Preparation of body for burial or cremation
Aerosol transmission and aerosol generating procedures
Aerosol transmission refers to the presence of particles which can remain in the air for long periods of time and be transmitted to others over distances greater than 1 metre.
Certain activities can result in the release of aerosols that may carry disease, including COVID-19. These are known as aerosol generating procedures (AGPs). AGPs can create a risk of airborne transmission of infections that are usually only spread by droplet transmission, therefore, additional precautions are required .
Awareness of AGPs is required for funeral directors who are embalming presumed COVID-19 deceased, and where any action might involve high speed devices. A risk assessment must be undertaken to establish what precautions will need to be taken, taking into account appropriate PPE, SICPs requirements and wider guidance on embalming, as set out by HSE .
Manual handling of a body, removal of a pacemaker or embalming without high speed devices is not considered an AGP.
Aerosol transmission can also occur in the absence of AGPs, in specific settings, particularly in indoor, crowded and inadequately ventilated spaces, where infected person(s) spend long periods of time with others .
First offices and embalming
In cases of presumed COVID-19 infection of the deceased, all routine preparations which would include first offices, as well as embalming and viewing of the deceased by family, may continue, subject to appropriate mitigations and standard SICPs and TBPs being in place . If embalming is carried out, the correct PPE should be worn and other standard infection control procedures followed .
Clinical waste should continue to be managed following normal processes and procedures . Funeral directors can consult with their contracted waste company of any further precautions that company may have in place at this time.
Where the deceased has a medical implant device, such as a pacemaker, cremation should not go ahead until the device is removed. Medical implants can continue to be removed safely from presumed COVID-19 deceased .
A funeral director must always make a risk assessment before carrying out any invasive procedure and ensure that all required infection control procedures are in place. In the absence of the correct PPE or required infection control measures being in place, removal of implant devices should not be performed. This will mean cremation cannot proceed.
Faith or cultural considerations
Specific practices observed by any faith group can continue for presumed COVID-19 deceased. However, they must only be carried out subject to all required infection prevention and control procedures being in place. If approached, a funeral director should seek to safely fulfil the requests of any faith or cultural group for the deceased in their care.
However, subject to an appropriate risk assessment, and if it is the view of the funeral director these requests cannot be safely fulfilled, for example due to a lack of appropriate PPE being available for all those who may wish to handle the body, then a sensitive discussion will need to take place with the family regarding any request.
People who have tested positive for COVID-19 or are symptomatic with COVID-19 should not attend. Those who are considered a higher risk or are shielding must carefully consider if they can attend safely, in line with public health advice applicable to them available on NHS Inform.
People who are not symptomatic or have not tested positive with COVID-19, but are self-isolating due to another member of their household either showing symptoms of COVID-19 or has tested positive with COVID-19, should not attend a funeral service in person. They should instead continue to follow household self-isolation advice.
In line with wider public health advice, viewings should be kept to the minimum number of attendees possible, and no more than the indoor gathering rules at a single time.
Taking account of similar restrictions in place for funeral services, visitors attending a viewing who do not live together should maintain at least a 2 metres distance from each other (except where they are from the same household, or are a carer and the person who is assisted by the carer).
Appropriate PPE for funeral director staff, such as wearing disposable gloves in a viewing area or a surgical face mask/visor, can be used to further mitigate infection risk to staff from visitors. Visitors must wear face coverings (see below, section 6), to help mitigate potential risk of their spreading infection within the viewing area.
It is not advisable for the family to touch the deceased or coffin during a viewing, unless wearing appropriate PPE such as disposable gloves/apron and if the funeral director can safely facilitate this request . Hand hygiene by all those in attendance should be carried out both before and after a viewing. Further information on effective hand hygiene is set out below.
Viewing at home
If the deceased are taken to family homes for viewings, the general rules of meeting indoors at all Protection Levels are to be observed. Funeral directors or others carrying the coffin in and out of the home, who are not part of the household, should wear PPE and take all other public health precautions. To further minimise any risk of infection, the coffin should remain closed if the following hazard boxes are ticked on the Certificate of Registration of Death (risk to public health from an (1) infectious disease and/or (2) from radioactive material or hazardous implant).
In order to reduce the risk of transmission of COVID-19, it is recommended that all viewings should be undertaken at a funeral director premises when possible, overseen by and kept under the control of funeral directors and/ or trained staff.
Personal possessions, including clothing
In order to spare families any additional distress, consideration must be given to jewellery, religious articles, mementoes and keepsakes. If it was the deceased’s and/or the family’s wish to retain such items, then they should be removed as soon as possible after death, and prior to insertion into a body bag or coffin. Families should be informed that these items will need to undergo appropriate disinfection processes before being returned to them.
Items can be cleaned with a household detergent and disinfected with a household bleach solution. Any items of clothing should be placed in a bag and taken home by the family who should be advised that the items should be washed separately from other household members’ items, in accordance with the manufactures instructions using the hottest water setting. If families do not have access to their own washing machine, items should be kept bagged for 72 hours and can then be taken to a laundrette.
However, families need to be sensitively reminded that it might not be possible for all items requested to be removed, as some items may not be able to be disinfected due to their composition. Should this be the case, then the removed items will remain with the deceased and will be buried or cremated with them.
If it is the wish that they remain on the body, and cremation is requested, consideration of cremation requirements and associated potential hazards should be considered by the funeral director before placing an object with the deceased. If in any doubt, you should contact your local crematorium to discuss this.
Environmental cleaning – mortuary
Regular cleaning of the mortuary environment in line with routine SICPs, should continue. This will include cleaning of surfaces with a chlorine based disinfectant, in the form of a solution at a minimum strength of 1,000ppm available chlorine. Follow manufacturer’s instructions for dilution, application and contact times for all detergents and disinfectants.
 For further context on AGPs see joint PHS/PHE guidance, COVID-19: infection prevention and control guidance, page 32
 HSE, Managing infection risks when handling the deceased, pages 17-22, 37-43
 World Health Organisation, Coronavirus disease (COVID-19): How is it transmitted?, 20 October 2020
 PHE, Guidance for care of the deceased with suspected or confirmed coronavirus, subheading ‘risk of transmission of COVID-19 from an infected body’ and HSE, Managing infection risks when handling the deceased, page 17-22, 37-43
 Managing the environment of the funeral home and managing infection risks within embalming spaces is set out in detail in HSE Managing infection risks when handling the deceased, from page 39
 Joint UK publication, COVID-19 Infection prevention and control guidance, section 4.10. NHS Scotland have also published a National Infection Prevention and Control Manual. Aimed at a healthcare setting Section 1.9, safe disposal of waste, may help inform processes in the mortuary environment if not already in place.
 If the deceased has a micro pacemaker implanted and it is not possible to remove in advance of cremation, due to its size or position within the deceased, funeral directors should consult their cremation authority. The cremation authority will be able to advise if cremation can safely proceed with the micro pacemaker in situ, following consultation with their cremator manufacturer
 European Centre for Disease Prevention and Control, Considerations related to the safe handling of bodies of deceased persons with suspected or confirmed COVID-19, page 3, ‘storage and preparation of body before burial or cremation’.
 Practical steps to help manage mortuary environments safely are set out in HSE Managing infection risks when handling the deceased, pages 17-22, 27-34, 37-43