Bodies in the mortuary at the NHS trust at the centre of the health services biggest ever maternity care scandal were found 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 discovered eight bodies in a state of advanced decomposition due to not being transferred to a freezer within a sufficient timeframe.
The inspectors concluded that the trust, which is the subject of the NHS’s largest inquiry into maternity services, has “insufficient storage to meet the needs of the mortuary service”.
Inspectors also found that identification wristbands were not always checked when bodies, which were kept in hermetically sealed bags due to their deterioration, were transferred to funeral services, increasing the risk of the wrong body being released to families.
Problems with mortuary care at the trust emerged after the parents of Harriet Hawkins, who was stillborn at Nottingham city hospital in 2016, questioned why her body had decomposed so badly in the mortuary it had to be “triple-bagged” for her funeral.
A review published on Wednesday, led by Donna Ockenden, an independent senior midwife, found that more than 500 mothers and babies died or were harmed at the “toxic” trust between 2012 and 2025 due to “systemic, deep-rooted” failures in maternity and neonatal care.
Ockenden devoted 29 pages of her 400-page report to the Hawkinses’ experiences, arguing their case had many “hallmarks” of how the trust’s maternity units “cruelly” treated parents and babies.
The chief executive of Nottingham University Hospitals trust, Anthony May, apologised on behalf of the trust after he was asked about the “lack of care” shown to bodies in its mortuary during the inspection in March. Commenting on BBC Radio 4’s Today programme, he said: “I will take responsibility and accountability for that, because you’re absolutely right, that happened on my watch.
“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.”
He did not name the Hawkinses, but said that the matter had been brought to his attention after “one of the maternity families found something in their subject access requests about the way we cared for their daughter”.
May said: “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.”
Since the HTA inspection, the trust has submitted an action plan to the regulator, he said. “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.
“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,” May said.
Separately, two men, aged 55 and 59, have been bailed after they were arrested on Monday on suspicion of misconduct in a public office “in connection with operating practices at the mortuary service”, Nottingham police said.
“The enforcement was carried out by Operation Perth, which is Nottinghamshire police’s investigation into maternity services at both hospitals,” the force said in a statement at the time.
“Operation Perth discovered breaches of regulations of the Human Tissue Act in relation to the management and operating practices of the mortuary services.”
