Mass Fatality Plan Checklist

The Pan American Health Organization has developed a checklist on mass fatalities that can serve as an annex to any National Health Sector Emergency Management Plan or National Disaster Management Plan. It is based on the London Resilience Mass Fatality Plan, 2006 and Management of Dead Bodies after Disasters: A Field Manual for First Responders.

The checklist contains the essential elements for consideration by Ministries of Health and Disaster Management Offices as they develop a mass fatality plan. The plan does not need to stand alone; it can be an annex to the National Disaster Management Plan. As such, the mass fatality annex only needs to focus on elements unique to a mass fatality. It is important that countries exercise their plans on a regular basis to evaluate organization's capability to execute one or more portions of the plan and to promote preparedness.

The Essential Elements

Outline the purpose of the plan.
List assumptions of a Mass Fatality Plan.
Define the scope of the plan and local hazards that can create mass fatalities, i.e. type, frequency, level of impact, etc.
List members of mass fatality coordination committee/key partners, stakeholders in the planning and implementation process.

Describe the activation process and identify who or what agency will be responsible for activating the Plan, i.e. Same authority as in the National Health Sector Emergency Management Plan or the National Disaster Management Plan.
Include a call out chart and attach roles and responsibilities to each individual for this phase of the plan.

Discuss with local health, law enforcement and disaster management officials where/how mass fatality fits in with national plans.
Discuss role of health authorities, NGOs and national disaster offices during mass fatalities.
Discuss legal authority for handling of dead bodies from the point of examination by a physician/pathologist to the actual burial process. Consider the investigative needs of law enforcement agencies.
Outline the local incident command structure and provide an organizational chart for chain of command, including operations, logistics, planning, and finance/administration. Reference all hazards/emergency operations plan as appropriate.

Consider arrangements for providing transportation for the movement of the deceased/remains/personal effects.
Storage facilities for temporary morgues may involve the commandeering of 20/40 ft refrigerated containers. Remember that each container has limited capacity and requires considerable quantities of fuel - the cost of which can be substantial.
Emergency communications with all relevant parties must be done through secured channels that are not easily accessible by the media and general public.
Provision of resources - are there national/regional stocks available that can be used i.e. coffins, body bags, waterproof labels, dry ice etc.
There may be the need for provision of portable electrical supply and water to field sites.
Designate a trained individual supporting team members to mange and oversee logistical arrangements.
Identification of local and regional technical specialists/resources and arrangements for obtaining their services through agreements.

Mention provisions that will be made for handling the welfare needs of family and friends including a designated area for viewing/identifying bodies (consider cases where bodies have to be isolated as in the case of some epidemics).
Discuss with the medical examiner the process involved in releasing or allowing for burial of the dead and the recognized forms of burial in the country. Ensure that provisions are made in the plan for addressing local cultural and religious needs of the community.
Include linkages with local Crisis Intervention Teams or psycho-social support teams and define procedures for their activation based on level of assistance that they can provide.

Identify a team of persons from law enforcement, health authority, social services etc. who can serve to identify the deceased (with use of forensic procedures), securing the remains and reuniting with family/friends. Consider the local rescue and recovery procedures in place and how these will be linked to the work of this team. A physician or pathologist should determine how partial remains would be handled and these decisions included in the plan.
Include information regarding the legal rights of the deceased, e.g. Law Enforcement Acts, Interpol Resolution AGN/65/res/13 (1996), humanitarian laws and other ethical and social norms.
Arrangement for viewing of bodies should be included, facilities identified and arrangements for setting these up as well. Consider how the bodies will be stored and presented and who will be responsible for these activities.
The matter of investigation should be carefully considered and the relevant information included - review legislation relevant to inquests, registration of death, insurance procedures, criminal actions etc.
The plan should consider disaster situations when specialist identification teams are not available or the scale of the disaster exceeds local capacity. Arrangements for external assistance and/or local arrangements to facilitate identification at the local level should be considered.

Mass fatality incidents may involve foreign nationals. These may be foreign workers living in the affected areas, tourists, illegal immigrants or relatives of affected families.
The mass fatality plan should be distributed to foreign embassies or consulates of countries from which large tourist populations arise.
Many countries deal with illegal immigrants on a regular basis and therefore procedures should be available to support this element of the plan. Include all provisions for repatriation of victims to home country - consult with Immigration and Attorney General's chambers and consider finances for such actions.
Department of Foreign Affairs or Governor's Offices should be consulted on arrangements for returning victims who are nationals from your country who died in the country where the disaster has occurred. Arrangements for receiving these victims should be included in the plan and provisions for handling the deceased once they have been received.
Consider special arrangements that may be required such as embalming and how the death certificates will be issued.
In the event that tourists or high level officials are involved and their remains are being shipped, consideration must be given to the sensitivity of such situation and the controlled release of information to the local and international media. Consult the Pan American Health Organization/World Health Organization resolution on the International Transportation of Human Remains (1966).
Identify the national and regional INTERPOL counterparts and define arrangements for requesting their assistance when required.

Clearly define procedures for photographing victims/body parts and placement of proper identification tags - what tagging system will be used as per police procedures and who will be responsible for keeping accurate records of these. Also consider where these procedures will take place (collection point) and provision of adequate security measures.
Procedures for photographing, labeling and securing personal effect must also be included in the plan - who will be responsible for these processes? Most likely assigned to the Police. Are resources available such as digital cameras with sufficient memory?
Provisions should be made for a victim audit (may be advisable to have an external group to the police) to verify that the correct procedures were followed. The plan must define who, where and how this will be preformed.
In certain situations such as criminal and/or terrorist attacks the disaster site must be preserved for investigative purposes - whose responsibility will this be and how will it be done, This should be outlined in the plan in a step by step format - consult with a law enforcement agency on this matter.

For storage and body preparation local morgue facilities and funeral homes - location, capacity, resources etc., should be listed in the plan with relevant contact details. Transportation to these facilities must be considered. The plan should consider the development of national/regional stocks of coffins, body bags etc. MOUs can be developed with private morgue/funeral homes and included as part of the plan. Consult with Attorney General's Chambers on these arrangements.
Ensure that the plan addresses issues such as individuals who die while being transported and those who die in hospitals as a result of injuries sustained from the disaster. In some countries they are passed through the same procedures as those who have died at the disaster site.
Consider arrangements for handling the media and for security at these facilities.
A general principle should be applied - hospital mortuaries should NOT be used unless numbers are manageable especially in the case where there is only one available hospital. Temporary mortuary facilities should also be considered.
Ensure that law enforcement agencies identify and provide procedure for securing routes for transporting victims to identified morgue facilities.

Procedures for returning the deceased to families must be clearly defined - these can be provided by the physician/pathologist. The wishes of the family for returning partial remains must also be considered.
Discussions should take place with the physician/pathologist and social welfare or other relevant local agencies regarding the disposal/burial of unclaimed victims/remains. The legal issues must be considered and discussed with the Attorney General's Chambers. Ensure that these are clearly documented in the plan.

Include procedures for handling such events including how remains should be handled, personal protective equipment, decontamination requirements and procedures and ongoing monitoring of the site and any remains or items removed and where cold storage facilities can be located.
Consider decontamination arrangements for vehicles and other storage equipment and facilities and environmental impacts along with requirements for evacuation or isolation of surrounding communities.
Arrangements with external agencies may have to provide for risk assessments and advice on viewing, return of bodies, burial, cremation and repatriation. Identify such agencies in the plan and establish MOUs accordingly.

Many countries have National Public Information Plans and Policies. These can be applied to this element of the plan. Official statements should be channeled through the relevant media centers either at the National Emergency Operations Centre (NEOC) or incident command post in the field. Information from all sites, i.e. mortuary, hospital, family viewing areas, should be channeled to the NEOC for compilation.
Media should be restricted from entering mortuary facilities or crisis intervention centers/family viewing areas - include procedures for securing these areas and for channeling information to the media center.
Procedures for releasing names of deceased should be clearly defined in the plan especially considering large numbers of unidentified deceased victims. Provisions should be made for setting up facilities for the public to enquire about missing/deceased persons and these site should be away from the hospital and mortuary.

Consider provisions for the welfare and psychological needs of responders - the local Crisis Intervention Teams or mental health services can lend support in this area. Consider how volunteers from the Red Cross and other similar services can be accommodated to provide such support - once they are trained.
There may be a need to identify and equip rest areas - whose responsibility will this be and how will the resources be acquired should be established locally.
Provision should also be made to determine how responders who have lost family members and friends will be handled and by whom.

In many countries it is the responsibility of the Police to set up and manage the documentation of the deceased at the mortuary and for evidential continuity. Relevant forms, procedures and a layout of the mortuary should be included in the plan.
In the event of a large scale event involving numerous victims it may be necessary to establish a mortuary management team. The composition of the team should be included in the plan along with call out procedures and responsibilities for each individual.
Include as part of this element the mortuary procedures to be followed: Registration and arrival, storage, examination and photographing, cleaning of body, radiography, fingerprints, Odontology, re-bagging, embalming, viewing, release of body, bodies not claimed, repatriated bodies, DNA and toxicology, documentation, securing of property, equipment list, waste disposal, staffing, visitors, health, safety and welfare.

Contact

Department of Emergency Preparedness and Disaster Relief
Tel: (202) 974-3434
Email: disaster@paho.org