Standards › Standard 33 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · LBT-SOP-006 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 33.10
At a glance
- Each forensic or legal specimen has a chain of custody from collection (LBT-FRM-004).
- Each transfer is signed and dated.
- The specimen is disposed of only as recorded.
- Any gap in custody is reported at once.
- Stop and get help straight away if: a legal specimen is handled with a gap in its chain of custody.
1. Purpose
To make sure forensic and legal specimens can be shown to be the same specimen, handled the same way, from collection to disposal (33.10).
2. Scope
| Applies to | Clinical and support staff in the hospital |
| Locations | All wards, clinics and departments of the facility |
| When | Whenever the activity described is carried out |
| Does not apply to | Activities covered by another document listed in section 15 |
3. Definitions
| Term | Meaning |
|---|---|
| Clinical lead | The doctor or nurse in charge of the area at the time |
4. Background
A specimen used as legal evidence must show, at each step, who held it and what happened to it. Without that custody record, the evidence can be challenged.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Senior scientist | Owns the custody process and the forms | Laboratory director |
| Each person who handles the specimen | Signs and dates each transfer | Senior scientist |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Records and forms named in this document | Current version | Checked before use |
7. Safety
- Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.
8. Before you start
- Confirm the forms and equipment named in this document are available and current.
9. Procedure
Step 1. Start the form.
- Start the chain of custody at collection and record the collector.
Key point: Started.
Step 2. Sign each transfer.
- Sign and date each transfer of the specimen (LBT-FRM-004).
Key point: Signed.
Step 3. Dispose.
- Dispose of the specimen only as the form records.
Key point: Disposed.
10. Decision points
- No decision points in this procedure.
11. Special situations
| Situation | Action |
|---|---|
| Out of hours | Follow the same steps. Use the on-call contact on the wall of the area. |
12. Escalation
- Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Forensic specimens with a complete custody form | 100% | Quarterly | Senior scientist | Escalate to the laboratory director |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Record named in this document | Patient record or the area file | the period set by the facility’s records policy years |
15. Training
- Staff are trained in this document at induction and refreshed each year, with a recorded competency check.
16. Related documents
| ID | Title | Use |
|---|---|---|
| LBT-FRM-004 | Chain of custody form | Form |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on ISO 15189:2022 Medical laboratories: requirements for quality and competence, ISO 9001:2015 for supplier control, and the Global Patient Safety Action Plan 2021–2030 for critical results. |
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
E-learning for this document
References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)