The Local Health Unit of São José, in Lisbon, was forced to review corpse identification procedures after two bodies were swapped, an error that was only detected by one of the families during the funeral. The case occurred in January and was disclosed by the Health Regulatory Authority, which considered the occurrence of "special gravity," highlighting that the swap was not identified by any of the participants in the process, from the health auxiliary technicians of the mortuary to the funeral agency representative, despite the existence of a formal double verification procedure in force.
According to the ERS, on January 15th, the body of a patient who had died the day before was improperly delivered to a funeral agency, when the corpse of another patient, also deceased on the same day, should have been delivered. The health auxiliary technicians admitted they did not follow the mandatory double verification procedure for corpse identity, nor did they report the incident to their hierarchy, justifying the omission with "focus on the immediate resolution of the situation."
The regulatory authority identified as causes of the incident a significant increase in the number of deaths, which caused overcrowding of the mortuary, the adoption of exceptional storage solutions in the morgue, and a high number of corpse releases on a single day. These factors contributed to physical fatigue among professionals and to decreased attention to rigorous procedure compliance. After the swap, ULS São José implemented corrective measures, such as the daily allocation of a health auxiliary technician exclusively for administrative tasks and service to funeral agencies, and reinforced supervision of the mortuary.
The ERS also mandated additional preventive measures, including the revision and reinforcement of internal corpse identification procedures, the implementation of robust double verification mechanisms, internal audits, and the adoption of measures appropriate for overcrowding situations, including reinforcement of human and material resources. In another deliberation, the ERS also issued an instruction to the ULS of Braga to ensure that all instruments used in procedures are properly counted and removed before patient discharge.
