Eight bodies were found in a state of “advanced deterioration” in the mortuary of an NHS trust in March, after hospitals ran out of freezer space.

An inspection of the Queen’s Medical Centre (QMC) in Nottingham by regulator, the Human Tissue Authority, also found insufficient identity checks meant a risk of the wrong bodies being released to families.

On Wednesday, mortuary care at Nottingham University Hospitals (NUH) NHS Trust, which runs the QMC, was strongly criticised by review chair Donna Ockenden, who revealed hundreds of local families had experienced poor maternity care.

NUH chief executive Anthony May said he took “responsibility” for the shortfalls that “happened on my watch”.

May confirmed the trust had “commissioned a separate review into the state of mortuary services today”.

Separately, two men have been bailed after being arrested in connection with operating practices at the mortuary service.

The arrests were made on suspicion of misconduct in a public office as part of Operation Perth, a police investigation which began in 2023 following failings that led to hundreds of babies dying or being injured.

Operation Perth discovered breaches of regulations of the Human Tissue Act in relation to the management and operating practices of the mortuary services.

Problems with post-death care came to light after the parents of Harriet Hawkins, who was stillborn under the care of NUH in 2016, discovered her body had been allowed to decompose so badly that it had to be triple-bagged for her funeral.

A subsequent investigation found 17 areas of concern and prompted an examination by the independent maternity review into the after-death care provided to 16 other babies and one mother.

They found that one early gestation baby had been disposed of as clinical waste, the wrong baby had been passed to funeral directors and a mother who died had deteriorated so badly that her family were advised not to see her, prior to her funeral.

“The review found evidence of recurring examples of failure to protect the dignity of the deceased… including inadequate arrangements for undertaking paediatric post-mortems,” Ockenden said in her report.

The problems prompted the Human Tissue Authority (HTA), which regulates mortuary care in England, Wales and Northern Ireland, to examine the trust’s services.

In an unannounced inspection, external, which was carried out in March 2026 but only published this week, it found three critical shortfalls, six major and one minor against its standards at the two hospitals run by the trust, the QMC and City Hospital.

The HTA found lack of freezer space at both Nottingham hospitals meant some bodies had been put in a refrigerated area instead.

Eight of the bodies were showing “advanced deterioration” because they had not been transferred to a freezer in time.

Instead of being conducted in a post-mortem suite, some baby post-mortem examinations were carried out in a laboratory that was inadequately ventilated, with support staff who had not been trained in mortuary care, the HTA found.

HTA inspectors also said “identification wristbands were not always checked when transferring bodies in hermetically sealed body bags into the care of funeral services”.

“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,” the report added.

An accompanying audit found just over half of the 145 recorded incidents that should have been escalated to the regulator were not.

The HTA noted the QMC met the majority of its standards, and that improvements had been made since its inspection.

The trust’s chief executive Anthony May told the BBC that the findings were “very disappointing”, and said an “action plan” was now in place, adding “for anyone who feels we haven’t respected their dignity. I’m very, very sorry”.

He said: “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.”

May added: “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.”

Manjeet Shehmar, medical director at NUH, said: “We recognise that some of the systems and processes used in our mortuary did not meet the standards expected by the Human Tissue Authority, our trust, or of our patients, for which we are truly sorry.

“We take the concerns raised by the HTA very seriously and have already taken action to make improvements. We are grateful for the feedback from the HTA following the inspection and have met them to talk through their concerns and how we can improve.”

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