Dr Clare Gerada
When you die, you have to have your death certified by a doctor and a death certificate or a cremation certificate issued. If we have had contact with a patient in the previous two weeks and know the cause of death - if someone has been terminally ill, say - we can sign the death certificate immediately. If we haven't seen the patient in the two weeks before their death, or if they have died after being discharged from hospital, then we must report it to the coroner, who may request a postmortem. The coroner may also request a postmortem if drugs or alcohol are suspected, or if there's any suggestion of a violent death. It's my job to say if somebody is dead, not how they died.
What I'm essentially looking for is brainstem activity. The brainstem is the part of the brain where the body's vital functions are controlled - the breathing, the heart, the brain itself; it is the computer room of the body. If that bit of the brain is dead, then the person is essentially dead. You can still have reflex actions, so you may twitch after death.
To certify that someone is dead, you listen to the heart for one minute and feel for a pulse for one minute. You examine for signs of breathing, you look at the pupils to check there is no response to a shining light. If you're not certain, you can rub on the breastbone, which is a very painful procedure: if they are not dead, they'll quickly jump up and say, "That hurt!"
Nowadays there are machine tests for brainstem death that involve connecting up the brain and looking at the activity. Those tests would be done before organ donation.
Rigor mortis is the stiffening of the body, which begins a few hours after death and then after a while starts to reverse. A forensic scientist can estimate the time of death by whether rigor mortis has come and gone.
Most people will die in bed, but of the group that don't, the majority will die sitting on the lavatory. This is because there are some terminal events, such as an enormous heart attack or clot on the lung, where the bodily sensation is as if you want to defecate. Also, many people die on special occasions. People tend to hang on for a birthday or Christmas. I'm not saying that death is psychologically motivated, but there's a sense that people stay alive for these events and their loved ones, and then pass away, so the death rate increases on birthdays and during religious festivals.
When a death is expected, the ideal place for it is at home, in a familiar environment, surrounded by family. But that is becoming a rarer event. What is becoming more common is people being rushed into hospital for what I believe is a more undignified and worse death, in an anonymous room with nurses who are busy. In my view that is a failure of health professionals, because we should be preparing the families of terminally ill people for death, showing them that it doesn't have to be frightening and that they can do it at home. Palliative care is all about making death comfortable - you do not need to die in pain, you can die in a dignified manner. People worry that having a death at home will be horrible and traumatic for the family, but a good death is like a good birth - it is a beautiful event, not at all undignified.
Most people who come to me for a postmortem examination will have died from heart disease. In the elderly, strokes and pneumonia are also very common. The young are more likely to die from accidents, suicide or particular types of tumours one gets in youth. If a young person dies, the likelihood of them having a postmortem is high because their death is much more likely to be unexpected. Many older people who die won't have a postmortem because they are likely to have had a known illness that has led to their death.
The first part of a postmortem is an external examination that notes the condition of the patient, any unique identifiers such as tattoos, evidence of recent medical intervention or injuries. Their notes might say "found dead in bed", but you don't know whether they have fallen and banged their head the day before and have a subtle but significant injury, so you are looking out for things like that.
The internal examination starts with an incision from the sternum to the pubic bone. You go through the skin, fat and muscles to expose the rib cage. Then you cut through some of the ribs for access to the upper organs.
When removing the organs you work in three blocks. The thoracic block contains the throat, tongue, lungs, heart and aorta. Then you have the liver, stomach and pancreas in the second block. The final block includes the kidneys, the remainder of the aorta, bowels, bladder and reproductive organs.
The incision doesn't go all the way up to the chin because we don't want anything to be visible to the relatives if they view the body. So, to remove the tongue and windpipe, we work up under the skin from the chest. You loosen the skin up to the jawline, then you can work the blade to cut around the tongue, across the vessels and pull them down under the jaw.
Using a scalpel, the mortuary technician will make an incision at the back of the head and lift up the scalp to reveal the skull. A little hand-held saw is used to cut through the skull. The technician will ask you to observe as they take off the skull in case there is something immediately obvious, such as a brain haemorrhage. They will then take out the brain for examination.
Many good things may come from a postmortem. You may find something that is relevant to subsequent generations - say, if a young mother has died and you find a coincidental breast cancer, you would suggest screening for her children.
If you can't find a cause of death from looking at the organs with the naked eye, you take tissue and fluid samples, which are examined under microscopes and submitted for toxicological analysis.
Once you have finished, everything is put back into the body and the incisions are sewn up. It is not possible to re-site the organs into the positions they held in life, but the body is reconstructed as far as possible. It is cleaned to remove traces of fluid or blood. The hair is washed. You complete the cause of death documentation and the body can be released for cremation or burial.
Once the death has been certified, we'll go to the family's home or hospital to remove the body and bring it back to the funeral parlour. Because of health and safety regulations, we have to be careful with manual handling - using stretchers enables us to slide the body rather than do heavy lifting. If someone is being collected from a hospital, they would probably be in a hospital shroud; if it's a removal from a home, they are more likely to be in nightclothes. People don't have the close family networks they used to. It's more frequent these days for someone to have died alone in their house and not be found for two or three days and sometimes two or three months. We have to go in and remove the body, which can be quite an unpleasant experience.
If a body is left untreated at room temperature, it will deteriorate quickly, so at the funeral parlour it will be put into a refrigerated unit until the death is registered. Then, with the family's permission, the body can be embalmed.
With the Muslim faith, an imam will come in and wash the body and wrap it in an unbleached cloth. Hindu and Sikh families will come and do the washing themselves. If the deceased is male, the male family members will come; if female, it will be the women. After embalming, we will dress the body before placing it in a coffin. It depends on the size of the person, but usually two or three people do the dressing. The family usually provide clothing - a favourite outfit or something apt. African families often provide full robes and headdress, and Chinese families will bring spare clothing to go with the deceased on their journey into the next life. So we dress them and put all the spare clothing around them in the coffin.
If the body has been dead for a while and the skin has deteriorated, you have to be very careful. Often, a person may have had a lot of drips and incisions and certain drugs, which can affect the skin, so the skin may be fragile, almost like paper, or weeping. If this is the case, we dress the body in a plastic bodysuit under their clothes to protect the clothes and prevent leakages. Once the body is dressed, and hair and make-up have been done, the body is placed in the coffin and put in a private viewing room. It can stay there for a day, or longer if required. The longest we've had a body in our chapel is 13 months.
A lot of my work is arranging for bodies to go back to their home abroad. About a fifth of our work is repatriation now because of the cultural diversity of the area we are based in - east London. This requires tropical embalming because the body may be kept for longer. Tropical embalming takes longer and uses stronger chemicals. Ghanaian funerals, for example, can be anything from two months to two years after death. We've had bodies here for three or four months before they've been flown home to Africa for the funeral.
The body is brought out of the fridge and removed from the body bag or the sheets in which it has been wrapped. I gently clean the deceased with a formaldehyde or disinfectant spray. The body might be quite clamped with rigor mortis, so I massage the hands and limbs to work it out, then make an incision to raise an artery so I can inject the formaldehyde. I tend to use the brachial artery under the armpit, or the femoral artery in the groin area, to avoid incisions being seen, which can be stressful for the families when they come for a viewing. As the formaldehyde flows through the body, you begin to get colour and a more lifelike appearance. The features will plump out slightly and the deceased will look less drawn.
If a body is going abroad, the strength and amount of fluid used is increased, to ensure preservation and sanitation for a longer period.
After the formaldehyde, I drain the body of blood and fluid from the organs and chest cavity. I make an incision just under the rib cage and insert a metal suction tool, known as a trocar, attached to a suction pump. I then puncture the internal organs to drain the fluid. I remove the contents of the intestines, bowels and bladder, too, as these can give off gases and smell. I don't come into contact with the fluids. It's very clean and tidy. After I have drained the body, I distribute a litre of cavity fluid between the thoracic and abdominal cavities so that all the tissues are saturated and do not smell. Although the bowels will have already been emptied, I put an incontinence pad on the body to protect the clothing and the coffin.
We have to take out pacemakers because they can't go into the crematorium. Usually you are told that the person has a pacemaker that needs to come out, but if you are not, you can see the incision where it has gone in.
Next, I pack the throat and nose with cotton wool to stop fluid seepage. If the deceased doesn't have teeth, I put cotton around the mouth to plump it out a little; if they have dentures, I put them in place. I then stitch the mouth closed from the inside. Sometimes glue is used but I do not like the white residue it can leave after it has dried. I dry the eyes and insert plastic half-moon caps under the lids to help them hold their shape, and a touch of Vaseline helps to hold them closed. If the eyes are not dried, they can give the appearance of having a tear, which may be distressing to the family.
I will wash and style the hair, ensure that the men are shaved and any nasal and ear hair removed. Nails are cleaned and cut. It's a myth that your hair and nails keep growing after you are dead - what actually happens is that your skin retracts, so they appear longer. Even if the family are not planning to view the body, I like to make sure everything is done thoroughly in case they change their minds.
I try to make the face look peaceful because this is the last memory the family will have and I want it to be a good memory. I use very few cosmetics, just enough to take away the "waxy look" that can occur.
Of the bodies that come to the funeral homes I work in, around 90% will be embalmed. The ones that don't will be where the family have refused or the funeral is taking place very quickly. Embalming is an art. The deceased is always treated with respect and I always do the best job I can. I believe that you have to care about what you do. When you stop caring, then it is time to leave the profession.
All coffins have a card with a number that is checked against the nameplate on the coffin before cremation. That card goes on the back of the cremator so we can keep track throughout. There is only room for one coffin per cremation chamber, so it's impossible to cremate two people at once.
I often get asked about taking the bodies out and selling the coffins and taking off the brass handles or taking out gold teeth - it's just not done. Everything goes into the cremator. Any metal will melt down and become blackened and mingled with the ashes. You have to be careful with watches, though, because the batteries will explode. The undertaker should have removed any watches before the funeral.
The cremation chamber is fuelled by gas and has to be heated to at least 750C before we can load, or "charge", the coffin. We have to adhere to strict guidelines and everything is logged automatically on the computer - time, date, duration, emissions, smoke levels, carbon monoxide, oxygen levels and the temperature in the different parts of the cremator. The computer prints out a report and every few months these are sent to environmental health.
During the cremation, the coffin burns first, then the flesh and then the organs. After 60 minutes or so, you can look through the spyhole to see how it is going. After 90 minutes, depending on the size of the person, all that is left is the glow of the ashes, no flames. A person with a lot of fat will burn hotter and for longer, up to three hours, whereas a small, frail person may take 80 or 90 minutes.
People think wicker and cardboard coffins are saving the planet, but they burn very quickly instead of creating a slow, even heat like wood. That means you need more heat to cremate the body, so use more gas. It's also more hazardous for us, because they catch alight so quickly and harder on us because we can sometimes see the body through the wicker.
Once there are no more flames, you can stop the cremation and rake it out using a 15ft stainless-steel rake. There are no short cuts. We clean out the cremator every time.
All that is left are the ashes from the body, plus nails and screws from the coffin and any artificial steel joints or metal plates. There may also be some bone fragments left. It tends to be the hip and the shin bones, because they are quite large. There will be more bones if it is a large-framed or young person. Young bones are stronger and reduce less easily. The remains are raked into a steel bin at the bottom of the cremator to cool, before being transferred into a machine called a cremulator, which contains steel balls that grind down the remains into a fine ash. Your ID card goes into the cremulator, along with a plastic urn with your cremation number on it that the ashes fall into at the end. The cremulator filters any artificial joints or metal and these are buried in a deep hole at the back of the crematorium, although we are looking into ways of recycling them.
The cremulator may sound callous, but breaking down the remains is important because if you are going to have a scattering it means the remains can be dispersed as a fine ash rather than as bones, which is less distressing for the family.
We carry out the whole process of cremation and cremulation as if we were doing our own family - with the utmost dignity at all times. It's not right to be slapdash.
If a body were buried illegally in a shallow grave less than 2ft deep, the decomposition rate is only 18 months to three years. That's banking on disturbance by small mammals and insects. Whereas, with a proper burial, with the coffin deep in the ground, the decomposition rate is much slower. The ground conditions affect the decomposition rate. If the coffin is sealed in a very wet, heavy clay ground, the body tends to last longer because the air is not getting to the deceased. If the ground is light, dry soil, decomposition is quicker. Generally speaking, a body takes 10 or 15 years to decompose to a skeleton.
Some of the old Victorian graves hold families of up to eight people. As those coffins decompose, the remains will gradually sink to the bottom of the grave and merge. The coffin at the bottom will often be the first to collapse and may pull down the remains above it.
Graves are dug by machine, where possible. On our new sites, where there is more room, we use a mechanical digger similar to the type you might see on the roads. We are told two days in advance what the coffin size will be. So we tailor the grave to fit.
With a reopened grave, or in a traditional area where you have had to move memorials to get to the grave, you are likely to be digging by hand. With good soil conditions, it's possible to hand-dig a grave in 1½ hours. But I've experienced it taking five hours because of roots or hard ground. A dry summer will make the ground very hard for up to 2ft. A hard frost will mean 6in of ground is frozen solid.
For £27,000 you can buy a vault grave. This is the most expensive grave we have. We excavate a big hole and concrete the sides and bottom and then put brickwork and a landing on the top. Generally, the coffin is encased in concrete - or entombed, as we call it. The coffin can be wood, but it must be sealed, usually using lead or zinc. We do this to stop noxious fumes and because we don't backfill the vault, so if you moved the landing off you could look down and see remains in the grave.
Sometimes we do exhumations. The grave owner must obtain an exhumation licence before we can do this. There have been cases of people who have moved away from the area and wanted to take their loved ones with them, or wanted to transport them back to their roots abroad. Some people have an aversion to burial and decide they would rather have a cremation after all.
One of the biggest problems with cremation is the amount of mercury going into the atmosphere and the ecosystem. In Britain, about 16% of the mercury that goes into the atmosphere is caused by cremations. Resomation is a greener alternative to cremation. It uses water, potassium hydroxide and steam heat to dissolve the body. At the moment there are only a few resomation chambers in operation in the world, all of them in the US - ours is at Mayo Clinic, Rochester, Minnesota - but there has been interest from several UK councils and cemeteries about installing them. It does offer people a greener option.
We place the body in a basket with small holes in it and slide the body into the round resomation chamber. Once you've loaded the body, you input the temperature, body weight and duration. We calculate the amount of chemical needed by the size of the body.
Once the body is in the sealed chamber, it is immersed in around 425 to 500 litres of water mixed with around 15 to 20 litres of potassium hydroxide. A coil running though the unit generates steam, which heats all the ingredients to 150C, and then a recirculation pump creates a whirlpool effect that helps the body to dissolve. All the tissue, muscle, hair and nails inside the unit will dissolve. Resomation turns the body back into its original elements. It breaks down the body and neutralises everything, including the chemicals used to preserve the body, such as formaldehyde.
What we're doing is speeding up the natural process of being in the ground, breaking down the body in hours instead of 20 or 30 years. All that is left at the end of a resomation cycle are bone remains and liquid.
Only certain clothing fibres will dissolve during resomation, though. Cotton will not dissolve, silk and wool will. If you had on an outfit that was half wool and half cotton, you'll see cotton fibres left in the basket with the bone shadows at the end.
The innocuous fluid left at the end of the process contains what the body is ultimately comprised of - nitrogen, phosphate, proteins, amino acids, salts and sugars. It's got a greenish-brown tint and it flows just like water. This liquid contains no DNA so has no detectable link with the original body. It can be safely disposed of or used on land as a fertiliser if requested.
I don't think resomation will necessarily replace cremation or burial, but I think it will grow in popularity.