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(1) Western Sydney University runs teaching and research activities in the fields of medicine and health sciences which could involve the conduct of anatomical examinations. The conduct of these examinations at the University will comply with the provisions of the Anatomy Act, 1977 and the Human Tissue Act, 1983. (2) Anatomical examinations at the University are carried out in the University's anatomy facilities, using bodies that have been donated for medical or scientific purposes. (3) This document provides a framework for management and utilisation of the University's anatomy facilities and sets out the University's requirements in respect to the receipt, handling, storage and disposal of donated bodies. It covers bodies that have been donated directly to the University and those procured by the University from other sources. It applies to all University staff, students and visitors. (4) For the purpose of this policy: (5) The University recognises the magnitude and solemnity of the contribution that is made by those who donate their bodies for medical or scientific purposes and is committed to treating the human remains entrusted to its care with the utmost respect and professionalism. In keeping with this commitment the University requires its employees and students to obey and uphold all legal, public health and ethical standards associated with the handling of bodies and human tissues. (6) The University will not tolerate any activity that undermines its ability to meet its legislative obligations or that devalues the contribution made by those who donate their body for medical or scientific purposes. (7) Licences to conduct anatomical examinations are issued by the Director-General of the Department of Health in accordance with the Anatomy Act, 1977. The Director-General may also revoke a licence to conduct anatomical examinations. The University may only conduct anatomical examinations when in possession of a valid and current licence. (8) In addition to complying with the general requirements set out in the Anatomy Act, 1977, all University anatomy facilities covered by a licence to conduct anatomical examinations (e.g. mortuaries, laboratories, museums) must comply with the standards set out in the following Acts and Regulations: (9) The licence holder/s is responsible for monitoring the University's compliance with these licensing provisions and ensuring that the University retains or, where necessary, updates its licence to conduct anatomical examinations. (10) The Vice-President, Infrastructure and Commercial, will provide support to the relevant Dean in meeting compliance requirements with respect to the maintenance of the University's anatomy facilities. In this respect the Vice-President, Infrastructure and Commercial is responsible for: (11) University employees and students will cooperate with any reasonable request or instruction issued by relevant Dean, or their nominees, to enable the University to fulfil its obligations with respect to these licensing requirements. (12) The University's anatomy facilities are to be secured at all times. Keys (physical or electronic) to these facilities will only be provided on completion of the mandatory induction program, and then only to: (13) Individuals provided with keys are responsible for ensuring the facility remains secure. Employees who have been issued with keys will be responsible for admitting all other non-key holding users of the facility and will restrict access to: (14) Students, contractors (other than contracted cleaners) and other authorised users must be supervised by an anatomy employee or Campus Security Officer when in a University anatomy facility. Anatomy employees controlling access to these facilities must ensure appropriate supervision is available prior to granting admittance to these parties. (15) Under no circumstances are unauthorised persons to be granted access to the University's anatomy facilities at any time. Any attempt to gain unauthorised access to the University's anatomy facilities, whether the attempt is successful or not, will be considered to be in breach of this policy and may be subject to disciplinary action. (16) While in a University anatomy facility all individuals are required to comply with the relevant 'Anatomy Facility Code of Conduct' (the Code). The Anatomy Facility Code of Conduct will be clearly displayed in the facility. Individuals are responsible for reading the Code and conducting themselves accordingly. Failure to comply with the requirements set out in the Anatomy Facility Code of Conduct may be considered a breach of this policy. (17) Equipment used to store bodies and/or human tissues (e.g. fridges, specimen tanks, human tissue bins) is only to be accessed by anatomy employees. Under no circumstances is any other individual to touch or otherwise access this equipment. Any attempt to gain unauthorised access to body and/or human tissue storage equipment, whether the attempt is successful or not, will be considered to be in breach of this policy and may be subject to disciplinary action. (18) All individuals must complete a formal induction prior to being admitted to any University anatomy facility. At a minimum, this induction will cover: (19) Individuals who are likely to see and/or handle bodies or human tissues while in a University anatomy facility must, prior to entering the facility, complete a formal induction covering: (20) The relevant Licence holder will be responsible for ensuring processes are in place to provide all anatomy facility users with the necessary induction. Students will receive the relevant induction requirements as part of their introductory (21) Staff and students are required to familiarise themselves with legislative requirements and related University procedures pertaining to the receipt, storage, handling, tracking and disposal of bodies and human tissues and ensure they conduct all their activities in strict adherence with these requirements. Students will be provided with information regarding applicable legislative and procedural requirements. (22) Approval to retain a body or human tissues beyond the approved retention date, will be obtained in accordance with the Anatomy Act, 1977. Requests for extended retention of bodies or human tissues must be lodged well in advance to ensure approval is obtained prior to the expiration of the initial approved retention date. (23) The University will conduct audits into the management and handling of bodies and human tissues to ensure that it is complying with legislative requirements. These audits will be undertaken independently of School(s). (24) Students may feel distressed when first encountering bodies or human tissues, and/or they may raise issues of grief. There is also a slight possibility that a student may recognise a body as a person they may have known prior to that person's death (e.g. a relative, friend or neighbour). University staff should be aware of these potential problems and are expected to respond sympathetically and appropriately. (25) To enable University staff to provide assistance and take steps to rectify the situation, students are encouraged to inform staff as soon as possible if the student feels: (26) All students' concerns will be treated confidentially and where necessary counselling made available. (27) Students are not to take devices used to record images into University anatomy facilities without the explicit permission of their supervisor. (28) In the event that an anatomy employee or student wishes to record an image of a body or human tissue for teaching or research purposes they must obtain written approval in accordance with the appropriate procedures. Anatomical sketches, such as those used for (29) Permission to record an image of a body or human tissue may be granted, but only where the approving officer is satisfied that the recording fulfils a valid teaching or research need. (30) Where permission to record an image is granted the image must be used solely for the approved purpose. Under no circumstances is the image to be used in any manner that goes beyond the scope of the approval. (31) Participation in any activity that directly or indirectly breaches any part of this policy or its underlying principles may result in participants being subject to internal disciplinary proceedings. The University reserves the right to instruct individuals (including staff, students and visitors) to vacate its facilities and/or premises and will enforce this right through legal means (i.e. the police) where necessary. (32) Failure to follow the reasonable directions of supervisors or other authorised University employees (e.g. the relevant a Campus Security Officer, any employee acting in relation to the performance of their duties as a University employee) and subsequent actions which directly or indirectly undermine those directions are considered to be breaches of this policy. (33) Internal disciplinary action will be managed in accordance with the relevant staff agreement or Student Misconduct Rule. (34) Participation in any activity that directly or indirectly breaches State or Federal law may be subject to internal and/or external disciplinary proceedings. Where observed, the University will report illegal activity to the appropriate authorities (e.g. the police). The Director, Campus Safety and Security must be informed in all cases of potential offences under the NSW Crimes Act, 1900 and will be responsible for liaison with external bodies including law enforcement agencies, should an event arise. (35) Prior to granting access for a student to an anatomy facility, anatomy employees will: (36) Students who are not formally registered in a relevant (37) Repairs and general maintenance of anatomy facilities must be booked through the Division of Infrastructure and Commercial. When booking contractors to conduct repairs and general maintenance of anatomy facilities the Division of Infrastructure and Commercial will advise that contractors are required to: (38) Once arrangements for repairs or general maintenance have been confirmed, the Division of Infrastructure and Commercial will notify the relevant Campus Security Officer and the relevant Team Leader, Medical and Allied Health (Technical Support Services), advising: (39) Upon arrival, Campus Safety and Security will provide contractors with any necessary instructions and escort the contractor to the relevant anatomy facility and/or arrange for an anatomy employee to be ready to meet the contractor on arrival at the building. In the event that anatomy employees will be unable to provide adequate supervision for the duration of the work, the Team Leader, Medical and Allied Health (Technical Support Services) or nominee will make arrangements for supervision to be provided by Campus Safety and Security. (40) In respect of contractors (other than contracted cleaners), prior to granting access to an anatomy facility, an anatomy employee or the relevant Campus Security Officer will: (41) In respect of internal auditors and external inspectors, prior to granting access to an anatomy facility, an anatomy employee will: (42) In respect of internal auditors, anatomy employees must also ensure each auditor has completed the necessary induction prior to granting access to the facility. (43) Appropriate supervision of users of anatomy facilities will be determined prior to admittance. The assigned supervisor/s will remain responsible for these users until such time as the supervisor/s: (44) Bodies must be delivered to the University mortuary for verification and receipting purposes. Bodies may only be accepted into the mortuary by authorised receiving officers. (45) Delivery by or from the University's contracted funeral director must be scheduled to ensure an authorised receiving officer is present at the time of delivery. (46) Prior to accepting a body, the authorised receiving officer must ensure that there is sufficient refrigerated storage capacity to take the body and that the body: (47) Adequate precautions must be taken to ensure that the transfer of bodies into the Anatomy facility is not witnessed by members of the University community or general public. (48) On accepting a body, the authorised receiving officer must: (49) Prior to using a donated body for any teaching or research purposes, the University must establish clear consent for the procedures that may be applied to that body. This consent will be established using: (50) In the event that the original consent is unclear, the University shall seek clarification in the form of the appropriate consent form and/or other pertinent information from the: (51) In the event that a new area of consent arises, for example where it is believed that a teaching or research activity will go beyond the established boundaries of consent covered on the University Body Donation Consent Form, the matter must be referred to Human Research Ethics Committee (HREC) for investigation and advice. (52) Following investigation, HREC will: (53) If HREC finds the activity acceptable, but deems it is not covered by the existing consent, the necessary consent must be obtained before conduct of the activity commences. (54) In reaching its decision, HREC will determine whether it is appropriate to seek additional consent for an existing body in respect of the activity. As the University wishes to limit anxiety and inconvenience for next of kin, HREC will only approve the seeking of additional consent for an existing donor body where: (55) In all other cases the University will address a lack of consent for a particular activity by updating the University Body Donation Consent Form for application in respect of new donor bodies. (56) The HREC shall, in consultation with anatomy employees, review any amendments to the University Body Donation Consent Form. This review will aim to ensure that the form: (57) Bodies and human tissues are only to be removed from storage equipment: (58) Bodies and human tissues must be retrieved from storage equipment by an anatomy employee. (59) When retrieving bodies and human tissues from storage, the anatomy employee must ensure that they adhere to all applicable safety procedures and conduct themselves in accordance with the Anatomy Facility Code of Conduct. The Anatomy Facility Code of Conduct will be clearly displayed: (60) On retrieving a body or human tissue from storage equipment, prior to handling any other body or human tissue, the anatomy employee must ensure that the identification number is firmly affixed to the body (via the identification tag) or is correctly displayed on the human tissue bin or specimen tank. (61) Bodies and human tissues may only be transferred between licenced anatomy facilities under the supervision of anatomy employees. In supervising transfer, anatomy employees are responsible for ensuring that the: (62) Each licenced anatomy facility will have its own body transfer register. When a body or human tissue is moved from one licenced anatomy facility to another: (63) Each buildings body transfer register is to be updated as transfers occur. Under no circumstances should bodies/human tissues be removed from or introduced to a licenced anatomy facility without concurrent update of the relevant body transfer register. (64) Depending on the purpose of the transfer, upon updating the body transfer register, the anatomy employee must ensure that the body/human tissue is secured, either by placing it in appropriate storage or delivering it to a licenced anatomy facility employee. (65) At the point of receipt into the University mortuary each body is allocated an identification number. The purpose of this number is to enable the University to identify all tissue belonging to a body at any given point in time and to re-unite all tissue belonging to a body, prior to disposal. (66) Staff are required to tag each body part with the body's identification number as the body is dissected. Tags are to be firmly affixed to each body part. Immediately following the dissection, staff must update the Anatomy Register with details of the dissection. (67) Staff are required to place all human tissue that is removed from a body during an anatomical examination into the body's allocated human tissue bin. (68) Staff and students must submit a written application and obtain written approval before they record an image of a body or human tissue. The written application must specify: (69) A separate application must be submitted for each image. (70) Applications to record an image of a body/human tissue are to be lodged with the Team Leader, Medical and Allied Health (Technical Support Services)of the relevant anatomy facility, or their delegate. (71) On receiving an application to record an image of a body/human tissue the Team Leader, Medical and Allied Health (Technical Support Services) of the relevant anatomy facility, or their delegate will check: (72) On receiving an application to record an image of a body/human tissue the approving officer will consider the application and, having sought whatever assistance or information they deem necessary, make a determination. The approving officer will notify the applicant of their decision in writing. In the event that the approving officer wishes to approve the recording of the image subject to additional requirements not specified in the original application, these additional requirements will be included in the notification to the applicant. Images may only be used after written approval has been received. (73) Having notified the applicant, the approving officer will then forward the application along with a copy of their written determination, to the relevant Team Leader, Medical and Allied Health (Technical Support Services) for filing and recording in the University's record management system. (74) All requests to defer disposal of a body or human tissue must be lodged at least six months in advance of the approved retention date to ensure the University is in receipt of a decision before the approved retention date lapses. (75) Bodies are normally retained for a maximum period of four years from death. Where need arises and consent is available, a request may be submitted to the NSW Department of Health to extend the approved retention period. (76) All requests to extend the approved retention period for a body are to be submitted to the NSW Department of Health via the licence holders. (77) Approval to extend the retention date must be obtained in writing from the NSW Department of Health. On receipt of written approval, the Anatomy Register must be updated to reflect the amended details regarding retention. (78) In the event that the NSW Department of Health refuses to grant the extension, disposal of the body is to be arranged in accordance with the appropriate procedures. (79) All human tissue from a body must normally be re-united in preparation for disposal, except where the: (80) All requests to retain human tissue must be submitted to the NSW Department of Health via the licence holder. (81) Approval to retain human tissue for an extended or unspecified period must be obtained in writing from the NSW Department of Health. On receipt of written approval, the Anatomy Register must be updated to reflect the details of the approval. Preparation for disposal of the rest of the body's remains should then commence. (82) In the event that the NSW Department of Health refuses to grant the approval to retain the human tissue, disposal of the body is to be arranged in accordance with the appropriate procedures. (83) At least two months before a body's approved retention date is due to lapse, the relevant Team Leader, Medical and Allied Health (Technical Support Services) will arrange for the body and all human tissue dissected from it, excluding any human tissue that is exempted from disposal in accordance with the Anatomy Act, 1977, to be re-united and placed in a coffin. (84) The relevant Team Leader, Medical and Allied Health (Technical Support Services) will then commence arrangements for the disposal of the body. Such disposal is to be conducted in accordance with the Anatomy Act, 1977 and, so far as possible, is to comply with the wishes of the deceased. (85) In respect of cremation, the Manager of the Donor Program must provide the Funeral Director with a copy of the: (86) In respect of burial, the Manager of the Donor Program must provide the Funeral Director with a copy of the: (87) At least one month prior to the arranged disposal date, the Manager of the Donor Program must notify the senior available next of kin of the arrangements that have been made in respect of the disposal of the body, including the: (88) Collection of bodies must be coordinated between the funeral director and the Team Leader, Medical and Allied Health (Technical Support Services) or delegate who must be present at the time of collection. (89) At the time of collection of a body the Team Leader, Medical and Allied Health (Technical Support Services) will provide the Funeral Director with: (90) Immediately following collection of the body the Team Leader, Medical and Allied Health (Technical Support Services) will: (91) Legislation pertaining to the management and utilisation of anatomy facilities and the receipt, handling, storage, tracking and disposal of bodies has developed over a period of time. It is envisaged that legislation will continue to evolve as new areas of scientific and medical interest emerge. Due to the emergent nature of science and medicine, individuals involved in these fields have an inherent responsibility not only to comply with existing legislation, but also to recognise when they are likely to transcend existing legislation and exercise due caution. (92) The following provides information about valuable sources of related information. It should be noted that the information in the documents listed refers to summary information only and does not replace the need to refer to the legislation. (93) This document clarifies the requirements of the Public Health (Disposal of Bodies) Regulation 2002 for hospital and health facility staff when managing the bodies of deceased patients within their facility. This document also provides guidance to the management of mortuaries and mortuary services. (94) The document stresses the importance of consulting relevant standards and guidelines for standards and procedures; the use of labelled body bags during transport, in addition to the use of labels on bodies; and the use of ongoing internal audits and monitoring against the relevant legislation, standards and guidelines. (95) These guidelines aim to assist the funeral industry and key people to understand and comply with the detail of the Public Health (Disposal of Bodies) Regulation 2002. The guidelines are not intended to be a manual on how to manage and dispose of a body, but rather to assist in deciding what is legal/illegal and what approvals may be required for the safe and hygienic handling and management of bodies. (96) Coverage includes topics such as: (97) This document provides guidance on mortuary facilities and operation as to the minimum standards considered acceptable for good laboratory practice. (98) Coverage includes topics such as: (99) This document provides guidance on the Human Tissue Act for Human Research Ethics Committees when reviewing research proposals involving human tissue. (100) The National Statement on Ethical Conduct in Human Research, 2007, contains a variety of information relevant to the management and utilisation of bodies that have been donated for medical and scientific purposes. For example, it contains information related to prohibited actions (e.g. trade in human bodies or tissue) as well as options, requirements and considerations that should be addressed in obtaining consent, such as the types of consent that can be obtained. (101) Records must be managed in accordance with the University's Records and Archives Management Policy and in consultation with the Records and Archives Management Services Unit.Anatomy Policy
Section 1 - Purpose and Context
Section 2 - Definitions
Top of Page
Section 3 - Policy Statement
Part A - Licence to Conduct Anatomical Examinations
Part B - Access
Access to Anatomy Facilities
Access to Body and Human Tissue Storage Equipment
Part C - Induction
Part D - Receipt, Storage, Handling, Tracking and Disposal of Bodies/Human Tissues
Part E - Duty of Care
Part F - Photographs and Images of Bodies/Human Tissue
Part G - Disciplinary Proceedings
Section 4 - Procedures
Part H - Admitting Users to Anatomy Facilities
Admitting Students
Admitting Contractors
Admitting Auditors/Inspectors
Departure of Admitted Parties
Part I - Receipt and Storage of Bodies
Part J - Obtaining Consent
Part K - Handling of Bodies and Human Tissues
Retrieving Bodies/Human Tissues from Storage Equipment
Transporting Bodies/Human Tissues between Licenced Anatomy Facilities
Tracking Bodies / Human Tissues during Anatomical Examination
Applying to Record Images of Bodies/Human Tissues
Part L - Disposal of Bodies and Human Tissues
Applications for Extended Retention of Bodies/Human Tissues
Deferring Disposal of a Body
Deferring Disposal of Human Tissue
Disposal
Collection of Bodies for Disposal
Top of PageSection 5 - Guidelines
Anatomy Facilities, Standards, Maintenance and Operation
NSW Department of Health (2007) "Deceased Persons in Health Facility Mortuaries & Management of Health Facility Mortuaries"
NSW Department of Health (2004) "Guidelines for the Funeral Industry"
National Pathology Accreditation Advisory Council, NPAAC (2004) "Guidelines for the facilities and operation of hospital and forensic mortuaries"
NSW Department of Health (2006) "Human Tissue - Requirements of the Human Tissue Act 1983 in relation to research and use of tissue"
National Statement Requirements
Record Management