London Mass Fatality Plan Main Body

LONDON MASS FATALITY PLAN
March 2007 Version 2

PROLOGUE
Dealing with the consequences of mass fatality incidents requires the dedication of
numerous agencies. These agencies are committed to ensuring that the deceased and the
bereaved receive sensitive and dignified treatment, in accordance with the ideals projected
in the quotes below:
“Show me the manner in which a nation or community cares for its dead and I will
measure with mathematical exactness the tender sympathies of its people, their
respect for the laws of the land and their loyalty to high ideals.”
(Gladstone, William, 1871)
“All persons involved with the bereaved will be mindful of the following
recommendations:
• Provision of honest and accurate information at all times and at every stage
• Respect for the deceased and the bereaved
• A sympathetic and caring approach throughout
• The avoidance of mistaken identification.”
(Clarke, Lord Justice, 2001, para 34:1)
“The care with which our dead are treated is a mark of how civilised a society we are.
Much goes on for understandable reasons behind closed doors. For this reason
there is a special responsibility placed on those entrusted with this work and the
authorities that supervise it to ensure that the bodies of the dead are treated with the
utmost care and respect. That is what bereaved and loved ones are entitled to
expect and what society at large demands.”
(Haddon-Cave, Charles, 2000)

Representing the Marchioness Action Group
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London Mass Fatality Plan Version 2 Acknowledgements
ACKNOWLEDGEMENTS
The London Mass Fatality Plan has been made possible through the efforts of the London
Resilience Partnership. The London Resilience Team is especially grateful to the below-
listed organisations for their advice and assistance, without which this document would not
have been possible:
Association of Chief Police Officers (ACPO)

ACPO Major Disaster Advisory Team (MDAT)
British Transport Police (BTP)
Cabinet Office - Emergency Planning College
City of London Police (CoLP)
De Boer
Environment Agency (EA)
Health & Safety Executive (HSE)
Health Protection Agency (HPA)
HM Coroners in London and the Home Counties
HM Coroner to the Royal Household
Home Office Mass Fatalities Team
Home Office CBRN Team
Human Tissue Authority (HTA)
Interpol
Local Authorities in London and the Home Counties
London Mass Fatality Working Group
Metropolitan Police Service (MPS)
Military – London District
National Health Service (NHS)
Royal College of Pathologists
Society and College of Radiographers
Thames Water
and all partner agencies not so far mentioned but represented on the London Regional
Resilience Forum.
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London Mass Fatality Plan Version 2 Executive Summary
EXECUTIVE SUMMARY
Focus Reference
Activation of the Plan: Section 2.1

The London Mass Fatality Plan may be invoked when an incident occurs
in London which is likely to overwhelm existing procedures for managing
fatalities. The plan may also be activated in response to an incident
overseas which calls for the identification and repatriation of large
numbers of UK nationals.
Activation Cascade:
On recognising the need for the London Mass Fatality Plan the police or
Section 2.3
relevant Local Authority(s) will notify the Coroner and contact the London
Resilience Team (LRT). The LRT contact the relevant Coroner(s) and
Diagram 2.1
other personnel necessary to make-up the Mass Fatality Co-ordination
Group.
The Mass Fatality Co-ordination Group:

The Mass Fatality Co-ordination Group, as the name suggests, co-
Section 2.16
ordinates the implementation of the plan and will:
identify – by reference to section 5 – the most appropriate level of
implementation of this plan to be called in response to the nature, Section 5
scale, and complexity of the incident i.e.
1. Local: whereby it is possible to utilise existing mortuary

infrastructure with only minor enhancement or modification
2. Regional: the nature and/or extent of the incident calls for the
use of a Designated Disaster Mortuary within the existing Section 5.7
mortuary infrastructure of London Appendix A
3. National: the demands of the incident have exceeded local
and regional capability and assistance is requested from the Section 5.11
Home Office in the guise of the National Emergency Mortuary Appendix B
Arrangements (NEMA) (see Appendix B)
identify – by reference to section 5 of this plan – the most

Section 5
appropriate form of disaster mortuary to be used in the response
to the nature, scale, and complexity of the incident
identify – by reference to Appendices A & B of this plan – the
Appendix A
most appropriate location for the establishment of the mortuary
Appendix B
(dependent on the required tier of response)
manage any applications made in respect of the National
Emergency Mortuary Arrangements (NEMA)
oversee and the supply and construction of the NEMA in relation
to operational requirements and contractual timelines
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London Mass Fatality Plan Version 2 Executive Summary
act as a liaison and co-ordination forum in respect of:

o victim recovery issues (with particular focus on those issues
affecting the reception of deceased victims within the
mortuary)
o identification processes within the mortuary (and by
associated support services)
o Family Liaison issues relative to the processes within the
mortuary
o financial issues
o the work within the mortuary (through regular liaison with
the Mortuary Management Team)
The Mortuary Management Team:

Section 5
The principle responsibilities of the Mortuary Management Team are
focused on the effective operation of the mortuary (regardless of its nature
or type). The responsibilities of this team thus include:
overall supervision of mortuary procedures
constant assessment of the workings of the mortuary to identify
and address any problems
the day-to-day operational management of the mortuary
the co-ordination of supplies, equipment, services and staff
the briefing to family members regarding viewing arrangements
(to be arranged via the Family Liaison Co-ordinator)
liaison with the police Media Liaison Officer, government
departments and press offices, with regard to the progress of the
identification process and other relevant issues (controlled by the
Senior Identification Manager)
the recording of any information which may be relevant for the
purpose of any subsequent debriefing (see section 18)
Mortuary Procedures:
Section 6
The mortuary procedures produced in this plan reflect those tried and
tested methods approved by ACPO and the police Major Disaster
Advisory Team (MDAT).
Mortuary Equipment:
Appendix B
Details of national mortuary stockpiles and their locations are contained in
the National Emergency Mortuary Arrangements.
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London Mass Fatality Plan Version 2 Table of Contents
CONTENTS
SECTION 1 – OVERVIEW 10
Introduction ............................................................................................................. 10
Command and Control ............................................................................................ 11
Audience ................................................................................................................. 11
Scope of the Plan.................................................................................................... 11
Tiers of Implementation........................................................................................... 12
Purpose................................................................................................................... 13
Overarching Principles ............................................................................................ 13
Reviewing the Plan ................................................................................................. 14
Security Classification ............................................................................................. 14
SECTION 2 – ACTIVATION AND MANAGEMENT OF THE PLAN 15

Activation of the London Mass Fatality Plan ........................................................... 15
Activation Cascade ................................................................................................. 15
‘Presiding’ or ‘Incident Coroner’ .............................................................................. 15
‘Lead Coroner’ Principle.......................................................................................... 15
‘Lead Local Authority’ Principle ............................................................................... 16
The Mass Fatality Co-ordination Group .................................................................. 17
SECTION 3 – ROLES AND RESPONSIBILITIES OF ORGANISATIONS IN THE 20

MASS FATALITY CO-ORDINATION GROUP
HM Coroner............................................................................................................. 20
Supervising Forensic Pathologist............................................................................ 21
The Local Authority ................................................................................................. 21
The Police Service .................................................................................................. 23
The London Resilience Team ................................................................................. 25
SECTION 4 – DISASTER VICTIM IDENTIFICATION 26

Reasons for Identification ....................................................................................... 26
The Identification Commission ................................................................................ 26
The Inquest ............................................................................................................. 29
SECTION 5 – THE MORTUARY 30

Purpose ................................................................................................................... 30
The Mortuary and Implementation of this Plan ....................................................... 30
Local............................................................................................................ 30
Regional (Designated Disaster Mortuary) ................................................... 31
National (National Emergency Mortuary Arrangements)............................. 31
Disaster Mortuary.................................................................................................... 31
The Single Mortuary Principle ................................................................................. 31
Unsuitable Facilities ................................................................................................ 32
Holding Audit Area .................................................................................................. 33
Local Authority Mutual Aid ...................................................................................... 33
The Mortuary Management Team........................................................................... 33
Facilities at the Mortuary ......................................................................................... 34
Catering................................................................................................................... 35
Office and Technical Equipment ............................................................................. 35
Waste Disposal ....................................................................................................... 36
Security ................................................................................................................... 36
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SECTION 6 – MORTUARY PROCEDURES 37

Arrival and Registration........................................................................................... 37
Storage.................................................................................................................... 37
External Examination and Photography .................................................................. 38
Swabbing, Cleaning and Photographing the Deceased.......................................... 39
Radiography............................................................................................................ 39
Oral Radiography .................................................................................................... 40
Fingerprints ............................................................................................................. 40
DeoxyriboNucleic Acid (DNA) ................................................................................. 40
Taking of Samples and Removal of Human Remains............................................. 41
Fluoroscopy............................................................................................................. 41
Odontology.............................................................................................................. 41
Anthropology ........................................................................................................... 41
Re-bagging.............................................................................................................. 42
Embalming ............................................................................................................. 42
Release of the Deceased to the Relatives .............................................................. 42
Unclaimed Deceased Victims ................................................................................. 42
Deceased Victims to be Repatriated Abroad .......................................................... 43
The National Body Identification Number................................................................ 43
Property................................................................................................................... 43
Disposal of Personal Property................................................................................. 43
Evidence ................................................................................................................. 43
Evidence of Terrorist Incidents................................................................................ 44
Evidence (Non-Medical).......................................................................................... 44
Medical Evidence .................................................................................................... 44
Storage of Evidence................................................................................................ 44
Deceased Victim Documentation: ACPO Victim Label Booklet .............................. 44
Deceased Victim Documentation: Interpol Disaster Victim Identification Booklet ... 45
Deceased Victim Documentation: Victim Profile Check List ................................... 45
Deceased Victim Documentation: Overview of Use................................................ 45
Deceased Victim Documentation: Options.............................................................. 46
Evidential Disclosure............................................................................................... 46
Confidentiality Considerations................................................................................. 46
Non-Family Visits to the Mortuary ........................................................................... 47
SECTION 7 – FAMILY VIEWING 48

Family Viewing Area ............................................................................................... 48
Environmental Conditions of the Family Viewing Area............................................ 48
Religious Needs Specific to the Viewing Process ................................................... 48
Ritual Hand Washing .............................................................................................. 49
Additional Requirements ......................................................................................... 50
Medical Aid.............................................................................................................. 50
SECTION 8 – RELIGIOUS AND CULTURAL ISSUES 51

Buddhist .................................................................................................................. 51
Chinese (Confucianism, Taoism, Astrology and Christianity) ................................. 51
Christians ................................................................................................................ 51
Christian Scientists.................................................................................................. 51
Church of Jesus Christ of Latter Day Saints (Mormons) ......................................... 51
Hindus ..................................................................................................................... 51
Humanist ................................................................................................................. 52
Jain.......................................................................................................................... 52
Jehovah Witness..................................................................................................... 52
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Jews ........................................................................................................................ 52
Muslim..................................................................................................................... 53
Sikh ......................................................................................................................... 53
SECTION 9 – ROLES AND RESPONSIBILITIES OF ORGANISATIONS 55

The London Resilience Team ................................................................................. 55
The Local Authority ................................................................................................. 55
The Coroners Officer............................................................................................... 55
Mortuary Professions .............................................................................................. 56
The Police ............................................................................................................... 57
Mortuary Resources Manager................................................................................. 63
The Salvation Army................................................................................................. 63
National Health Service........................................................................................... 64
Human Tissue Authority.......................................................................................... 64
Health and Safety Executive ................................................................................... 64
Military..................................................................................................................... 64
Private Sector and Others ....................................................................................... 65
SECTION 10 – HEALTH AND SAFETY 66

Fire Safety............................................................................................................... 66
Radiation Safety...................................................................................................... 66
First Aid ................................................................................................................... 66
SECTION 11 – WELFARE 68
Police Family Liaison Officers ................................................................................. 69
Religious and Cultural Issues.................................................................................. 70
The Survivor Reception Centre ............................................................................... 70
Family and Friends Reception Centres ................................................................... 70
Humanitarian Assistance Centre............................................................................. 71
The Staff Welfare .................................................................................................... 71
SECTION 12 – COMMUNICATIONS AND MEDIA POLICY 72

SECTION 13 – SITE CLEARANCE 73
Rescue and Recovery ............................................................................................. 73
Recovering Deceased Victims ................................................................................ 73
Holding Audit Area .................................................................................................. 74
Site Preservation (Investigation) ............................................................................. 74
Site Stabilisation Stage ........................................................................................... 74
Site Clearance Stage .............................................................................................. 75
Transport to the Mortuary........................................................................................ 75
SECTION 14 – CHEMICAL, BIOLOGICAL, RADIOLOGICAL, NUCLEAR (CBRN) 76

SECTION 15 – INTERNATIONAL DIMENSION 77
Interpol .................................................................................................................... 77
Foreign and Commonwealth Office......................................................................... 77
Death Certification................................................................................................... 77
SECTION 16 – DECOMMISSIONING AND CLOSURE 78
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SECTION 17 – GUIDANCE ON DEALING WITH COSTS ASSOCIATED WITH AN 79

EMERGENCY MORTUARY
Introduction ............................................................................................................. 79
Types of Costs Likely To Be Incurred ..................................................................... 79
Responsibilities for Payment and Recovery of Costs ............................................. 79
Authorisation of Expenditure ................................................................................... 80
Recoverability of Costs ........................................................................................... 80
Summary................................................................................................................. 81
SECTION 18 – DEBRIEFING 82
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London Mass Fatality Plan Version 2
THE LONDON MASS FATALITY PLAN
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London Mass Fatality Plan Version 2 Section 1
SECTION 1 - OVERVIEW
INTRODUCTION
1.1 The London Mass Fatality Plan (LMFP) has been produced by the London Resilience
Team (LRT) under the auspices of the London Mass Fatality Working Group
(LMFWG) to the London Regional Resilience Forum (LRRF). This plan was agreed
by the London Regional Resilience Forum (LRRF) in January 2007.
1.2 The plan is primarily designed to supplement existing multi-agency emergency

preparedness arrangements in London. It is focused on facilitating the response to a
‘sudden impact’ event or ‘emergency’ (see paragraph 1.17) which involves mass
fatality. It may not, however, be entirely appropriate for use in the response to all
‘rising tide’ incidents (see paragraph 1.18). Due to the nature of the challenges they
represent, such incidents may be the subject of separate plans already in existence.
Nonetheless, consideration may be given to the implementation of distinct elements
of this plan in support of other arrangements where it is felt to be appropriate e.g. the
deployment of storage elements of the Emergency Mortuary.
1.3 An emergency is defined by the Civil Contingencies Act, 2004 as: ‘an event or
situation which threatens serious damage to human welfare in a place in the UK; an
event or situation which threatens serious damage to the environment of a place in
the UK; or, war, or terrorism, which threatens serious damage to the security of the
UK.’ Additionally, to constitute an emergency, an event or situation must also pose a
considerable test for an organisation’s ability to perform its functions.
1.4 This plan is designed to negate or mitigate the possibility that the magnitude and
complexity of the incident or emergency would overwhelm the emergency services
and those other agencies involved in the response.
1.5 Since its inception in June 2004, the plan has been successfully implemented to
handle victims of the Asian Tsunami in 2004 and during the operational response to
the bombings of London in July 2005. The plan has been updated as a consequence
of lessons learnt through those deployments and to interact with and complement the
National Emergency Mortuary Arrangements (NEMA) introduced by the Home Office
in June 2006.
1.6 Where appropriate it is important that this regional response plan is read in
conjunction with existing emergency procedures and guidance contained in:
a) the National Emergency Mortuary Arrangements (NEMA) - ‘Supplementing
the Local Response’ - Home Office, 2006 (see Appendix B)
b) the London Emergency Services Liaison Panel (LESLP) Emergency
Procedures Manual - Version 6 - July 2004
c) ‘Emergency Preparedness’ - Home Office 2005
d) ‘Guidance on Dealing with Fatalities in Emergencies’ - Home Office / Cabinet
Office, 2004
e) the Association of Chief Police Officers (ACPO) Emergency Procedures
Manual – ACPO 2002
f) the London Strategic Emergency Plan - London Resilience Team, 2005
g) the London Command and Control Protocol - London Resilience Team, 2006
h) the London Recovery Management Protocol - London Resilience Team, 2006
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i) the London Humanitarian Assistance Centre Plan - London Resilience Team,

2006
j) the London Site Clearance Plan - London Resilience Team, 2003 1
k) The Needs of Faith Communities in Major Emergencies: Some Guidelines –
Home Office, 2005.
COMMAND AND CONTROL

1.7 Emergency response is based on the emergency services’ system of Gold, Silver
and Bronze command. A brief explanation of the command framework is offered in
the following text.
1.8 Strategic Level – ‘Gold’ - The Gold level is responsible for formulating strategy and
commanding resources but delegates all tactical decisions to Silver.
1.9 Tactical Level – ‘Silver’ - The purpose of the tactical level is to ensure that the
actions taken by the operational level are co-ordinated, coherent and integrated in
order to achieve maximum effectiveness and efficiency.
1.10 Operational Level – ‘Bronze’ - The level at which the management of immediate
practical work is undertaken at site(s) of the emergency or other affected areas.
AUDIENCE
1.11 This document is intended for tactical (SILVER) and operational (BRONZE)
representatives of all agencies within the London Resilience Partnership who would
have a role to play in the management of large-scale human fatality following an
incident or emergency in London.
1.12 Strategic (GOLD) representatives should refer to London’s Generic Regional
Response Plan (GRRP) currently referred to as the London Strategic Emergency
Plan (SEP).
SCOPE OF THE PLAN

1.13 The London Mass Fatality Plan has been produced in response to the requirements
of the UK Capabilities Programme and, in particular, the programme’s stated
planning aim which is ‘to ensure that a robust infrastructure of response is in place to
deal rapidly, effectively and flexibly with the consequences of civil devastation and
widespread disaster inflicted as a result of conventional or non-conventional
disruptive activity.’
1.14 The plan is designed to provide tactical options and guidance to all agencies
responding to an incident involving mass fatality. In addition, it provides detailed
information that is designed to assist in the administration of a broad range of
operational matters allied to the management of the deceased.
1.15 An incident such as that mentioned in paragraph 1.14 may be referred to as a ‘Mass
Fatality Incident’. A ‘Mass Fatality Incident’ is any incident in which the number of
fatalities is greater than normal local arrangements can manage.
1
Under review and development.
11
1.16 Thus, the scale of any incident to which this plan may be applied will be such that
normal operations are not possible. Such incidents may include both ‘Sudden Impact’
and ‘Emerging’/’Rising Tide’ events.
1.17 Sudden Impact events – Immediate impact ‘emergency’ events or situations are
those that occur with little or no prior warning. The effects are usually felt right away
and include:
Accidental – transport, public place incidents and collapse of structures
Natural – floods and storms
Terrorism – explosions, fire and physical attack
Hazardous – Chemical, Biological, Radiological & Nuclear (CBRN) 2 .
1.18 Emerging or ‘Rising Tide’ incidents – As the name suggests, these incidents
provide some degree of warning prior to their impact and include:
Outbreaks – epidemics, pandemics
Extreme weather conditions – heat, cold.
1.19 Both types of event may be considered to be a ‘Major Incident’ and may fall within
the scope of this plan. It should be noted, however, that due to the nature of the
challenges represented by ‘rising tide’ incidents, such incidents may be the subject of
separate plans already in existence. Nonetheless, consideration may be given to the
implantation of distinct elements of this plan in support of other arrangement where it
is felt to be appropriate e.g. the deployment of storage elements of the Emergency
Mortuary (see also paragraph 1.2). The London Emergency Services Liaison Panel
(LESLP) Major Incident Procedure Manual defines the criteria to be used by the
emergency services for declaring a ‘Major Incident’.
TIERS OF IMPLEMENTATION
1.20 Depending on the scale and nature of the relevant incident there may be a
requirement for this plan to be implemented on one of three possible levels:
i. Local: whereby it is possible to utilise existing mortuary infrastructure with
only minor enhancement or modification
ii. Regional: the nature and/or extent of the incident calls for the use of a
Designated Disaster Mortuary within the existing mortuary infrastructure of
London (see Appendix A)
iii. National: the demands of the incident have exceeded local and regional
capability and assistance is requested from the Home Office in the guise of
the National Emergency Mortuary Arrangements (NEMA) (see Appendix B).
1.21 For the purposes of this plan each of London’s eight Coroners has identified a
designated mortuary within the area of their jurisdiction (see Appendix A).
1.22 When implementing this plan it should be borne in mind that any one event could
involve a mixture of features. The response may need, therefore, to address a single
event that impacts over a wide area or, alternatively, several events that occur
simultaneously in any number of locations.
2
Subject to current national planning projects.
12
PURPOSE
1.23 Generally, the London Mass Fatality Plan (LMFP) supplements existing Emergency
Procedures which provide for an integrated emergency response to an incident in
London. The plan provides additional options for dealing with incidents involving
large numbers of human fatalities. It may also be used to cater for the response to an
incident overseas which calls for the identification and repatriation of large numbers
of UK nationals.
1.24 Specifically, the plan details arrangements for the provision of suitable mortuary
facilities as well as offering advice and guidance aimed at facilitating:
an appreciation of the definition and purpose of available mortuary types
effective coronial management structures
effective co-ordination of the local authority lead
an understanding of the roles and responsibilities of relevant organisations
and key individual roles therein
successful management of the mortuary and the procedures therein
an understanding of the structures that exist to assist in the identification of
disaster victims
an appreciation of religious and cultural issues relative to the management of
the deceased
insight into the international dimensions of mass fatality incidents
knowledge of property and evidence management procedures
an awareness of complementary plans and protocols available for use by all
relevant agencies.
OVERARCHING PRINCIPLES
1.25 In meeting these aims it is important to recognise and support the principles to
emerge from the Public Inquiry into the Identification of Victims following Transport
Accidents in March 2001. Generally referred to as Lord Justice Clarke’s
recommendations (of which they form a part), there are four key principles which
should underpin any mass fatality plan. They are:
the provision of honest and, as far as possible, accurate information at all
times and at every stage
respect for the deceased and the bereaved
a sympathetic and caring approach throughout; and
the avoidance of mistaken identity.
1.26 In addition, the response provided will need to:

prioritise care for the living over the management of the deceased, and
be mindful of the needs and concerns of the bereaved.
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REVIEWING THE PLAN

1.27 In developing this plan the London Resilience Team (LRT) made wide use of learning
emanating from post-incident debriefs, public inquiries, associated reports and
relevant exercises. The content of this plan has been designed to reflect known best
practice from throughout the world.
1.28 The LRT is conscious, however, that things move on and is therefore committed to
the continual review and improvement of the plan. As such this plan must remain an
evolving document. In practice, this means that the LRT will actively monitor the
content of the plan against contemporary good practice and issue important
amendments as required.
1.29 The plan has been designed in the format of a loose-leaf four-ring binder to facilitate
the inclusion of any such amendments by you, the user. In addition to this ongoing
review process the LRT will formally re-examine the plan for accuracy and bearing
not later than every two years from the date of last publication (where practicable).
SECURITY CLASSIFICATION
1.30 The main part of this plan is unrestricted and may be shared with relevant interested
parties. Some appendices, however, are marked as ‘Restricted’ and should,
therefore, not be released to agencies outside of the London Resilience Partnership
without the authority of the London Resilience Team.
1.31 The London Resilience Team can be contacted on telephone: 020 7217 3666
(24hrs).
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SECTION 2 – ACTIVATION AND MANAGEMENT OF THE PLAN
ACTIVATION OF THE LONDON MASS FATALITY PLAN

2.1 The London Mass Fatality Plan, or part(s) thereof, may be invoked when an incident
occurs in London which is likely to overwhelm existing procedures for managing
fatalities. The plan, or any component part, may also be activated in response to an
incident overseas which calls for the identification and repatriation of large numbers
of UK nationals.
2.2 Regardless of its nature, it is generally accepted that either the emergency services
or appropriately placed London Local Authority will be the first of the agencies to be
alerted to an incident requiring the implementation of the plan.
ACTIVATION CASCADE
2.3 On recognising the need for the London Mass Fatality Plan the police or relevant
Local Authority(s) will notify the Coroner and contact the London Resilience Team
(LRT). The LRT will then contact the relevant Coroner(s) and other personnel
necessary to make-up the Mass Fatality Co-ordination Group (see section 2.16 for
further details). This process is demonstrated by the model that follows:
Diagram 2.1: Activation cascade
Police or LA to notify the Coroner and inform

the LRT Duty Director (via the LRT Duty Officer)
Tel: 020 7217 3666 (24/7 answer-machine
which gives the number of the on call LRT Duty Officer)
HM Coroner invokes the London Mass Fatality Plan
LRT contacts HM Coroner to seek authority to call out the

London Mass Fatality Co-ordination Group
‘PRESIDING’ OR ‘INCIDENT CORONER’

2.4 The plan may be activated by any HM Coroner in London. In doing so that Coroner
accepts the responsibilities of the presiding or ‘Incident Coroner’. The remit of this
role may be influenced by the ‘Lead Coroner’ Principle outlined below.
‘LEAD CORONER’ PRINCIPLE

2.5 In the event of a multi-sited incident - or one which transcends coronial jurisdictions -
it may be considered appropriate for the relevant Coroners to agree which of their
number will preside in the position of ‘Lead Coroner’. The Lead Coroner may then act
on behalf of all the Coroners concerned in the incident.
2.6 Once known, the Incident or Lead Coroner will convene and chair the Mass Fatality
Co-ordination Group (see paragraph 2.16 below).
15
2.7 It may be possible for an individual other then the Incident or Lead Coroner to Chair
the group. The identity of the Chair in such circumstances must be agreed by both
the Coroner and Gold.
‘LEAD LOCAL AUTHORITY’ PRINCIPLE

2.8 The Lead Local Authority Principle provides a framework for the management of
chosen mortuary facilities which:
may be remote from the site(s) of any incident, and
is within the borough boundaries of a local authority other than that (or those)
directly affected by the incident(s).
2.9 The principle can be applied in relation to three separate scenarios within the remit of
this plan:
the use of designated mortuaries
the use of emergency mortuaries; and
the related application of the Lead Coroner Principle.
These scenarios are described below.
2.10 The Use of Designated Mortuaries (see section 5.7): in the event of a chosen
‘designated mortuary’ being outside the borough boundary of the local authority
directly affected by an incident (Local Authority ‘A’):
the local authority in whose area the mortuary is located (Local Authority ‘B’)
will staff, equip and manage the facility on behalf of the authority affected by
the incident (Local Authority ‘A’); but
the local authority in whose borough boundary the incident took place (Local
Authority ‘A’) will be responsible for all reasonable costs incurred in respect of
running the mortuary for this purpose.
2.11 The Use of Emergency Mortuaries (see section 5.11): in the event of an activation of
the National Emergency Mortuary Arrangements (NEMA) it is possible that the site
chosen for the emergency mortuary (a mortuary comprising a temporary
demountable structure) will lie outside the borough boundary of the local authority
directly affected by an incident (Local Authority ‘A’).
2.12 In such circumstances the emergency mortuary may be staffed, equipped and
managed by either local authority (‘A’ or ‘B’ mentioned above). The ‘Lead’ Local
Authority, however, will always be the local authority directly affected by an incident
(Local Authority ‘A’) regardless of which authority actually manages the mortuary.
2.13 The decision as to which authority manages the mortuary should be the subject of
early discussion between the local authorities concerned. In reaching this decision,
due regard should be taken of the Coroners view in relation to those aspects of the
Lead Coroner Principle mentioned below.
2.14 Lead Coroner Principle: by reference to paragraph 2.5 above, it can be seen that in
the event of a multi-sited incident - or one which transcends coronial jurisdictions - it
may be considered appropriate for the relevant Coroners to agree which of their
number will preside in the position of ‘Lead Coroner’. In such circumstances, it may
be felt appropriate for the choice of Lead Local Authority to reflect the day-to-day
partnerships between a Local Authority and associated Coroner.
16
2.15 Each Local Authority affected by an incident may either choose to sit on the Mass
Fatality Co-ordinating Group or be represented by the Lead Local Authority.
THE MASS FATALITY CO-ORDINATION GROUP

2.16 Purpose: The Mass Fatality Co-ordination Group, as the name suggests, co-
ordinates the implementation of the plan and will:
identify – by reference to section 5 – the most appropriate level of

implementation of this plan relative to the nature, scale, and complexity of the
incident i.e.
o Local: whereby it is possible to utilise existing mortuary infrastructure
with only minor enhancement or modification
o Regional: the nature and/or extent of the incident calls for the use of a
Designated Disaster Mortuary within the existing mortuary
infrastructure of London (see Appendix A)
o National: the demands of the incident have exceeded local and
regional capability and assistance is requested from the Home Office
in the guise of the National Emergency Mortuary Arrangements
(NEMA) (see Appendix B)
identify – by reference to section 5 of this plan – the most appropriate form of

disaster mortuary to be used in the response to the nature, scale, and
complexity of the incident
identify – by reference to Appendices A & B of this plan – the most
appropriate location for the establishment of the mortuary (dependent on the
required tier of response)
manage any applications made in respect of the National Emergency
Mortuary Arrangements (NEMA)
oversee and the supply and construction of the NEMA in relation to
operational requirements and contractual timelines
act as a liaison and co-ordination forum in respect of:
o victim recovery issues (with particular focus on those issues affecting
the reception of deceased victims within the mortuary)
o identification processes within the mortuary (and by associated
support services)
o Family Liaison issues relative to the processes within the mortuary
o financial issues
o the work within the mortuary (through regular liaison with the Mortuary
Management Team) (see section 5.29)
2.17 Core Membership: The Mass Fatality Co-ordination Group’s core membership*
comprises the following individuals or their chosen deputy:
the presiding Incident or Lead Coroner (Chair)
the designated Supervising Forensic Pathologist
the Senior Investigating Officer (SIO) (police)
the Senior Identification Manager (SIM) (police)
17
the Mortuary Facilities Manager (usually appointed by the Local Authority)

a strategic representative from the Local or ‘Lead’ Local Authority
a representative of the London Resilience Team (LRT)/Government Liaison
Team.
*For a visual representation of this membership see Diagram 2.2 below.
2.18 Complementary membership: In addition the following individuals and

organisations may be considered for membership of the group (as and when
appropriate):
all other Coroner(s) with jurisdictional responsibility within the confines of the
incident footprint (if different to the Incident or Lead Coroner)
subject-matter advisors from:
o the police
o the London Resilience Team
o the Home Office Mass Fatalities Unit
o Kellogg Brown and Root (KBR)
o London District (military)
the Mortuary Operations Manager (police)
the Family Liaison Co-ordinator (police)
the Welfare Co-ordinator
the Family Viewing Co-ordinator
the Disposal Co-ordinator
the Disaster Site Recovery Manager
the Logistics Support Manager
the Media Liaison Officer.
2.19 This list is not exhaustive and other members may be subsequently identified as
being necessary to the purpose of the MFCG. Beyond the core membership, it is not
intended that members listed here will be required to attend all meetings of the group
but may be called on to attend as and when required.
2.20 Whilst it may not possible for every member of the group to be present at each
relevant meeting, their advice should be sought before a decision is made on the
placement of any disaster mortuary facilities.
2.21 Administrative support for the Mass Fatality Co-ordination Group will be provided by
the relevant Local Authority.
2.22 A written record must be made of all decisions made by the Mass Fatality Co-
ordination Group. If practical all meetings will be minuted.
2.23 The roles performed by both the organisations and individuals concerned in the
group are illustrated at Diagram 2.2 on the page that follows.
18
Diagram 2.2 - Mass Fatality Co-ordination Group - Core Membership
HM Administration Support
(Local Authority/LRT)
Coroner
Chair
Operation Support *
Mortuary Facilities Supervising
Casualty Manager Forensic
Bureau (Usually appointed by Pathologist
Manager Local Authority
Family
Liaison Co-
ordinator
Senior Strategic Local Authority

Victim Identification Representative
Recovery Manager (Local or agreed Lead)
Team Leader
Mortuary
Operations
Manager LRT
London Resilience
Representative
Team
Advice/Support
Government Liaison Team
* Attendance may be required for update purposes. Other complementary members may attend as required.
19
SECTION 3 - ROLES AND RESPONSIBILITIES OF ORGANISATIONS IN THE

MASS FATALITY CO-ORDINATION GROUP 3
HM CORONER
3.1 Coroners are independent judicial officers whose appointment and duties are
regulated by law. They inquire into certain kinds of death set out in the Coroners Act
1988, s 8(1), namely those which the coroner has reasonable cause to suspect (a)
are violent or unnatural, (b) are sudden, of unknown cause, or (c) occur in prison.
The death may result from a major disaster and for a particular coroner to have
jurisdiction, it does not matter where the death occurred (even outside the UK).
Jurisdiction is established as consequence of ‘where the body now is’.
3.2 Only the Coroner can authorise procedures relating to the deceased and human
remains in circumstances outlined above. Thus, in the event of a disaster it is only
the Coroner who can authorise the moving of deceased victims and/or human
remains at or from the associated scene(s).
3.3 In addition, it is only the Coroner who can authorise:

a post-mortem examination of a dead person
the taking of forensic samples or specimens for analysis
the retention of forensic samples or specimens for further investigation, and
the release of the deceased and residual human tissue 4 to the bereaved or
their agent.
3.4 It may be important to note that in exercising the authorities above the Coroner
assumes control and possession of the deceased: at no time does the Coroner take
on ownership of the deceased.
3.5 As the Coroner has statutory responsibility for the identification of disaster victims, in
London, he or she will:
chair the Mass Fatality Co-ordination Group (where appropriate)
appoint:
o a Supervising Forensic Pathologist (see paragraph 3.8)
o all necessary remaining pathologists
o all necessary Forensic Odontologists (see paragraph 9.23)
o all necessary Forensic Anthropologists (see paragraph 9.12)
o all necessary Forensic Archaeologists (see paragraph 9.18)
assign responsibilities to relevant Coroners Officers (see paragraph 9.4)
convene and chair an Identification Commission (see paragraph 4.6)
in consultation with the Supervising Forensic Pathologist and Senior
Identification Manager (SIM) (see paragraph 3.24), determine the
identification criteria to be used as well as the extent of any post-mortem
examination in the circumstances of the particular incident
3
Including individual and linked roles where appropriate
4
Residual Human Tissue (RHT) and its proper means of disposal will be defined and subject to policies agreed by the Mass Fatality Coordination
Group
20
authorises the type and the taking of DNA samples for identification purposes
liaise with the Senior Identification Manager (SIM) and the chosen forensic
service provider to:
o ensure that a policy of random sampling of DNA is in place (if
appropriate)
o validate the DNA identification process
in consultation with the Senior Identification Manager (SIM) and the Senior
Investigating Officer (SIO), will decide the strategy for recovering the
deceased, human remains and residual human tissue from the scene(s)
along with the Senior Identification Manager (SIM), liaise with the Family
Liaison Co-ordinator to discuss meeting with bereaved families so as to
explain relevant forensic and identification processes
open, conduct and close all relevant Inquests
issue all relevant disposal certificates.
3.6 The Coroner may wish to visit the scene(s) of the incident along with the Supervising
Forensic Pathologist.
3.7 In consultation with the membership of the Mass Fatality Co-ordination Group the
Coroner will also decide on the appropriate level of mortuary provision to the specific
incident i.e. local, regional or national (see section 2.16).
SUPERVISING FORENSIC PATHOLOGIST

3.8 The Supervising Forensic Pathologist works closely alongside the Coroner in
determining the extent of any post-mortem examinations which are to be undertaken.
In addition, he/she will supervise the authorised post-mortem and identification
examination procedures.
3.9 At the behest of the Coroner, the Supervising Forensic Pathologist may appoint other
pathologists to work within the mortuary. Whilst these pathologists are so engaged
the Supervising Forensic Pathologist will be responsible for their supervision.
3.10 In conjunction with the Mortuary Facilities Manager, the Supervising Forensic
Pathologist will arrange for the provision of adequate levels of appropriately skilled
staff to fulfil functions within the mortuary.
3.11 Along with the Senior Identification Manager (SIM), the Supervising Forensic
Pathologist will liaise with the Family Liaison Co-ordinator in order to discuss meeting
with bereaved families with a view to explaining relevant forensic and identification
procedures.
THE LOCAL AUTHORITY

3.12 The Local Authority is responsible for establishing and equipping those mortuaries
which are required in circumstances to which this plan applies. If so required this duty
can be performed by utilising the principles of ‘mutual aid’ (see section 5.26) and/or
calling on pan-London arrangements made available through this plan.
3.13 The Local Authority is responsible for alerting social services, the Environment
Agency and calling on support from Faith Leaders and the Voluntary Sector to assist
in welfare provision for family and friends of the deceased (see also the Multi-Faith
Plan).
21
3.14 Social Services will liaise with the police Family Liaison Co-ordinator to assess the
need for trauma support staff and other tangible support for families and friends who
view the deceased and/or need to deal with funeral arrangements.
3.15 The Local Authority will usually appoint and support a Mortuary Facilities Manager
(see paragraph 3.18). This appointment may be achieved by utilising the principles of
‘mutual aid’ (see section 5.6).
3.16 The Local Authority within whose area the mortuary is situated (unless otherwise
agreed) will assist in matters relating to:
the management of all sub-contracted services (unless stated as otherwise in
agreements contained within the National Emergency Mortuary
Arrangements)
public health
Health & Safety
hazardous waste collection
the management of effluent discharges in consultation with the water service
utility provider and the Environment Agency
refuse collection
cleaning and road-sweeping
the provision of garden and landscaping services
the upkeep and appearance of all public areas within the mortuary.
Mortuary Facilities Manager

3.17 The Mortuary Facilities Manager will be an experienced Mortuary Manager usually
appointed by the Local Authority. If pragmatic to do so, the Mortuary Facilities
Manager may be appointed by the relevant health authority (or Cribbs Ltd. for the
East London area).
3.18 The specific responsibilities of the Mortuary Facilities Manager include:

liaison with the Human Tissue Authority (HTA) to arrange for any necessary
licensing of the venue (if appropriate)
to ensure proper logistical support to all areas of the mortuary facility
in conjunction with the Mortuary Operations Manager (see paragraph 3.29) –
to oversee all relevant staffing requirements within the mortuary
in conjunction with the Mortuary Operations Manager – to ensure appropriate
consideration of all staff welfare issues
to ensure that a qualified First-Aider is on site and available at all times of
operation
in conjunction with the Supervising Forensic Pathologist (see section 3.8) - to
ensure appropriate consideration and enforcement of all relevant Health and
Safety legislation
working with the Supervising Forensic Pathologist and the Mortuary
Operations Manager - to ensure the application of all appropriate hygiene
practices (including wet/dry area discipline)
22
to manage the provision, use and stockpiling of Personal Protective

Equipment (PPE), stationary, office supplies and mortuary staff refreshments
to ensure the proper handling, storage and disposal of clinical waste
the supervision of the cleaning of all parts of the mortuary facility
to arrange and supervise the decommissioning of the mortuary facility
(including ensuring that all necessary cleansing and repairs are undertaken in
advance).
THE POLICE SERVICE

3.19 The police service is responsible for investigating the incident, tracing missing
persons, victim recovery and identification (as and when appropriate).
3.20 The police service accepts responsibility for managing the reception and
documentation of the deceased arriving at the mortuary as well as the gathering of
physical evidence of both crime and victim identification (Section 6).
3.21 The police will provide for the security of any mortuary site unless other satisfactory
arrangements are in place or agreed.
Gold
3.22 The Overall Incident Commander or police ‘Gold’ will chair the Strategic Co-
ordination Group and will appoint both the Senior Investigating Officer (SIO) and the
Senior Identification Manager (SIM).
Senior Investigating Officer (SIO)

3.23 The Senior Investigating Officer (SIO) leads the investigation into any relevant
criminal activity (including terrorism) or culpability issues.
Senior Identification Manager (SIM)

3.24 The Senior Identification Manager (SIM) acts on behalf of the SIO (and to the
satisfaction of the Coroner) in leading the investigation into the identification of the
deceased.
3.25 The Senior Identification Manager (SIM) has overall responsibility for all police
officers and staff involved in all aspects of the identification process. In order to
achieve his/her primary function the SIM will also have overall responsibility for the
following aspects of the identification process:
Victim Recovery
Mortuary Documentation
Casualty Bureau
Family Liaison.
3.26 The SIM will assist the Coroner in establishing an Identification Commission (see
section 4.6). In order to facilitate this process the SIM will work in conjunction with the
Coroner and Senior Investigating Officer (see above) to develop an Identification
Strategy.
23
3.27 The SIM will, in consultation with the Coroner and the Senior Investigating Officer
(SIO), develop a Recovery Strategy. This will establish when and how deceased
victims and human remains are to be removed from the scene(s) and transported to
the mortuary.
3.28 In consultation with both the Coroner and the chosen forensic service provider, will
ensure that a policy of random sampling of DNA is in place (if appropriate) to validate
the DNA identification process.
Mortuary Operations Manager

3.29 The Mortuary Operations Manager is responsible to the SIM and is responsible for
the implementation of this plan relative to:
obtaining, seizing and retaining evidence and personal property at the
mortuary
ensuring continuity of evidence through correct and systematic management
(including the deceased, human remains and residual human tissue which
has arrived at or been seized at the mortuary)
the correct completion of all relevant post-mortem documentation (including
its delivery of to the Mortuary Documentation Officer – see section 9.51).
3.30 Further, the Mortuary Operations Manager is responsible for:

the direct supervision and support of all police mortuary teams
liaison with the Mortuary Facilities Manager to ensure that wet/dry area
discipline is adhered to and that health and safety risk assessments are being
observed.
3.31 The Mortuary Operations Manager is a member of the Mortuary Management Team
(see section 5.28).
Family Liaison Co-ordinator (FLC)

3.32 The Family Liaison Co-ordinator (FLC) is to act on behalf of the SIM relative to:
the functions of family liaison
the availability and deployment of Family Liaison Officers (FLOs) (especially
in complex cases with multiple deployments)
the co-ordination of information arising from multiple FLO deployments
the skills, knowledge and experience of the FLO team in terms of culture,
lifestyle and diversity issues.
3.33 The FLC also acts in support for the Family Liaison Officers by:
monitoring workloads
maintaining a register of contact details of appropriate organisations/lay
people/professional consultants to assist them in their role
providing a networking point for FLOs requiring advice from other FLOs who
have experience in dealing with particular scenarios
acting as a channel for welfare, occupational health, defusing support
promoting/facilitating mutual FLO peer group support
24
monitoring mandatory attendance at the Welfare/Occupational Health

Department
acting as an independent channel for FLO debriefing to draw out good
practice
liaising nationally to share and gather good practice for implementation within
his/her own force area.
THE LONDON RESILIENCE TEAM

3.34 The Duty Director or a chosen representative will attend all meetings of the Mass
Fatality Co-ordination Group in order to:
represent the interests of the Government Office for London
form a link to the Government Liaison Team at the Strategic Co-ordination
Centre
act as a conduit between the Mass Fatalities Co-ordination Group and HM
Government / Ministers specific to issues concerning the mass fatality
process
assist in establishing funding agreements between the relevant Local
Authority, HM Government and all relevant third parties
advise on other relevant LRRF plans that may be pertinent to the aims of the
MFCG.
END NOTE
3.35 Details of additional responsibilities of these and all other agencies involved in the
plan can be found at Section 9.
25
SECTION 4 – DISASTER VICTIM IDENTIFICATION
REASONS FOR IDENTIFICATION

4.1 In police terms, Interpol Resolution AGN/65/Res/13 (1996) (see Appendix H)
recognises that for legal, religious, cultural and other reasons, human beings have
the right not to lose their identity after death, and that the identification of victims is of
importance for police investigations.
4.2 Additional calls for the identification of the deceased lie in:
a statutory requirement – s. 8 (1) Coroners Act, 1988 (see the Statutory
Framework at provided at Appendix I)
ethical and humanitarian needs relative to the provision of information to
surviving family members
fact of death in a particular individual to be reported for official, statistical and
legal purposes
administrative and ceremonial purposes in respect of burial or cremation
the need to provide information regarding any claims for life insurance,
contracts, survivors’ pensions and other related financial matters
the need to allow the legal process to proceed with a firm knowledge of the
identify of the deceased
the need to facilitate enquiries into criminal or suspicious deaths
the need to issue a death certificate
to comply with the resolution of the Interpol Standing Committee on Disaster
Victim Identification (see above).
4.3 Disaster Victim Identification (DVI), normally the responsibility of the police, is a
difficult and demanding exercise which can only be brought to a successful
conclusion if properly planned and which, of necessity, has to involve the active
participation of many other agencies. It is, however, only one aspect of dealing with
disasters which will always vary considerably in scale and effect.
4.4 The ultimate aim of all Disaster Victim Identification operations must always be to
establish the identity, without error, of every victim by comparing and matching
accurate ante-mortem (AM) and post-mortem (PM) data.
4.5 The Identification Commission is a group representing all aspects of the DVI process
which is set up to consider ante-mortem data and post-mortem data in order to
determine the identity of each of the deceased to the satisfaction of the Coroner.
THE IDENTIFICATION COMMISSION

4.6 The Coroner should assume responsibility for establishing an Identification
Commission (a term that is in standard use in Interpol countries).
4.7 In general the Coroner should chair the Commission but there may be, however,
cases where this is not appropriate. In such cases it should be for the Coroner to
decide who should take the chair.
26
4.8 The purpose of the Identification Commission is to identify all the deceased and
human remains. It directs procedures and scrutinises all evidence relating to identity,
so as to enable the Coroner to make decisions regarding their release.
4.9 It is essential that all matters relating to establishing the identity of victims are closely
controlled and regularly reviewed. To facilitate this policy the following should be
utilised:
the position of Senior Identification Manager (SIM) (see section 3.24)
the Identification Commission itself
the Post-Mortem Team
the Ante-Mortem Team.
4.10 Sitting at regular intervals the full Identification Commission will examine each
prospective identification against the evidence presented by the Post- and Ante-
Mortem teams until all victims have been identified or enquiries exhausted. The
meetings are not intended to replace the usual liaison between the various teams
working both within and outside the mortuary.
4.11 The Identification Commission should meet regularly and comprise the following core
members:
the Coroner
the Senior Identification Manager (SIM) or representative
the Supervising Forensic Pathologist
an Administrative Officer.
4.12 In addition, it may be appropriate to invite assistance from:

additional pathologists / forensic pathologists
the Odontologist
the fingerprint expert(s)
the Ante-Mortem Co-ordinator (see section 9.32)
the Family Liaison Co-ordinator
the Mortuary Documentation Officer
the Mortuary Operations Manager (see section 3.29)
other specialists as appropriate
independent advisor(s).
4.13 The use of identification methods will vary according to the nature of the incident and
must be agreed, in the first instance, by the ‘Presiding’ or ‘Incident Coroner’.
4.14 Identification may be classed into three categories in order of importance. Whilst it’s
contents are not exhaustive, the list below provides the groupings from which
identification evidence may be drawn:
27
Primary Factors
Fingerprints
Odontology
DNA
X-ray (in certain circumstances)
Unique medical identifier.
Note: One feature could be regarded as sufficient in isolation but it would be highly
desirable to have at least one secondary item to prevent any suggestion of
identification evidence being confused.
Secondary Factors
Distinctive deformity or medical condition
Marks, scars and tattoos
Blood grouping
Physical disease
X-ray
Jewellery
Distinctive clothing
Personal effects.
Note: A minimum of three such features might normally be required to confirm identity.
Assistance Only
Clothing
Photographic
Body location (at the time of recovery)
Visual
Description
Facial Mapping
Note: These characteristics are not generally regarded as sufficient in their own right but
may support primary or secondary features. Dependent on circumstances, Facial
Mapping may sometimes amount to at least a secondary feature.
4.15 Where the deceased are severely disrupted it will be for the Coroner to decide
whether any small identified remains amount to a ‘body’ for jurisdictional purposes.
4.16 Whilst the general principle has been that only ‘that part of a body which by itself is
inconsistent with life’ can, in law, amount to a body, it is submitted that this is naïve in
the context of mass fatalities. It is suggested that where there is clear independent
evidence that a death of a particular person(s) has occurred, then any fragmented
remains that are identified should be treated as a body.
4.17 A principle function of the Identification Commission is to set criteria by which

identification of the deceased is established. On reviewing all the available
28
identification evidence, the Coroner will decide whether there is sufficient certainty to
allow the release of the deceased.
4.18 Whilst the deceased will normally be released to the next of kin or their agent as
soon as identity is certain, the process may be delayed if the deceased are disrupted
and fragmented remains are to be separately identified and reunited. In cases such
as this, families should be given three options relative to the restoration of their loved
one(s):
to wait until all remains are recovered and identified
to hold a funeral of the remains in their possession but be informed when and
if further remains are identified
to hold a funeral or dispose of the remains in their possession with no further
contact being made.
THE INQUEST
4.19 HM Coroner has a duty to hold an inquest if:
there is reason to suspect that someone has died a violent or unnatural
death, or
has died a sudden death of which the cause is unknown, or
has died in prison or
in any other place, has died in such circumstances as to require an inquest
under any other Act (section 8(1) Coroner’s Act 1988).
4.20 The inquest is usually opened within a few days of the death when evidence is given
as to identification, the brief circumstances of the death, and the cause of death. The
inquest is then adjourned to allow for any enquires and investigations to be
completed.
4.21 Once all the evidence has been obtained, a full inquest hearing is usually held. The
purpose of the Inquest is to confirm identity and determine when, where and how the
deceased came by their death. However, if there is to be a prosecution for certain
offences or there is to be a public inquiry, the inquest will be adjourned and may or
may not be resumed.
4.22 At the conclusion of the coroner’s proceedings, the Registrar of Deaths will be
notified so that a death certificate can then be issued.
4.23 The Coroner has no automatic power or duty to investigate the deaths of persons
who are assumed to have died but whose bodies cannot be found. However, in such
circumstances, the Coroner may apply to the Secretary of State for permission to
hold an inquest under s.15 Coroners Act 1988.
29
SECTION 5 – THE MORTUARY
PURPOSE
5.1 The purpose of a mortuary is:
to establish identity, through careful examination of the deceased and
associated property in order to obtain evidence which can be matched with
data obtained by the Ante-Mortem Team and the Casualty Bureau
to facilitate the establishment of the precise cause of death through proper
examination of the deceased by pathologists
to facilitate the collection of evidence of crime: not only in the cause of death
but by examination of clothing and other exhibits recovered from the
deceased e.g. bomb fragments
to allow for the preservation and recording of personal effects of the
deceased
to provide facilities for the preparation of deceased victims for release to
family members by reconstructive techniques where necessary (embalming
may be appropriate in some cases - particularly in the case of repatriation
overseas).
5.2 The mortuary will play a central part in the collection of evidence. The police will work
within the mortuary for documentation purposes and work in close liaison with the
Casualty Bureau as well as all Ante Mortem Teams.
THE MORTUARY AND IMPLEMENTATION OF THIS PLAN

5.3 By reference to paragraph 2.16 (reproduced below) it can be seen that the London
Mass Fatality Plan can implemented one of three possible levels:
Local: whereby it is possible to utilise existing mortuary infrastructure with
only minor enhancement or modification
Regional: the nature and/or extent of the incident calls for the use of a
Designated Disaster Mortuary within the existing mortuary infrastructure of
London (see Appendix A)
National: the demands of the incident have exceeded local and regional
capability and assistance is requested from the Home Office in the guise of
the National Emergency Mortuary Arrangements (NEMA) (see Appendix B)
Local:
5.4 As stated above, the implementation of the plan at the local level will utilise those
mortuaries already in existence within the infrastructure of London. In such
circumstances the relevant Local Authority may provide a Public Mortuary for use as
a disaster mortuary.
5.5 This facility may, in fact, be provided by either the Local Authority or the local Health
Authority (or Cribbs Ltd. in the East London area). Regardless of its source, however,
the mortuary holds the deceased for the purposes of identification, post mortem
examination and storage prior to their return to the bereaved.
5.6 Should it be that the demands of an incident exceed the capabilities of the local
mortuary the Coroner may decide to invoke the regional tier of the plan by making
use of the relevant Designated Disaster Mortuary.
30
Regional: Designated Disaster Mortuary

5.7 Once again, by reference to the paragraph above, it can be seen that should the
nature and/or extent of the incident call for it, the use of designated, enhanced
facilities within the existing mortuary infrastructure of London may be necessary.
5.8 It has been agreed with each of the London Coroners (responsible for nominating a
disaster mortuary) and London Local Authority Chief Executives (responsible for
providing it) that the most suitable mortuary in each Coroner’s area, be nominated as
a single ‘Designated Disaster Mortuary’ (see Appendix A for details).
5.9 In the event of an incident to which this plan refers, HM Coroner will liaise with the
local authority responsible for providing the relevant ‘Designated Disaster Mortuary’
in order to ensure that arrangements are in place for it to be used operationally.
5.10 Each ‘Designated Disaster Mortuary’ (see Appendix A) has an agreed maximum
capacity but, in the event of this capacity being exceeded, the National Emergency
Mortuary Arrangements (see Appendix B) may be appropriate for use.
National: National Emergency Mortuary Arrangements (NEMA)

5.11 Should it be that the demands of an incident exceed the capabilities of the regional
plan i.e. the Designated Disaster Mortuary, the Coroner may decide to invoke the
national tier of the plan by making a request for an Emergency Mortuary via the
National Emergency Mortuary Arrangements (see Appendix B for full details).
5.12 The National Emergency Mortuary Arrangements (NEMA) form the basis of HM
Government’s programme of central assistance to supplement existing local and
regional plans. The arrangements which can be offered as part of that central
assistance package include:
a temporary demountable structure(s) acting as an ‘Emergency Mortuary(s)’
stockpiles of general mortuary equipment
chilled storage for use at an incident site
specialist radiographic equipment; and
the UK Disaster Victim Identification Team (UK-DVI).
5.13 Full details of the concept of operation for this national capability programme can be
found at Appendix B.
DISASTER MORTUARY
5.14 The phrase ‘disaster mortuary’ should be taken as a generic term loosely describing
any mortuary which is being utilised as such in the response to a disaster. The term
may, thus, apply to the facilities known as the ‘Designated Disaster Mortuary’ or the
‘Emergency Mortuary’.
THE SINGLE MORTUARY PRINCIPLE

5.15 Deaths at the Scene: All deceased victims and human remains from a disaster
scene must be taken to a single mortuary. In the event of a multi-sited incident it may
be appropriate to dedicate a single mortuary (or independent access to the mortuary
along with associated separate storage) for the deceased from each scene. This
requirement is necessary because:
31
the nature of the incident could cause a quantity of human remains greater
than the sum of victims involved (this would require a single mortuary so as to
ensure that all such human remains are gathered in one place for subsequent
identification and repatriation)
procedures for examining and identifying disrupted deceased victims require
a great deal of space
the use of multiple mortuaries would increase the burden on the
communications system which would already be under great strain during a
disaster
there will be intense media interest which will require a high degree of
security and co-ordination
containment of the incident and associated security problems would be made
more difficult if more than one mortuary was in use simultaneously
the use of multiple mortuaries would require significantly higher staffing levels
in terms of the identification team
the use of multiple mortuaries would lead to scattering of vital identification
information
the use of multiple mortuaries may cause unnecessary distress to the
bereaved in the event of the need to attend viewings at several different
mortuaries
the use of a single mortuary minimises the impact on the existing mortuary
infrastructure in London allowing for the continuity of business in the capital.
5.16 Deaths Elsewhere: Victims who, as a result of the disaster, die en route to or at the
hospital will be moved to the disaster mortuary and managed by that facility’s staff.
UNSUITABLE FACILITIES
5.17 Hospital Mortuaries: The National Health Service (NHS) hospital mortuary caters
for persons who die in hospital and has post mortem and storage facilities. As a
general principle it is recommended that hospital mortuaries are NOT used as
Designated Disaster Mortuaries unless the number of fatalities involved is
manageable and well within the capabilities of the particular hospital facility. Hospital
mortuaries are not generally suited to use as a disaster mortuary because:
the access and egress requirements of large numbers of vehicles carrying the
deceased victims to such a mortuary may interfere with the ability of
ambulances to access/egress the hospital
large numbers of deceased victims arriving at the hospital mortuary might
overwhelm the capacity of the facility which might:
o necessitate the use of a second or third mortuary
o seriously disrupt the routine work of that mortuary for periods of
several days or weeks
a hospital mortuary is usually ill-equipped and ill-suited to deal deceased
victims from a major disaster which may be disrupted, burnt, or may have
undergone decomposition (there may also be many more mutilated human
remains than intact deceased victims which would create a need for
disproportionately large storage facilities)
32
the deceased may need to undergo extensive radiological examinations, and

this would be difficult for overstretched hospital radiology departments to
bear.
5.18 Non-designated Public Mortuaries: For similar reasons to those stated above it is
undesirable to use a non-designated public mortuary as a disaster mortuary but this
will depend on the number of deceased victims and on the storage capacity of the
relevant public mortuary.
5.19 It should be realised that a major disaster could totally monopolise the facilities of the
public mortuary (including the storage and office space) for several months. This
would cause severe disruption of the mortuary’s day-to-day operations during the
period of the major disaster investigation.
5.20 It may not be practical to move those deceased already in place in a public mortuary
in order to accommodate incoming mass fatality victims.
5.21 The physical attributes of many existing mortuaries may affect their ability to deliver
evidential continuity and care for the families of the victims.
5.22 In addition, public mortuaries are usually located centrally in urban areas which may
pose problems of security, traffic congestion and potential intrusion by the media.
5.23 Private Mortuaries: Private Mortuaries are maintained by the private undertaking
sector. Although they may have post mortem facilities they are mainly used for
storage of deceased prior to burial or cremation (see, however, paragraph 3.17).
HOLDING AUDIT AREA

5.24 The Holding Audit Area (previously known as the Body Holding Area) is a designated
area for containing the deceased victims in one place, at or near to the scene, prior
to transportation to the mortuary. This area should not be confused with a mortuary
and no post-mortem procedures or examinations will take place at this point. The
Holding Audit Area is both designated and managed by the police.
LOCAL AUTHORITY MUTUAL AID

5.25 Each Coroner in London has designated a mortuary to use in response to a mass
fatality incident within their jurisdiction (the Designated Disaster Mortuary).
5.26 In addition, the London Resilience Team has brokered a ‘Mutual Aid’ agreement so
that in the event of a mortuary being used as part of the ‘local’ tier response
(described earlier in this plan), a Designated Disaster Mortuary would supply
resources, if need be, to other responding Local Authorities within the same
Coroners jurisdictional area.
5.27 This mutual aid agreement was signed off by the London Local Authority Working
Group meeting of May 2004.
THE MORTUARY MANAGEMENT TEAM

5.28 The principle responsibilities of the Mortuary Management Team are focused on the
effective operation of the mortuary (regardless of its nature or type). The
responsibilities of this team thus include:
overall supervision of mortuary procedures
33
constant assessment of the workings of the mortuary to identify and address

any problems
the day-to-day operational management of the mortuary
the co-ordination of supplies, equipment, services and staff
the briefing to family members regarding viewing arrangements (to be
arranged via the Family Liaison Co-ordinator)
liaison with the police Media Liaison Officer, government departments and
press offices, with regard to the progress of the identification process and
other relevant issues (controlled by the Senior Identification Manager)
the recording of any information which may be relevant for the purpose of any
subsequent debriefing (see section 18).
5.29 A written record must be made of all decisions made by the Mortuary Management
Team. If practical all meetings will be minuted.
5.30 The Chair of the Mortuary Management Team will decide on the frequency of the
teams meetings.
5.31 Membership of the team will include:

Senior Identification Manager (or deputy)
Mortuary Documentation Officer
Mortuary Facilities Manager
Mortuary Operations Manager
Supervising Forensic Pathologist
Coroner’s Officer
Ante-Mortem Co-ordinator
Resources Manager
Health & Safety Co-ordinator (see section 10)
Senior Radiographer / Radiation Protection Supervisor
specialist advisers (as required).
5.32 Should the Emergency Mortuary be set up it will be advisable for a liaison
representative from the designated site to attend Management Team meetings. This
will be particularly useful in the initial stages of the process.
5.33 When an Emergency Mortuary is situated on Ministry of Defence property the

relevant military Commanding Officer will designate a Liaison Officer to attend the
team’s meetings.
FACILITIES AT THE MORTUARY

5.34 The following facilities should be made available to staff:
changing facilities
lockable storage for clothing and personal property
showers and toilets
water fountains (or other suitable sources of fresh drinking water)
34
rest area
a designated smoking area.
5.35 Operational areas will have heating and air conditioning in place to ensure the
optimum temperature relative to working practices.
CATERING
5.36 Catering arrangements will be put in place at the mortuary for the supply of hot food
for the staff. If this catering is not provided on a 24 hour basis there will be facilities
for staff to store and cook food. If necessary, food lockers should be provided.
5.37 Arrangements will include the provision of an area for staff to safely consume food.
5.38 Under no circumstances will food or drinks be consumed in the wet area of the
disaster mortuary.
OFFICE AND TECHNICAL EQUIPMENT

5.39 The Resources Manager, in liaison with the Mortuary Facilities Manager, will take on
responsibility for arranging the supply and placement of the following:
Electricity
240-volt mains electricity with sufficient 13 amp sockets will be required in all
areas. Portable electric equipment used in the mortuary (such as electric
saws) will be used with power-breaking devices.
An Emergency Power Supply (EPS) will be made available.
It is particularly important that the body storage area and refrigeration for
evidence and specimens is kept at a constant temperature. Consideration
should be given for such facilities to be alarmed in case the temperature
changes to the detriment of effective storage of the deceased/evidence.
Water
Running water will be required at tables / benches used for:
o washing the deceased
o Post Mortems examinations
o organ cutting and examination
o embalming.
Hot and cold running water will be required in other areas of the mortuary:
o toilets
o shower and washing facilities
o catering
o cleaning.
Waste water will either be tanked and removed from the site or discharged
into the local sewerage system as deemed to be appropriate.
35
Telecommunications
o telephone and fax lines will be required
o the use of mobile phones should be discouraged in the mortuary
facility as such systems are not secure and can be monitored by the
media
o due to Health and Safety requirements, mobile phones (whether
switched on or off) will not be permitted within the wet area of the
mortuary.
Surveying & Engineering
o support office accommodation where possible (including structural
advice).
IT equipment
It will be necessary for a computer link to be made between the disaster
mortuary and the HOLMES II Casualty Bureau database. The provision of this
service lies with the Metropolitan Police Service.
Other IT services will be provided by the local authority or police service as is
seen to be appropriate to the surrounding circumstances and needs.
5.40 The Mortuary Resources Manager will also arrange and supply other office
equipment and accommodation services which may be required.
WASTE DISPOSAL
5.41 It is important to maintain tight control of the handling, packaging and disposal of
clinical waste from the wet area of the mortuary. The Mortuary Facilities Manager will
thus appoint a member of the mortuary staff to supervise the disposal of clinical
waste.
5.42 Yellow clinical waste containers will be required from the Local Authority. The request
should be made by the Mortuary Facilities Manager.
5.43 Appropriate ’sharps’ containers will be required for the disposal of needles, syringes
etc.
5.44 Black plastic refuse bags should be used for domestic waste and disposed of
separately and in accordance with existing Local Authority policy.
SECURITY
5.45 The Mortuary Management Team will arrange with the police and the Local Authority
to supply security at the disaster mortuary site. The Local Authority may use private
sector services for certain security tasks such as perimeter patrols. Security
personnel supplied by the Local Authority must be licensed by the Security Industry
Authority (SIA).
5.46 The Mortuary Operations Manager will be in charge of security arrangements. If the
disaster mortuary is on a military site security will be arranged in co-operation with
the Military Liaison Officer.
5.47 Consideration should be given for an Air Exclusion Zone to be arranged over the
disaster mortuary to discourage attempts at filming the facility from the air.
36
SECTION 6 – MORTUARY PROCEDURES
NOTE: The following procedures are presented in a linear sequence so as to aid their
assimilation by the reader. It is important to note, however, that real life events do not
always sustain such a rigid approach. Varying degrees of flexibility may be required,
therefore, in the operational application of the process described below.
ARRIVAL & REGISTRATION

6.1 Deceased victims and human remains may be recovered from places other than the
scene of the incident e.g. hospitals and other mortuaries. All deceased victims,
human remains and residual human tissue should be transferred to a single mortuary
where the process of identification and examination will take place. On arrival at the
mortuary details will be recorded using the Disaster Victim Identification (DVI) forms
or the Victim Profile Forms (VPF) as appropriate (see sections 6.82 to 6.97).
6.2 Great care should be taken to ensure there is no cross contamination of forensic
evidence in the event of the incident resulting in multiple crime scenes. The
methodical recovery of human remains from the disaster site is vital to the mortuary
process.
6.3 In the event of the deceased coming to the mortuary from such multiple sites
(especially the scenes of terrorist activity) it may be appropriate to arrange for their
reception and storage to be aligned to the relevant site i.e. one reception area and
one storage area to be provided at a rate of one per site. In such circumstances all
effort should be made to prevent commingling of the deceased, human remains or
residual human tissue.
6.4 On their arrival body bags must be inspected to ensure that the ACPO Victim Label
Booklet accompanies the body bag and its number corresponds with the attendant
paperwork received from the scene.
6.5 So as not to interfere with the integrity of evidence, it is imperative that no body bags
are opened at this stage unless authorised by the SIO/SIM.
6.6 So as to ensure evidential continuity, the Body Reception Officer (see section 9.35)
must complete and manage all relevant documentation in accordance with policy and
instructions.
6.7 The Body Reception Officer will ensure that personal property (unless enclosed
within the body bag) does not come into the mortuary.
6.8 On their arrival, consideration should be given to examining the deceased by means
of a radiological scan. This will ensure that there are no munitions attached to the
deceased. A visual search for such munitions should have been made, however,
prior to the deceased being removed from the scene.
STORAGE
6.9 Whenever deceased victims or human remains are not undergoing any part of the
mortuary process they must be securely stored in the mortuary’s refrigerated storage
areas for safeguarding.
6.10 In order to prevent commingling and cross-contamination, the deceased victims must
always be stored separately from each other.
37
6.11 Refrigerated storage within the mortuary should be constructed or organised into two
distinct sections: one section for storage of the deceased prior to a post-mortem and
the other for those who have undergone post-mortem procedure. Should the
provision of distinct areas not be possible, the same distinction can be made through
the use of different coloured body bags or distinctive labelling attached to the bag.
6.12 Every effort must be made for deceased victims and/or human remains to be stored
and handled in accordance with all known faith issues (see section 8)
EXTERNAL EXAMINATION & PHOTOGRAPHY (STRIP AND SEARCH)

6.13 As each body bag is opened the deceased and/or human remains should be placed
on a mortuary tray.
6.14 If the contents of a body bag are severely disrupted it maybe necessary for the
remains to be kept in the original body bag throughout the process of examination /
post mortem (see section 6.52 in regard to the re-bagging of the deceased).
6.15 At this stage (before any further work is undertaken) photographs should be taken of
the deceased victim, whilst clothed, to show the front, rear and side profiles. The
unique body identifier number should be clearly visible in all photographs. A digital
photograph should also be taken and attached to the Body File.
6.16 All jewellery, wallets, documents, etc. should then be removed from the deceased
and the details recorded on the Disaster Victim Identification (DVI) form or the Victim
Profile Forms (VPF) as appropriate (see sections 6.82 to 6.97).
6.17 Close attention should be paid to obtaining detailed descriptions of jewellery or other
body adornments (particularly if engraved with an inscription or jewellers mark) as
such details can greatly assist in the identification of the deceased.
6.18 All jewellery and other property ascribed to the deceased should be photographed
and passed to the Post Mortem Team Exhibits Officer who will place the items into a
property bag bearing the body number. The Team Exhibits Officer will complete a
property label in respect of each item of property recovered.
6.19 Each item of such property will be given an exhibit number in accordance with the
following configuration:
Eight (8) figure Body Number / Post Mortem Team Exhibit Officer’s initials /
sequential number, e.g.
60012345 / KG / 123
6.20 In addition the Post Mortem Team Exhibits Officer will make an entry describing the
property in an Exhibits Register. There will be at least one Exhibit Register per body
bag (i.e. an Exhibit Register must not be used for more than one body bag).
6.21 The Post Mortem Team Exhibits Officer will ensure that a self-adhesive
identification/barcode sticker from the victim recovery documentation is affixed to
every completed property label.
6.22 An additional digitally produced photo must be taken of each item of property and
attached to the outside of the sealed property bag so as to save any future need to
open and re-seal the bag in order to check it’s contents.
38
6.23 If any item of property is damaged or contaminated/bloodstained brief details will be

shown on the property label. If the item is wet or damp it may not be appropriate for it
to be sealed in a plastic property bag. The Post Mortem Team Exhibits Officer will be
responsible for deciding the correct way of sealing and storing such items.
6.24 The deceased victim should be stripped of all clothing and their details (size, colour,
make etc.) recorded on the Disaster Victim Identification (DVI) or Victim Profile Form
(VPF) as appropriate.
6.25 The clothing and personal effects should be placed into appropriate packaging,
labelled with the unique body reference number and sealed.
6.26 The clothing may be stored within the mortuary until the contents are returned to
family or destroyed. Clothing should be photographed before final disposal in this
way.
6.27 The Post Mortem Team Exhibits Officer will formally hand over all items recovered
during examination and post-mortem (along with the relevant Exhibits Register) to
the Mortuary Exhibits Officer who will then be responsible for their appropriate
storage.
SWABBING, CLEANING AND THE PHOTOGRAPHING THE BODY

6.28 All deceased victims will always need to be washed. It is imperative, however, that
before this is done, due consideration should be given to the taking of external body
samples/swabs etc. Such swabs and samples will be of particular concern in the
case of terrorist offences. The SIO or SIM will advise as to whether such swabs are
necessary.
6.29 A purpose of washing the deceased is to expose any distinguishing marks or scars
on the body. After washing, therefore, a physical description of such marks and scars
will be recorded on the Disaster Victim Identification (DVI) or Victim Profile Form
(VPF) as appropriate.
6.30 Once the deceased has been washed, the appropriate documentation should be
completed and the deceased should again be photographed showing his/her front
and back. Each photograph must clearly show the relevant body number so as to
assist with evidential audit trails.
RADIOGRAPHY
6.31 Additional fluoroscopy or radiography of identifying features may be required as
determined by the Supervising Forensic Pathologist, Odontologist or Anthropologist.
The Association of Forensic Radiographers will be able to facilitate the supply of
qualified staff for radiography, either directly or via the UKDVI forensic staff
arrangements maintained as part of the National Emergency Mortuary Arrangements
(NEMA).
6.32 Traditional radiography is both time-consuming and cumbersome in terms of

photographic development. The process requires the presence of dangerous
chemicals and component elements on the site of the mortuary. In order to save the
need to address the numerous Health and Safety issues brought about by the
presence of such materials, digital radiography will be used in the post mortem
process.
39
6.33 In addition, digital radiography offers benefits in the time savings relative to image
development and enhancement (instant) as well as being far easier to disseminate
for investigative consultation. Digital (electronic storage media) images can be
communicated by email and thus, if so required, be despatched to any destination
throughout the world in a matter of seconds. The same distribution of traditional
radiography products could take days. This time-saving feature of digital radiography
has the potential to afford significant benefits to the speed of any pertinent forensic
investigation.
6.34 Radiography should be used to establish physical features not visible to the naked
eye such as medical plates, physical irregularities, healed fractures and unique bone
structure. All such discoverable features have the potential to assist with the
identification process.
6.35 Radiography can protect mortuary staff by exposing dangerous items concealed
within the deceased (munitions, shrapnel etc.).
6.36 If, during radiography, items are discovered within a deceased victim or human
remains which may be considered to be evidence (e.g. munitions or shrapnel) this
information should be documented and the Supervising Forensic Pathologist and
Mortuary Documentation Officer informed.
ORAL RADIOGRAPHY
6.37 Digital dental radiography will be performed as part of the odontological examination.
Provision should be made for the use of relevant oral radiography equipment in the
design of the mortuary (see Odontology section at paragraph 6.49)
FINGERPRINTS
6.38 Fingerprints (fingers, hands, toes and feet) should be taken and processed according
to policy and instruction. Details of any missing fingers and toes should be
documented on the Disaster Victim Identification (DVI) or Victim Profile form (VPF)
as appropriate.
6.39 The deceased should not be disfigured or mutilated in any way in order to obtain
fingerprints (see section 1.25).
DEOXYRIBONUCLEIC ACID (DNA)

6.40 It is for the Senior Identification Manager and Coroner to liaise with the forensic
science service provider to agree an appropriate strategy for the collection, profiling
and matching of ante-mortem and post-mortem samples for DNA analysis.
6.41 The overarching aim will be to ensure that, where appropriate, deceased victims and
human remains are identified and re-united using the most suitable and effective
scientific methods available. The process must be undertaken in a way that is legal,
proportionate, accountable and necessary whilst ensuring integrity and continuity
throughout.
6.42 It may be considered appropriate to establish scientific facilities at the mortuary for
the purpose of examining DNA.
6.43 It is for the Senior Identification Manager to consider arrangements for the forensic
scientific service provider to appoint a Liaison Officer within the mortuary.
40
TAKING OF SAMPLES AND REMOVAL OF HUMAN REMAINS 5

6.44 The methods used for establishing the identity of the deceased should, wherever
possible, avoid any unnecessary invasive procedures or disfigurement or mutilation.
Body parts will not be removed for the purposes of identification except where it is
necessary to do so.
6.45 All requests for specific forensic procedures regarding the deceased or human
remains (including the taking of samples, organs, limbs etc) must be made to the
Coroner.
6.46 Should the Coroner give authority regarding the taking of samples or human remains,
such authority will be in writing with copies retained by the Coroner and SIM as
appropriate.
FLUOROSCOPY
6.47 Fluoroscopy is an imaging technique commonly used to obtain real-time images of
the internal structures of the deceased victim through the use of a fluoroscope. In its
simplest form, a fluoroscope consists of an x-ray source and fluorescent screen
between which a patient is placed. However, modern fluoroscopes couple the screen
to an x-ray image intensifier and CCD video camera allowing the images to be played
and recorded on a monitor for immediate review.
6.48 In the context of the mortuary process, fluoroscopy is especially useful for identifying
the presence of foreign matter within the deceased or human remains and identifying
any threats to staff safety in real-time. In addition, the use of fluoroscopy allows for
instantaneous identification of matter which may be considered to be evidence. This
process might be of particular use following cases of terrorist activity.
ODONTOLOGY
6.49 When required, an Odontologist will undertake the charting of teeth. To aid
identification, comparison of the radiography data may be made with the deceased’s
dental records which are obtainable from domestic dentist with the assistance of the
relevant Family Liaison Officer.
6.50 Authority must be requested from the Coroner prior to the commencement of any
invasive procedures which may be required to obtain dental identification data (see
section 6.37 above)
ANTHROPOLOGY
6.51 Digital radiography examination in conjunction with anthropology will negate the
requirement for invasive procedures in many circumstances. The precise protocol to
be followed will be determined by the Coroner in conjunction with the Supervising
Forensic Pathologist, Senior Anthropologist and Senior Radiographer.
5
See “The Public Inquiry into the identification of Victims following Major Transport Accident” (The Report of Lord Justice
CLARKE). See also the Human Tissue Act 2004.
41
RE-BAGGING
6.52 After the identification examination process the human remains will be stored in a
fresh body bag. The original body bag should be retained, carefully sealed,
packaged, recorded and processed as an exhibit. As such, it should be formally
taken into the possession of the Post Mortem Team Exhibits Officer before being
passed to the Mortuary Exhibits Officer.
6.53 This is because the original bag will be soiled and contaminated but may be of
significant evidential value. The use of colour coded bags at this stage may assist
with a system of effective storage of the deceased.
6.54 It is a role of the Body Storage Officers to assist in re-bagging the deceased and
human remains.
EMBALMING
6.55 Embalming will not be permitted until written authority is received from the family of
the victim or their representative. Only when authorised to do so by the Coroner (on
receipt of the family mandate introduced above) may third party, private sector
representatives embalm and encoffin the deceased.
6.56 If possible, embalming should only be carried out in accordance with religious and
cultural considerations (see section 8).
6.57 Embalming may be required if a deceased victim is to be repatriated abroad.
RELEASE OF DECEASED VICTIMS TO RELATIVES

6.58 When the Coroner is satisfied that a deceased victim can be released to the next-of-
kin he/she will authorise the release and complete the appropriate documentation.
6.59 In the event that the deceased are not intact, arrangements will be made in
accordance with the wishes of each family which will be ascertained via the relevant
Family Liaison Officer (see section 9.4).
6.60 Burial or Cremation Orders are obtained from the Coroner on completion of the
Inquest (see section 4.19).
UNCLAIMED DECEASED VICTIMS

6.61 The Coroner will decide the procedures in relation to the deceased that are
unclaimed. A deceased victim may go unclaimed if a next of kin cannot be found or in
circumstances where a next of kin is, in fact, identified but does not wish to claim the
deceased.
6.62 If a deceased victim is unclaimed the Local Authority will arrange for burial or
cremation in accordance with their statutory obligation imposed by the Public Health
(Control of Diseases) Act, 1984. Any such disposal will be in accordance with any
identified faith requirements.
6.63 In circumstances where a next of kin is identified but does not wish to claim the
deceased, he or she must still be advised of the time, date and location of any burial
or cremation.
42
DECEASED VICTIMS TO BE REPATRIATED ABROAD

6.64 When a deceased victim is to be repatriated abroad the Coroner will be required to
sign an ‘Out of England’ form (Form 103). This form must bear the National Body
Identification Number (see below).
NATIONAL BODY IDENTIFICATION NUMBER

6.65 The National Body Identification Number a unique eight (8) digit identification number
which is issued by the National DNA Database. Each number is allocated against a
single form within the stocks held by police across the nation.
6.66 This Unique Reference Number (URN) is generally presented as eight (8) digits
which are representative of the far larger number issued by DNA Database. The
longer number is encoded in an associated bar-code displayed on the ACPO Victim
Recovery Labels in use today.
6.67 The ACPO Victim Label (see Appendix E) includes a number of self-adhesive Unique
Reference Numbers which are required to be fixed to every document created in
relation to the deceased victim or human remains. Copies of the self-adhesive label
must also be affixed to the container or packaging for every item of personal property
and samples taken from all deceased victims or human remains.
PROPERTY
6.68 Property at the mortuary will be either:
personal property of the deceased attached to them; or
evidence.
DISPOSAL OF PERSONAL PROPERTY

6.69 Careful consideration should be given to making a decision to clean property without
first consulting family members through the Family Liaison Co-ordinator. Certain
faiths require that all parts of a deceased victim are buried or cremated and this may
include bloodstained clothing. Details of family requirements in respect of property
are included on the VPF14 form.
6.70 In addition to ascertaining the wishes of families, the SIM/SIO should also seek
advice in relation to any Health and Safety implications in returning unclean items to
relatives.
6.71 A photograph of each item should be retained before it is returned.
EVIDENCE
6.72 Evidence will be:
items recovered following a terrorist incident
items required for other evidential purposes
medical evidence.
43
EVIDENCE OF TERRORIST INCIDENTS

6.73 Following a terrorist incident it may be decided that any device or item will need to be
re-constituted to provide evidence. Examples include:
a bomb or other explosive device
a vehicle used for a vehicle borne explosive device (car-bomb)
a vehicle involved in the incident (the fuselage of an aircraft).
6.74 Fragments of such items maybe recovered at the mortuary and be discovered during
radiography or during “Strip and Search” prior to post mortem.
6.75 In terrorist incidents, trained Exhibits Officers from the Metropolitan Police Service
Counter Terrorism Command (SO15) will be attached to the mortuary.
6.76 The Metropolitan Police Service Counter Terrorism Command (SO15) will be
responsible for the safekeeping of all exhibits recovered following a terrorist incident.
EVIDENCE (Non-Medical)
6.77 Items identified as evidence will be labelled and stored in accordance with the
instructions shown at sections 6.13 to 6.27.
6.78 Advice should be sought from the Senior Investigating Officer before any items of
evidence are cleaned.
MEDICAL EVIDENCE
6.79 Medical evidence such as samples should be refrigerated or frozen depending on the
nature if the item. The Main Exhibits Officer will seek advice on the methods of
storage from the scientific service provider.
STORAGE OF EVIDENCE
6.80 All evidence should be securely stored. Access to stored evidence should be
controlled. It is the duty of the Mortuary Operations Manager assisted by the
Mortuary Duty Officer to ensure the security of evidence.
6.81 It may be necessary for soiled items to be refrigerated. The Mortuary Exhibits Officer
will, however, seek advice on the methods of storage from the engaged scientific
service provider.
DECEASED VICTIM DOCUMENTATION: ACPO VICTIM LABEL BOOKLET

(see Appendix E)
6.82 The ACPO Victim Label Booklet was introduced across the UK in 2004. Its purpose
is to ensure a comprehensive and robust system of continuity and record
maintenance. It is relevant to the recovery, movement, examination and identification
of deceased victims and human remains together with associated property. The
content has been designed to be ‘user friendly’ and in a booklet format acceptable to
the identification, investigative and judicial processes.
6.83 The booklet incorporates the capability to utilise, if required, the national bar coding
system whereby each booklet, and therefore each victim or human remains has a
unique national reference number (with the series dedicated only to disaster victim
identification). A number of detachable and self-adhesive labels printed within the
booklet will be attached, as appropriate, to the deceased victim, the bag containing
44
the victim or human remains and all other related articles that require individual but
linked identification and continuity. This includes any samples taken from the victim
or human remains (see sections 6.17 to 6.24 above).
6.84 The booklet also makes provision for the inclusion of sketches and photographs to
assist the continuity and identification process.
6.85 The booklet and its contents have been approved nationally through ACPO
Emergency Procedures Committee.
DECEASED VICTIM DOCUMENTATION: INTERPOL DISASTER VICTIM

IDENTIFICATION BOOKLET (See Appendix G)
6.86 The police forces of Interpol Member States are committed to utilising the Interpol
DVI Booklet as a means of obtaining information relating to the identity of disaster
victims when making enquiries abroad. The booklet is split into two halves: yellow
Ante-Mortem Forms and pink Post-Mortem Forms. It also contains a template for a
comparison report.
6.87 The completion of Ante-Mortem Forms was previously the responsibility of the police
Ante-Mortem Team. In most cases this responsibility is now more likely to fall to the
police Family Liaison Officers.
6.88 The pink Post-Mortem Forms will be completed in respect of victim recovery,
identification etc. It will be completed by personnel from the police Mortuary
Documentation Team.
DECEASED VICTIM DOCUMENTATION: VICTIM PROFILE CHECK LIST

6.89 The Victim Profile Check List was introduced to provide a more user friendly, efficient
and comprehensive method of recording information in respect of deceased victims
and human remains.
6.90 The check list accommodates the processes used in respect of deceased victims and
human remains within the mortuary. The content reflects experience of the victim
identification process gained within the UK and abroad in recent years. The booklet is
designed to replace the pink Post Mortem section of the Interpol DVI Booklet. The
checklist highlights fields comparable to the Interpol DVI booklet with the
corresponding field number being coloured red.
DECEASED VICTIM DOCUMENTATION: OVERVIEW OF USE

6.91 The particular Victim Label Booklet which is completed at the scene of the incident
from where the deceased victim or human remains are recovered initiates the
recording of the Disaster Victim Identification process. Those personnel involved in
the scene management and victim recovery process complete the relevant sections
of the document as part of the associated evidential audit trail.
6.92 The Victim Label Booklet containing the remaining sections travels with the deceased
victim or human remains via the ‘Body Holding Area’ or ‘Holding Audit Area’ (if
appropriate), to the mortuary. The relevant documentation teams at the mortuary will
then complete the remaining sections of the booklet as appropriate alongside
associated documentation e.g. the Victim Profile Check List, the Interpol DVI Booklet,
Major Incident Room Property Registers etc.
45
6.93 All deceased victims and human remains (recovered separately) will be the subject of
individual documentary records (as alluded to above). The document type (UK Victim
Profile Check List v. Interpol Disaster Victim Identification Booklet) will be dictated by
policy relative to each incident. It is important that adequate stockpiles of booklets
are maintained together with there being a system in place to obtain further copies if
necessary.
6.94 Consideration should be given to the dissemination of information contained within

the completed booklets to those other areas involved in any related process i.e.
Casualty Bureau, Exhibit/Property Officers, Family Liaison and the Incident Room.
DECEASED VICTIM DOCUMENTATION: OPTIONS

6.95 The form templates within the Interpol Booklet are incompatible with administrative
processes maintained internationally and as a result, the use of the UK Victim Profile
Check List as a replacement has not been accepted. Therefore, within the UK, the
potential number of enquiries abroad relating to victim identification will be a
contributing factor as to whether the UK Victim Profile Check List or the Interpol
Booklet is the most appropriate documentation to use.
6.96 The Senior Identification Manager will make a policy decision as to which forms are
used. If, however, details of the victim need to be sent overseas it may be
appropriate to merely to copy across information from the UK Victim Profile Check
List onto an Interpol DVI Form.
6.97 Copies of both Interpol DVI and Victim Profile forms are shown in Appendices G and
F.
EVIDENTIAL DISCLOSURE
6.98 All documentation created within the mortuary maybe subject to disclosure 6 . The
police Disclosure Officer will be attached to the Major Incident Room (MIR). He/she
must be advised of all documentation that is created in relation to the incident.
6.99 Consideration should be given for key members of staff to be issued with a hardback
book in which to write notes including decisions / rationale etc. These books can then
be submitted to the Disclosure Officer on completion of the operation.
6.100 The Mortuary Documentation Officer will liaise with the police Disclosure Officer
regarding documentation and other disclosable data created within the mortuary.
CONFIDENTIALITY CONSIDERATIONS
6.101 Care should be taken to shred copies of personal or sensitive documentation that are
no longer required, particularly items which may identify the deceased. 7
6.102 The Police will ensure that appropriate police documentation is available at the
mortuary.
6.103 No person will take any photographic image by any means within the mortuary other
than an official photographer authorised by the police.
6
Criminal Procedure and Investigation Act 1996
7
Data Protection Act 1998
46
NON-FAMILY VISITS TO THE MORTUARY

6.104 Requests may be received from parties wishing to view the mortuary. The Mortuary
Management Team will grant or deny such with this decision being made against the
backdrop of their affect on the operational efficiency of the mortuary and the
processes therein.
6.105 A log of all visitors will be maintained by the Mortuary Facilities Manager.
6.106 All visits will need to comply with Health and Safety and risk management advice and
guidance.
6.107 Visitors will not be permitted to take photographs or other recordings whilst in the
mortuary complex.
47
SECTION 7 – FAMILY VIEWING

FAMILY VIEWING AREA
7.1 Viewing of the deceased traditionally takes place once the deceased has been
released to the bereaved. The viewing then takes place at a location chosen by the
bereaved and provided by their agent. In extreme circumstances, however, viewing
may take place at the mortuary. Should this unusual circumstance become the case,
viewing facilities should be made available as soon as practicable. They should be
provided in an area which has been specially prepared and, wherever possible, takes
into account religious or cultural needs. At the behest of the family, viewings may be
arranged via their chosen funeral director at a location other than the disaster
mortuary.
7.2 Those families that chose to view their loved ones at the mortuary will gather, with
their Family Liaison Officers (FLOs), to be briefed about the procedure when they
arrive at the mortuary’s Family Viewing Area.
7.3 As soon as the viewing party is ready to drive to the mortuary a telephone call will be
made to the Family Viewing Area Supervisor and the security staff at the mortuary
site entrance to warn them of their impending arrival.
7.4 They will travel, with their FLO, in unmarked mini-buses with darkened windows (to
prevent media intrusion) to and from the mortuary.
7.5 It is important that their every effort is made to enable their passage through the
mortuary security is as speedily as possible.
7.6 The viewing party will be met by appropriate personnel and welcomed into the outer
reception room, shown to the seats provided and offered refreshments.
ENVIRONMENTAL CONDITIONS OF THE FAMILY VIEWING AREA

7.7 The décor within the viewing area should be simple and peaceful. Cream and blue
are considered to be the most appropriate colours with small arrangements of green
shrubs.
7.8 Flowers – cream roses, with labels attached to enable family members to write
messages, should be available within the viewing area. These could be left with their
loved ones, left in the memorial garden, or taken away with them.
7.9 A Memorial Garden sited near to the viewing area gives family members a quiet
place for contemplation and opportunity to compose themselves before leaving the
mortuary. The choice of colours of flowers within this area could be contentious to
some faith groups but foliage plants with hues of blues and mauves appropriate.
RELIGIOUS AND CULTURAL NEEDS SPECIFIC TO THE VIEWING PROCESS

(also see Section 8)
7.10 The following is a brief guide to the major religions and church denominations which
may be encountered and their particular requirements. It is important to note that it is
preferable for there to be no religious symbols in the viewing area at all rather than
risk offence to any group.
48
Christian: High Anglican, Roman Catholic, Orthodox may require a crucifix (cross
with the figure of Jesus on it)
Free Churches (includes Baptist, Methodist, United reformed, Evangelical and The
Salvation Army may require a Plain Cross to be present in the viewing area.
Jewish: There should be no symbols unless there is a request for the Star of David
to be placed in the viewing area. A two handled cup should be available for use in
the ritual hand washing process.
Muslim: There should be no symbols
Hindu: There should be no symbols unless there is a request for ‘Om’ the painted
blue and gold disc symbols to be placed in the viewing area.
Buddhist: There should be no symbols; however, it is customary for the family to

bring incense, fruit, and rice and candles to leave with the deceased.
Sikh: There should be no symbols unless there is a request for the Sikh symbol
‘KHANDA’ to be placed in the viewing area.
7.11 Religious and cultural needs will be addressed with the assistance of The Salvation
Army personnel present within the viewing area. While consideration should be given
to the concerns of those individuals and communities for whom post mortem
investigations are unwelcome and where there is a requirement for prompt burial,
their needs should not be met at the expense of others who are grieving in equal
proportion.
7.12 Viewings are usually restricted to the face, head and hands of the deceased. It
should, however, be noted that in some cultures it is acceptable for a close relative to
view the whole body of the deceased.
7.13 The Family Viewing Area Supervisor will communicate (prior to the visit to the
viewing area) the family wishes for religious and cultural support to The Salvation
Army Co-ordinator who will arrange for the appropriate faith leader to be present and
ensure that any requests for religious symbols are present.
7.14 The Salvation Army personnel present (who will be ordained ministers) will provide
pastoral support to those family members who have not made prior arrangements for
a particular faith leader to be present but who, when they arrive to view their loved
one, feel it appropriate to be supported in this way.
RITUAL HAND WASHING

7.15 Ritual hand washing is as much a cultural need as a religious requirement, it is
important that the ritual hand washing equipment is available for every viewing to
ensure that all those who wish to participate are not overlooked.
7.16 The equipment needed is a clear glass bowl with unopened litre bottles of water and
new hand towels. It is preferable for the bowl to be empty so that their particular
requirements can be observed.
7.17 The Jewish faith use a two handled cup and will facilitate the hand washing process
themselves.
49
ADDITIONAL REQUIREMENTS
7.18 It may be possible that family members may request for music to be placed while
they attend the viewing area and it would be prudent to ensure that a CD player is
available should this be requested
7.19 Family members may request locks of hair from the body of their loved one. This
could be arranged with prior notification when the mortuary technician can prepare
for this in advance. Small clear plastic exhibit containers are ideal for this purpose.
Alternatively, some family members may wish to cut the locks of hair themselves.
Again, the containers should be made available together with scissors.
MEDICAL AID
7.20 London Ambulance Service will provide a paramedic to the Family Viewing Area
during the period when families are visiting the area to ensure that, should a medical
emergency arise, there is a trained professional available to provide the highest level
of care.
END NOTE
7.21 It is important to note that, in responding to an incident of the type covered by this
plan, every effort will be made by the responders to comply with each and every
religious and/or cultural requirement. Disasters are, however, extraordinary events
and, as such, which may require the responding agencies to carefully consider the
needs of religions against the practical demands of the operation.
50
SECTION 8 – RELIGIOUS AND CULTURAL ISSUES
BUDDHIST
8.1 After death, the body of the deceased may be handled by non-Buddhists. In some
cases a monk may perform some additional chanting, but this is not a universal
practice. There are no objections to post-mortems.
8.2 Preparation of the body for the funeral is generally left to the undertaker, but in some
instances relatives may also wish to be involved. The deceased may be put in a
coffin, or wrapped in cloth (sometimes white), or dressed in the deceased’s own
clothes. The deceased may be surrounded by candles, flowers, incense,
photographs and coloured lights, but this is a matter of individual choice and there
are no hard-and-fast rules. The deceased is usually cremated, at a time dependent
upon the undertaker and the availability of the crematorium’s facilities.
CHINESE (CONFUCIANISM, TAOISM, ASTROLOGY, CHRISTIANITY)

8.3 After death, undertakers handle the deceased. Some undertakers in areas with long
established Chinese populations are accustomed to Chinese needs such as
embalming and the deceased being fully dressed in best clothes including shoes and
jewellery. In such areas some cemeteries have a Chinese section.
8.4 Burial or cremation may take place a week after the person has died. If the deceased
is a child, parents usually do not want to visit the mortuary. A sibling or close relative
would be asked to deal with any viewing of the deceased.
CHRISTIANS
8.5 The choice between cremation and burial can either be a matter of personal choice
or a denominational requirement. In all cases, the wishes of the deceased’s family, or
friends, should be sought if possible. If this cannot be done, then Christians should
be buried.
CHRISTIAN SCIENTISTS
8.6 Questions relating to care of the body should be answered by the individual’s partner/
family. In general, Christian Scientists request that, whenever possible, the body of a
female should be prepared for burial by a female. The individual’s family should
answer questions relating to post mortem examinations.
CHURCH OF JESUS CHRIST OF LATTER-DAY SAINTS (MORMONS)

8.7 The Church takes no position on post mortem examinations. Church or family
members will usually arrange for the deceased to be clothed for burial.
8.8 Burial rather than cremation is recommended by the Church, but the final decision is
left for the family of the deceased.
HINDUS
8.9 It is preferred if all Hindu bodies can be kept together after death. A deceased Hindu
should be placed with the head facing north and the feet south.
8.10 Cleanliness is important and the body can be undressed and cleaned, but the family
should be consulted where possible. The arms should be placed to the sides and the
legs should be straightened. The face should be pointed upward with eyes closed
and the whole body must be covered with white cloth. Any detached body parts must
51
be treated with respect as if they were a complete body. Post mortems are permitted,
usually with prior agreement of the immediate family.
8.11 When a person dies their body is washed, dressed in new clothes and flowers are
placed around it.
8.12 The bereavement in the family lasts a minimum of two weeks during which several
rituals are followed. Hindus believe in cremating the body so that the soul is
completely free of any attachment to the past physical matter.
HUMANIST
8.13 No specific requirements. The choice between cremation and burial is a personal
one, although cremation is more common. Most will want a humanist funeral, and
crosses and other religious emblems should be avoided. However, since many
humanists believe that when someone dies the needs of the bereaved are more
important than their own beliefs, some may wish decisions about their funeral and
related matters to be left to their closest relatives.
JAIN
8.14 There are no specific rituals in Jain philosophy for this event. Bodies are always
cremated and never buried except for infants. Cremation must be performed as soon
as practicable, even within hours if possible, without any pomp. Many Jains still
pursue Hindu customs as a family preference. All normal practises of UK undertakers
are acceptable if handled with respect. The family normally provide the dress and
accessories for the preparation and final placement in the coffin.
JEHOVAH WITNESS
8.15 If a post mortem is required by law, the wishes of an appropriate relative should be
ascertained and, if possible, their wishes observed. The dead may be buried or
cremated, depending on personal or family preferences and local circumstances.
JEWS
8.16 The prompt and accurate identification of the dead is particularly important for the
position of a widow in Jewish law. Post mortems are forbidden unless ordered by the
civil authorities. Body parts must be treated with respect and remain with the corpse
if possible. When a person dies, eyes should be closed and the jaws tied; fingers
should be straight. The body is washed and wrapped in a plain white sheet, and
placed with the feet towards the doorway. If possible it should not be left unattended.
For men a prayer shawl, tallit, is placed around the body and the fringes on the four
corners cut off.
8.17 The Chevra Kadisha (Holy Brotherhood) should be notified immediately after death.
They will arrange the funeral, if possible before sunset on the day of death, but will
not move the body on the Sabbath. Coffins are plain and wooden (without a Christian
cross). Someone remains with the body constantly until the funeral. It is not usual to
have floral tributes. Orthodox Jews require burial but Reform and Liberal Jews permit
cremation.
8.18 The burial should take place as quickly as possible after death. The body should not
be left alone as this is thought to be disrespectful. The body will be washed
thoroughly, male bodies by men and female bodies by women. It is then placed in a
simple unpolished box with no handles and padding. This is to symbolise that in
death all are equal, despite personal wealth.
52
MUSLIM
8.19 As a Chaplain, in a death situation you should NEVER touch the body, whether male
or female. The safest guideline is also to never touch a family member. The best
advice for viewing the deceased after death would be to escort the family in and then
stand off to the side, out of the line of sight. You are there to help if needed, not
pretend to be part of the family. Try to identify who is the effective leader within the
family. That person should be the one approached with practical details, rather than
presuming that it would be the next of kin
8.20 Muslim dead should be placed in Holding Audit Areas or temporary mortuaries, and
ideally be kept together in a designated area (with male and female bodies
separated). Post mortems are acceptable only where necessary for the issue of a
death certificate or if required by the coroner.
8.21 Ideally only male Muslims should handle a male body and female Muslims a female
body. The body should be laid on a clean surface and covered with a plain cloth,
three pieces for a man and five for a woman. The head should be turned on the right
shoulder and the face positioned towards Makkah.
8.22 As soon as possible after death the body is given a ritual washing called Ghusl. This
is to wash away all sin so the body can meet Allah in a pure state. The deceased is
anointed with perfumes and spices and wrapped in white cloth, usually the Ihram
clothes used for the Hajj. This ritual is the same for rich and poor, in death, Muslims
believe all are equal.
8.23 Muslims try to bury the deceased within 24 hours of death if possible. They believe
that the soul departs at the moment of death. The deceased is placed with their head
facing the Muslim holy city of Makkah.
8.24 Ritual washing is performed usually by family members or close friends, usually
according to the sex of the deceased. The body is wrapped in a shroud of usually
simple, white material. Afterwards, salat (prayers) will be said for the deceased.
8.25 Next of Kin or the local Muslim community will make arrangements to prepare the
body for burial. Muslims believe in burying their dead and would never cremate a
body. Burial takes place quickly, preferably within 24 hours.
SIKH
8.26 The five Ks (5 Ks are five physical symbols worn by Sikhs i.e. underwear ‘kachha;
wristband ‘kara’; sword ‘kirpan’ unshorn hair ‘kes’ and comb ‘kanga’) should be left
on the dead body, which should, if possible, be cleaned and clothed, in clean
garments before being placed in a coffin or on a bier. According to Sikh etiquette,
comforting a member of the opposite sex by physical contact should be avoided,
unless those involved are closely related. Deliberate expressions of grief or mourning
by bereaved relatives are discouraged, though the bereaved will want to seek
comfort from the Sikh scriptures. The dead person should always be cremated, with
a close relative lighting the funeral pyre or activating the machinery. This may be
carried out at any convenient time. The ashes of the deceased may be disposed of
through immersion in flowing water or dispersal.
53
END NOTE
8.27 It is important to note that, in responding to an incident of the type covered by this
plan, every effort will be made by the responders to comply with each and every
religious and/or cultural requirement. Disasters are, however, extraordinary events
and, as such, which may require the responding agencies to carefully consider the
needs of religions against the practical demands of the operation.
54
SECTION 9 – ROLES AND RESPONSIBILITIES OF ORGANSIATIONS
GOVERNMENTAL STAFF:
The London Resilience Team (LRT)
9.1 The London Resilience Team (LRT) will become part of the Government Liaison
Team (GLT) which acts as the liaison point between the Strategic Co-ordinating
Group (SCG) and HM Government. In addition, the team may act in support of the
both the Mass Fatality Co-ordination Group and the Mortuary Management Team.
9.2 The Mass Fatality section of the London Resilience Team is responsible for
production and update of the London Mass Fatality Plan.
THE LOCAL AUTHORITY:

Administration Assistant(s)
9.3 Assists other mortuary staff through the provision of administrative support including
the taking of minutes at all mortuary meetings (may also be provided by the police).
MORTUARY STAFF:
The Coroner’s Officer
9.4 The Coroner’s Officer works in support of the Coroner. With appropriate authorisation
from the Coroner, the Coroner’s Officer may represent the Coroner in his/her
absence.
9.5 He/she will support the Coroner in all their functions and, in particular, may
document:
the extent of the examination of the deceased
the taking of specimens or samples for analysis and examination
the retention of material for further examination
the release of deceased victims and human remains to the family (including
secondary remains)
the disposal of deceased victims and human remains (where there are no
family or none are known to have an interest).
9.6 The Coroner’s Officer is an acknowledged expert in dealing with procedures following
death. Their assistance and advice will be invaluable following an incident which
results in mass fatality.
9.7 If circumstances warrant it, a ‘Senior Coroner’s Officer’ maybe appointed to

supervise and oversee a team of Coroner’s Officers.
55
MORTUARY PROFESSIONS:
Anatomical Pathology Technologists
9.8 The technologist will be a professional who will be responsible to the Supervising
Forensic Pathologist and who will assist the pathologist with the Post Mortem
process.
9.9 In the Autopsy Suite, the technician assists the pathologist, whose role it is to
examine the deceased to discover the cause of death. The technician helps the
pathologist to examine the deceased and to take samples of tissue for analysis.
9.10 After the examination it is the technician’s job (on the authority of the Coroner) to
acceptably reconstitute the deceased and to store the tissue specimens until they are
analysed. The technician is also responsible for maintaining the equipment and
instruments used.
9.11 Technicians must be able to recognise safety hazards, particularly the risk of
infection from those who have died of viral diseases.
Forensic Anthropologist
9.12 Forensic anthropology is the examination of skeletal remains. This examination can
be used to first determine if the remains are in fact human. Then the forensic
anthropologist can determine the gender, approximate age, physical stature, and
likely racial affiliation of the person in life. The examination can also yield
approximate time since death, likely cause of death and any identifying illnesses or
wounds suffered in life that could leave traces in the bone structure. This information
can then be used to help identify the remains.
9.13 The Forensic Anthropologist may be required to assist the Senior Identification
Manager in providing primary identification evidence through dental examination of
the deceased.
9.14 The Forensic Anthropologist is appointed by the Coroner.
9.15 The Forensic Anthropologist may need an assistant.
Forensic Anthropologists Assistant

9.16 The Forensic Anthropologists Assistant is responsible to the Mortuary Documentation
Officer.
9.17 The Forensic Anthropologists Assistant records all matters - as directed by the
anthropologist - on the approved post mortem documentation and passes the same
into the formal possession of the Mortuary Documentation Officer.
Forensic Archaeologist
9.18 Forensic Archaeology is the application of archaeological methods to forensic (crime
scene) work.
9.19 The Forensic Archaeologist combines knowledge of osteology (a branch of anatomy

dealing with bones) and human remains with archaeological techniques to help
recover finds and provide vital evidence for the investigative team.
9.20 With an osteology background, the Forensic Archaeologist can provide field guidance
on the age, sex, and other physical characteristics of human remains.
56
Forensic Archaeologists Assistant

9.21 The Forensic Archaeologist’s Assistant is responsible to the Mortuary Documentation
Officer.
9.22 The Forensic Archaeologist’s Assistant records all matters - as directed by the
archaeologist - on the approved post mortem documentation and passes the same
into the formal possession of the Mortuary Documentation Officer.
Forensic Odontologist
9.23 Forensic Odontology (dentistry) is that aspect of dental science, which interacts with
the legal justice system. It covers a wide range of activities. Primary among these are
the identification of unidentifiable human remains, mass disaster preparedness, and
being an effective expert witness, both in the criminal, as well as civil trials.
9.24 The Forensic Odontologist is appointed by the Coroner. He/she may be required to
assist the Senior Identification Manager (SIM) in providing primary identification
evidence through dental examination of the deceased.
9.25 A Forensic Odontologist is likely to need an assistant.
Forensic Odontologists Assistant

9.26 The Odontologists Assistant is responsible to the Mortuary Documentation Officer.
9.27 The Odontologists Assistant records all matters - as directed by the Odontologist - on
the approved post mortem documentation and passes the same into the formal
possession of the Mortuary Documentation Officer.
Forensic Radiographer
9.28 Radiography will be deployed in the mortuary as part of the Disaster Victim
Identification (DVI) and investigative process. It will be used as requested in support
of Forensic Pathology, Anthropology and Odontology (described above).
9.29 The Forensic Radiographer is a qualified UK State registered diagnostic radiographer

who has received additional training in forensic and emergency mortuary procedures
accredited by the Association of Forensic Radiographers and College of
Radiographers. The Forensic Radiographer will work under the direction of the
Supervising Forensic Pathologist.
9.30 The Forensic Radiographer will be provided by the Association of Forensic

Radiographers upon the request of the Coroner, Supervising Pathologist or via
UKDVI arrangements.
THE POLICE
Administration Assistant(s)
9.31 Assists other mortuary staff through the provision of administrative support including
the taking of minutes at all mortuary meetings (may also be provided by the local
authority).
57
Ante Mortem Co-ordinator

9.32 The Ante Mortem Co-ordinator, as part of the Ante Mortem Team, is responsible for
compiling a file in respect of each person reported missing, believed to have been
involved in the incident and not yet accounted for or identified as deceased. This file
comprises information for comparison with post mortem data and is compiled for the
information of the Coroner.
Ante Mortem Team

9.33 The size of the Ante Mortem Team will depend to a large extent on the number of
fatalities but the Ante Mortem Co-ordinator and a nucleus of the team should be
activated as soon as practicable to work closely with the Casualty Bureau.
9.34 The functions of the team are to:

prepare a list of missing persons believed to have been involved in the
disaster
obtain evidence of the likelihood that the missing persons were involved
prepare a file of evidence for comparison with that from the Post Mortem
documentation (this file will be presented to the Coroner for deliberation by
the Identification Commission)
liaise with the Family Liaison Co-ordinator to inform the next-of-kin when all
identifications have been completed (the authority of the Senior Identification
Manager will be required)
provide a single point of contact for the Family Liaison Co-ordinator and
Family Liaison Officers and provide all possible assistance.
Body Reception Officer

9.35 The Body Reception Officer can be either a police officer or an appropriately trained
member of police staff and will:
supervise the reception of each deceased victim and/or human remains
ensuring that: each of the deceased victims/human remains is accompanied
by a completed ‘Scene Note’ section of appropriate Disaster Victim
Identification documentation (see Appendices E, F and G) which has been
completed at the scene and bears matching unique body identifier numbers
enter the details of the body bag in the appropriate Mortuary Reception and
Post Mortem Log / Register
enter the details of the deceased victim/human remains in the Individual
Body/Part Movement Log and maintain the log as appropriate
maintains the Mortuary Reception and Post Mortem Log / Register (as may
be appropriate)
ensure that personal property of the deceased does not come into the
mortuary (unless carried on the deceased).
9.36 In the event of a multi-sited incident, it may be appropriate to employ a separate

Body Reception Officer in respect of each scene. This course of action may be
appropriate to ensure that there is no cross-contamination of evidence between any
of the relevant scenes.
58
Body Storage Officer

9.37 The Body Storage Officer may be a police officer or an appropriately trained member
of police staff and:
ensures effective and respectful temporary storage of the deceased
seizes the original body bag in which the deceased was transported (plus
associated labels) and carries out the approved re-bagging process
maintains and completes the Body Storage Log / Register
liaises with the Viewing Area Supervisor so as to ensure efficacy in the family
viewing process
(where appropriate) completes the Victim Profile Form 13/13a (record of
viewing)
liaises with the Coroner’s Officer, Family Liaison Officers and undertakers
regarding the release of the deceased
maintains the Body Release Log.

Body Storage Officer in respect of each scene. This course of action may be
Body Transit Team

9.39 The Body Transit Team is likely to be made up of police officers who will be
responsible to the Body Reception Officer. The team may move deceased victims
and human remains around the mortuary as required (for examination, storage and
viewing).
9.40 The team will be responsible for the completion of the Body Movement Log in respect
of all such actions.

Body Transit Team in respect of each scene. This course of action may be
Family Liaison Officer (FLO)

9.42 The primary function of an FLO is that of an investigator. In performing this role the
officer will offer, give and facilitate support with consideration being given to the
needs of the family.
9.43 The role involves the day to day management of the partnership with the family in the
investigation and close liaison with the SIO/SIM to ensure families are treated
appropriately, professionally and with respect to their needs. This may involve
working in a variety of situations in very demanding and stressful conditions over
sustained periods of time.
9.44 Family Liaison Officers are selected from volunteers who have the appropriate
qualities and skills. All FLOs are trained to the accepted ACPO standard before being
deployed in cases of mass disaster and, as a consequence, will be conversant with
the contents of the ACPO Emergency Procedures Manual.
59
9.45 Family Liaison Officers must not be expected, under any circumstances, to attempt to
assume the responsibility of personally counselling a victim’s family whether qualified
to do so or not. This does not, however, preclude an FLO from offering sympathy
and/or moral support.
Family Viewing Area Supervisor

9.46 The Family Viewing Area Supervisor will be a trained and experienced Family Liaison
Co-ordinator (FLC).
9.47 The Family Viewing Area Supervisor reports directly to the Mortuary Operations
Manager and has overall responsibility for all the FLOs deployed at the Family
Viewing Area in order to facilitate the viewing of the deceased by family members
and friends. Responsibilities include:
managing the Family Viewing Area
liaison with mortuary staff to ensure that the correct deceased victim has
been prepared and is ready for viewing at the right place and at the right time
(including the completion of Victim Profile Forms VPF 13/13a)
ensuring that Family Viewing Area is properly prepared in accordance with
the family’s need and, as far as practicable, desires (due account should be
taken of the family’s religious and cultural requirements) (see also ‘The
Salvation Army’ at section 9.57)
the briefing/debriefing of all FLOs visiting the Family Viewing Area
ensure that a Paramedic is on stand by, close to the Viewing Area, prior to
and during the time of any family viewing
facilitating with FLO welfare issues (only those FLOs assigned to the Family
Viewing Area)
ensuring appropriate logistical support to the Family Viewing Area (in
conjunction with the Mortuary Facilities Manager).
Fingerprint Officer
9.48 The Fingerprint Officer is an authorised police employee who is responsible to the
Mortuary Documentation Officer and will:
obtain fingerprints, hand and/or footprints from the deceased, as directed
(ear-prints have previously been used for identification purposes and should
also be considered)
arrange for the prints to be taken for comparison purposes through liaison
with Ante-Mortem Co-ordinator
prepare print comparisons for presentation to the Identification Commission
and Coroner.
Mortuary Access Controller

9.49 The Mortuary Access Controller is responsible to the Mortuary Duty Officer. He/she
controls access and egress to the mortuary by maintaining, or causing to be
maintained, a log of all persons who enter and leave the site.
9.50 The Mortuary Access Controller may be required to supervise the issue of passes for
people and/or vehicles entering the site.
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Mortuary Documentation Officer

9.51 The Mortuary Documentation Officer is a police officer who is responsible to the
Senior Identification Manager. The Mortuary Documentation Officer will:
ensure evidential continuity is maintained in respect of each fatality
assume responsibility for all aspects of documentation in relation to the post
mortem examination of victims
liaise with pathologists, odontologists and other specialists engaged in the
mortuary to establish what paperwork is created and to agree the correct
methods for this to be submitted to Identification Commission
collate post mortem data in respect of each victim into a single file for the
benefit of the Coroner
liaise with the police Disclosure Officer regarding documentation and other
disclosable data created within the mortuary.
present identification evidence to the Identification Commission as part of the
Post Mortem Team
supervise any visual identification of the deceased along with the Coroner’s
Officer (performed with the authority of the Senior Identification Manager)
liaise with the Ante Mortem Co-ordinator regarding identification matters and
the release of remains after identification
identify areas of responsibility relative to any relevant undertakers.
Mortuary Duty Officer

9.52 The Mortuary Duty Officer is a police officer who is responsible to the Mortuary
Operations Manager (see paragraph 3.29) and will:
ensure the smooth running of the mortuary (particularly in the absence of the
Mortuary Documentation Officer, Mortuary Operations Manager and Mortuary
Facilities Manager)
ensure that the London Mass Fatality Plan (as it relates to mortuary
management) is adhered to at all times.
liaise with the mortuary managers to assist with logistical and operational
support within the mortuary
ensure security of the mortuary
assume responsibility for all visitors to the mortuary.
Mortuary Exhibits Officer

9.53 The Mortuary Exhibits Officer is a trained police officer who is responsible to the
Mortuary Documentation Officer. He/she will:
record details of all property received from the Post Mortem Team Exhibits
Officer(s)
assume responsibility for property taken from the deceased
place copy(s) of property exhibit book in the relevant body file
ensure that personal effects are stored securely until disposal
ensure continuity of any items identified as evidence
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liaise with his/her counterparts (Scene Exhibits Officer and/or those attached
to the Major Incident Room) 8
consult with the Family Liaison Co-ordinator concerning which items of
property the relatives wish to be returned in due course (the form VPF14
refers to this process)
liaise with the Family Liaison Co-ordinator, the Senior Investigating Officer
and funeral directors concerning the cleaning and restoration of property
dispose of property according to instructions from the Senior Investigating
Officer and the Senior Identification Manager.
Mortuary Photographer
9.54 The Mortuary Photographer should be a police authorised photographer and is
responsible to the Mortuary Documentation Officer. He/she and will:
be responsible for photographing deceased victims and/or human remains:
as removed from the body bag, prior to being stripped
after clothing (but not jewellery) has been removed 9
after all personal effects removed.
take any photographs required by the pathologist and other specialists during
the course of their examinations
prepare photographs for production in any Inquest or inquiry or for
identification purposes as specified by the Identification Commission.
Post Mortem Documentation Officer

9.55 The Post Mortem Documentation Officer is a police officer who is responsible to the
Mortuary Documentation Officer and will:
supervise the police post mortem teams
ensure that the deceased (including personal effects) is photographed before
and after removal of clothing (see also the duties of the Mortuary
Photographer)
record on the DVI/VPF forms details of all items removed or taken from the
deceased
ensure that property so removed is handed into the possession of the Exhibits
Team for recording
make notes as directed by the pathologist
pass the completed form (including notes) into the possession of the Mortuary
Documentation Officer.
8
It will be necessary to record details of items seized and recovered on the HOLMES II Incident Database
9
This photograph should pay particular attention to the jewellery and personal effects. Photographs will always include the
body number.
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Post Mortem Team Exhibits Officer

9.56 The Post Mortem Team Exhibits Officer is an appropriately trained police officer who
is responsible to the Post Mortem Documentation Officer and will:
receive all items of property and/or samples removed from the deceased by
the pathologist and/or Post Mortem Team (as appropriate)
complete a Major Incident Exhibit Register in respect of all such items,
maintaining at least one register for the contents of each body bag examined
completes an Exhibit Label in respect of each item of property and/or sample
removed from the deceased/human remains and secure them to the
appropriate packaging/container
ensure that all items of property / exhibits / samples are packaged and stored
in accordance with exhibit handling policies
ensure that photographs are taken of individual items of property removed
from the deceased including an additional digital photograph (see also the
Mortuary Photographer) (the digital photograph should be firmly affixed to the
outside of the packaging/container to show the contents).
Post Mortem Team Search Officer

9.57 The Post Mortem Team Search Officer is responsible to the Post Mortem
Documentation Officer and will:
assist the Pathologist and Anatomical Pathology Technologist to
systematically remove all items of clothing and property from the deceased
victim/human remains
search all items of clothing and property removed from the deceased
victim/human remains to establish evidence of identification
provide an accurate detailed description of all such items, narrating the same
to the Team Exhibits Officer
where appropriate, assist the Team Exhibits Officer in the packaging of items.
MORTUARY RESOURCES MANAGER

9.58 The Mortuary Resources Manager reports directly to the Mortuary Management
Team. He or she may be an employee of the police service or Local Authority and
will assist with the supply and set up of the mortuary. He/she assists the Mortuary
Managers in the supply of services and equipment. The Mortuary Resources
Manager may require an assistant.
THE SALVATION ARMY
The Salvation Army Co-ordinator

9.59 The Salvation Army is able to provide trained and experienced officer(s) who are
ordained minister(s) to act as The Salvation Army Co-ordinator in the Family Viewing
Area. Should this service be considered to be appropriate in the given circumstances
of the incident, the co-ordinator may:
assist the local authority in ensuring that the Family Viewing Area (FVA) is fit
for purpose
liaise with the Family Viewing Area Supervisor each day to facilitate the faith
needs of family members
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facilitate the faith response within the FVA

greet family members when they arrive at the FVA
provide emotional, practical and spiritual support to family members
ensure that the FVA is appropriate for each family group i.e. the correct
number of chairs, drinking glasses water etc.
ensure that the faith and cultural needs of family members are met e.g. ritual
hand washing
liaise with senior faith leaders to identify the most appropriate individual to
provide specific faith support
be available to provide emotional support to the police and local authority
team within the FVA
be available to provide support to the multi-agency team within the mortuary
facility.
NATIONAL HEALTH SERVICE

9.60 The provision of support, staff and equipment as considered to be appropriate.
HUMAN TISSUE AUTHORITY

9.61 The HTA was set up to regulate the removal, storage, use and disposal of human
bodies, organs and tissue for a number of Scheduled Purposes – such as research,
transplantation, and education and training – set out in the Human Tissue Act 2004
(see also paragraphs 3.17-3.18: the Mortuary Facilities Manager).
HEALTH AND SAFETY EXECUTIVE

9.62 The Health & Safety Executive will usually be the enforcing authority for the
regulation of health and safety statutory requirements at the mortuary. The Health
and Safety at Work etc Act 1974 and subordinate regulations require employers and
the self-employed to ensure that controls are in place to safeguard workers and the
public against risk of injury and ill health.
9.63 It is not the role of the HSE to provide Risk Assessments. These should be carried
out by all employers and self employed persons at the location, with co-operation and
co-ordination between the parties to ensure that safe systems of work have been
devised for the protection of all. At the site of a disaster mortuary, particular attention
should be paid to controlling the risk of infection.
MILITARY
9.64 The military may be required to provide logistical support to the civil community by
way of the Military Aid to Civil Authorities (MACA) protocol already in existence.
9.65 In addition, the military in ‘London District’ stockpile emergency mortuary equipment
on behalf of the Home Office (see Appendix B).
64
PRIVATE SECTOR AND OTHERS

9.66 The provision of specific advice and support as requested. Examples of such
assistance might include:
embalming and encoffining
assistance with personal property
licensed security.
65
SECTION 10 – HEALTH AND SAFETY
10.1 Health and Safety at Work legislation requires all employers to follow safe-working
practices as far as possible. This applies in the same way to permanent and
temporary facilities (such as represented by the types of mortuary referred to in this
plan).
10.2 Consideration must be given to the enormous demands placed upon responding staff
to a mass fatality incident. Plans must make provision for welfare and psychological
support for all staff (see section 11).
10.3 Such support measures might include:

the provision of a separate rest area, away from media and from the
bereaved
monitoring members of staff, who may, because of family bereavement,
illness, relationship problems or other similar problems, could be considered
to be vulnerable to external factors
consideration of any long-term impact on staff (with appropriate monitoring
and support initiatives)
inclusion of occupational health departments in planning, response and
monitoring arrangements.
FIRE SAFETY
10.4 The Local Authority will liaise with the local element of the London Fire Brigade to
ensure that the Disaster Mortuary complies with Fire Safety Standards.
10.5 The Local Authority will ensure that there are sufficient:
Fire Alarms
Fire Signage
Fire Blankets
Fire Extinguishers
Fire Exits.
10.6 The Mortuary Facilities Manager will ensure that fire precautions are maintained.
10.7 All staff at the disaster mortuary should know the correct procedures in the event of a
fire.
10.8 Further guidance on fire safety can be found at:

Fire Safety Orders http://www.opsi.gov.uk/si/si2005/20051541.htm
Outdoor Events http://www.dclg.gov.uk/index.asp?id=1162112
RADIATION SAFETY
10.9 A Radiation Protection Advisor should be appointed to the site. Such advisors are
able to recommend safety measures to take in respect of the use of radiography
equipment within the mortuary (see http://www.hse.gov.uk/radiation/index.htm for
further information and guidance).
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FIRST AID
10.10 First Aid Facilities will be provided at the disaster mortuary.
10.11 A First Aid Room should be provided in a ‘neutral’ area of the mortuary so it is
accessible both to both mortuary staff and visitors (such as grieving next-of-kin).
10.12 The Mortuary Facilities Manager will ensure that there is a qualified First Aider on site
at all times.
10.13 A fully equipped Paramedic (including defibrillator capacity) must be in attendance in

the Family Viewing Area (see Section7) at all times when families are in attendance
for viewing purposes.
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SECTION 11 - WELFARE
11.1 This section is not intended to be a comprehensive guide for meeting all the welfare
issues pertaining to a major emergency but rather seeks to highlight some of the
processes, facilities and agencies that have a role to play in providing such support.
11.2 Those directly involved in the incident may require welfare support at a number of
locations and over a long period of time. These may include:
receiving hospitals
the Survivor Reception Centre
the Friends and Family Reception Centre
the Humanitarian Assistance Centre
Emergency Mortuary Family Viewing Area
site visits
memorial services
anniversaries
Inquests.
11.3 The provision of welfare support involves a multiplicity of statutory bodies and
voluntary organisations. The following all have a role in providing practical,
emotional, psychological or spiritual support to those directly involved in the
emergency:
Local Authorities
voluntary organisations
faith communities
National Health Service
Bereavement Counsellors
Interpreters
Police Family Liaison Officers (see also paragraph 9.45).
11.4 The level of support to survivors will vary depending upon their individual needs.
What is important is that survivors are aware of where they can access support both
in the immediate and long term.
11.5 The importance of a Support Helpline, dedicated web site and advice in setting up
survivor support groups has been highlighted in recent emergencies.
11.6 Family 10 members and friends of the deceased are likely to be in a state of shock
and their reactions will vary considerably in the way in which they respond. They will
invariably have an urgent need for accurate information about their loved ones.
10
The term family is used in its widest sense. This may include partners, parents, siblings, children, guardians and others who
may have had a direct and close relationship with the deceased victim.
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11.7 HM Coroner is responsible for all issues relating to the deceased until such time as
they are released for burial or cremation. Family members will need to have the role
of the Coroner and the process of identification explained to them with care and will
need to be kept informed about the progress of the investigation.
11.8 It is important that those dealing with the deceased should ensure that family
members feel that time and care has been spent dealing with their loved ones as
individuals as opposed to ‘anonymous deceased victims’.
11.9 The manner in which family members are dealt with in the immediate aftermath of the
disaster will have a direct bearing on their ability to cope with their bereavement in
such traumatic circumstances, both in the short and longer term.
11.10 The local authority will lead in co-ordinating both immediate and long term support to
survivors, the bereaved and all those directly involved in the emergency.
11.11 The services of the National Health Service (GP’s and Mental Health services) are
key to the provision of psychological support in the long term.
11.12 The bereaved will need support through a number of different potentially traumatic
processes:
providing items for identification
viewing of property (if required)
viewing of deceased victims (if required)
return of deceased victims to family members
issue of the Death Certificate
return of personal property
visit to site of emergency
the Inquest
other judicial or public inquiries
memorial services
ongoing support.
POLICE FAMILY LIAISON OFFICERS

11.13 The police Senior Identification Manager (SIM) or Senior Investigating Officer (SIO)
will appoint Family Liaison Officers (FLOs) as part of their overall strategy.
11.14 The primary role of the Family Liaison Officer is that of investigator.
11.15 Police Family Liaison Officers have a key role in facilitating the provision of support to
those who have been directly involved in the emergency (see also paragraph 9.45).
11.16 Family Liaison Officers will assist the SIO and/or SIM throughout the investigation:
by acting as a conduit of information between family members and the
appointed SIO/SIM and ensuring that each family is treated appropriately,
professionally and in accordance with their diverse needs
by explaining the mortuary process to the family
69
by making arrangements, if appropriate, with family members to view their

loved ones
by liaising with family members to obtain ante-mortem information i.e. dental
records, DNA, Disaster Victim Identification information, lifestyle and family
background statements and other information to assist in the
investigation/identification process
by liaising with Coroner’s Officers, to ensure that consistent and reliable
information is provided to family members.
RELIGIOUS AND CULTURAL ISSUES

11.17 Every care is taken to attend to religious and cultural needs where possible. The
legal requirements of the UK will need to be effectively communicated to the family of
the deceased.
11.18 Any area provided for family members and friends to view the deceased will be
constructed with proper regard for religious symbolism. This may include the total
absence of certain such items.
11.19 The religious cultural and ethical considerations of the main religious faiths and
ethnic groups in the UK are included in the Home Office document The Needs of
Faith Communities in Major Emergencies: Some Guidelines (2005).
THE SURVIVOR RECEPTION CENTRE (SRC)

11.20 The Survivor Reception Centre will provide immediate support to people directly
involved in the incident (including those who may have been slightly injured). It will be
set up at a location close to the incident and may be used as a first aid point for
minor injuries. Survivors are likely to require immediate emotional and practical
support.
11.21 The purpose of the SRC is to formally record details of all survivors involved in the
incident. Survivors are potential witnesses to the incident and any related inquiry or
investigation. The SRC will provide opportunity for them to be interviewed by the
police and by any other relevant investigative body e.g. the Rail Accident
Investigation Branch (RAIB). It also permits the gathering of information to assist the
police in the collation of data (in terms of known survivors) for the Casualty Bureau.
11.22 In transportation incidents the relevant transportation provider may be involved in the
welfare response.
FAMILY AND FRIENDS RECEPTION CENTRES (FFRC)

11.23 The purpose of the FFRC is to enable those involved in the incident to be reunited
with their loved ones. It should be set up as soon as possible after the incident to
give and obtain information regarding the whereabouts of individuals involved in the
incident. This process may involve family and friends being interviewed by the police
so as to enhance the survivor data held by the Casualty Bureau.
11.24 It is possible that more than one FFRC is set up, particularly in transport accidents
when an FFRC may be set up at the point of departure or destination as well as close
proximity to the incident crash site.
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THE HUMANITARIAN ASSISTANCE CENTRE (HAC)

11.25 The HAC is a facility where bereaved, families, survivors and anyone else directly
affected by the incident can receive information and appropriate support from all
relevant agencies, without the need for immediate referral elsewhere. It is
acknowledged that while the support will take various forms and will require a wide
range of services and agencies, the privacy of individuals requiring psycho-social
support is of paramount importance.
11.26 The purpose of the HAC is to:

act as a focal point for the giving and receiving of information and assistance
to anyone directly involved in an emergency
to enable those affected to benefit from appropriate information and
assistance in a timely and coordinated manner
enable the gathering of forensic samples in a timely manner (where
appropriate and in order to assist the identification process)
offer access to a range of services that will allow affected people to make
informed choices according to their needs
ensure a seamless multi-agency approach to humanitarian assistance in
emergencies that should minimise duplication and avoid gaps.
STAFF WELFARE
11.27 Any incident where there have been mass fatalities will place enormous demands
upon all those staff involved in the response. There will be a requirement to work for
long hours in very difficult circumstances. This work will be very arduous, traumatic
and emotional and it is important to ensure that provision is in place to support all
those involved in such work.
11.29 Health and Safety at Work legislation requires all employees to follow safe working
practices, as far as practicable. While the facilities in an emergency mortuary might
be different from those in a permanent facility, the health and safety provision should
be of an equal standard.
11.30 It is important to ensure that staff members have appropriate periods away from
situations which may prove distressing and traumatic. The provision of therapeutic
services (e.g. shoulder massage, chiropody etc) has proved helpful in the past to
those working in similar environments.
11.31 It is imperative that due care is given to the long term impact on staff, particularly
those working on specialist teams where the accumulative effect may contribute to
adverse physiological, psychological and welfare consequences. Occupational health
departments have responsibility to ensure that correct procedures are in place to
respond appropriately to incidents and that all employees are aware that such
processes are in place to support their individual needs. The responsibility of
accessing these services lies with the individual, and/or their line manager(s). It is
acknowledged, however, that any support given is based upon expert opinion and
the unique circumstances affecting the individual.
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SECTION 12 - COMMUNICATIONS AND MEDIA POLICY
12.1 In the event of an incident causing mass fatality in London, existing media and
communications plans and protocols will be used. Each individual agency will have a
communications strategy in place to appropriately respond to the emergency or
incident. Such strategies should include an agreed pan-agency approach to
responding to multiple fatalities at both the local and regional level.
12.2 The communications strategies should outline the process for establishing a Media
Centre to facilitate the release of accurate and timely information to the general
public.
12.3 The media will not be allowed access to the mortuary, to the Humanitarian
Assistance Centre or any Friends and Relatives or Survivor Reception Centres.
12.4 In general, all communications must be undertaken with sensitivity. The deceased
must be treated with dignity and the needs of the bereaved should be respected.
12.5 The media will receive all information regarding the mass fatality incident only at the
Media Centre. A designated local authority Press Officer and/or police Media Liaison
Officer will represent the necessary departments. Facts and figures pertaining to the
number of fatalities etc. will only be provided to the media when verified and, then,
through the use of a single, pre-identified, point of contact. This contact MUST be the
only means of communicating these figures.
12.6 Names of the deceased will not be released until their family members have been
notified and sufficient time has elapsed to enable them to notify other relatives and
loved ones. The identities of the deceased MUST not be released without the
expressed authority of the SIM.
12.7 The London Resilience Team provides a useful link between central government and
local responders during an emergency, and is well positioned to take a multi-agency
and cross-departmental view of an event.
12.8 The London Resilience Team, therefore, will play a key communications role in a
mass fatalities incident by: cascading information from central government, liaising
with the Lead Government Department, providing advice, guidance and expertise
(particularly in relation to London’s regional plans) to local responders and facilitating
inter-agency communications within and between the region(s).
12.9 Key stakeholders to be consulted and informed include: Category 1 and 2

responders, the voluntary sector, the faith community, local community
groups/leaders and businesses.
12.10 It is essential that Coroners are kept abreast of all developments.
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SECTION 13 – SITE CLEARANCE
RESCUE AND RECOVERY

13.1 In the immediate aftermath of the incident the emergency services will take the lead
role in co-ordinating the efforts of government agencies and departments, local
authorities and private companies.
RECOVERING DECEASED VICTIMS

13.2 In the event of an emergency it is possible there will be human remains in the debris.
Providing there is no contamination preventing it, all human remains should be
recorded at the site or at the rubble sifting area. However, remains identified during
the site clearance or rubble-sifting stages will be treated in an identical way to those
recovered from the site. All human remains will be conveyed to the relevant disaster
mortuary.
13.3 Removal of the deceased should be carried out as expediently as possible given the
particular circumstances of the disaster, taking into account the requirement to
preserve evidence relating to the identify of the deceased or the criminal inquiry.
Early systematic photography of the scene, with grid marking and careful
documentation of the position of deceased victims, human remains and personal
possessions is essential. Recognising this, the police have a cadre of selected and
trained officers responsible for the recovery of disaster victims (Victim Recovery
Teams).
13.4 As deceased victims or human remains require continuity in evidence handling the
police will arrange and supervise the movement of remains from the scene or
Holding Audit Area to the mortuary utilising these teams. This movement of
deceased victims and human remains may be regulated and undertaken in phases to
avoid mortuary staff becoming overwhelmed by large numbers arriving at the same
time.
13.5 Deceased victims should be removed as soon as is practicably possible.

Requirements relative to evidence-gathering and weather conditions may, however,
influence operational timeframes for this procedure. None of the remains should be
removed until HM Coroner has given permission to do so. It is accepted that some
deceased victims may have to be moved in the initial rescue efforts, however, every
attempt should be made to leave the remaining deceased victims, and their
associated property in the position initially found.
13.6 It is possible that HM Coroner, the Supervising Pathologist, the SIM, and other
investigating agencies (e.g. Road, Rail, Air or Marine Accident Investigation
Branches) may wish to view the deceased victims insitu in order to assist in
determining both the cause of the incident and the cause of death.
13.7 Before removal, deceased victims/human remains will be photographed insitu and an
ACPO Victim Label booklet completed in every case. This number will remain with
the deceased victim/human remains throughout the mortuary procedures until final
identification has been achieved. The location from where the deceased victim was
removed will also be labelled with corresponding numbers to those on the deceased
(see sections 6.83 to 6.98).
13.8 There is a well-documented systematic approach to the recovery of all items -

including property - from the disaster scene. This effort will be co-ordinated by police
search teams.
73
13.9 Unattached personal effects found on or near the human remains will, after
documenting their position and appropriate photography, be placed in a container,
and tagged with unique reference numbers and information reflecting the local
surroundings.
HOLDING AUDIT AREA

13.10 A Holding Audit Area will be necessary between the site of retrieval and the
mortuary. A number of Holding Audit Areas may be necessary.
13.11 At the Holding Audit Area the body bags will be checked to ensure they are securely
and correctly labelled. These bags will remain sealed throughout their transfer to the
mortuary. No post-mortem procedures or examination will take place at the Holding
Audit Area.
13.12 In cases where terrorism is suspected it may be necessary for an examination of the
deceased to take place to ensure that there are no live munitions attached. In such
circumstances, the advice of the MPS SO15 Counter Terrorism Command should be
sought.
13.13 The Holding Audit Area should be:

under cover and out of the public view and within the police cordon (for both
security and protection purposes)
in close proximity to the disaster site
secure
a flat outdoor area that can be covered with tarpaulins or on which tenting can
be erected to ensure that there is no exposure to the elements, or, an indoor
facility on the ground floor of a suitable building
accessible to vehicles.
13.14 The Holding Audit Area should have controlled access (no access to family members
and friends of the deceased or to the media)
13.15 The Holding Audit Area was formerly referred to as the Body Holding Area.
SITE PRESERVATION (INVESTIGATION)

13.16 The site may be treated as a designated crime scene. The police are responsible for
securing, protecting and preserving such scenes. They are also responsible for the
investigation of any crime and obtaining and securing evidence in conjunction with
other investigative organisations.
SITE STABILISATION STAGE

13.17 The local authority will take the lead on site stabilisation with assistance from: other
local authorities (through their own mutual aid agreements), the emergency services,
private contractors and government departments/agencies. As the incident
progresses towards the site stabilisation phase, the emergency services will need to
consider a formal handover to the Local Authority in order to facilitate the authority’s
leading role in the return to normality and restoration of the environment. The Health
and Safety Executive will give ongoing advice and guidance.
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SITE CLEARANCE STAGE

13.18 As time moves on the site will move into a clearance phase. The relevant Local
Authority will lead in this phase supported by relevant government departments and
agencies. Calls will be made on non-governmental resources as required.
13.19 Landfill sites and bulk debris examination sites (with suitable back up sites) have
been identified for use as part of the London Site Clearance Plan. These sites will
need to be made secure areas.
TRANSPORT TO THE MORTUARY

13.20 In the event that deceased victims are contaminated expert advice will be sought
from the Joint Health Advisory Cell (JHAC) 11 before they are removed from the
scene.
11
At the time of going to press, the concept of JHAC is under review. This and future entries regarding JHAC should therefore
be read as encompassing the arrangements that come in to replace JHAC. This plan will be revised to reflect those new
arrangements in due course.
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SECTION 14 - CHEMICAL, BIOLOGICAL, RADIOLOGICAL, NUCLEAR (CBRN)

14.1 There is currently little guidance about the management of contaminated fatalities
following a CBRN incident. As a result, the Home Office is taking forward a
programme of work which examines in detail how contaminated fatalities can be
safely handled from recovery to disposal. As part of this work, the Home Office is
planning to issue guidance on the Safe Handling of Contaminated Fatalities in due
course. Until such guidance as this is available, and in the event of a CBRN incident
resulting in fatalities, NO decisions or actions should be taken until specific advice is
sought from the Joint Heath Advisory Cell (JHAC) (see footnote attached to
paragraph 13.20).
14.2 Decontamination may not remove or reduce the hazard completely as deceased
victims/human remains may continue to emit fluids or gases after decontamination.
14.3 Advice should be sought from JHAC on:

level of personal protective equipment required to handle human remains
the benefits of decontamination (if any)
a risk assessment of the continuous hazard which may be posed by remains
post decontamination
any requirement for ongoing detection, identification, monitoring of human
remains, or storage facilities in order to detect the presence of new hazards.
14.4 Transportation of remains should not be undertaken until a full risk assessment has
been undertaken with JHAC.
14.5 The Coroner, SIM and Supervising Forensic Pathologist should agree with the
options available for safe handling and identifying the remains.
14.6 It may not be possible to use certain methods of identification and it may also be
impractical to conduct post mortem examinations.
14.7 Guidance should be sought from JHAC on whether vehicles or storage locations for
remains may themselves become contaminated and if or how this contamination can
be safely managed and/or removed (environment, buildings, and vehicles).
14.8 If decontamination facilities prove difficult it may well be appropriate to consider

temporary facilities that could be disposed of after the use.
14.9 It may be necessary to provide temporary cold storage for contaminated remains at,
or close to the scene, within the warm/cold zone or until detailed plans can be
developed and managed to address the range of issues arising. This should be
achieved within 24 hours.
14.10 JHAC and Specialist Risk Assessments will determine where there should be any
restrictions in relation to:
viewing
return to families
repatriation, burial and cremation.
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SECTION 15 – INTERNATIONAL DIMENSION
15.1 Many, if not all, disasters will have an international dimension, in the causation, in the
location, in the aftermath or in the nationality of victims.
15.2 Provision will need to be made for the repatriation of family members to the UK if the
disaster occurs abroad.
15.3 Foreign nationals who die in England and Wales (and thus in London) may be
repatriated to their home country for a funeral. In these circumstances the Coroner
will need to issue formal documentation authorising the deceased to be taken outside
England & Wales.
15.4 There may be special considerations for victims who are to be repatriated abroad
e.g. the necessity for embalming prior to transportation. The Foreign and
Commonwealth Office (FCO) may be able to advise on the entry requirements for
any country relative to the carriage of deceased persons.
INTERPOL
15.5 Interpol recognises that the responsibility for co-ordinating the investigation, recovery
and identification of victims will always rest with the ‘host nation’.
15.6 Factors such as geography, capability and the high proportion of victims (also
political, religious or cultural reasons) may require a multi-national response.
15.7 If a multi-national response is required, this will be organised by Interpol however, the
‘host nation’ must always agree to any multi-national support effort.
FOREIGN AND COMMONWEALTH OFFICE (FCO)

15.8 The Foreign and Commonwealth Office (FCO) are able to respond and/or assist in
fatality incidents involving either foreign nationals who have died or have been killed
in the UK or British nationals who have died or been killed whilst overseas.
DEATH CERTIFICATION
15.9 In similar circumstances to those outlined at section 4.22, at the conclusion of the
coroner’s proceedings, the Registrar of Deaths will be notified so that a Death
Certificate can then be issued. It should be noted, however, that a Coroners Interim
Certificate may not be sufficient to satisfy legal procedures overseas.
77
SECTION 16 – DECOMMISSIONING AND CLOSURE
16.1 The Coroner, in consultation with the Senior Identification Manager (SIM), will decide
when to close the mortuary.
16.2 The Mortuary Management Team will supervise the decommissioning of the disaster
mortuary and ensure that the Post Mortem, Body Receiving and the Family Viewing
Areas are clear of all waste and hazardous materials and the equipment is left clean.
16.3 It is probable that the following actions will be required:

steam clean/disinfect all equipment, floor surfaces and refrigerated
units/vehicles that will have been contaminated
disposal of the wet area floor covering (as clinical waste)
clean the whole floor area of the mortuary building
clean all office floors and work surfaces
clean all toilets, showers and kitchen/dining areas
arrange for clinical waste skips to be removed, and have waste disposal
records completed and retained
arrange for the return of all contractors and health service equipment.
16.4 Once all equipment has been returned and cleaning carried out, the Mortuary
Management Team will formally hand back the premises to its owners.
78
SECTION 17 – GUIDANCE ON DEALING WITH COSTS ASSOCIATED WITH AN

EMERGENCY MORTUARY
INTRODUCTION
17.1 Establishment and operation of a disaster mortuary, even for a short period of time,
will cost a considerable amount of money. Several different organisations will be
involved in the process. It is important therefore, that financial responsibilities are
agreed before the mortuary is required to be established.
TYPES OF COSTS LIKELY TO BE INCURRED

17.2 Expenditure associated with the establishment and operation of the disaster mortuary
is likely to fall into several categories:
the initial construction or adaptation of the premises and any operating costs
incidental costs incurred during operation: supplies, catering, telephone and
fax charges etc.
the professional fees and expenses of those medical and technical staff
working within the mortuary
the costs of the movement of the deceased to and from the disaster mortuary
the costs of police officers time associated with the administration of the
disaster mortuary
the costs of liaison arrangements incurred by outside agencies
displacement of existing arrangements
site recovery / reinstatement of routine facilities.
RESPONSIBILITIES FOR PAYMENT AND RECOVERY OF COSTS

17.3 The payment of fees and expenses to people whose evidence will facilitate the
conduct of an inquest is the responsibility of the Coroner (Coroners Act 1988, s.26).
17.4 The Coroner is also able to make expenditure in connection with the removal of the
deceased to certain places provided for the purpose of making post-mortem
examinations (Coroners Act 1988, s.22).
17.5 The Coroner is funded by the ‘relevant council’ (Coroners Act 1988, s.27). The
‘relevant council’ is the council which appoints the Coroner. However, any costs
incurred by the Coroner ‘shall be apportioned’ between the authorities whose areas
are covered by each Coroner’s jurisdiction.
17.6 If the deceased are found in the jurisdictions of more than one Coroner, the Coroners
will decide amongst themselves the appropriate division of costs. This implies that
responsibilities for costs will follow the same division.
17.7 The professional fees and expenses of persons, such as pathologists, working within
the disaster mortuary are the direct responsibility of the Coroner as it is the Coroner
who authorises the work. The costs of removing the deceased to the disaster
mortuary are also the Coroner’s responsibility. The Coroner would therefore pay and
reclaim these costs from the ‘relevant council’ in the same manner as for any other
inquest.
79
17.8 The costs of police officers’ time and associated expenditure should be aggregated
with other police costs arising from the incident, for example the costs of
administering the incident site. The police would then need to make a separate and
complete claim for recovery of costs in the normal manner. It is however likely that
only claims for costs in excess of normal operating budgets will be recoverable, so
again, accurate and complete record-keeping will be vital.
17.9 Other organisations, including local authorities, will incur costs for liaison
arrangements with the disaster mortuary, for example, the costs of social workers
attending the mortuary with relatives. These are costs that the organisation would
expect to incur in the normal performance of its role, but there may be excess costs
directly attributable to increased workloads resulting from the disaster which would
need to be recovered as detailed below.
AUTHORISATION OF EXPENDITURE
17.10 In practice the costs associated with an disaster mortuary will require authorisation
by different people and will be dealt with in different ways:
costs associated with the establishment and on-going provision of the
facilities will need to be authorised by the authority responsible for provision
of the disaster mortuary or persons acting on its behalf
costs directly related to the facilitation of the inquests will require authorisation
by the Coroner or persons acting on his/her behalf and will fall to the ‘relevant’
district council under the terms of the Coroners Act 1988
costs incurred by the police and other organisations in support of the
operation of the mortuary will have to be authorised by the appropriate
persons in the organisations incurring them.
17.11 In all cases, those authorising expenditure should have regard to obtaining best
value. Whilst it would be unreasonable to expect any sort of prolonged competitive
tendering procedure to be followed in an emergency situation, those authorising
expenditure must be aware that any payments made may be the subject of future
claims and possible legal action. They would be well-advised to record in writing at
the time of authorising any expenditure the reasons for the particular decision and
any steps taken, such as telephoning more than one supplier that would aid the later
justification of their actions.
RECOVERABILITY OF COSTS
17.12 Ultimately most costs incurred by the London Authorities in the response to a major
disaster should be recoverable. Local authorities and other bodies carry their own
insurance which, depending on the nature of the disaster, may cover some or all
expenditure. Costs may be recoverable from those judged responsible for the
incident or their insurers.
17.13 One way for local authorities to obtain recompense for disaster-related expenditure is
by claiming from the Government through grant aid schemes such as the “Bellwin”
rules (operated under Section 155 of the Local Government and Housing Act 1989),
details of grant rates and thresholds are on the website:
http://www.local.odpm.gov.uk/finance/bellwin.htm
80
17.14 Whether costs are claimed from insurers, through the courts or from the Government,
it is important that clear records are available showing the amounts expended and
especially the authorisation for the expenditure. Having agreed procedures before an
incident occurs aids the compilation of these records, which may need to be kept for
many years until claims are settled.
17.15 The proper authorisation of expenditure will be the key to deciding which organisation
will actually bear the costs and be in a position to recover them when responsibility
for the disaster and its costs is final determined.
SUMMARY
17.16 It is important that all expenditure associated with the disaster mortuary is properly
authorised and clearly accounted for. Prior agreement about the responsibilities for
costs will aid this process. Proper record-keeping will allow those making the
expenditure the best possible opportunity of later reclaiming the costs from insurers,
the Government or those judged responsible for the deaths which cause the
temporary mortuary to be required.
81
SECTION 18 – DEBRIEFING
18.1 Debriefing serves a number of different purposes in any operation and fall into three
general categories; the ‘hot’ debrief, the operational debrief, and the critical incident
stress debrief. Each have some particular characteristics and each can be used
either separately or in conjunction with one another, depending on the type of event
to be debriefed, staff involved, organisational purpose, amongst a number of
variables.
18.2 The immediate post event or ‘hot’ debrief can be used to capture information in fast
time in order to promote and enable continuous improvement. Despite the name, it
need not only be conducted at the conclusion of the event. It can be held at many
distinct stages. For example, shift change, command handover, and operational
phase completion will provide opportunities for these debriefs to take place. There
are some general principles about a ‘hot’ debrief. It should be conducted before staff
go off shift or are deployed to other duties. For this reason it should be short. Unless
a traumatic event has occurred, (which is mentioned later), it should focus on
immediate events and the suggested process is for the person responsible for first
line supervision to ask staff to identify any operational difficulties that presented
during the time period. They should also be asked how they overcame these issues.
These should be recorded, quality assured by the supervisor, prioritised for action,
and passed up the command chain.
18.3 In this way the ‘hot’ debrief can be a means of highlighting emerging themes and
addressing potential difficulties before they become embedded in the operational
process. High priority issues can be fast tracked to the appropriate command
authority for decision and action, whilst other issues can be dealt with as a slower-
time process. There should be a means for the information to be reviewed
contemporaneously as part of the command support functions.
18.4 The main operational debrief is the next stage up the debriefing process. Generally,
operational debriefing is a means of giving the opportunity to staff, involved in any
event, to use their experiences in a determination of what took place in any specified
aspect of that event. Debriefing ought to be viewed as part of the event process and
integral to feeding back results. Debriefing should be seen as routine in all
operations, and should, wherever possible, be planned in at the earliest possible
opportunity. Debriefing should also be regarded as a vital part of the planning
process for future events.
18.5 Operational debriefing is designed to analyse the event and seeks to improve future
performance. It will also highlight any significant aspects of the event with a view to
dissemination or identification of other work arising from it.
18.6 Its purpose should not be to apportion blame, but to identify the most and least
effective aspects of the operation or event. It has many uses and these often
determine the structure of the debrief itself.
18.7 The purpose and objectives of any debrief should be carefully agreed beforehand so
that all necessary information is gathered and every one of the issues is covered.
The debrief can be organised in any number of different ways. The simplest two
processes are to divide participants into their functional groups for the debrief, or to
divide participants along a timeline of the event.
82
18.8 In either case, it should be borne in mind that it is at least as important to identify and
repeat, where appropriate, those things that went well, as it is to identify and avoid
those things that did not go well. In view of this, equal time should be apportioned to
them. It is also useful to get the participants to reflect on what changes they would
make in future as a result of their experiences.
18.9 Following this data collection phase, a report is compiled. This report can be used
for a number for purposes. Fundamentally, however, the report is used as part of a
process of continual improvement. The information gained should be fed back into
the operational context as soon as practicable, and should also inform the
development of training and doctrine.
18.10 One other important point about the report. It is common organisational practice,
following a debrief that identifies areas for improvement, as all will, to restrict the
circulation of the report. If the debrief has been conducted with an appropriate focus,
i.e. ‘what happened’ as opposed to ‘who did it’, then this reaction should be actively
avoided. Not only is it bad practice, but it actively inhibits the process of improvement
that should form part of the culture of all modern organisations.
18.11 By applying this focus, the debrief process is the ‘engine room’ of operational
practice; driving the process of identifying issues from real operations (or realistic
exercises), analysing the results, and disseminating the learning for the benefit of all.
18.12 Both ‘hot’ and operational debriefs should be subject to some organisational policies
about possible evidential issues, if the event experienced has the potential to involve
future criminal proceedings. The general rule is that, so long as the participants have
already made any evidential notes of their involvement prior to its commencement,
the debrief can take place. Advice should be sought if any new evidential information
arises out of the debrief itself.
18.13 The final debrief type can be broadly referred to as a critical incident stress debrief.
This is generally used when staff have been exposed to traumatic events. The
purpose of this debrief is to enable participants to talk about what happened and their
reactions to it from a personal rather than an operational context. It is often most
useful if the suitably trained debriefers are from a similar organisational background,
as they will often have some experiences to draw on. This debrief is not for the
benefit of the organisation, but for the benefit of those involved in it. It can help them
to ‘normalise’ their experiences, feelings and personal responses to what has
happened to them.
18.14 Staff conducting these debriefs should be suitably trained and there should be an
organisational recognition that, as the purpose is broadly therapeutic, rather than
operational, no records will be kept and that staff who were not involved in the event,
(even at command level), should not be present.
18.15 Debriefing of operations and events has a number of organisational benefits if

appropriately conducted. Fast time information capture and tactical changes can
result; organisational learning can be gained and put into practice; and staff welfare
can be assisted. It should be part of organisations’ planning for major events and
operations, and is an important contribution to organisational effectiveness. As
important as a plan for debriefing is that organisations develop a ‘culture of
debriefing’ in which operational effectiveness and continuous improvement are seen
as every staff member’s business.
83
Enquiries to:
London Resilience Team

1st Floor, Riverwalk House
157 - 161 Millbank
London
SW1P 4RR
enquiries-lrt@gol.gsi.gov.uk
www.londonprepared.gov.uk

London Mass Fatality Plan Main Body

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LONDON MASS FATALITY PLAN

March 2007 Version 2

(Gladstone, William, 1871)

(Clarke, Lord Justice, 2001, para 34:1)

(Haddon-Cave, Charles, 2000)

Association of Chief Police Officers (ACPO)

Activation of the Plan: Section 2.1

The Mass Fatality Co-ordination Group:

1. Local: whereby it is possible to utilise existing mortuary

identify – by reference to section 5 of this plan – the most

act as a liaison and co-ordination forum in respect of:

The Mortuary Management Team:

SECTION 2 – ACTIVATION AND MANAGEMENT OF THE PLAN 15

SECTION 3 – ROLES AND RESPONSIBILITIES OF ORGANISATIONS IN THE 20

SECTION 4 – DISASTER VICTIM IDENTIFICATION 26

SECTION 5 – THE MORTUARY 30

SECTION 6 – MORTUARY PROCEDURES 37

SECTION 7 – FAMILY VIEWING 48

SECTION 8 – RELIGIOUS AND CULTURAL ISSUES 51

SECTION 9 – ROLES AND RESPONSIBILITIES OF ORGANISATIONS 55

SECTION 10 – HEALTH AND SAFETY 66

SECTION 12 – COMMUNICATIONS AND MEDIA POLICY 72

SECTION 14 – CHEMICAL, BIOLOGICAL, RADIOLOGICAL, NUCLEAR (CBRN) 76

SECTION 16 – DECOMMISSIONING AND CLOSURE 78

SECTION 17 – GUIDANCE ON DEALING WITH COSTS ASSOCIATED WITH AN 79

THE LONDON MASS FATALITY PLAN

1.2 The plan is primarily designed to supplement existing multi-agency emergency

i) the London Humanitarian Assistance Centre Plan - London Resilience Team,

COMMAND AND CONTROL

SCOPE OF THE PLAN

1.26 In addition, the response provided will need to:

REVIEWING THE PLAN

SECTION 2 – ACTIVATION AND MANAGEMENT OF THE PLAN

ACTIVATION OF THE LONDON MASS FATALITY PLAN

Diagram 2.1: Activation cascade

Police or LA to notify the Coroner and inform

HM Coroner invokes the London Mass Fatality Plan

LRT contacts HM Coroner to seek authority to call out the

‘PRESIDING’ OR ‘INCIDENT CORONER’

‘LEAD CORONER’ PRINCIPLE

‘LEAD LOCAL AUTHORITY’ PRINCIPLE

These scenarios are described below.

THE MASS FATALITY CO-ORDINATION GROUP

identify – by reference to section 5 – the most appropriate level of

identify – by reference to section 5 of this plan – the most appropriate form of

the Mortuary Facilities Manager (usually appointed by the Local Authority)

*For a visual representation of this membership see Diagram 2.2 below.

2.18 Complementary membership: In addition the following individuals and

Senior Strategic Local Authority

SECTION 3 - ROLES AND RESPONSIBILITIES OF ORGANISATIONS IN THE

3.3 In addition, it is only the Coroner who can authorise:

SUPERVISING FORENSIC PATHOLOGIST

THE LOCAL AUTHORITY

Mortuary Facilities Manager

3.18 The specific responsibilities of the Mortuary Facilities Manager include:

to manage the provision, use and stockpiling of Personal Protective

THE POLICE SERVICE

Senior Investigating Officer (SIO)

Senior Identification Manager (SIM)

Mortuary Operations Manager

3.30 Further, the Mortuary Operations Manager is responsible for:

Family Liaison Co-ordinator (FLC)

monitoring mandatory attendance at the Welfare/Occupational Health