Eight bodies have been found in a state of "advanced deterioration" at an NHS trust due to lack of freezer space.
Three critical and six major shortfalls were highlighted in a report by the Human Tissue Authority (HTA) on Queen's Medical Centre, run by the Nottingham University Hospitals (NUH) NHS Trust.
It comes after a major inquiry found hundreds of mothers and babies died or suffered potentially avoidable harm because of "deeply embedded systemic failures" at the hospital trust.
Chair Donna Ockenden highlighted that leaders at NUH NHS Trust knew there were serious issues in the maternity department - but failed to take action.
Experts concluded there were "potentially avoidable" outcomes relating to 444 maternity cases examined up to May 2025, alongside 76 newborn cases.
Problems first came to light after Jack and Sarah Hawkins, whose daughter Harriet was stillborn in 2016, found out her body had been allowed to decompose so badly that it needed to be triple-bagged for her funeral.
Critical shortfalls highlighted
During the HTA body audit, the inspection team, who visited the trust in March, identified eight bodies that were showing "advanced deterioration due to not being transferred to a freezer within a sufficient timeframe".
The report said: "Due to the lack of freezers, it has become routine practice to use hermetically sealed bags, or body bags, to store the deteriorating deceased within a refrigerated 'isolation' area."
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The inspection team noted that this had a "detrimental effect on the condition and dignity" of the deceased.
They also pointed out that a lack of checks on wristbands in the mortuary was increasing the risk of the "wrong body being released to funeral services".
Another critical shortfall highlighted in the report was that "no systematic checks were being undertaken for certain categories of bodies".
The report added: "Bodies held in frozen storage, those contained within hermetically sealed bags, and those received in an advanced state of deterioration were not subject to ongoing condition checks."
A critical shortfall was defined in the report as being one which "poses a significant risk to human safety and/or dignity or is a breach of the HT Act or associated Directions" or is a "combination of several major shortfalls".
NHS trust responds to findings
Responding to the findings, Tracy Pilcher, chief nurse at NUH NHS Trust, 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 (HTA), 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."
She added: "While we have met the majority of the HTA standards, we know that there are some very important areas we need to change to ensure our patients and families have confidence that we care for their deceased loved ones in a manner which is dignified and respectful.
"Our teams have been working hard to take immediate actions, including transfer of paediatric post-mortems to our central post-mortem space as soon as it was highlighted by the HTA, increasing mortuary capacity, increasing condition checks, audit oversight and regularity, and further staff training and oversight for incident reporting. In addition, we have increased oversight of our services, to ensure that our practices are in line with standards and with an agreed route to board level reporting.
"We have also increased governance in this area, with further senior oversight and escalation to ensure continuous monitoring, timely escalation of risks, and assurance of sustained compliance."
Reaction to Ockenden report
James Murray, the health secretary, promised the government will present a national action plan to improve maternity care informed by Ms Ockenden's report by the end of the year.
The chief executive and chairman of the NUH NHS Trust have also reacted to the report's findings.
The independent review marks "a watershed moment for affected families, our staff and for the communities we serve", CEO of the trust Anthony May and chair of the board, Nick Carver, wrote in what they call "an open letter to the people and communities of Nottinghamshire".
"We apologise unreservedly to the women and families who have suffered harm, loss, trauma or distress while receiving care in our services," they added.
"We failed you, and on behalf of Nottingham University Hospitals Trust, we accept responsibility for our failings."
(c) Sky News 2026: Eight bodies found in state of 'advanced deterioration' at NHS trust


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