Eight bodies in an advanced state of decomposition were discovered inside the mortuary of Nottingham University Hospitals NHS Trust during an inspection in March, a damning regulatory report has revealed — the latest blow to a health organization already at the center of the NHS’s biggest ever maternity care scandal.
The Human Tissue Authority (HTA) conducted the inspection at Queen’s Medical Centre, operated by the trust, and found three critical shortfalls, six major shortfalls, and one minor shortfall. The body responsible for regulating the use and storage of human tissue said the root cause of the decomposition crisis was straightforward but shocking: the mortuary simply did not have enough freezer space to handle its caseload.
Bodies Stored in Bags Due to Freezer Shortage
With long-term freezer capacity falling well short of operational needs, mortuary staff had resorted to sealing deteriorating bodies in hermetically sealed bags and storing them in a refrigerated isolation area — a workaround that regulators said caused direct harm to the condition and dignity of the deceased. When inspectors conducted a physical body audit, they found eight individuals in an advanced state of deterioration because they had not been moved to freezer storage quickly enough. Staff were instructed to transfer those bodies to remaining freezer spaces at Nottingham City Hospital before the inspection team departed the site.
According to the HTA report, insufficient freezer capacity led staff to routinely place decaying bodies in sealed bags within a refrigerated isolation zone, damaging both their physical condition and the dignity owed to the deceased.
Inspectors also found that systematic condition checks were not being carried out on certain categories of bodies — including those held in frozen storage, those already sealed in body bags, and those received at the mortuary in an already deteriorated state. For the bodies that were checked at all, staff kept records on an ad hoc basis with no consistent schedule in place.
Risk of Wrong Bodies Released to Families
The HTA report raised another alarming concern: because hermetically sealed bags were not opened when bodies were handed over to funeral directors, staff were unable to physically verify the identity of the deceased against the wristband on the body. Instead, identification was confirmed only through accompanying paperwork — a gap that regulators warned increased the risk of the wrong body being released to grieving families.
Separate problems emerged around the care of babies. HTA inspectors found that some perinatal post-mortem examinations were being carried out in a non-mortuary laboratory area that does not meet regulatory standards. Support staff working in that area lacked documented training or formal competency assessments in mortuary procedures.
The Hawkins Family and the Ockenden Report
The mortuary failures came to light in part because of the persistence of Jack and Sarah Hawkins, whose daughter Harriet was stillborn at Nottingham City Hospital in 2016. The couple discovered through a subject access request that Harriet’s body had been allowed to deteriorate so severely while in the trust’s care that it had to be triple-bagged ahead of her funeral. Independent senior midwife Donna Ockenden dedicated a 29-page section of her 400-page report to the Hawkinses’ experience, concluding it bore many hallmarks of how the trust treated bereaved parents.
Donna Ockenden’s report, published on Wednesday, concluded that more than 500 mothers and babies either died, were harmed, or experienced preventable harm due to deeply embedded systemic failures at what she described as a “toxic” organization. The review covered events between 2012 and 2025 and identified failures that included an early gestation baby being disposed of as clinical waste, a wrong baby being released to a funeral director, a stillborn baby girl left in a refrigerator rather than being transferred to the mortuary, and the use of dehumanizing language by clinicians. On Monday, Nottinghamshire Police announced that two men, aged 55 and 59, had been arrested under Operation Perth over alleged misconduct in public office related to how the trust’s mortuary service was run.
Trust Chief Apologizes, Vows to Improve
Anthony May, the chief executive of Nottingham University Hospitals NHS Trust, acknowledged the failures publicly and did not deflect responsibility. Speaking on BBC Radio 4’s Today programme, May said, “I’m very sorry. I’m really disappointed… dignity and respect of people in death matters just as much as it does during their lives.”
May said the trust had commissioned a review alongside the affected family once the mortuary issues came to its attention, and separately commissioned a broader review of mortuary services. He said the trust continues to work with police and the regulator and that, while the HTA licence remains in place, every condition attached to it must now be fully met. The HTA confirmed it took prompt regulatory action following the inspection, including issuing formal directions to the trust to address the serious shortfalls identified.
Sources: The Independent | AOL News | The Guardian | Yahoo News UK
