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					 File name : SOP/GB/006.01                    Page 1 of 4
 Date printed 10/09/11

                         STANDARD OPERATING PROCEDURE (SOP)


 Title : GIFT Post-Retrieval Procedure
 Area of application                              Leeds GIFT Tissue Bank
                                                  SJUH/LGI Mortuary
 Index code/version number                        SOP/GB/006.01
 Reason for change                                New procedure
 Date of implementation                           23rd March, 2010
 Review interval                                  Annual
 Authorised by
 Author                                           Aidan Hindley, Tissue Bank Coordinator
 This copy issued to                              Master Copy: Laboratory Manager, LIMM Welcome
                                                  Building, St James’s, Leeds (SJUH)
                                                  Tissue Bank Staff, LIMM, SJUH




                  Document review history – completed when no changes required
 Review date                            Reviewed by                              Signature




1.       CLINICAL RELEVANCE/PURPOSE OF PROCEDURE
         To ensure tissue retrieved for Leeds GIFT tissue bank is stored processed appropriately so
         that Trust and HTA standards are met.

2.       PRINCIPLE OF PROCEDURE
         To provide an appropriate, safe, timely and auditable system of processing and storing
         tissue retrieved for Leeds GIFT tissue bank

3.       PERSONNEL / TRAINING REQUIREMENTS

4.       SPECIMEN REQUIREMENTS
         (see below)


This is a controlled document, dates of review and locations of authorised copies are recorded in the Pathology and Tumour Biology
Quality Management System. It is forbidden to photocopy or write on SOPs.
                               Department of Pathology and Tumour Biology                                        Page 2 of 4
                                             SOP/GB/006.01


5.       EQUIPMENT
         Tissue retrieved (where consent has allowed), appropriate containers, -80C freezer
         Safety equipment and liquid nitrogen safety equipment if necessary; gloves/goggles

6.       HEALTH AND SAFETY
         COSHH for Liquid nitrogen and formalin.
         Wear protective clothing (goggles/ gloves etc)
         As per Trust/University SOP’s

7.       REAGENTS
         Formalin
         Liquid nitrogen

8.       QUALITY CONTROL

9.       COMPUTER / TELEPATH CODES

10.      PROCEDURE OR METHODOLOGY
         1. IF donor is to be cremated, ensure that consultant pathologist completes cremation
             form as per SOP GB/008.01
         2. If donor is to be cremated, send letter to Funeral Director re. no pathologist fee. Please
             detail which bones/joints have been removed as well.
         3. Bone and brain samples should be double-bagged (using labelled bags) and sealed
             using the bag sealer in the Mortuary.
         4. All retrieved tissue except large material which is fixing should be transferred from
             the Mortuary to the designated area in level 4 LIMM by Tissue Bank Staff on
             completion of the retrieval. Large samples e.g. brains must be stored in the allocated
             place in the mortuary.
         5. Once in liquid nitrogen room, the liquid nitrogen from the flask containing the
             cassettes should be transferred to an empty flask, using the funnel to capture the
             cassettes. The remaining liquid nitrogen to be left in the flask, in designated area, to
             evaporate. Cassettes to be sealed into the labelled plastic bag provided, prior to
             storage in marked area in -80 freezer , CSB freezer room room.
         6. All containers used in retrieval to be washed using detergent in appropriate area
         7. When blood results are received, and if the infection screen is negative, cassettes can
             be re-packaged into small cardboard boxes (labelled with GIFT number and numbers
             of cassettes they contain). If infection screen is not negative, cassettes must remain in
             sealed bag, until disposal can be carried out.
         8. The sealed metal box containing cassettes in formalin should be taken to Laboratory
             Manager, Level 4, Wellcome Trust Brenner Building, LIMM, St James’ University
             Hospital for processing asap after the retrieval. Cassette box should be sealed into bag
             provided, and then in the Tissue Bank transport box. A Tissue List should be sent with
             the cassettes.
         9. Documentation should then be carried out following GIFT Documentation
             SOP.GB/007.01.
         10. Retrieval trolley should be re-stocked asap, and if necessary further supplies made-up
             so that a minimum of two further kits are available. (see Appendix)

11.      REFERENCE RANGE / ACTION LIMITS
         N/A

This is a controlled document, dates of review and locations of authorised copies are recorded in the Pathology and Tumour Biology
Quality Management System. It is forbidden to photocopy or write on SOPs.
                               Department of Pathology and Tumour Biology                                        Page 3 of 4
                                             SOP/GB/006.01



12.       REFERENCES
          N/A

13.       APPENDIX


          LEEDS GIFT TISSUE BANK RETRIEVAL TROLLEY CONTENTS

         Numbered (G/year/.no.) cassettes, standard size and large with lids.
         Bag of spare cassettes (various sizes).
         Metal cassette box (to be half-filled with formalin once in mortuary).
         Labelled bags sufficient for material to be retrieved to be double bagged.
         Casting tape
         Super glue
         Pre cut strips of foil (plus spare).
         Red topped blood phials.
         NTMRL Blue plastic blood sample box
         Clip board
         Red file, containing;
              - Tissue List
              - Tissue Labels
              - Donor details from NHSBT/TS (for each retrieval)
              - NBS consent form (for each retrieval)
              - Specimen copies of NTMRL form
              - Details of how to retrieve specific samples
              - Pens and pencils
              - Blank letters for funeral directors

PLUS, for each retrieval;
          - 2 flasks ½ full of liquid nitrogen, if required,( flasks in block preparation room)
          - Required prosthetics, dependant on consent from box in Tissue Bank office.

* NOTE
Make bags in cut-up, use bagging machine.
Spine bags approx 90cm long
Large sample bags approx 30cm long
All small bags approx 15cm long
Seal label detailing contents into each bag.




This is a controlled document, dates of review and locations of authorised copies are recorded in the Pathology and Tumour Biology
Quality Management System. It is forbidden to photocopy or write on SOPs.

				
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