Final report

In 2009, employees of the Dover Port Mortuary (DPM) alleged wrongdoing at the facility involving handling and disposition of human remains returning from Afghanistan and Iraq. Specifically, these individuals described improper preparation of remains of a deceased Marine; improper handling and transport of remains with possible contagious disease; improper handling and transport of fetal remains of military dependents; and improper handling of cases of missing portions of remains. Several Service-level investigations ensued as did a review of those investigations by the Office of Special Counsel, resulting in numerous corrective actions and personnel changes at the facility. In fall 2011, senior Department of Defense (DoD) leadership asked the Defense Health Board (DHB) to conduct an independent assessment of the current overall operations of DPM, the effectiveness of changes identified or taken to date, and the means by which those changes are examined for continued effectiveness. Specifically, the DHB subcommittee was asked to focus on the policies, procedures, and processes currently in place at DPM. The subcommittee did not focus its review on disciplinary or retaliatory personnel actions that followed these investigations, which were the subject of another review. Findings and recommendations: The subcommittee conducted its work based on several procedural and substantive principles. It adopted a comprehensive and long-term approach to addressing the systemic issues underlying the findings cited by previous investigations rather than focusing only on the most recent events. This report addresses and makes recommendations regarding relevant DoD policies and directives and whether they need reconsideration; command, oversight, and policy issues requiring attention and revision; AFMES organizational issues as it interfaces with AFMAO; and AFMAO workflow and operations. This report presents 20 recommendations for future action.