, such as a cloth or mask, over the mouth of the deceased when moving them may prevent the release of droplets from the respiratory tract.

Other than circumstances where body bags are recommended, their use is not essential and, the deceased may be wrapped in cloth or a shroud to manage the risk of contact transmission.

Current evidence indicates that the SARS-CoV2 virus can be present for up to 72 hours on some types of environmental surfaces. Other human coronaviruses have been identified on environmental surfaces for up to 9 days so as a precaution, the principles of SICPs and TBPs should continue to apply while deceased individuals remain in the care environment even if beyond 72 hours.

There are currently no reliable data on how long the virus can persist on the deceased under refrigeration conditions. Refrigeration should still be used, and the deceased should be considered a potential source of infection while they remain in the care environment whether refrigerated or not. The appropriate PPE should be worn when handling the deceased (see Table 1 and Table 2).

Preparations and final disposition

Viewing, hygienic preparations such as washing and post-mortem investigations are permitted when overseen or undertaken by those trained in handling bodies of the deceased.

Embalming can take place when necessary, with appropriate consideration of procedures which may generate aerosols. Cremation is permitted and where the deceased has a medical device that requires removal prior to cremation, this should be done using PPE as detailed in Table 1.

The majority of medical device removal will require droplet precautions only (for example, pacemakers and intrathecal pumps). Where there is the potential for aerosol generation through the use of high-speed tools or the removal of fixion nails, PPE should be used as indicated in the RCPath and AAPT guidance for autopsy procedures in Transmission-based precautions: Guidance for care of deceased during COVID-19 pandemic and as described in the second column of Table 1.

PPE requirements for mortuary staff, pathologists, pathology technologists, funeral directors and embalmers

RCPath and AAPT have published guidance on the PPE requirements for care of the deceased during the COVID-19 pandemic (Table 1 below).

Table 1: Transmission-based precautions for suspected or confirmed COVID-19

	Non-autopsy procedures, including admission of deceased, booking-in of deceased, preparation for viewing, release of deceased	Autopsy procedures, including other invasive procedures
Disposable gloves	Yes	Yes
Disposable plastic apron	Yes	Yes
Disposable gown	No	Yes
Fluid-resistant (Type IIR) surgical mask (FRSM)	Yes	No
Filtering face piece (class 3) (FFP3) respirator	No	Yes
Eye or face protection*	Yes	Yes

*This may be single or reusable face or eye protection, full face visor or goggles.

Employees should:

• make sure they are aware of their employer’s procedures regarding PPE
• make sure that they have been trained in their use and that they are using them correctly
• remove any PPE and contaminated clothing when they leave a dirty work area
• not enter clean areas wearing PPE

Guidance on donning and doffing of PPE, including posters and videos, is available from the UK Health Security Agency (UKHSA).

Guidance for processing of samples taken from bodies

Post-mortem examination may include taking samples for COVID-19 testing. The Chief Coroner’s office has published guidance on post-mortem examination practice.

The Human Tissue Authority (HTA) Post Mortem sector guidance advises on what constitutes ‘relevant material’ for removal of a body and specifies that removal must take place on HTA-licensed premises.

Detailed guidance on COVID-19: laboratory investigations and sample requirements for diagnosis is available, including upper and lower respiratory tract sampling. A poster detailing sampling and packing required can also be downloaded.

If a post-mortem examination is performed:

• a lung biopsy can be sent in a sterile universal container without any additive
• blood samples can also be collected and sent in a sterile container
• ideally, tissue samples should be fresh frozen and sent on dry ice where possible. The sample should NOT be placed in formalin

RCPath has developed guidance on histopathology frozen sections and cytology fine needle aspiration during infectious disease outbreaks.

Management of cleaning and waste

Advice on cleaning and disinfection for the mortuary and similar workplace environments is available in the HSE guidance Managing infection risks when handling the deceased with specific reference to appendix 3. This should be read in conjunction with Department of Health (2013) guidance Environment and sustainability. Health Technical Memorandum 07-01: Safe management of healthcare waste which provides information about managing waste that can be characterised as clinical waste and gives practical advice and examples for classifying waste, in particular the infectious and offensive waste streams.

The use of jet washers should be avoided due to the potential for aerosol generation.

Precautions for others who are involved in the care of the deceased

Staff involved in the care of the deceased outside of the formal funeral home or mortuary setting should consider what actions they need to take to ensure safe working. Table 2 details activities involved in the care of the deceased and the appropriate PPE required for these.

Table 2: PPE requirements for care of the deceased in non-clinical settings

Activity	Disposable gloves (single use)	Disposable plastic apron	Disposable gown	Fluid-resistant surgical mask (FRSM)	Eye protection**
Death verification	Yes	Yes	No	Yes	Risk assess
Moving the deceased	Yes	Yes	No	Yes	Risk assess
Washing the deceased	Yes	Yes	No	Yes	Risk assess
Preparing for transportation, for example, shrouding, placing in a body bag or coffin*	Yes	Yes	No	Yes	Risk assess
Transporting the deceased in a body bag or coffin or cloth wrapping	No	No	No	No	No

*The outside of the body bag or coffin should be wiped down with a combined detergent disinfectant solution as normally used within mortuary practice. Follow manufacturer’s instructions for dilution, combination, application and contact times for all detergents and disinfectants.

**Eye and face protection is recommended only if there is an anticipated/likely risk of contamination with splashes or droplets of blood or body fluids.

Hygienic preparations, faith and belief practices and final disposition

For those for whom care of the deceased is part of their faith, rituals such as viewing, keeping watch and hygienic preparations such as washing are an important part of the mourning process.

Where such practices involve close contact with the deceased, those handling the deceased should be aware that in cases where COVID-19 infection has been identified or is suspected, there is likely to be a continuing risk of infection from body fluids and tissues.

We strongly advise that any rituals or practices that bring people into close contact with the deceased with suspected or confirmed COVID-19 should be undertaken using appropriate PPE (Table 2), under supervision of somebody trained in its use.

Individuals with an underlying health condition that puts them at higher risk of severe illness if they were infected with COVID-19 should consider seeking advice from their health professional before having contact with the deceased.

Guidance for funerals and commemorative events during the coronavirus is available.

Transporting the deceased

Despite the additional precautions required as a result of the COVID-19 pandemic, every effort should be made to treat the deceased with sensitivity, dignity and respect.

Other than circumstances where body bags are recommended, their use is not essential. Cloth wrappings (shrouds or wraps) and coffins may also be used to manage the risk of contact transmission but are not a replacement for body bags in situations where they are recommended.

If neither body bag nor coffin has been used, cleaning of the vehicle should be in line with COVID-19: cleaning in non-healthcare settings outside the home.

Associated legislation

Please note that this guidance is of a general nature and that an employer should consider the specific conditions of each individual place of work and comply with all applicable legislation, including the Health and Safety at Work etc. Act 1974.

In the event of any conflict between this guidance and any applicable legislation, the applicable legislation will prevail.