Family Management and Victim Identification in Mass Fatality Incidents Onora Lien Planning Manager

2. Family Management and Victim Identification in Mass Fatality Incidents Onora Lien Planning Manager May 29, 2013 The Northwest Healthcare Response Network is administered by Public Health – Seattle & King County, in partnership with the Tacoma-Pierce County Health Department.

3. Overview of Family Assistance Centers Tools and resources available for local planning Family Assistance Center planning through the Regional Catastrophic Preparedness Grant Program Overview

4. Response to mass fatality incidents is about: Serving the living Identifying victims Reuniting with loved ones Providing explanation about cause and manner of death Supporting the medico-legal investigative process Criminal justice Public health and safety Facilitating community recovery Key points about MFIs

5. MFI’s come in two primary types Closed population incidents the number and names of the victims is known (e.g. through a manifest) Open population incidents the number and names of the victims is not known; a “manifest” or list of likely affected individuals needs to be established Key points about MFIs cont’d

6. MFI’s are DVI’s: Primary function is to identify victims Two phases of identification Establishing that an individual is deceased Identifying as much of that decedent as possible (matching body parts) Disaster Victim Identification (DVI)

7. An effort in matching and confirming antemortem (pre-death) with postmortem (after death) information about the decedent: context fingerprints medical/dental radiography photo ID comparison Description of scars, tattoos, identifying marks DNA Identification Process

8. Identification Status • Unidentified: • There is no indication of who the body is • Tentative Identification: • The decedent has a name but identity must be confirmed • Positive Identification: • Identity is confirmed either scientifically or by other means (i.e. visual)

9. What happened to loved one/whereabouts Expectation management: recovery, identification and investigative processes Rumor control Media and lawyer management Managing political expectations and environment They have information to give…and we need it! Highly traumatic incidents Basic needs may be neglected May be asked to make extremely difficult decisions – collectively Gaining trust and maintaining it! Managing Family Incidents (MFI)

10. A crash on I-5 in the during rush hour involving a transit bus, a school bus, an oil tanker, and a sedan carrying three passengers has occurred. The crash resulted in an explosion and fire. Both busses were estimated to be at full capacity. First responders are estimating 160 victims. 8 patients with injuries are known, the rest are known or suspected to be fatalities. Now Imagine…

11. Tragically, you suspect one of your loved ones was involved… Now Imagine…

12. Take 5 min Begin completing the Disaster Missing Persons form for Partner/Spouse/ Significant Other; sibling; parent or child (your choice) Do not need to do contact information Do the best you can… Exercise

13. Easy? Difficult? Which questions were the hardest? Reactions?

14. Family Management: Provide structure amidst the chaos Coordinate information and manage expectations Facilitate information sharing to enable identifications Provide assistance that will facilitate health, well-being and recovery as well as help meet short term goals Establish coordination to flexibly adapt to issues that arise (political, legal, public opinion) Do the right thing

15. Family Assistance is more than just a physical location for families to come, but a concept of coordination to support families of victims to meet their physical, emotion, spiritual, and information needs following an incident • Family Assistance can be delivered in many forms • In person in a physical location • Virtually via a Call Center and virtual resources • Family Assistance is scalable to meet the needs of the specific families in an incident Concept of Family Assistance

16. Family: In the context of the Family Assistance Center (FAC), Family is defined as any individual (family, friend, partner, distant relative) that considers them to be a part of the victim’s family, even if there is not a legal familial relationship. This includes individuals whom other family members characterize as family. Next of Kin: The legally authorized individual(s) with whom the Medical Examiner/Coroner coordinates and who is authorized to make decisions regarding the decedent. Who is a Family Member?

17. Coordinated information sharing and bi-directional communications Antemortem data collection and information management Media and partner communications management Access to mental/spiritual care and basic social services assistance as needed Key Components of Family Assistance

18. Provide a private and secure place for families to gather, receive information about the response and recovery • Protect families from the media and curiosity seekers • Address family informational, psychological, spiritual, medical and logistical needs • Centralize and coordinate missing person inquiries A FAC should be activated to…

19. Collect antemortem information on the missing or known deceased Facilitate information sharing with the Medical Examiner/Coroner or other response agencies (e.g. hospitals) to support family reunification with the injured and deceased Provide death notifications and facilitate the processing of death certificates and the release of human remains for final disposition as needed. FAC activation cont.

20. Registration and Reception • Family Briefings • Victim Information • Call Center • Missing Persons • Antemortem Data Collection • Notification • Health Services (medical/first aid, mental health, spiritual care) • Support Services (childcare, interpretation, social services) Components of a FAC Operation

21. Considerations for activating a FAC • Complexity of incident/duration of response • Conditions of remains and ease of identification • Number of potential family members • Location of incident • Political/social context of the incident • Resource needs of the MEO/other partners • Political or social pressure or expectation Activation of a FAC

22. Incident Scale • Planning Assumption: for every potential fatality approximately 8 family members may visit a FAC Activation of a FAC King County Example

23. Numerous other factors can influence the scale of an incident including • The condition of the disaster site • Access to the disaster site • The condition of the remains • The duration of the Mortuary Operations • Whether or not there are other organization that can continue ongoing case management needs • Whether or not the disaster is an ongoing event • Open vs. closed population Incident Scale Cont.

24. One large FAC is preferred over several smaller ones • Will the FAC be a physical location for families to attend or a virtual operation? • Proximity to the disaster site • Proximity to lodging, public transportation and social services • The facility must be accessible for all family members Considerations for a FAC site

25. Prospective Site Assessment Worksheet • Comprehensive worksheet and instruction guide for identifying a FAC location • Staffing Overview • Outlines all possible roles in a FAC and suggested staffing numbers based on incident scale • Scalable Org Chart • Equipment and Supplies • Outlines equipment and supply types based on staffing numbers • Floor Plans and Site Scale Guides Tools for Activating a FAC

26. FAC Organization Chart

27. Intake and Badging • to ensure only family of potential victims are admitted into the FAC all visitors will be badged and complete and intake form • Behavioral Health • It is important to have mental health and spiritual care providers available near the reception area to provide assistance if necessary • Family Hosts • Family hosts greet visitors, provide families with an overview of the FAC resources, a brief tour of the facilities, and help address any immediate needs • Interpretation as needed Reception and Registration

28. Provides families written resources to answer their questions throughout their stay in the FAC • Orient them to a FAC and the services provided • Resources for families to help find a missing family member • Frequently asked questions for when a family member is missing or deceased • Resources on what they will need to provide in a family interview • Information on how identification is made • Contact information for additional community resources • Notes pages Family Resource Packet

29. Family briefings are extremely important for providing information to family members about response and recovery efforts Briefings should always be given to family members before information is released to the press Briefings should be provided, ideally, twice a day and at regularly scheduled times Briefings should be done by figures or authority (e.g. the Medical Examiner/Coroner, Chiefs) Family Briefings

30. Family Briefing Protocols • Briefing topics may include • Rescue and recovery efforts • Victim identification efforts • Investigation updates • Site visits, memorial services • Disposition and return of remains • Return of personal effects • Description of services available at FAC Sample Family Briefing Topics

31. The call center creates a critical link for family members seeking information about missing family members • Primary Functions • To provide a centralized number for families or the public to call regarding inquires about missing or potentially deceased persons. • To collect missing persons reports • To serve as the primary communications point for families • To funnel and triage all calls to the FAC Missing Persons Call Center

32. Call takers • should be appropriately trained to handle basic crisis intervention strategies, strategies for talking to individuals about traumatic circumstances • Call Center Intake Form • Provides preliminary information to law enforcement and the medical examiner/coroner (ME/C) to assess the likelihood the person is truly missing or deceased. • Provides caller information if law enforcement or a family interviewer needs to follow up Missing Persons Call Center Cont.

33. A key component to identifying who is deceased is identifying who is missing and reuniting family members • Missing persons information may come from: • Missing persons reports from the Call Center • Hospitals, Alternate care facilities (ACFs) • Shelters • Law enforcement • Family interviews • Social Media • Missing persons staff will need to coordinate with law enforcement, patient tracking, shelters, the morgue and other sources to reunite families Missing Persons

34. Antemortem data is collected from family members of victims to aid in the identification of their family members. • Family Interviews • Collection of antemortem data, medical/dental records, DNA reference samples, pictures, etc. from families for use by the Medical Examiner in identification • Data Collection • The Medical Examiner should decide how antemortem data will be collected based on the incident • Multiple potential data collection methods Antemortem Data

35. Unidentifiable Remains • Determination by the families with the Medical Examiner how unidentifiable remains should be handled • DNA Analysis • Morgue operations will determine how DNA will be used for identification and how small a fragment will be identified using DNA • Family Liaison Teams • Liaison teams can be created in larger FAC operations to provide families a core group of individuals that will be able to address their needs. • Protocols and Forms Antemortem Data Cont.

36. Notification to family members may be made at several stages in the identification process • Notification should be made by a small team of individuals. Composition of the team will depend on the family and the situation, and may include: • Notification staff member • Missing Persons Staff Member (law enforcement or their designee) • Medical Examiner/Coroner (or their designee) • Behavioral Health Staff (if requested) • Interpretation Staff (if necessary) • Medical Staff (on stand-by only) Notification

37. Composition of the notification team will depend on the family and the situation, and may include: • Notification staff member • Missing Persons Staff Member (law enforcement or their designee) • Medical Examiner/Coroner (or their designee) • Behavioral Health Staff (if requested) • Interpretation Staff (if necessary) • Medical Staff (on stand-by only) Notification Team

38. Position Checklists • Checklists for all of the command positions and operations positions of the Family Assistance Center • Position Matrix • Gives a breakdown of the mission and possible staffing sources for section/group/unit outlined in the organization chart Staffing Position Tools

39. Medical/First Aid • Basic first aid should be provided to families at the FAC • Staff can also act as a liaison to other medical resources in the community • Mental Health/Spiritual Care • Basic triage/needs assessment • Psychological First Aid as needed • Address immediate emotional, psychological and spiritual needs • Assist with referrals to additional support Health Services

40. Childcare - allows families to attend to necessary business and provides respite • Safe secure area for children of families visiting a FAC • Childcare services should be provided by licensed childcare providers • Secure Check-in/Check-out procedures • Interpretation and Translation • All written material should be translated into the appropriate languages for families. • Trained interpreters should be available at the FAC to assist with registration, family interviews, mental/spiritual health services, etc. Support Services

41. Social Services • Depending on the nature of the incident social services may be required in addition to the other FAC services. These services could include • Benefits Counseling/Assistance • Child/Youth and Family Services • Crime Victims Assistance • Foreign Nationals • Housing Assistance • Legal Assistance • Provision of Medications • Transportation Support Services Cont.

42. Cultural and Religious practices of families should be considered in all aspect of FAC operations • Memorial ceremonies, services and anniversaries • Food preparation and consumption • Communications with families (e.g. family interviews, family briefings, notifications) • Resources (e.g. texts, cultural/religious leaders) • Space for cultural or religious practices • Behavioral Health and Spiritual Care • Tools Cultural/Religious Considerations

43. Staffing • Because of the sensitive nature of the operations, it is important to identify staff with the appropriate skills to fill the roles at the FAC • Equipment and Supplies • IT support, tissues, etc. • Food Services • Be sure to consider the cultural appropriateness of the food served at the FAC • Security • Security plans are crucial to ensuring only the right family members are allowed into the FAC and members of the media are kept out Other Planning Considerations

44. Patient Tracking Family Reception Area Mental Health and Spiritual Care Security Coordination with Family Assistance Center Hospital Considerations

45. Regional Catastrophic Preparedness Grant Program* • Victim Information and Family Assistance Annex • Outline the key essential elements of information for determining when a FAC is needed after a catastrophic incident; • Provide a structure for multi-county coordination for determine the need for a FAC; and • Provide tools that may be used for planning or response to implement a FAC *King, Pierce, Snohomish, Kitsap, Thurston, Skagit, Mason, Island Counties

46. Challenges in a Catastrophic Incident • Infrastructure impacts and limitations to local capability • Scarce resources early on followed by (potential) influx of outside resources • Competing priorities • Greater need for cross-county, state and federal coordination • Greater need (and/or expectation) for centralized, response operations

47. Regional Coordination • Early information sharing across counties to identify when a FAC will be needed • Estimated fatalities (activation of mass fatality plan?) • Estimated injured • Anticipation of large scale evacuation and patient movement across counties or out of state • Determine when assistance from State may be required • Activation of Victim Information Coordination Group

48. Coordination Mechanisms • Regional Emergency Management Conference Call • Sharing information about potential injuries and fatalities; identifying the need for a FAC • Victim Information Coordination Group • Ongoing coordination about need for FAC, local or central FAC operations

49. Victim Information Coordination Group • Emergency Support Function 8 representative • e.g public health • Situational awareness and system impacts • Mass Fatality Branch representative • e.g. coroner/medical examiner • Mass fatality operations/coordination issues • Law Enforcement representative • Missing persons coordination • Mass care representative • e.g. human services or American Red Cross • Family reunification coordination • Public Information Officer as applicable • WA Department of Health rep as applicable • Federal representatives as applicable

50. Information Sharing Needs • Missing persons information • Public inquiries • Patient tracking • Updates on mortuary response activities including identification processes and timelines • Antemortem data • Availability of resources to assist family members/loved ones • Public messaging