Bodies found in 'advanced deterioration' at scandal-hit Nottingham NHS trust
"Critical shortfalls" have been found at mortuaries run by a Nottingham NHS trust, which is already under fire for maternity failings.
Bodies in the mortuary at a scandal-hit NHS trust were found this year in a state of “advanced deterioration” due to not being transferred to a freezer in time, inspectors have said.
Human Tissue Authority (HTA) inspectors who visited Nottingham University Hospitals NHS Trust in March found eight bodies in advanced decomposition due to a lack of freezer space.
They also highlighted how a lack of checks on wristbands in the mortuary was increasing the risk of the “wrong body being released to funeral services”.
A report published on Wednesday into the trust led by former senior midwife Donna Ockenden found more than 500 mothers and babies were harmed, suffered potentially avoidable harm or died due to “deeply embedded systemic failures” at the “toxic” organisation.
In the March HTA report, the regulator said that although Queen’s Medical Centre run by the trust met most standards, there were three “critical”, six “major” and one “minor” shortfall.
The report pointed to “insufficient long-term freezer storage to meet the needs of the mortuary service”.
It said: “Due to the lack of freezers, it has become routine practice to use hermetically sealed bags, or body bags, to store the deteriorating deceased within a refrigerated ‘isolation’ area.
“The inspection team noted that this had a detrimental effect on the condition and dignity of the deceased.
“During the body audit, the inspection team identified eight bodies that were showing advanced deterioration due to not being transferred to a freezer within a sufficient timeframe.
“Establishment staff were advised to organise a transfer to the remaining freezer spaces on the Nottingham City Hospital site before the inspection team left site.”
Inspectors also found “no systematic checks were being undertaken for certain categories of bodies”.
The report added: “Bodies held in frozen storage, those contained within hermetically sealed bags, and those received in an advanced state of deterioration were not subject to ongoing condition checks.
“For the bodies that were checked, the timeframe for doing so lacked consistency.
“Although checks were carried out, they were not conducted in accordance with a defined schedule, and records were maintained on an ad hoc basis.”
Ms Ockenden’s report into the trust was heavily critical of the trust’s mortuary services.
Problems first came to light after Jack and Sarah Hawkins, whose daughter Harriet was stillborn in 2016, discovered her body had been allowed to decompose so badly that it had to be triple-bagged for her funeral.
In her report, Ms Ockenden found examples “including an early gestation baby disposed as clinical waste; dehumanising language by clinicians; and poor mortuary care, including failure to comply with legal requirements”.
In one case, the wrong baby was released to a funeral director and in another, a stillborn baby girl remained in a fridge when she should have been taken to the mortuary.
On Monday, Nottinghamshire Police said two men had been arrested “in connection with operating practices in the mortuary service” provided by the trust.
The HTA report from this March found problems relating to the bodies of babies.
Inspectors “observed that some perinatal post-mortem examinations were not being conducted within the mortuary post-mortem suite”.
They said: “Instead, they were transferred to a non-mortuary laboratory area that does not meet HTA standards.
“Consequently, support staff working in this area did not have documented training or competency assessments in mortuary processes.
“The establishment submitted sufficient evidence to address this shortfall before the report was finalised.”
Overall, HTA inspectors found “identification wristbands were not always checked when transferring bodies in hermetically sealed body bags into the care of funeral services”.
The report said: “The mortuary uses hermetically sealed bags for bodies in a state of deterioration; however, these seals are not opened at the point of release.
“As a result, identification is verified solely against accompanying documentation rather than by confirming the wristband on the deceased.
“This increases the risk of the wrong body being released to funeral services.”
In a statement, the HTA said it found “serious shortfalls” at the trust and “took prompt regulatory action, including issuing formal directions”.
Trust chief executive Anthony May told BBC Radio 4’s Today programme: “I take responsibility and accountability for that… That happened on my watch.
“I’m very sorry. I’m really disappointed. The dignity and respect of people in death matters just as much as it does during their lives.
“This initially came to my attention after one of the maternity families found something in one of their subject access requests about the way we’d cared for their daughter.
“We immediately commissioned with the family a review. We commissioned a separate review into the state of mortuary services today.
“We work closely with the police and the regulator. The regulator eventually came and inspected our services and found further shortfalls. We’ve got one action plan now submitted to the regulator.
“That action plan will have independent oversight, so that we’ve got the right governance and assurance in place.
“We took a lot of actions at the time. Those actions are still under way, and we’re absolutely determined to put this right, because local people deserve better, and these services need to be of a higher quality.
“We do still have the licence from the HTA, but we need to make sure we fulfil every single aspect of it.”