View Document

Surgical Skills and Anatomy Procedure

This is the current version of this document. To view historic versions, click the link in the document's navigation bar.

Section 1 - Purpose

(1) This Procedure specifies the activities for receipt, handling, storage, tracking, recording and disposal of Bodies/Human Tissue in the Surgical Skills Centre and Anatomy Laboratory (SSAC) within the Faculty of Medicine, Health and Human Sciences.

Scope

(2) This Procedure applies to all Macquarie University (University) staff, students and visitors.

Top of Page

Section 2 -  Policy

(3) Refer to the Surgical Skills and Anatomy Policy.

Top of Page

Section 3 -  Procedures

(4) The Director, Surgical Skills Centre and Anatomy Laboratory will ensure the Body Donation Program and Anatomical Examinations are conducted in accordance with:

  1. the Relevant Laws;
  2. the Anatomy Licence;
  3. the University’s contractual obligations to third parties, in particular the terms and conditions of a Tissue Supplier; and
  4. consents to Anatomical Examinations.

(5) The Director, Surgical Skills Centre and Anatomy Laboratory will provide advice to the Executive Dean, Faculty of Medicine, Health and Human Sciences and seek advice from the Human Research Ethics Committee (Medical Sciences) as necessary.

(6) In consultation with the Executive Dean, Faculty of Medicine, Health and Human Sciences and other SSAC Staff, the Director, Surgical Skills Centre and Anatomy Laboratory will conduct regular and ongoing reviews of the terms of the Body Donation Program to ensure that it:

  1. encompasses all Anatomical Examinations conducted or to be conducted at the University; and
  2. addresses statutory requirements.

(7) All SSAC Staff, Students and Authorised Users will be provided with the relevant induction into the SSAC.

Oversight of the Surgical Skills and Anatomy Policy and Body Donation Program

(8) The Human Research Ethics Committee (Medical Sciences) (the Committee) has oversight of the Surgical Skills and Anatomy Policy and Body Donation Program.

(9) When requested by the Executive Dean, Faculty of Medicine, Health and Human Sciences and/or the Director, Surgical Skills Centre and Anatomy Laboratory, the Committee will provide advice on:

  1. whether new areas of teaching or research go beyond the established boundaries of consent given under the University’s Body Donation Program; and
  2. review of the terms of the Body Donation Program consent forms.

(10) The Executive Dean, Faculty of Medicine, Health and Human Sciences will monitor:

  1. the University’s compliance with the Surgical Skills and Anatomy Policy and this Procedure and all Relevant Laws, including compliance with the conditions of the Anatomy Licence; and
  2. the University’s Body Donation Program.

Licencing

(11) The Director, Surgical Skills Centre and Anatomy Laboratory is responsible for obtaining and maintaining a current Anatomy Licence to conduct Anatomical Examinations from NSW Health.

(12) When the named Anatomy Licence holder will be absent for more than three (3) months, the Director, Surgical Skills Centre and Anatomy Laboratory must apply to NSW Health for reissue of the Anatomy Licence in the name of the holder’s delegate.

Consent

(13) The Director, Surgical Skills Centre and Anatomy Laboratory will review consent to use a Body/Human Tissue as follows:

  1. on receipt of donated Body/Human Tissue; and
  2. prior to using a donated Body/Human Tissue for any Anatomical Examination, by viewing relevant consent for the procedures that may be applied. The consent may be:
    1.  a Body Donation Program consent form;
    2. an equivalent consent/agreement form obtained from the Anatomy Licence holder; or
    3. documented in the terms and conditions of the Tissue Supplier from which a Body/Human Tissue has been procured or transferred.

(14) In the event that a new area of consent arises, e.g. where it is believed that an activity will go beyond the consent, the Director, Surgical Skills Centre and Anatomy Laboratory will refer the matter to the Committee for advice.

(15) If consent is revoked by a donor, the Director, Surgical Skills Centre and Anatomy Laboratory will complete the revocation form acknowledging that receipt of the revocation has been received and return a copy to the donor.

Transfer of a Body/Human Tissue

(16) A transfer of a Body / Human Tissue to another Anatomy Licence holder within Australia may only occur if:

  1. this is in accordance with the relevant consent or Tissue Supplier’s terms and conditions; and
  2. approval has been received from NSW Health.

(17) In such circumstances, the University retains control over the disposal of Bodies/Human Tissue.

Access to Anatomical Facilities

(18) Access to the SSAC will only be granted by the Director, Surgical Skills Centre and Anatomy Laboratory if the following are confirmed:

  1. the identity of the individual seeking access;
  2. the individual's authority to gain access; and
  3. that appropriate supervision is in place, where required.

(19) All users must wear appropriate personal protective equipment.

(20) Prior to granting a Student access to the SSAC the following is required:

  1. confirmation of a Student's formal enrolment in a relevant unit;
  2. verification of a Student's identity against their Student identification card;
  3. confirmation that a Student completes or has completed induction; and
  4. confirmation that supervision is in place for the Student at all times.

(21) Access to the SSAC will not be granted to a Student who is not formally enrolled in a relevant unit or who fails to produce a valid Student identification card. No other form of identification will be accepted.

(22) Contractors will only be admitted to the SSAC if they:

  1. have booked repairs and general maintenance through the Director, Surgical Skills Centre and Anatomy Laboratory;
  2. have completed an induction in order to be granted access to the SSAC;
  3. carry formal photographic identification with them during the course of the repairs or maintenance; and
  4. present their formal photographic identification on each entry to the SSAC and/or upon request of the Director, Surgical Skills Centre and Anatomy Laboratory or a Campus Security Officer.

(23) Auditors/Inspectors will be admitted to the SSAC following confirmation:

  1. of the identity of the auditor/Inspector by sighting their staff identification card that each auditor/Inspector has completed the necessary induction; and
  2. that supervision is in place to monitor and assist the auditor/Inspector while they are in the SSAC.

(24) An Authorised User must be supervised until such time as:

  1. supervisor responsibility is handed to another SSAC Staff member; or
  2. the Authorised User has departed the facility.

(25) The SSAC should be secured following the departure of the Authorised User.

Receipt

(26) Prior to accepting a Body/Human Tissue into the SSAC, the Director, Surgical Skills Centre and Anatomy Laboratory will confirm that:

  1. the Body has been delivered by an accredited funeral director in accordance with the Anatomy Act 1977 or in the case of tissue sourced internationally or from interstate, the tissue is delivered by an approved courier;
  2. the Body/Human Tissue is accompanied by all necessary documentation pertaining to the consent/authority to conduct an Anatomical Examination;
  3. the Body/Human Tissue is consistent with the accompanying paperwork, as far as can be determined by visual inspection;
  4. the transfer of Bodies/Human Tissue into the SSAC is conducted discreetly;
  5. the required screening for Human Immunodeficiency Virus (HIV), Hepatitis B and Hepatitis C and any other Prescribed Infectious Disease has been performed prior to or on receipt of the Body/Human Tissue;
  6. an infected Body/Human Tissue received through the University’s Body Donation Program is quarantined in accordance with any Relevant Laws and not used for teaching/research and NSW Health is notified; and
  7. there is sufficient storage capacity to take the Body/Human Tissue.

(27) The Director, Surgical Skills Centre and Anatomy Laboratory will coordinate the receipt of a Body/Human Tissue from the contracted funeral director or Tissue Supplier, as appropriate and ensure that it is delivered to SSAC for verification and receipting purposes.

Handling

(28) Personal Protective Equipment must be worn while conducting or participating in Anatomical Examinations.

(29) Handling and transportation of Bodies/Human Tissue must be undertaken in accordance with the Public Health Regulation 2012 and the Australian Guidelines for the Prevention and Control of Infection in Healthcare published by the National Health and Medical Research Council.

(30) On accepting a Body/Human Tissue the Director, Surgical Skills Centre and Anatomy Laboratory will ensure:

  1. a numbered identification tag is attached to the Body/Human Tissue so that the SSAC Staff and the Inspector can identify all Bodies/Human Tissue and cross reference with the Body Register;
  2. all prescribed details pertaining to receipt of the Body/Human Tissue, is recorded in the Body Register; and
  3. the Body/Human Tissue is placed in the refrigerator/freezer storage, where the Body/Human Tissue remains until required.

(31) If after receiving a Body/Human Tissue the SSAC has reasons to believe is infected with a Prescribed Infectious Disease, the body bag must be clearly labelled with “prescribed infectious disease – handle with care” before removing the Body/Human Tissue from SSAC in accordance with the Australian Guidelines for the Prevention and Control of Infection in Healthcare.

Storage

(32) On completion of an Anatomical Examination, a Body/Human Tissue is placed in appropriate storage equipment in accordance with the Relevant Laws.

(33) A Body/Human Tissue should be removed from storage in the following circumstances:

  1. when required for Anatomical Examination;
  2. to enable repairs, maintenance or upgrade of facilities;
  3. in preparation for disposal;
  4. to satisfy requirements of an internal audit;
  5. to satisfy requirements of an external inspection conducted by an Inspector; or
  6. as otherwise required by Relevant Laws.

(34) When retrieving a Body/Human Tissue from storage, adherence to any applicable safe work procedure is required.

(35) On retrieving a Body/Human Tissue from storage, prior to handling any other Body/Human Tissue, confirmation is required that the identification tag is firmly affixed to the Body or bag.

Tracking

(36) During an Anatomical Examination, each Body part must be tagged with the Body's identification number as the Body is dissected. Immediately following the dissection, the Body Register must be updated with details of the dissection. Any tag which is removed, lost or damaged must be replaced.

Recording 

(37) To request approval to record an image of a Body/Human Tissue, a completed Recording Agreement – Anatomy Laboratory form must be submitted to the Director, Surgical Skills Centre and Anatomy Laboratory.

(38) On receiving a Recording Agreement – Anatomy Laboratory form, confirmation is required that:

  1. the application is complete and clearly addresses each of the requirements; and
  2. the relevant consent has been provided.

(39) Following assessment, the application will be either be:

  1. returned for completion/clarification;
  2. rejected and the applicant advised in writing; or
  3. approved.

(40) Body/Human Tissue should be retained for the period specified in the relevant consent, Relevant Laws or as permitted by NSW Health.

Disposal

(41) In preparation for disposal all Human Tissue from a Body should be reunited, except where:

  1. the Human Tissue is sourced from a Tissue Supplier which allows Human Tissue to be disposed of separately;
  2. the University has obtained written consent to permanently retain the Human Tissue;
  3. the Human Tissue being retained is a small sample of Human Tissue, in the form of tissue slides or tissue blocks that enable microscopic examination of the tissue; or
  4. tissue is removed during prosecution and is not identifiable (refer to NSW Health Policy Directive [PD2011_052]).

(42) The Director, Surgical Skills Centre and Anatomy Laboratory will arrange for the disposal of a Body/Human Tissue in accordance with the Relevant Laws and, as far as possible, with the relevant consent.

Body Sourced in New South Wales

(43) The Director, Surgical Skills Centre and Anatomy Laboratory will co-ordinate the collection of a Body with the relevant funeral director. The collection will be scheduled to ensure the Director, Surgical Skills Centre and Anatomy Laboratory or SSAC Staff delegate is present at the time of collection.

(44) At the time of collection of a Body, the Funeral Director must be provided with:

  1. a Medical Certificate of Cause of Death;
  2. a Cremation Risk Advice;
  3. a Transfer Authority Form when authorising transport from a hospital; and
  4. any additional documentation relevant to the wishes of the deceased.

(45) Immediately following collection of the Body:

  1. the Body Register will be updated ensuring that details of any disposed Body/Human Tissue are clearly described in accordance with the Relevant Laws; and
  2. where applicable, the relevant Anatomy Licence holder will be notified of the actions that have been taken in disposing of the Body.

(46) For a locally donated Body, if requested on the consent form, the available Senior Next-of-Kin will be notified when cremation has taken place and when the ashes are available for collection.

Body/Human Tissue Sourced from Tissue Supplier

(47) In order to cremate Human Tissue obtained from a Tissue Supplier:

  1. a written application must be submitted to NSW Health requesting permission to dispose of the identified Body/Human Tissue;
  2. the identified Body/Human Tissue is placed in a coffin;
  3. the funeral director collecting the coffin is provided with a copy of the letter of authority from NSW Health; and
  4. the Body Register must be updated, ensuring that details of any disposed Body/Human Tissue are clearly described in accordance with the Relevant Laws.

Defer Disposal of a Body/Human Tissue

(48) Where the need arises for disposal to be deferred and consent is available, a request to NSW Health must be submitted via the Executive Dean or nominee to extend the approved retention period. All requests should be submitted at least six (6) months in advance of expiry of the approved retention date to ensure the SSAC receives a decision before the approved retention date lapses.

(49) Upon receipt of written approval to extend the retention date from NSW Health, the Body Register must be updated to reflect the amended retention details.

(50) In the event that NSW Health refuses to grant the extension, the Body/Human Tissue should be disposed of in accordance with the Relevant Laws.

Reporting Illegal Activity

(51) Any Authorised User who is acting unlawfully or inappropriately should be instructed to leave the SSAC, as appropriate.

(52) If there is any activity that directly or indirectly breaches State or Commonwealth law, such suspected illegal activity, it must be reported to the appropriate authorities (e.g. the police). The Campus Security Manager must be informed in all cases of potential offences under the Crimes Act 1900 (NSW).

(53) The Director, Surgical Skills Centre and Anatomy Laboratory will liaise with external bodies, including law enforcement agencies, as required.

Disposal of Records

(54) Records relating to the Anatomy Licence (including applications for the Anatomy Licence) may be disposed of one (1) year after expiry.

(55) The Body Register may be destroyed after five (5) years from the date of transfer or disposal of a Body/Human Tissue.

(56) Records relating to the acquisition, storage, maintenance and management of Bodies/Human Tissue may be disposed of one (1) year after the transfer or disposal of the Body/Human Tissue.

(57) All other records must be retained as required by the State Records Act 1998 and disposed of as authorised by that Act.

Reporting Distress

(58) Authorised Users should inform SSAC Staff as soon as possible when experiencing anxiety, distress or grief when first encountering a Body/Human Tissue or recognising a Body as a person known prior to that person's death (e.g. a relative, friend or neighbour).

Top of Page

Section 4 - Guidelines

(59) Nil.

Top of Page

Section 5 - Definitions

(60) The following definitions apply for the purpose of this Policy:

  1. Anatomical Examination means the examination of a Body/Human Tissue, including the dissection of a Body/Human Tissue, for medical or scientific purposes, but not including post-mortem examination.
  2. Anatomy Licence means a licence to conduct anatomical examinations, as issued by the Director-General of NSW Health in accordance with the Anatomy Act 1977.
  3. Authorised User means a person who is authorized by any SSAC Staff member to access SSAC facilities.
  4. Body/Bodies means a deceased human body.
  5. Body Register means a register as prescribed by the Anatomy Act 1977 and that records:
    1. receipt of a Body/Human Tissue;
    2. transfer of a Body/Human Tissue; and
    3. disposal of a Body/Human Tissue.
  6. Human Tissue means part of a deceased human Body.
  7. Inspector means an officer of NSW Health.
  8. NSW Health means the New South Wales Ministry of Health.
  9. Prescribed Infectious Disease is as defined in the Public Health Regulation 2012.
  10. Relevant Laws means the Anatomy Act 1977, the Human Tissue Act 1983, the Public Health Regulation 2012 (NSW), the Anatomical Examinations and Anatomy Licensing Policy Directive 2023 and any associated subordinate legislation or guidelines.
  11. Senior Next-of-Kin is as defined in the Relevant Laws.
  12. SSAC Staff means a Macquarie University staff member employed at the SSAC.
  13. Student means a student of Macquarie University or another institution who requires access to the SSAC for the purpose of their training/research.
  14. Tissue Supplier means an interstate or international Body donation facility authorised by NSW Health that holds a valid import licence from the Department of Agriculture, Fisheries and Forestry, Australian Quarantine and Inspection Service.