Mortuary Conditions: Eight Bodies Found in Advanced Deterioration
Eight bodies were found in a state of “advanced deterioration” at the mortuary of Nottingham University Hospitals NHS Trust (NUH) during an inspection by the Human Tissue Authority (HTA) in March, the regulator has disclosed. The HTA said the bodies had not been transferred to a freezer within a sufficient timeframe, a failure attributed to “insufficient long-term freezer storage to meet the needs of the mortuary service”.
According to the HTA report, the lack of freezers had led to a “routine practice” of storing deteriorating deceased in hermetically sealed body bags within a refrigerated “isolation” area. Inspectors noted that this had “a detrimental effect on the condition and dignity of the deceased”. During a body audit, they identified eight bodies showing advanced decomposition and advised staff to organise an immediate transfer to the remaining freezer spaces at the trust’s Nottingham City Hospital site.
The report also highlighted a lack of systematic checks on certain categories of bodies, including those held in frozen storage, those contained in sealed bags, and those received already in an advanced state of deterioration. For the bodies that were checked, inspectors found the timeframe “lacked consistency” and records were maintained on an “ad hoc basis” rather than in accordance with a defined schedule.
Risk of Wrong Body Release to Funeral Services
The inspection team warned that inadequate identification checks were increasing the risk of “the wrong body being released to funeral services”. The HTA report stated that identification wristbands were “not always checked” when transferring bodies in hermetically sealed bags into the care of funeral directors. Because the seals on the bags are not opened at the point of release, staff verify identity solely against accompanying documentation rather than by confirming the wristband on the deceased.
Additional concerns were raised about the handling of perinatal post-mortem examinations. Inspectors observed that some of these examinations were being conducted in a non-mortuary laboratory area that does not meet HTA standards. Support staff working in that area had no documented training or competency assessments in mortuary processes, though the trust submitted sufficient evidence to address this shortfall before the report was finalised.
The wider Ockenden review into NUH, published on 24 June, found that more than 500 mothers and babies died or suffered “potentially avoidable harm” at the trust between 2012 and 2025. Of these, 444 women and 76 newborn babies experienced “potentially avoidable” outcomes, and 162 died after substandard care — including 94 stillbirths, 62 neonatal deaths and six maternal deaths. The review described the organisation as “toxic” with a “bullying culture” and “deeply embedded systemic failures”.
Failings in the trust’s mortuary and post-death care were a significant part of the Ockenden report. Examples included an early‑gestation baby disposed of as clinical waste, a stillborn baby left in a domestic fridge rather than a mortuary, a baby placed on a storage tray alongside an unrelated adult, and dehumanising language used by clinicians. In one case the wrong baby was released to a funeral director; in another a stillborn baby girl remained in a fridge when she should have been taken to the mortuary. The problems first came to light after Jack and Sarah Hawkins, whose daughter Harriet was stillborn in 2016, discovered her body had decomposed so badly that it had to be “triple-bagged” for her funeral. The family later received a £2.8 million settlement in 2021, believed to be a record for a stillbirth clinical negligence case.
Trust Response and Regulatory Action
The HTA said it found “serious shortfalls” at the trust and took “prompt regulatory action, including issuing formal directions”. NUH retains its HTA licence but must now fulfil every aspect of it. The trust has submitted an action plan to the regulator, which will be subject to independent oversight.
NUH 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.” He said the trust had commissioned a review into the state of mortuary services and was working closely with the police and regulator. “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.”
On 22 June, Nottinghamshire Police arrested two men, aged 55 and 59, on suspicion of misconduct in a public office in connection with operating practices in the trust’s mortuary service. They have been released on bail with strict conditions. The arrests form part of Operation Perth, the wider criminal investigation into maternity and mortuary failings at NUH, which had previously launched a corporate manslaughter inquiry. The Ockenden review also noted that the trust had failed to report 73 incidents to the HTA over the past decade, and that senior staff had largely declined to participate in the review — a decision families called “appalling”.
The HTA is now initiating a sector-wide assurance exercise requiring all trusts to check ten years of mortuary records to identify patterns of mispractice, while the government is introducing stronger regulation on mortuaries and considering statutory regulation for anatomical pathology technologists. Calls for a statutory public inquiry into maternity care across England continue, with the Ockenden review noting that maternity harm accounted for £2.5 billion of NHS negligence costs in 2024/25.