Background: Death during international travel and the repatriation of human remains to one’s home country is a distressing and expensive process. Much organization is required involving close liaison between various agencies.

Methods: A review of the literature was conducted using the PubMed database. Search terms included: ‘repatriation of remains’, ‘death’, ‘abroad’, ‘tourism’, ‘travel’, ‘travellers’, ‘travelling’ and ‘repatriation’. Additional articles were obtained from grey literature sources and reference lists.

Results: The local national embassy, travel insurance broker and tour operator are important sources of information to facilitate the repatriation of the deceased traveller. Formal identification of the deceased’s remains is required and a funeral director must be appointed. Following this, the coroner in the country or jurisdiction receiving the repatriated remains will require a number of documents prior to providing clearance for burial. Costs involved in repatriating remains must be borne by the family of the deceased although travel insurance may help defray some of the costs. If the death is secondary to an infectious disease, cremation at the site of death is preferred. No standardized procedure is in place to deal with the remains of a migrant’s body at present and these remains are often not repatriated to their country of origin.

Conclusions: Repatriation of human remains is a difficult task which is emotionally challenging for the bereaving family and friends. As a travel medicine practitioner, it is prudent to discuss all eventualities, including the risk of death, during the pre-travel consultation. Awareness of the procedures involved in this process may ease the burden on the grieving family at a difficult time.

Introduction

The death of a family member or friend is a traumatic event. This trauma is intensified in the setting of foreign travel. Repatriation is the process whereby human remains are transferred from a foreign territory to the native land of the deceased. It is estimated that the risk of fatal injury to foreign travellers is 20–90 per 100 000 person-years of exposure for many destinations worldwide.1 Conveying human remains to one’s home country in this scenario can be a complicated, distressing and expensive procedure. Considerable organization is required involving liaison between a number of agencies. This review will discuss the steps involved in repatriating human remains following the death of a traveller overseas.

Methods

In order to evaluate the measures required to repatriate human remains following death overseas, a comprehensive review of the literature was undertaken. The electronic database PubMed was searched, through 2016, using combinations of the terms: ‘repatriation of remains’, ‘death’, ‘abroad’, ‘tourism’, ‘travel’, ‘travellers’, ‘travelling’, and ‘repatriation’. Search results were confined to publications in the English language. Additional citations were obtained from grey literature sources, including official government publications.

Results

Repatriation Procedures

A number of common themes emerge when assessing the procedures involved in repatriation.2–6 Contacting the local national embassy, travel insurance broker and tour operator, if applicable, are important initial steps in the repatriation of the deceased traveller. The embassy will have experience in the protocols involved and it can help to overcome language barriers, mobilize the relevant local authorities and contact family members. The embassy can also help to obtain important documents such as medical cause of death certificates on behalf of the family if requested to do so.2 Consular officials may also serve as provisional conservators of the deceased person’s estate if no other legal representative is present in the foreign country where the death occurred.7

Embassies will not be able to fund the repatriation of remains, however; costs involved in repatriating remains must be borne by the family of the deceased.2–6 Expenses vary in different countries with expatriation costs from Australia and the USA ranging between Au$8000–16 000 and US$6000–12 000, respectively.8 Transportation distance and cargo weight are key variables in determining the cost.9 Travel insurance may help defray some of the costs depending on the policy, and independent trusts are also capable of providing monetary assistance in specific circumstances.10

Formal identification of the deceased’s remains is required. Rules on who can identify a deceased person vary depending on the country or jurisdiction involved. In many instances identification may be carried out by a travelling companion or business partner of the deceased; however, in certain circumstances it may be necessary for a family member to travel to the country of death to formally confirm the identity of the deceased.8 A decision must then be made to repatriate the body or to bury or cremate the remains in its current location. A funeral director must then be appointed who will prepare the remains for repatriation. The deceased individual’s family, the relevant embassy or the tour operator may appoint the funeral director. The role of the funeral director may extend to organizing transportation and making flight arrangements, preparing appropriate documentation, obtaining the death certificate and liaising with a funeral director in the country of destination. A specific coffin is required for repatriation of remains by air or sea. All coffins crossing international frontiers must be metal-lined.11 Zinc or lead linings are considered acceptable for this purpose.12 These coffins are not suitable for cremation and additional measures should be put in place if cremation is to be pursued once the remains have returned to the home country. Figure 1 summarizes the key steps involved in repatriating human remains.

Figure 1

Summary of procedure to repatriate remains from another country

Figure 1

Summary of procedure to repatriate remains from another country

The Role of the Coroner

The coroner or legally equivalent judicial officer or authority in the country receiving the repatriated remains (e.g. Procurator Fiscal in Scotland) will require a number of documents prior to providing clearance for burial. These documents generally include the following: medical certificate giving the cause of death, certification as to whether or not a post-mortem examination has been carried out, post-mortem report, authorization to remove the body or ashes from the country where death occurred, embalming or cremation certificate, and a certificate to the effect that the body is not coming from an area of infectious disease.13,14 If the documents are not in English or in the language of the destination country, it may be necessary to have them translated and certified. If a post-mortem is carried out in the country of death, the coroner in the native country of the remains must be satisfied with the report and standard of the post-mortem performed. One study of bodies repatriated to the UK found discrepancies in the accuracy of original post-mortem examinations.15 An effort is being made to harmonize medico-legal post-mortem rules across the European Union in an effort to standardize post-mortem procedures and results following a Council of Europe recommendation deriving from the European Council of Legal Medicine which updated its recommendations in 2014.16 If any concerns exist, a further examination of the body may need to be carried out including a second autopsy. Funeral arrangements should not be confirmed until the office of the coroner has cleared all relevant documentation. If the death is registered in the country where the person has died, it is not normally registered again after the body has been returned to its native country.8Table 1 presents the key documents required by the coroner.

Table 1

Documentation required by coroner (with translation if necessary)

Death certificate 
Post mortem report (if applicable) 
Authorization to remove remains from country where death has occurred 
Embalming or cremation certificate 
Infectious certificate 
Death certificate 
Post mortem report (if applicable) 
Authorization to remove remains from country where death has occurred 
Embalming or cremation certificate 
Infectious certificate 

Causes of Death in Travellers

Cardiovascular deaths and deaths due to injuries received abroad are the most common causes of death in the international traveller.17,18 Coronary heart disease is the leading cause of death during international travel, accounting in various studies for 35–46% of all fatalities.18–21 The risk of cardiovascular death increases proportionately with advancing age of the traveller, with younger travellers succumbing to accidental and trauma-related deaths more frequently.17 A similar pattern of mortality has been observed in studies of Swiss,22 American23 and Canadian24 travellers abroad. A summary of the causes of deaths and their relative frequency in international travellers is given in Table 2.

Table 2

Causes of death in travellers to foreign countries17

Cause of death Proportion (%) 
Cardiovascular 46 
Motor vehicle accident 31 
Water-related 14 
Air crash 
Infection 
Other 
Cause of death Proportion (%) 
Cardiovascular 46 
Motor vehicle accident 31 
Water-related 14 
Air crash 
Infection 
Other 

The most common traumatic deaths abroad are road traffic and drowning accidents, which together represent ∼50% of all unintentional injury deaths.17 Injuries and related deaths are more likely to occur while travelling than while residing in one’s native land.19,25 Injury-related deaths are most common in countries in the low-to-middle income Americas, followed by high-income European countries and low-to-middle income Eastern Mediterranean countries.26 Other documented causes of death in travellers include falls,26 homicide26, infectious disease17 and suicide.26

Death in International Waters

Death and the management of remains in certain circumstances may necessitate additional protocols and procedures. In the event of death taking place in international waters, some restrictions on body storage and repatriation apply. Cruise ships are required to contain a morgue.27 However, these morgues may only hold bodies for up to one week. Some ports require immediate offloading of bodies, while others will allow the body to remain on the cruise ship until it arrives at its destination, which could potentially save repatriation costs if conducted within the morgue’s containment time limit.28 Approximately 200 people die on board cruise ships annually. This is relatively few given the estimated 21 million passengers that board cruise ships, coupled with the older age demographic and often multiple medical comorbidities of the passengers involved.27 Over the course of an 11-year period, a study found that 135 German passengers had died on board ships. Of the 135 deaths, 110 deaths occurred on cruise ships. The majority of the deaths occurred within an elderly population due to cardiovascular causes, while a minority died as a result of accidents.29 A further study examined the mortality rates aboard two cruise ships over a 6-year period. Twenty-five deaths were reported during this time, representing one death for every 6 months per ship.30

Death during International Air Travel

Death while flying is likely to become a more common occurrence in the future with larger airplanes embarking on longer flights. At present, a lack of medical staff on board aircraft means that a person may not be pronounced dead mid-flight. It is not inevitable that flights should divert in the event of a passenger dying on board and many continue to their intended destination.31 Current practice is to notify the captain of the aircraft of the death of a passenger on board, placing the deceased passenger in a passenger seat or corpse cupboard, restraining the corpse with a seat belt and covering the corpse in a dignified manner with a drape.32,33 All issues pertaining to repatriation of the remains, if necessary, are dealt with on landing at the flight’s destination.32 Human remains may be transported in the cargo hold of airplanes if they are hermetically sealed within an inner containment of lead or zinc which must then be packed inside a wooden or metal coffin. This may then be covered in tarpaulin so that the nature of its contents are not apparent.34 Zinc is the preferred material for lining coffins as it facilitates scanning of contents for security purposes.35 Additional protective cushioning must surround cremated remains contained in urns and human remains must be distanced from any foodstuffs in the cargo hold of the airplane.34 Airlines may also have terms and conditions of carriage specific to transportation of human remains and human ashes carried on board by passengers.36,37

Death Due to Infectious Diseases

If the deceased is known to have had a communicable disease, the remains will be classified as an infectious substance.38 There are two categories of infectious substance, category A and category B.38 Category A includes highly transmissible agents—Lassa virus, Ebola virus and Marburg virus, for example. Category B includes less transmissible agents such as HIV. Strict packaging rules apply to the transport of specimens considered infectious and oftentimes cremation at the site of death is preferred.7 A special permit must be issued from the aviation authority and from the countries of transit and destination. It can be difficult to receive a permit in this instance with the sole purpose of repatriating human remains.39 A significant global shortage of flight operators with the appropriate aircraft and isolation equipment to oversee the transfer of remains renders repatriation in this scenario difficult and cremation may thus be the only viable option.38 It is an accepted practice in Muslim countries to bury the dead before sundown or within 24 h without embalming the remains. This is slightly different practice to that in Western countries and may potentially complicate the repatriation process.40

Death following a Crime

Death as a result of a crime can substantially delay the repatriation of human remains.2–6 All investigations and enquiries into crimes committed abroad are the responsibility of the local police and judicial authorities and may take significant time to complete. The Department of Foreign Affairs or its equivalent can keep families informed of progress but they cannot interfere with any investigations.2–6 If the circumstances of the death are unnatural through violence or criminal activity, the coroner in the country of origin or the family may request that a further examination be carried out when the body has been repatriated. This is of particular importance in circumstances where the forensic investigation does not meet the equivalent requirements of the destination country or where properly interested persons, especially the family of the deceased, raise questions as to the certified cause of death or its categorization as natural, unnatural or being as a consequence of accident, trauma or violence. Additional medical and investigative reports may also be sought by the coroner.

Death Due to Terrorism

In the event of death occurring during a terrorist attack, financial compensation may be available to the deceased’s family. The UK allows compensation claims for certain terrorist attacks for those living in their country for 3 years prior to the event.41 European legislation has recently been passed in the Republic of Ireland that obliges the state to have mechanisms in place for its citizens to claim such compensation. Each European country is responsible for compensation for terrorist attacks which occur within its own borders.42 Identification of remains in this setting can be complex and it may be necessary for families to provide additional information to the relevant authorities including photographs of the deceased, fingerprint samples and the name of the deceased individual’s medical practitioner to obtain records which may aid in identification.5 Similarly, following death due to a natural disaster, further documents for the purpose of identification may be required.5

Social Media

Social media may be useful in the setting of repatriation of remains. Tools such as Facebook Safety Check®, Google Person Finder® and Twitter® are useful in propagating information about accidents, deaths and disasters. Flaws do exist, however, with it being practically very difficult for the traveller to access the internet during a disaster or terrorist attack. It can be difficult to determine the veracity of reports online using such tools. Spurious tweets can be propagated online during disasters, but do tend to be identified and questioned far more than true tweets.43

Repatriation of Migrant Remains

An increasing number of migrants die each year as they attempt to make perilous sea and land crossings to reach the European Union.44,45 However, the remains of migrants or those of refugees are often not repatriated to their country of origin.46 High costs and a lack of political will are cited as reasons for this.46 It is estimated that at least 3772 migrants died crossing the Mediterranean sea in 2015 with an untold number of unrecorded deaths.47 Despite this large volume of deaths and bodies to be managed, regulations pertaining to the repatriation of these remains are ill defined.46 No standardized procedure is in place to deal with the remains of a migrant’s body at present. This ambiguity, coupled with financial constraints, can lead to minimal efforts at identification of the remains with the result that they are often buried locally without formal identification. Costs are allocated to treating and caring for live migrants rather than repatriating the remains of migrants who have already perished.

Travel Insurance, Organ Donation and Suicide Tourism

There is much literature pertaining to the ethics of organ donation tourism and its growth.48,49 Legitimate and successful cross border organ donation schemes exist.50 In the setting of death while travelling, however, no clear information was identified on how best to fulfil the wishes of organ donors should they expire while travelling in the absence of recognized international organ sharing schemes. The advent of so-called ‘suicide tourism’ is also well documented.51,52 This pertains to the practice whereby people travel to countries where euthanasia or physician-assisted death is legal. In terms of repatriation of the remains of these individuals, no specific obstacles were identified in our literature search. In addition, it is relevant to note the fine detail of travel insurance policies as the cost of repatriating the remains in these circumstances may not always be covered. It is important that travellers do not have unrealistic expectations of their travel insurance cover.53 Travel insurance is the most important safety net for travellers in the advent of accident or misadventure and usually underwrites basic travel, medical and dental expenses incurred by travellers abroad.53 It may be necessary to incur extra expenses to cover high-risk activities or indeed the repatriation of remains from a foreign country. Repatriation costs must not be underestimated and the correct travel insurance policy can underwrite these fees substantially. In one instance, a family without adequate travel insurance resorted to desperately smuggling the dead remains of a family member on board a commercial flight in an effort to avoid the expenses involved in the repatriation of their loved one.54

Death in Remote or Hostile Environments

Death in remote or hostile environments can also complicate the repatriation process. Unfortunately, the retrieval of remains may not always be possible in this setting. In an expedition to high altitude or in polar extremes, a decision must be made whether or not it is safe to retrieve the remains should an expedition team member perish. Ensuring no further death or injury to living expedition members is of paramount concern.55 If the retrieval or transport of remains would jeopardize the safety of further team members it is deemed inappropriate to retrieve remains and they are often left in situ.55

Repatriation of Remains Containing Medical Devices

No studies or data were identified to elucidate whether or not death abroad with an implanted device posed any barriers to repatriation. The practice at autopsy is to confirm the presence or absence of any device to exclude iatrogenic injury as the cause of death.56 Cremation of bodies containing an implantable cardiac device is contraindicated due to the explosion risk. Other prosthetic implants or devices such as radioactive implants or artificial limbs must also be removed prior to cremation. This may complicate the repatriation of remains, in particular in the setting of death secondary to an infectious disease where cremation of remains is preferred.57

Conclusions

Repatriation of human remains is a difficult task which is emotionally very challenging for the bereaving family and friends. It requires much organization as well as the coordinated interaction of a number of agencies in a foreign setting. The complexity of this process is exacerbated by the fact that the person scheduling the repatriation is also grieving. Local embassies, travel insurance companies and tour operators are good sources of information on how to organize the repatriation of remains to the home country. The general procedures involved have been highlighted in this review as well as certain complications that may arise in specific circumstances. Repatriation of human remains is likely to become a more common occurrence with the advent of cheaper, more frequent air travel and the increasing age at which people continue to travel.

Despite its morbid elements, as a travel medicine practitioner, it is prudent to discuss all eventualities, including the possibility of death, during the pre-travel consultation. It is also pertinent to advise travellers to review their travel insurance policy in detail to determine if repatriation costs are covered. Awareness of the procedures involved in this process may ease the burden on the grieving family at a very difficult time in their lives and serve public interests.

Conflict of interest: None declared.

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