The public's attitude to death and the care of the deceased's body after death has evolved, reflecting cultural diversity and an expectation of being involved and consulted in all important decisions regarding their relatives.
To place the extent of organ retention in context, in 2013 there were 5,105 post-mortems authorised by Procurators Fiscal. Of these, 853 were forensic post-mortems. There were only three cases where organs were retained representing 0.351% of forensic post-mortems and 0.059% of all post-mortems conducted in 2013.
Greater awareness of cultural sensitivities and medical advances has significantly impacted on the need to retain whole organs and should result in the retention of organs authorised by COPFS occurring only in exceptional cases. The overriding aim is to complete any examination of an organ prior to the deceased's body being released to the nearest relatives. This is evidenced by the low number of organs retained following a post‑mortem. In recent years, the highest number of organs retained was five, in 2007.
The systematic failures that led to nearest relatives not being informed that an organ had been retained were two-fold. The first was a failure to adhere to COPFS procedures as a result of an oversight by those dealing with the death in local Procurator Fiscal offices. The second arose due to a lack of clarity, following the creation of specialist homicide teams, on whether it was the responsibility of the team investigating the criminal aspect of the death or those, to whom the death was initially reported, to liaise with the nearest relatives.
Regardless of those failings, what is evident is that there was no internal warning mechanism within the COPFS system or any reconciliation system between COPFS and the pathology service providers that would have alerted those dealing with the death that an organ was still being retained.
While there is an understanding of the professional responsibilities of those dealing with the investigation of deaths, the particular obligations relating to organ retention were not specified in the pathology service providers' contracts or in written protocols between the pathology service providers and COPFS which resulted in a breakdown of communication in the cases identified in the COPFS internal audit.
There is a considerable body of guidance on communicating with bereaved relatives issued by COPFS, emphasising the importance of providing information timeously, sensitively and appropriate to the particular needs of the deceased's relatives. However, there was no procedure or policy to deal with organ retention if the nearest relatives did not want to engage with COPFS on issues such as their preference for the disposal of an organ.