Failings at hospital mortuaries mean there is “significant risk” of bodies being mixed up, inspectors have warned.
More than 500 “shortfalls” were found during inspections of mortuaries in 2017-18, representing a steep rise from previous years, sparking concerns by the Human Tissue Authority, which regulates the post-mortem sector.
One of the hospitals, which inspectors identified as having critical failings, almost lost its licence to store bodies and carry out post-mortems.
Torbay Hospital, in Devon was found to have such weak checks in place there was “a significant risk of misidentification of the deceased”. Inspectors also found that post-mortem suites and fridges storing dead babies and foetuses were left unlocked.
During 2017/18, 151 major failings were identified in hospital mortuaries in the UK compared with just seven the year before, an investigation by Health Service Journal revealed.
In eight of the 151 cases, inspectors identified critical failings which posed a “significant risk” to human safety or dignity, or were a breach of the Human Tissue Act 2004. In the previous four years, no such failings were reported.
Overall, 510 failings were identified across 58 mortuaries inspected in 2017/2018, a steep rise from 59 failings found the previous year.
During the visit to Torbay Hospital in May last year, inspectors found critical failings at the hospital mortuary, including “extensive rusting” of equipment used for post-mortems, which meant they could not be properly cleaned, while a broken drainage system meant bodily fluids became pooled during examinations.
The report found that a temporary storage unit for 12 bodies for use at busy times had been in near constant use for at least a year.
Inspectors said the conditions posed significant risks to the dignity of the deceased, as well as to the health and safety of staff.
After visiting the hospital again, inspectors found “all urgent actions” had been taken, which meant it could keep its licence.
At Alexandra Hospital in Redditch, a dirty fridge/freezer was used to store bodies which posed a “significant health and safety or environmental risk”.
Leaks, exposed plaster on the wall, and the poor condition of the floor between Southend Hospital and its body basement risked incidents resulting in damage to bodies.
Both hospital trusts have since taken action to remedy the issues.
Representative bodies for pathologists said they are taking the rise “extremely seriously” but that many of the failings stemmed from staff shortages, increasing demand and lack of funds to repair facilities.
Ishbel Gall, chair of the Association of Anatomical Pathology Technologists, said the figures gave the impression of a “dramatic rise” but that the data needs to be properly analysed before conclusions can be drawn and that changes to HTA’s inspection standards need to be taken into account.
However, she told HuffPost UK that a lot of the issues identified could be put down to an “incredible shortage of pathologists” which has resulted in long delays and the increased use of temporary fridges, normally only used during the winter months when there is a seasonal increase in the death rate.
The temporary fridges are less likely to have the required security and are more difficult to connect to temperature monitoring systems used for permanent fridges. She added that during a normal workload, deep cleans can be done on empty fridges but when there is a backlog, there are no empty fridges.
She added that the funding crisis in the NHS meant a lack of investment in maintenance, and when budget is used for this, the public areas of hospitals get priority for refurbishment.
Dr Michael Osborne, of the Royal College of Pathologists, said the college was taking the increase “extremely seriously”.
He stressed that it was important to ensure the HTA standards are both reasonable and achievable under the current circumstances the NHS finds itself in.
“Some things are more addressable than others,” he said. “Governance and quality are things people can deal with. You can send staff on courses, and you can educate them to improve governance and quality.
“It is much harder to improve premises, facilities, and equipment because that often has a much larger capital overlay.”
Nicolette Harrison, HTA director of regulatory delivery, said that the increase in major and critical shortfalls exceeds what they had expected given the recent changes in inspection standards.
She said: “We have undertaken further analysis of this trend and will be using the results of that work to produce further advice and guidance for mortuary staff, to help them better understand what is required of them, and improve compliance.
“We expect all establishments to meet our standards, to ensure public confidence that mortuaries are handling bodies with appropriate dignity and care”