Two funerals were mixed up in the hospital morgue in Lisbon: The mistake was noticed by the family at the funeral ceremony

At ULS São José in Lisbon, when two bodies were mixed up, the wrong body was delivered to a funeral company, and the mistake was discovered by the family during the funeral, not by the institution's control mechanisms. Portuguese Health Regulatory Authority ERS considered the case a security breach of “particular gravity” and asked the hospital to strengthen its identity check procedures. RTP

The incident took place in January, but was made public on September 9 with the publication of ERS' decisions for the second quarter of 2026.

Wrong body delivered on January 15

According to the ERS investigation, the ULS São José morgue handed over the body of another person to a funeral company on January 15, 2026, instead of the one it was supposed to hand over.

Both people had died the day before. RTP

The more serious problem was that although the institution had a formal double ID check procedure, the mistake was not detected by hospital staff or the funeral company representative.

It was only during the funeral that the family realized that the wrong body had been delivered to them.

No mandatory double checks

In the ERS investigation, it was stated that the auxiliary medical staff at the morgue did not comply with the mandatory double check procedure to verify the identity of the corpse.

It was also determined that the staff did not report the situation to the hierarchical management after the incident.

This second negligence of the employees, the mistake of priority It is reported that they explained that they wanted to solve the problem quickly. RTP

ERS, on the other hand, evaluated the events as a serious system error in terms of safely identifying the bodies.

Overcrowding in the morgue is the background of the incident

The regulator examined not only individual errors but also the working conditions in which the incident occurred.

It was stated that due to the extraordinary increase in the number of deaths during the said period, the hospital morgue worked beyond its capacity, temporary storage solutions were used and many bodies were removed from the morgue on the same day. RTP

According to ERS, these conditions may have contributed to physical fatigue and loss of attention in workers.

However, density was not accepted as a justification for not performing mandatory identity checks.

The hospital took new measures

Following the incident, ULS São José made changes to its mortuary operations.

These include having an auxiliary medical staff on duty every day solely for administrative procedures and communication with funeral companies, increasing surveillance on the morgue, and carrying out unannounced checks by the management. RTP

ERS, on the other hand, called for additional preventive measures to ensure that a similar incident does not occur again despite the existing corrections.

Resources

RTP / Lusa — ULS obrigada a reforçar medidas de identificação de cadáveres após troca detetada no velório — 9 September 2026

RTP direct news

Renascença / Lusa — Troca detetada em velório obriga ULS de Lisboa a reforçar medidas de identificação de cadáveres — 9 September 2026

Renascença direct news