Workplace hazards in forensic mortuaries in Saudi Arabia: A survey of forensic mortuary personnel

Abstract

Forensic mortuaries have always presented a potential threat to workers who come into contact with dead bodies. This research aims to identify hazards faced by forensic mortuary personnel, including forensic pathologists and technicians working in forensic mortuaries in forensic medicine centres throughout Saudi Arabia, to recognise the prevalence of exposure to workplace hazards and to discover the degree of awareness and use of safety practices. A descriptive, cross-sectional study was conducted in a total of 20 forensic medicine centres, using an online questionnaire distributed among forensic mortuary personnel. A total of 113 participants responded to the questionnaire. Just over half (53%) of workplaces always provided personal protective equipment, and 75% of participants always used them. The most common hazards were needle-prick wounds and accidental slips or falls. Almost two thirds (64%) of participants witnessed or experienced a work-related accident in the forensic mortuary. The lack of previous studies concerning hazard exposure among forensic mortuary personnel in Saudi Arabia means that this study provides foundational evidence for future research concerning forensic autopsy-related work accidents in Saudi Arabia.

Keywords

Forensic pathology forensic autopsy forensic mortuary occupational hazard occupational safety Saudi Arabia

Introduction

Work conditions in forensic medicine, particularly in forensic autopsy rooms, can be challenging. The term ‘autopsy’ means ‘to see for oneself’ and is synonymous with ‘post-mortem examination’ and ‘necropsy’.¹ Forensic autopsies play a major role in determining the cause of death in cases of unnatural, sudden or unexpected deaths and in finding answers in difficult cases.² Forensic mortuaries have always had the potential to pose threats to the workers and attendants, who have direct or indirect contact with dead bodies.^1,3 From this perspective, every dead body must be considered a potential source of infection, and dealt with according to recommended precautions and the fundamentals of pre-exposure prophylaxis.⁴ The terms ‘hazard’ and ‘risk’ are often used synonymously, but each term differs in definition.¹ Hazard is ‘the potential for a substance, activity or process to cause harm or adverse events’. However, risk is defined as ‘a combination of the likelihood and the severity of a substance, activity or process to cause harm’.⁵ Occupational hazards affecting health-care professionals can be classified into biological, chemical, physical, ergonomic and psychosocial hazards.⁶ Forensic autopsy‐related risks can be grouped as physical, biological, chemical, electrical and psychosocial risks, as described below:

Physical risks include injuries via sharp instruments, accidents associated with lifting and dragging heavy loads, falling, slipping, eye strain and burns.^3,7

Biological risks include infectious agents in dead bodies via inhalation, ingestion or splashing into eyes of infectious agents.^3,7 According to the Health and Safety Executive Advisory Committee on Dangerous Pathogens, biological agents are stratified into four groups (see Figure 1), depending on the likelihood of infection, the severity of disease, the availability and efficacy of treatment and the risk of transmission to the public.^1,7

Figure 1.

Stratification of biological agents into hazard groups.^1,7

Chemical risks include exposure to fixatives (formalin), solvents, disinfectants, and latex.^3,8

Electrical risks include poorly maintained cables and connections.⁷

Psychosocial risks include work‐induced stress, stigmatisation and depression.⁹

Saudi Arabia has 20 forensic medicine centres, catering for both forensic pathology and clinical forensic medicine services.¹⁰ The centres are affiliated with the Ministry of Health, which has its head office in Riyadh and branches across the country in major cities and towns.^10,11 The 2018 annual forensic report showed that a total of 3459 medico-legal cases were referred to forensic medical centres throughout the country, of which 1344 were autopsied and 2155 were for external examination only.¹² Autopsies are performed only in medico-legal/forensic cases.^2,13

The literature on hazards and risks faced by workers in forensic mortuaries in Saudi Arabia is presently unclear. Hence, this cross-sectional study aimed to identify hazards faced by forensic pathologists and technicians working in the 20 forensic medicine centres throughout Saudi Arabia in order to understand the prevalence of exposure to these hazards, to discover the awareness and execution of safety practices after exposure and to provide recommendations to help close gaps that arise prior, during and after exposure to these potential hazards.

Methods

Sample

A cross-sectional, descriptive study was designed to collect data from forensic mortuary personnel working in all 20 forensic medicine centres in Saudi Arabia. Forensic mortuary personnel included forensic pathologists, technicians and other mortuary staff, and 113 responses were received.

Setting

Forensic autopsies are conducted in the forensic mortuaries (autopsy facility/autopsy room) of forensic medicine centres located in various cities and towns throughout the country. Self-reported data were collected from March 2020 to May 2020 from forensic mortuary personnel working in forensic medicine centres using an online questionnaire.

Instrument

A literature review was performed to identify existing relevant surveys, and accordingly, we used these previous studies to assist in developing our questionnaire.^9,14 Three academicians in forensic medicine reviewed the questionnaire for content validity. Further, their comments and suggestions were discussed among the authors and considered in the development of the final version of the questionnaire. The questionnaire included multiple domains: socio-demographic characteristics, hazard exposure, occupational and vaccination histories, use of personal protective equipment (PPE) and training.

Procedure

The questionnaire was distributed electronically to the heads of forensic medicine centres who in turn disseminated the online questionnaire to their respective staff.

Analysis

The completed questionnaires submitted by the participants were checked for completeness, and the data obtained were coded, entered and analysed using IBM SPSS Statistics for Windows v20.0 (IBM Corp., Armonk, NY). Categorical variables are presented as frequencies and percentages. We calculated the relative risk and applied the chi-square test to assess the association between characteristics of participants and their responses, and a p-value of <0.05 was considered statistically significant.

Ethical approval

This study was approved by the Institutional Review Board of Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia. A brief description of the study, including the objective, was presented as an introduction following which the consenting participants proceeded to answer the questionnaire. Monetary benefits or any other incentives were not offered to the participants, and participation was voluntary. Personally identifiable information of the participants was not collected. The questionnaire was anonymous, and confidentiality of the data collected was maintained.

Results

A total of 113 responses were obtained, representing a response rate of 57%. Most participants were male (91%), married (94%) and Saudi (92%). Fifty-five per cent were aged 25–40 years, and almost one third (29%) had a diploma degree (Table 1). All female respondents were forensic pathologists, and there were no female technicians among the respondents. Table 2 shows the occupational history of the participants. Twenty-four per cent had 6–10 years of work experience. According to participants, 53% of their workplaces always provided PPE, and 75% of participants always used it. Fifty-seven per cent of participants underwent proper education and training on infection control prior to working, and 40% received continuous training (Table 3).

Table 1.

Participants’ socio-demographic characteristics.

Variable	Frequency (N = 113)	Percentage (100%)
Age
25–40 years	62	54.9
>40 years	51	45.1
Sex
Male	103	91.2
Female	10	8.8
Marital status
Single	7	6.2
Married	106	93.8
Nationality
Saudi	104	92.0
Non-Saudi	9	8.0
Educational level
Secondary school	14	12.4
Diploma	33	29.2
Bachelor	15	13.3
Master	11	9.7
PhD	23	20.4
Other	17	15.0

Table 2.

Occupational history of the participants.

Variable	Frequency (N = 113)	Percentage (100%)
Current job
Technician	65	57.5
Forensic pathologist	43	38.1
Other mortuary staff	5	4.4
Working previously in another institute
Yes	40	35.4
No	73	64.6
Years of experience
<1 year	9	8.0
1–5 years	12	10.6
6–10 years	27	23.9
11–15 years	22	19.5
16–20 years	14	12.4
21–25 years	13	11.5
>25 years	16	14.2
Working days in mortuary
1	16	14.2
2	14	12.4
3	36	31.9
4	18	15.9
5	29	25.7
Any mental illness during the current job
Yes	5	4.4
No	108	95.6

Table 3.

Participants and protective measures.

Variable	Frequency (N = 113)	Percentage (100%)
The facility you work in provides protective equipment
Always	60	53.1
Sometimes	46	40.7
Never	7	6.2
You use protective equipment
Always	85	75.2
Sometimes	24	21.2
Never	4	3.5
You begin to use protective equipment when doing the following
Entering the mortuary	74	65.5
Transferring and preparing for autopsy	19	16.8
Undertaking an autopsy	20	17.7
You are provided with enough education about infectious diseases and proper preventative measures in the mortuary prior to working
Yes	65	57.5
No	48	42.5
You are provided with continuous education on infection and prevention through training, orientation and seminars
Yes	45	39.8
No	67	59.3

Those vaccinated against hepatitis B virus (HBV; n = 56; 49.6%) were equal in number to those who were not, and 41.6% (n = 46) reported that they had immunity against HBV confirmed by a serology test.

Although 63.7% of participants witnessed or experienced a work-related accident in the forensic mortuary, only 23% ever reported such an incident. The majority thought that training for safety measures (99%), raising awareness (93%) and using PPE (96%) reduce forensic mortuary–related risks.

The most common hazards were needle-prick wounds, encountered by 62% of participants, followed by slip and fall accidents (26%), skin rash/allergies (13%) and chemical exposure accidents (12%). Electrocution accidents were encountered by only 3% of participants (Table 4). Accidents resulted in disability or permanent infirmity in 8.8% (n = 10) of participants.

Table 4.

Hazards encountered by participants.

Hazard	Total
Hazard	n	%
Slip/fall accident	29	25.7
Electrocution accident	3	2.7
Chemical accident	14	12.4
Needle prick/wounds	70	61.9
Skin rash/allergy	15	13.3
HBV/HIV infections	7	6.2

HBV: hepatitis B virus; HIV: human immunodeficiency virus.

Needle-prick wounds occurred only in males. They occurred 1.13 times more often in those >40 years of age when compared to the lower age group of 25–40 years. They also occurred 1.13 times more often in technicians than in forensic pathologists and 1.4 times more often in those with >15 years of experience than in those with less experience.

Slip and fall accidents occurred only in males. They occurred 1.3 times more often in the 25–40 age group. All were technicians with <15 years of experience. Skin rashes and allergies occurred four times more often in males, four times more often in technicians and 1.5 times more often in people >40 years of age.

Chemical accidents involved only males. They occurred twice as often in the 25–40 age group, five times more often in technicians and twice as often in those with <15 years of experience. Electrocution accidents and HBV/HIV infections occurred only in males. All accidents causing disability or permanent infirmity involved males in the 25–40 age group who worked in the forensic mortuary as technicians.

Discussion

Forensic mortuaries pose workplace hazards for staff working there. The lack of previous studies concerning hazard exposure among forensic mortuary personnel in Saudi Arabia means that this study provides foundational evidence for areas of safety improvement and future research concerning forensic autopsy-related work accidents in Saudi Arabia.

The concept of PPE is known universally in health-care facilities.¹⁵ In the forensic mortuary, using appropriate safety measures helps protect dead-body handlers against occupational hazards.⁹ Many factors play a major role in compliance with using PPE, including PPE availability at the workplace.¹⁴ The UK Royal College of Pathologists recommends using standard protective clothing for all forensic autopsies.¹⁶ The present study revealed that not all workplaces always provided PPE and not all forensic mortuary personnel always used PPE. Therefore, PPE availability along with appropriate standards and guidelines should be implemented and monitored.

In the present study, only a third of those who experienced work-related accidents in the forensic mortuary reported such incidents. The reasons for minimal reporting of such incidents are unclear, especially as there are no financial or job security consequences on reporting. This subject may warrant further research. Evans et al.¹⁷ reported that the biggest barrier to reporting incidents among doctors and nurses is a lack of feedback. Douglas and Peterside⁹ noted that no action was taken after forensic mortuary staff reported hazard exposure. The lack of a clear pathway for reporting such accidents may cause misreporting.¹⁷

All workplaces should identify needs and gaps in the knowledge and experience of staff. Although educational training and a licence to practice are required to work in a forensic mortuary in Saudi Arabia, not all participants in the present study reported that they had proper training and education on infection control prior to beginning work. These participants may have obtained their qualification many years ago with an improper focus on hazards and infection control. Forensic mortuaries in Saudi Arabia under the Ministry of Health’s authority may be disconnected from academic institutes that offer continuous education which may be the reason for more than half of the participants not receiving continuous training. Therefore, more efforts should be considered to identify educational needs of forensic mortuary personnel. In addition, information should be offered in various forms, such as verbal instructions, job instructions and practice codes to enhance knowledge and practice.¹⁸

Half (50%) of the present study participants were vaccinated against HBV when compared to no forensic mortuary staff being vaccinated against HBV in the Ndola study conducted in Zambia.¹⁴ However, the percentage of forensic mortuary staff vaccinated against HBV in the present study is lower than that reported in a Chinese study where more than two thirds of staff were immunised.¹⁹ These findings show variations in universal precautions being followed in different countries.²⁰ Studies done in Nigeria blamed the lack and/or delay in completing the doses on decreased motivation, lack of knowledge by forensic mortuary staff and unavailability of HBV vaccines.^9,20

Needle pricks are a common injury among all health-care professionals and can lead to major pathogen infections. HBV, hepatitis C virus (HCV) and HIV are the most commonly reported pathogens associated with needle-prick wounds. The associated risk of HIV infection following a needle injury is about 0.3% compared to 3% for HCV and 30% for HBV.²¹ In the present study, needle-prick wounds were the most commonly encountered mortuary hazards, which may be linked to a small percent of the forensic mortuary personnel being infected with HBV/HIV. Awareness of these infections and routine vaccinations among the forensic mortuary staff have led to a decrease in forensic mortuary–acquired infections in the past 25 years.²² However, a significant number of dead bodies might be infected with pathogens and transmit infections when safety measures are not implemented appropriately. A study conducted in Iran found that 2.6% of dead bodies were infected with HIV, 3.8% with HBV and 9% with HCV. The total infection rate was 15.5%.²² Omitting pre-exposure vaccines among forensic mortuary staff is threatening and is associated with an increased risk of infection.²³

Similar studies showed varying prevalence of sharps injuries during autopsy via instruments and the body itself.²³ A study in Port Harcourt, Nigeria, showed that 91% of forensic mortuary staff reported needle pricks.⁹ In Ndola, Zambia, the prevalence was only 18.2%.¹⁴ These incidents could result from improper training and handling of sharp objects in the forensic mortuary. Therefore, safe sharp practices should be followed to reduce injury and its consequences. Furthermore, slip/fall accidents were reported as the second most common hazard, occurring in a quarter of the participants in the present study, which is low when compared to 94% reported in Port Harcourt, Nigeria.⁹ Slips and falls are commonly caused by inadequate lighting and ventilation and by slippery floors.²³

Additionally, 13% of participants reported having skin rashes/allergies, which is low in comparison to Port Harcourt, Nigeria (29%).⁹ Electrocution accidents were reported least in the present study. Any occupation using operating tools and machinery has a risk of electrical injury. This study reveals no further details about the nature and extent of such injuries. In addition, no published report exists on incidences of electrical injury in forensic mortuaries.

The present study reported that accidents resulting in disability or permanent infirmity occurred in <10% of participants. Unfortunately, no clear data exist from other places to compare. Permanent infirmity is a medico-legal concept that can lead to a long-lasting burden and loss of productive work, which might affect individuals and functioning at workplaces.²⁴

In the present study, occupational injuries were reported primarily by males. This is inevitable, as most of the participants in the present study were males, with females constituting <10% of participants. Gender differences should be considered in health safety policies because differences relate to job safety and hazards via different physical and psychological characters.²⁵ A 2001 survey conducted in the USA reported that 79% of certified forensic pathologists were male and 21% were female.²⁶ Generally, there has been a recent increase in females in the forensic field.²⁷

We found that those with >15 years of experience working in forensic mortuaries had a 1.4 times higher risk of needle pricks compared to those with less experience. This difference could be because more experienced forensic mortuary personnel have been exposed to more cases. In recent years, there were also advancements in techniques and safer ways to handle bodies in forensic mortuaries. So, those who were trained >15 years ago were not using these methods. In contrast to the present study, other studies suggested an inverse relationship between the number of years of experience and needle-prick injuries.¹⁴ On the other hand, the present study showed that fewer years of experience increased the risk of slip/fall accidents and chemical accidents.

Generally, technicians were more prone to all types of accidents when compared to forensic pathologists. All accidents resulting in disability or permanent infirmity occurred in technicians, and chemical accidents occurred five times more in technicians. The reasons behind these findings warrant further investigation. However, possible causes include technicians getting less training than forensic pathologists and technicians’ higher involvement with chemicals, dissection techniques and sharp object disposal. Besides, technicians are possibly less obliged to follow safety precautions. Skin rashes and allergies were four times more common in technicians than in forensic pathologists, possibly because technicians handle chemicals more in the forensic mortuaries. There is a lack of literature on comparisons of forensic mortuary hazards between forensic pathologists and technicians.

The limitations of the present study include the inability to measure and quantify the extent of some hazards and their cause. In addition, an evaluation of psychosocial hazards is missing. The potential bias of questionnaire-based self-reported data should also be noted. Although a low response rate is a major limitation, the present study lays the foundation for future regional research in this field.

Conclusion

Forensic mortuaries present various threats to staff if health and safety practices are not strictly followed. The most common hazards reported by participants were needle-prick wounds, followed by slip/fall accidents, skin rashes/allergies and chemical accidents. This study provides foundational evidence for future research concerning forensic autopsy-related work accidents in Saudi Arabia. All forensic mortuary facilities should assess their safety measures to provide a safe environment for forensic pathologists and technicians during, prior to and after direct exposure to many hazards. Increased awareness, education, professional courses, enforcing PPE use, completing all necessary vaccinations and establishing a well-defined reporting system for accidents will help forensic mortuary personnel.

Footnotes

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The authors received no financial support for the research, authorship and/or publication of this article.

ORCID iDs

Mohammed Madadin

Mohammed A Almarzooq

Ritesh G. Menezes

References

Burton

Rutty

The hospital autopsy: a manual of fundamental autopsy practice. 3rd ed. Hoboken: CRC Press, 2010.

Sohaibani

MO.

Autopsy and medicine in Saudi Arabia.

Ann Saudi Med 1993; 13: 213–214.

Shaha

Patra

Das

, et al. Awareness of risks, hazards and preventions in autopsy practice: a review. J Evol Med Dent Sci 2013; 2: 4030–4041.

Claydon

SM.

The high risk autopsy: recognition and protection. Am J Forensic Med Pathol 1993; 14: 253–256.

Lofstedt

RE.

Risk versus hazard – how to regulate in the 21st century. Eur J Risk Regul 2011; 2: 149–168.

Huei LC, Ya-Wen L. Ming YC, et al. Occupational health and safety hazards faced by healthcare professionals in Taiwan: a systematic review of risk factors and control strategies. SAGE Open Med 2020; 8: 2050312120918999.

Facilities for mortuary and post-mortem room services . 3rd ed. London: The Stationery Office, 2005.

Ulutasdemir

Tanir

Occupational risks of health professionals. In: Orthan K (ed) Occupational health. London: InTech, 2017, pp.45–57.

Douglas

Peterside

SS.

Assessment of workplace hazards in mortuaries in Port Harcourt, Nigeria. Port Harcourt Med J 2016; 10: 102–110.

10.

Ministry of Health. Statistical yearbook https://www.moh.gov.sa/Ministry/Statistics/book/Documents/book-Statistics-2018.pdf (2018, accessed 18 December 2020).

11.

Al-Waheeb

Al-Kandary

Aljerian

Forensic autopsy practice in the Middle East: comparisons with the west. J Forensic Leg Med 2015; 32: 4–9.

12.

Al Madani

Kharoshah

Zaki

, et al. Origin and development of forensic medicine in the Kingdom of Saudi Arabia. Am J Forensic Med Pathol 2012; 33:147–151.

13.

Kharoshah

Hussain

Madadin

, et al. Consented autopsy and the Middle-East. Sci Eng Ethics 2017; 23: 321–322.

14.

Litana

Kapambwe

Occupational health hazards among mortuary attendants at Ndola teaching and Arthur Davison children’s hospitals. Asian Pac J Health Sci 2017; 4: 88–94.

15.

Kadam

Akhade

Desouza

Autopsy practice, potential sources of occupational hazards: a review for safety and prevention. J Indian Acad Forensic Med 2015; 37: 196–201.

16.

The Royal College of Pathologists. Guidelines on autopsy practice, www.ihrdni.org/314-008-1.pdf (2002, accessed 7 March 2021).

17.

Wolf

Hughes

RG.

Error reporting and disclosure. In: Hughes RG (ed) Patient safety and quality: an evidence-based handbook for nurses. Rockville: Agency for Healthcare Research and Quality (US), 2008, Chapter 35.

18.

Health and Safety Executive. Managing infection risks when handling the deceased, https://www.hse.gov.uk/pubns/books/hsg283.htm (2018, accessed 18 December 2020).

19.

Zhang

Wang

Miao

, et al. Occupational exposure to blood and body fluids among health care workers in a general hospital, China. Am J Ind Med 2009; 52: 89–98.

20.

Ogunnowo

Anunobi

Onajole

, et al. Exposure to blood among mortuary workers in teaching hospitals in south-west Nigeria. Pan Afr Med J 2012; 11: 61.

21.

Parsons

EC.

Successful reduction of sharps injuries using a structured change process. AORN J 2000; 72: 257–279.

22.

Gharehdaghi

Khorasgani

Ghadiani

, et al. Prevalence of HCV, HBV, and HIV seropositivity among cadavers referred to autopsy hall of Legal Medicine Bureau of Tehran, Iran. Adv Prev Med 2017; 2017: 2043840.

23.

Burton

JL.

Health and safety at necropsy.

J Clin Pathol 2003; 56: 254–260.

24.

El-Hady

Thabet

Ghandour

, et al. Medico-legal aspects of permanent infirmities as a sequel of different types of injuries: a retrospective study in Assiut Governorate, Egypt. Ain Shams J Forensic Med Clin Toxicol 2013; 20: 92–98.

25.

TUC. Gender in occupational safety and health, https://www.tuc.org.uk/sites/default/files/GenderHS2017.pdf (2017, accessed 18 December 2020).

26.

Randall

Survey of forensic pathologists. Am J Forensic Med Pathol 2001; 22: 123–127.

27.

Barbaro

Women in forensics: an international overview.

Forensic Sci Int Synergy 2019; 1: 137–139.