Inspection Reveals Advanced Decomposition in Nottingham NHS Trust Mortuary
The Human Tissue Authority (HTA) has reported that bodies held in the mortuary at Nottingham University Hospitals NHS Trust, which is central to the NHS’s largest maternity care inquiry, were found in a state of "advanced deterioration". This condition was attributed to bodies not being transferred to freezers promptly due to inadequate storage capacity.
During an inspection in March, HTA inspectors discovered eight bodies exhibiting advanced decomposition, a result of delayed transfer to freezer storage. The trust was found to have "insufficient storage to meet the needs of the mortuary service," according to the inspectors' findings.
Additionally, inspectors identified that identification wristbands were not consistently checked when bodies—kept in hermetically sealed bags because of their deterioration—were handed over to funeral services. This lapse increased the risk of incorrect body release to families.
Concerns Raised Following Family’s Experience
Issues with mortuary care at the trust came to light after the parents of a stillborn child, who passed away at Nottingham City Hospital in 2016, raised concerns about the severe decomposition of their daughter’s body. The body had to be "triple-bagged" for the funeral due to its condition.
The independent inquiry, led by senior midwife Donna Ockenden, investigated the trust’s maternity services and found that over 500 mothers and babies died or were harmed between 2012 and 2025. The inquiry described the trust as "toxic," citing "systemic, deep-rooted" failures in maternity and neonatal care.
Donna Ockenden dedicated 29 pages of her 400-page report to the Hawkins family’s experience, highlighting it as emblematic of the "cruel" treatment of parents and babies within the trust’s maternity units.
Trust Leadership Responds to Mortuary Care Failures
Anthony May, chief executive of Nottingham University Hospitals NHS Trust, issued an apology on behalf of the trust regarding the "lack of care" observed during the March inspection. Addressing the issue, he stated:
"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."
While not naming the Hawkins family directly, May acknowledged that the issue was brought to his attention after a maternity family discovered concerning information in their subject access requests about the care of their daughter’s body.
He added:
"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."
Following the HTA inspection, the trust submitted an action plan to the regulator. May explained:
"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."
Police Investigation and Legal Actions
Separately, Nottinghamshire Police announced that two men, aged 55 and 59, have been bailed following arrests on suspicion of misconduct in a public office related to mortuary operating practices. The police statement noted:
"The enforcement was carried out by Operation Perth, which is Nottinghamshire police’s investigation into maternity services at both hospitals. Operation Perth discovered breaches of regulations of the Human Tissue Act in relation to the management and operating practices of the mortuary services."
