A-Z Policy Listing

BODY DONATION POLICY

Date first approved:

19 August 2016

Date of effect:

19 August 2016

Date last amended: N/A

(refer Version Control Table)

Date of Next Review:

19 August 2019

First Approved by:

University Council

Custodian title & e-mail address:

Team leader, Anatomy Laboratory - anatomylab-enquiries@uow.edu.au

Author:

Team leader, Anatomy Laboratory - anatomylab-enquiries@uow.edu.au

Responsible Division & Unit:

Faculty of Science, Medicine and Health

Supporting documents, procedures & forms of this policy:

Anatomy Laboratory Hire Procedure
Anatomy Management Committee Terms of Reference Authorisation Documents (available from the Licensee)
Body Donation Program Procedure
Laboratory Manuals and Inductions (available from Anatomy Laboratory staff)
Making an Offer of Remains for Anatomical Examination and/or Medical Research Form (Donor Registration Forms)
Private Study Agreement (available from Anatomy Laboratory Staff)
Records Management Policy

Research Misconduct Policy

Risk Assessments (available from Anatomy Laboratory staff or via SafetyNet)
Safe Work Procedures (available from Anatomy Laboratory staff or via SafetyNet)
Standard Operating Procedures (available from Anatomy Laboratory staff).
Student Conduct Rules

Transfer Certificate (available from Anatomy Laboratory staff)
University Code of Conduct

UOW Biosafety Manual

UOW Laboratory Safety Guidelines

Use of University Name in Public Statements Policy

Whole Body Transfer Agreement (available from Body Donation Program Coordinator)
Workplace Health and Safety Policy

Relevant Legislation

&

External Documents:

Anatomy Act 1977(NSW)
Australian and New Zealand Standard Safety in Laboratories AS/NZS 2243.3.2010
Births, Deaths and Marriages Registration Act 1995
(NSW)
Conduct of Anatomical Examinations and Anatomy Licensing in NSW
(NSW Health policy directive)
Coroner’s Act 2009
(NSW)
Guidelines for Certification of a Physical Containment Level 2 Laboratory

Human Tissue Act 1983
(NSW)
Public Health Act 2010
(NSW)
Public Health (Disposal of Bodies) Regulatory Impact Statement 2011

Public Health Regulation 2012
(NSW)
Waste Management Guidelines for Healthcare Facilities PD2005_132

Audience:

Public

Submit your feedback on this policy document using the Policy Feedback Facility

Contents

1 Purpose of Policy

  • 1. This policy provides a framework identifying key roles and responsibilities of staff, students and visitors and sets out principles and decision-making processes associated with the Body Donation Program (BDP) and the Anatomy Laboratory.
  • 2. This policy provides an overview of the operations of the Body Donation Program and Anatomy Laboratory to ensure compliance with the extensive legislative requirements relating to anatomical examination. This policy will be accessible as a reference and source of information to University staff and the wider community.

2 Definitions

  • 1. This policy will follow the definitions covered by the Conduct of Anatomical Examinations and Anatomy Licensing in NSW (NSW Health policy directive), as these are standard terms in the legislation. Terms not listed in the legislation (or that require clarification) are defined below.

Word/Term

Definition

Donor Registration Form

The completed “Offer of Remains for Anatomical Examination and/or Medical Research Form” (the formal consent form) which also encompasses information necessary for Body Donation Program administration purposes.

Anatomical examination

Anatomical examination of a body includes the use of the body for medical or scientific purposes. Medical and scientific purposes include educational and/or research purposes connected with medicine or science.

Anatomical Material

Material derived from a human body, either preserved or unpreserved, used for teaching or research purposes.

Anatomy Laboratory

The Anatomy Laboratory at the University of Wollongong.

Anatomy Laboratory Database

Online database software that securely houses donor information.

Anatomy Management Committee

A Committee consisting of University staff associated with the Body Donation Program and anatomical teaching and research. The Anatomy Management Committee is responsible for developing and maintaining governance practices and procedures to ensure compliance with relevant legislation and that the principles of the Body Donation Policy are upheld.

Body

A dead whole human body.

Body Donation Program

A program at the University of Wollongong whereby members of the community register their interest in donating their body to the University of Wollongong after death to be used for teaching and/or research purposes.

Donor

A person who has completed the Donor Registration Form and is registered within the Body Donation Program as wishing to donate their body to the University of Wollongong.

Licensee

The holder of a Licence to Conduct the Study and Practice of Anatomy issued by NSW Health. The Licensee is responsible for applying for the Licence to Conduct the Study and Practice of Anatomy and ensuring that all conditions of the licence are met.

SOP

Standard Operating Procedure. A document listing and explaining the steps in a procedure.

University/UOW

University of Wollongong.

Transfer certificate

UOW internal document completed by the Funeral Director when delivering a body to the Anatomy Laboratory and the same certificate for that donor is completed (by the Funeral Director) when the body leaves the Anatomy Laboratory

Body Donation Program Coordinator

The person appointed by the Faculty of Science, Medicine and Health to manage the Body Donation Program.

3 Application & Scope - Exclusions or Special Conditions (if any)

  • 1. This policy applies to all persons associated with the Body Donation Program and the Anatomy Laboratory at the University of Wollongong. This includes:
    • 1.1. Staff associated with the administration of the Body Donation Program
    • 1.2. Technical staff working in the Anatomy Laboratory
    • 1.3. The Anatomy License holder for the University
    • 1.4. Academic staff involved with teaching anatomy-based subjects at the University
    • 1.5. Students enrolled in subjects taught in the Anatomy Laboratory
    • 1.6. Volunteers working in the Anatomy Laboratory
    • 1.7. Visitors to the Anatomy Laboratory
    • 1.8. Anyone conducting research in the Anatomy Laboratory
    • 1.9. Contractors, maintenance and cleaning staff working in the Anatomy Laboratory
    • 1.10. Any other person entering the Anatomy Laboratory for any reason

4 Policy Principles

  • 1. The training and research enabled by the Body Donation Program can lead to important health discoveries that have the potential to alleviate suffering and improve community wellbeing. For this reason, it is greatly appreciated by medical researchers, teachers and students. The University of Wollongong offers a Body Donation Program to the public to help train health-care workers and scientists including doctors, nurses, medical scientists, exercise physiologists, and other health-related professionals.
  • 1. The University will use best endeavours to ensure that donors’ remains will be treated with dignity, respect and anonymity at all times. University of Wollongong students are made aware of the special and unique privilege that has been accorded to them by the generosity of Donors and their families.
  • 2. The University will undertake the following activities in fulfilling its commitment to conducting the study of Human Anatomy with the highest possible regard for the generous donation made by donors and their families, the highest possible teaching and research standards and compliance with all relevant legislation:
    • a. Develop and maintain governance practices and procedures to ensure compliance with relevant legislation;
    • b. Allocate sufficient financial and physical resources to enable compliance with the relevant legislation;
    • c. Provide potential donors and their families with sufficient information to make informed choices; and
    • d. Strive to make the best possible use of all donated anatomical material to ensure the highest standards of teaching and research can be maintained.

5 Licensing of the Anatomy Laboratory

  • 1. The Anatomy Laboratory at the University consists of a main teaching laboratory, a smaller tutorial room, a preparation room and a refrigerated mortuary space for the storage of specimens of bodies and anatomical material.
  • 1. The Anatomy Laboratory operates under a Licence to Conduct the Study and Practice of Anatomy from the Director General of NSW Public Health, in accordance with the Anatomy Act 1977 and the Conduct of Anatomical Examinations and Anatomy Licensing in NSW (NSW Health policy directive).
  • 2. This licence is subject to the provisions of the Anatomy Act 1977, the Human Tissue Act 1983 and the Public Health Act 1991 and is issued for a two-year period subject to satisfactory annual inspections.
  • 3. The licence is issued to an individual (or the holder of an identified position), who is responsible for authorising persons to conduct examination of anatomical material within the licensed space (Conduct of Anatomical Examinations and Anatomy Licensing in NSW (NSW Health policy directive)) and ensuring that all requirements of the licence are met.
  • 4. Under the Anatomy Act 1977, “any person who is in charge of the conduct of anatomical examinations” can apply for the licence to conduct anatomical examinations.
  • 5. The Licensee is responsible for applying to the Director General for a licence renewal at least three months prior to the expiry of the current licence
  • 6. Once a licence has been granted, the NSW Department of Health must be notified in writing of any change to the designated licence holder of an institution (Conduct of Anatomical Examinations and Anatomy Licensing in NSW (NSW Health policy directive)).

6 Body Donation Program

  • 7. The University operates a Body Donation Program whereby members of the community can offer to donate their bodies after death for anatomical teaching and research purposes. The Body Donation Program is managed by the Faculty of Science, Medicine and Health’s appointed Body Donation Program Coordinator (BDP Coordinator).
  • 8. No payment is made by the University to the donor in connection with a body donation. However, the University will cover the cost of transportation to and from UOW, cremation, medical documentation (medical certificate / cremation certificate) and registering the death if the body is accepted into the Program.
  • 9. A person wishing to donate his/her body to the University of Wollongong may apply to do so by completing the required forms and being registered as a donor, as detailed in the Body Donation Program Procedure.
  • 10. A body can only be accepted into the Body Donation Program on the condition that all requirements set out in the Body Donation Procedure are met. Potential donors and their families must understand that there are circumstances in which a body may not be accepted. These conditions are made clear in the information documents provided to potential donors at time of enquiry.
  • 11. A bequest may be retracted in writing at any time by the donor or person having Power of Attorney. A donor may also retract their own bequest over the phone providing their identity is proven to the satisfaction of the BDP Coordinator.
  • 12. Upon the death of a registered donor, the University must be contacted as soon as reasonably practicable during business hours. In the meantime, if removal is required by a licenced local funeral director, they should be informed that the deceased is a Donor.
  • 13. A body is transported to the Anatomy Laboratory by a licensed Funeral Director and should be accompanied by the Medical Certificate Cause of Death (MCCD) and the Attending Practitioner’s Cremation Certificate (APCC) (if relevant). The Funeral Director completes the Transfer Certificate and the Mortuary Register. Information relating to the donation must be recorded in a timely manner according to the Deceased Donor Arrival, Extension and Expiration SOP.
  • 14. The University (through the BDP Coordinator) is responsible for registering the death of donors accepted into the Program with the NSW Department of Births, Deaths and Marriages (Births, Deaths and Marriages Registration Act 1995).
  • 15. Upon acceptance into the Program, a body should be embalmed as soon as possible (Embalming SOP).

7 Appreciation of Donations

  • 1. The University has a dedicated space known as the Garden of Rest at Lakeside Memorial Park and Crematorium in Dapto where the ashes of donors can be scattered if this is the preference indicated on the Donor Registration Form.
  • 2. The University will pay the cremation fee for donors who have indicated on the Donor Registration Form that they wish to be cremated at the end of their time in the Anatomy Laboratory.
  • 3. The University will also pay the cost of a commemorative plaque to be placed in the Garden of Rest for donors who choose to have their ashes scattered there.
  • 4. The University conducts an Appreciation Ceremony for prospective donors and families of those who have donated, every two years.

8 Transfer of Bodies or Anatomical Material to other Licensed Institutions

  • 1. The University may transfer donated bodies (in full) surplus to the requirements of the UOW Anatomy Program to other licensed anatomy facilities, providing the donor has specifically given consent for the transfer as part of the Donor Registration Form.
  • 2. All transfers must follow the Anatomy Act 1977 and the Conduct of Anatomical Examinations and Anatomy Licensing in NSW (NSW Health policy directive). The procedure for this is detailed in the Direct Transfers SOP.
  • 3. A transfer to an institution in another state can only be conducted with the prior approval of a NSW inspector (Conduct of Anatomical Examinations and Anatomy Licensing in NSW (NSW Health policy directive)).
  • 4. The decision to transfer is made by the Licensee in consultation with the Anatomy Laboratory Team Leader and/or the BDP Coordinator. The Licensee/BDP Coordinator must seek information on the potential use of the bodies by the receiving institution and confirmation of the institution’s licence status.
  • 5. The receiving institution is required to cover UOW costs incurred in connection with the transfer of the donation and sign a Whole Body Transfer Agreement detailing their responsibilities following the transfer including disposal of the body at the end of the licence period.

9 Record Keeping

  • 1. The Anatomy Act 1977 and the Conduct of Anatomical Examinations and Anatomy Licensing in NSW (NSW Health policy directive) require that donated bodies are registered and tracked by the licenced Anatomy Facility. At the University of Wollongong, this is done using the Anatomy Laboratory Database, a specially designed database with restricted access. Backups of the electronic copies are conducted daily. Paper copies of documents are also stored securely in locked filing cabinets.
  • 2. All staff members associated with the Body Donation Program are responsible for updating information and uploading relevant documents as soon as possible to ensure information is available to all staff working in this area.
  • 3. Information relating to donations must be kept for at least 5 years from the date of the most recent entry (Conduct of Anatomical Examinations and Anatomy Licensing in NSW (NSW Health policy directive)) and stored according to the UOW Records Management Policy.
  • 4. The procedures for maintaining donor records are detailed in the following SOPs: Database Usage and Cadaver Tracking SOP, Deceased Donor Arrival Extension and Expiration SOP, Admitting Visitors into the Laboratory SOP.

10 Access to Anatomy Laboratory

  • 1. Access to the Anatomy Laboratory is dependent on having completed the required inductions and compliance with the regulations of the Laboratory Access is approved by the Anatomy Licensee and restricted to the following groups:
        • a. The Anatomy Licensee;
        • b. Authorised Anatomy Laboratory technical staff and their supervisors ;
        • c. Authorised academic staff involved in the teaching of Anatomy at UOW;
        • d. Authorised students enrolled in a subject at the University which is taught in the Anatomy Laboratory;
        • e. Authorised persons conducting anatomical research;
        • f. Authorised volunteers;
        • g. Authorised external groups with prior approval;
        • h. Authorised visitors with prior approval;
        • i. Contractors and maintenance staff under supervision of Anatomy Laboratory staff, and
        • j. Cleaning staff who have completed relevant inductions.
  • 1. Access for external groups can be arranged using the Anatomy Laboratory Hire Application Form providing the group meets the criteria for anatomical examination as stated in the Anatomy Act 1977. The process is detailed in the Anatomy Laboratory Hire Procedure.
  • 2. All persons must be inducted before entering the Anatomy Laboratory. Induction requirements vary according to the purpose of the laboratory visit as per the Admitting Visitors into the Laboratory SOP.
  • 3. All persons entering the Anatomy Laboratory with the intention of anatomical examination must first receive authorisation to conduct Anatomical Examinations from the Licensee.
  • 4. Access for students outside of scheduled class times is dependent upon staff supervision and the completion of and compliance with the Private Study Agreement.
  • 5. The Anatomy Laboratory is secured when staff are not present to prevent unauthorised access. The security systems, access and authorised staff are described in further detail in the Admitting Visitors into the Laboratory SOP.
  • 6. The access restrictions do not apply to rescue workers or UOW Security staff in the event of an emergency.

11 Authorisation to Examine Anatomical Material

  • 1. As per the Anatomy Act 1977, a person must not conduct anatomical examination of a body unless the person is the holder of a licence or is authorised to do so by the holder of a licence (the current UOW Licensee).
  • 1. The Anatomy Licensee is able to authorise the examination of anatomical material to persons having a legitimate involvement in the study and practice of anatomy (Anatomy Act 1977 and the Conduct of Anatomical Examinations and Anatomy Licensing in NSW (NSW Health policy directive)). This includes, but is not limited to:
    • a. Anatomy Laboratory technical staff;
    • b. Academic staff involved in the teaching of Anatomy at UOW;
    • c. Students enrolled in a subject at the University which is taught in the Anatomy Laboratory;
    • d. Persons conducting anatomical research;
    • e. Volunteers working within the laboratory;
    • f. External groups visiting for anatomical education, and
    • g. Other visitors or researchers with an anatomical purpose.
  • 2. Scientific research can only be conducted on bodies of donors who have specifically consented to have their bodies used for research purposes.
  • 3. The procedures for obtaining authorisation to examine anatomical material are described in the Admitting Visitors into the Laboratory SOP

12 Use of Images of Anatomical Material

  • 1. Images of donor’s body and /or tissues will only be used in a manner consistent with the Anatomy Act 1977 and/ or Human Tissue Act 1983 with the permission of the donor.

13 Disposal of Bodies

  • 1. In accordance with NSW law, the University of Wollongong is able to retain a body for up to four years after death. Upon application the local anatomy inspector may authorise the retention of a body for an additional four year period (Anatomy Act 1977 and the Conduct of Anatomical Examinations and Anatomy Licensing in NSW (NSW Health policy directive)). The procedure for disposal of a body within the licence timeframe is outlined in the Deceased Donor Arrival Extension and Expiration SOP.
  • 1. The University of Wollongong will attempt to fulfil the wishes of the deceased and their families with regards to disposal as far as reasonably possible. The Donor may advise the University of his/her preference for the disposal in the Donor Registration Form. (Public Health (Disposal of Bodies) Regulation 2002).

14 Permanent retention of tissue

  • 1. The University may permanently retain some anatomical tissue from a donor, provided the donor gave permission for this as part of the Donor Registration Form (Anatomy Act 1977 and the Conduct of Anatomical Examinations and Anatomy Licensing in NSW (NSW Health policy directive)).
  • 1. The Donor has the opportunity to nominate any organs or parts which they do not wish to be retained this way in the Donor Registration Form.
  • 2. Any permanently retained tissue must be kept in the best possible condition to ensure longevity.
  • 3. Should it become necessary to dispose of any retained tissue separately from the rest of the body, the Donor and their families are advised that small amounts of tissue may be disposed of as clinical waste or in the case of a body part which is not a small amount of tissue suitable for disposal as clinical waste, the part will be cremated and the ashes scattered at the University’s Garden of Rest.

15 Anatomy Management Committee

  • 1. The University has a dedicated Anatomy Management Committee for the review and management of Anatomy teaching and resources.
  • 1. The primary objective of the Committee is to ensure that the principles of the Body Donation Policy are upheld.
  • 2. The Chair of the Committee is responsible for communication with the University as a whole. For matters which require specific information, the chair can nominate a member of the Anatomy Committee as the spokesperson in that instance.
  • 3. The Chair will be the Head of School, or Senior Academic staff member appointed by the Head of School and the appointment may be reviewed at the Head of School’s discretion.
  • 4. Minutes are taken at Anatomy Management Committee meetings and circulated to all members.
  • 5. Other information regarding the committee may be found in the Anatomy Management Committee Terms of Reference.

16 External Communications

  • 1. Communication with the public about aspects of the Body Donation Program and the Anatomy Laboratory is conducted by the Chair of the Anatomy Management Committee (or their nominee) through the University Media Unit. Communication will comply with the Use of University Name in Public Statements Policy.

17 Breaches of this Policy

  • 1. Breaches of this Policy by students may be referred to the Student Services Division to be dealt with as misconduct under the Student Conduct Rules.
  • 2. Breaches of this Policy by Staff may be referred to the Human Resources Division to be dealt with as misconduct under the relevant Enterprise Agreement.

18 Roles & Responsibilities

  • 1. The Faculty of Science, Medicine and Health is responsible for providing financial, physical and staff development resources to enable compliance with relevant legislation, regulations and policies.
  • 1. The Anatomy Licensee is responsible for meeting all legislative requirements of the Anatomy Act 1977 and the relevant provisions of the Human Tissue Act 1983, the Coroner’s Act 2009 and the Public Health (Disposal of Bodies) Regulation 2010 or any subsequent regulation made under the Public Health Act. The Licensee is responsible for applying for the Licence to Conduct the Study and Practice of Anatomy and ensuring that all conditions of the licence are met (Conduct of Anatomical Examinations and Anatomy Licensing in NSW (NSW Health Policy Directive)).
  • 2. The Anatomy Laboratory Team Leader is responsible for managing the operational running of the laboratory, supervising students and staff while in the laboratory, ensuring sufficient resources are available for teaching and research, and supporting the Licensee in ensuring that the Anatomy Laboratory complies with relevant legislative requirements.
  • 3. Technical staff employed within the Anatomy Laboratory is responsible for supporting the Anatomy Team Leader in the operational running of the Anatomy Laboratory and ensuring compliance with relevant legislation by all users of the Laboratory.
  • 4. The Body Donation Program Coordinator is responsible for the day to day management of the program, including but not limited to the design, publication and ethics approval of program documentation, all communication with interested parties regarding donations, oversight of the donor registration process and all procedures relating to the acceptance / non-acceptance of registered donors into the Program at time of death. The Coordinator reports to the licensee on a needs basis.
  • 5. The Body Donation Program Coordinator is responsible for entering and maintaining records of donors and registering the death for donors accepted into the UOW Body Donation Program.
  • 6. Students, visitors, maintenance staff and contractors are responsible for completing relevant inductions, following directions given by Laboratory staff and complying with all rules of the laboratory. They are to be supervised by staff at all times (with the exception of cleaning staff) and are not permitted to allow access to any other person.
  • 7. Academic staff are responsible for completing all relevant inductions before entering the Anatomy Laboratory and also responsible for ensuring that students in their class have completed relevant inductions. They are also responsible for ensuring student compliance with relevant legislation and the rules of the Anatomy Laboratory. These rules (in their most updated form) are provided by the Anatomy Laboratory Team Leader at commencement of each academic session.
  • 8. Subject coordinators for classes taught in the Anatomy Laboratory are responsible for applying to the Licensee for authorisation (entering the laboratory, examining the anatomical material, and use of anatomical images as a teaching resource) for their students and teaching staff.
  • 9. Database management staff are responsible for ensuring the safety and security of information recorded on the database relating to the Body Donation Program.
  • 10. The Anatomy Management Committee is responsible for developing and maintaining governance practices and procedures to ensure compliance with relevant legislation and as well as ensuring that the principles of the Body Donation Policy are upheld. The Committee is also responsible for keeping the University informed of resources required to meet legislative requirements and of anything that may affect the reputation of the Body Donation Program and/or the University.
  • 11. All staff covered by this policy are expected to carry out their tasks and communications in a timely manner.

19 Version Control and Change History

Version Control

Date Effective

Approved By

Amendment

1

19 AUGUST 2016

University Policy

First Version

Here to Help

Need a hand? Contact the Governance Unit for advice and assistance on policy issues.