Inspectors from the Human Tissue Authority (HTA) found eight bodies in a state of "advanced deterioration" at the mortuary of Nottingham University Hospitals NHS Trust because the facility had run out of freezer space. The unannounced inspection, which occurred in March, also revealed that staff failed to check wristbands, increasing the risk of releasing the wrong bodies to grieving families.
These mortuary findings come shortly after a report on the trust's maternity services detailed more than 500 instances where mothers and babies died or were harmed due to "deeply embedded systemic failures." That review, which exposed what is considered the largest maternity scandal in NHS history, described a "toxic" environment where mistakes were concealed, women were routinely ignored, and speaking up was discouraged.
The HTA report indicated that the lack of freezers had led to a routine practice of storing deceased individuals in hermetically sealed bags within a refrigerated area. "The inspection team noted that this had a detrimental effect on the condition and dignity of the deceased," the report stated. During a body audit, eight bodies were identified as showing advanced deterioration because they had not been transferred to a freezer in a timely manner.
Further issues were identified regarding the bodies of babies. Perinatal post-mortem examinations were found to be taking place in a non-mortuary laboratory area that does not meet HTA standards, rather than within the designated mortuary suite. The report also cited instances of poor mortuary care, including a case where the wrong baby was released to a funeral director and another where a stillborn baby girl remained in a refrigerator when she should have been moved to the mortuary.
Two men have been arrested by Nottinghamshire Police in connection with operating practices in the trust's mortuary service. The trust's chief executive, Anthony May, apologized for the mortuary failings, stating, "The dignity and respect of people in death matters just as much as it does during their lives." He noted that the mortuary issues initially came to his attention after a maternity family discovered information in a subject access request concerning the care of their deceased daughter.
The scandal has intensified calls for immediate action on recommendations from the Ockenden report into maternity services. The report's author, Donna Ockenden, expressed disappointment that the government plans to wait until the end of the year to develop an action plan to address the issues. "In six months, how many obstetricians are going to walk away and say I can't do this anymore… How many more midwives are going to hang up their uniforms and say 'Enough, I can't do it'?" Ockenden questioned, highlighting the urgency of the situation. Bereaved families have also warned that more maternal and infant deaths could occur if the government does not act swiftly.
Sarah Hawkins, whose baby Harriet died in 2016 and whose body was found to have decomposed significantly, shared the emotional toll of the findings. "Harriet's first and last walk was in her tiny white coffin and we took some comfort in that so to find out later she was decomposed in the coffin - I can't even begin to describe the emotional toll," she said. Maternal deaths in the UK are currently at a 20-year high, with the NHS spending a substantial amount on legal claims for maternity blunders, equivalent to its expenditure on maternity care itself.