Bodies Found in Advanced Deterioration at Nottingham NHS Trust Mortuary
Eight bodies were discovered in a state of "advanced deterioration" in the mortuary of an NHS trust after hospitals ran out of freezer space.
An inspection of the Queen's Medical Centre (QMC) in Nottingham by the Human Tissue Authority (HTA), the regulator, also revealed insufficient identity checks, creating a risk of incorrect bodies being released to families.
Mortuary care at Nottingham University Hospitals (NUH) NHS trust, which operates the QMC, was strongly criticised by independent review chair Donna Ockenden on Wednesday. She disclosed that hundreds of local families had experienced poor maternity care.
The trust expressed it was "truly sorry" for failing to meet the expected standards.
Separately, two men have been bailed following arrests related to operating practices at the mortuary service.
The arrests were made on suspicion of misconduct in a public office as part of Operation Perth, a police investigation initiated in 2023 after failings led to hundreds of babies dying or being injured.
Operation Perth uncovered breaches of the Human Tissue Act regulations concerning the management and operational practices of the mortuary services.
The review led by Donna Ockenden found recurring failures to protect the dignity of the deceased.
Background and Findings of the Review
Concerns about after-death care emerged after the parents of Harriet Hawkins, stillborn at NUH in 2016, discovered her body had decomposed so severely it required triple-bagging for her funeral.
A subsequent investigation identified 17 areas of concern and prompted an independent maternity review into after-death care provided to 16 other babies and one mother.
The review found that one early gestation baby was disposed of as clinical waste, a wrong baby was handed to funeral directors, and a mother who died had deteriorated so significantly that her family was advised not to view her before the funeral.
"The Review found evidence of recurring examples of failure to protect the dignity of the deceased including inadequate arrangements for undertaking paediatric post-mortems," Ockenden stated in her report.
These issues led the Human Tissue Authority, which regulates mortuary care in England, Wales, and Northern Ireland, to inspect the trust's services.
Inspection Results and Shortfalls
In an unannounced inspection conducted in March, the HTA identified three critical, six major, and one minor shortfalls against its standards at the QMC and City Hospital, both run by the trust.
The HTA found that insufficient freezer space at both Nottingham hospitals caused some bodies to be stored in refrigerated areas instead.
Eight bodies exhibited "advanced deterioration" because they were not transferred to freezers promptly.
Some baby post-mortem examinations were performed in a laboratory lacking adequate ventilation instead of a dedicated post-mortem suite, with support staff untrained in mortuary care, the HTA reported.
An accompanying audit revealed that just over half of 145 recorded incidents that should have been escalated to the regulator were not reported.
Trust Response and Actions
NUH chief executive Anthony May described the findings as "very disappointing" and confirmed that an "action plan" was in place.
"For anyone who feels we haven't respected their dignity. I'm very, very sorry," May said.
Manjeet Shehmar, medical director at NUH, stated:
"We recognise that some of the systems and processes used in our mortuary did not meet the standards expected by the Human Tissue Authority (HTA), our Trust or of our patients, for which we are truly sorry.
We take the concerns raised by the HTA very seriously and have already taken action to makeimprovements. We are grateful for the feedback from the HTA following the inspection and have met them to talk through their concerns and how we can improve."
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