Regulator reviews huge rise in failings at hospital mortuaries

More than 500 “shortfalls” were exposed in mortuaries in 2017-18, triggering concerns by staff at the Human Tissue Authority, the regulator of the post-mortem sector.

Representative bodies for pathologists said they are taking the rise “extremely seriously”, and warned workforce problems and increasing demand were among the main factors.

The 510 failings last year, reported during HTA inspections, were found across nearly all the 58 mortuaries, which were inspected in 2017-18.

Each mortuary in England, Wales, and Northern Ireland is inspected around once every three years. The number of failings last year contrast starkly with the previous two years.

The rise is partly explained by a fourfold increase in the number of standards against which the mortuaries are assessed.

But the HTA told HSJ the new standards are unlikely to be the cause of growing numbers of “major” and “critical” shortfalls – the two most serious categories of breach. 

Eight “critical” failings were reported last year, which pose a “significant risk” to human safety and/or dignity, or is a breach of the Human Tissue Act 2004.

No such failings were reported in the four years prior to 2017-18.

The critical failings, which have since been addressed by the NHS trusts in question, included:

• A faulty drainage system on one post-mortem table which caused a “pooling” of body fluids during an examination at Torbay Hospital;
• A dirty fridge/freezer unit, used to store bodies, which posed a “significant health and safety or environmental risk” at Alexandra Hospital in Redditch; and
• Leaks, exposed plaster on the wall, and poor condition of the floor between Southend Hospital and its body basement which risked incidents resulting in damage to bodies.

The HTA figures also show the percentage of inspections in which no failings have been reported has fallen from 43.2 per cent in 2013-14 to 5.2 per cent in 2017-18.

In the same timeframe, the percentage of inspections, which have exposed major or critical failings rose from 11.4 per cent to 58.6 per cent.

Most of the increasing shortfalls have been reported in the “governance and quality” and “premises, facilities, and equipment” domains, according to the HTA.

Nicolette Harrison, HTA’s director of regulatory delivery, told HSJ the increase in shortfalls, including major and critical, “exceeded what we would have expected given the recent changes in our inspection standards”.

“We expect all establishments to meet our standards, to ensure public confidence that mortuaries are handling bodies with appropriate dignity and care,” she said.

She added the HTA is analysing the trend and will use the results of the work to produce further guidance for mortuary staff.

Ishbel Gall, chair of the Association of Anatomical Pathology Technologists, said the figures give the impression of a “dramatic increase”, but must be “examined closely by those within the sector to establish exactly what the data means”.

The “raw data” alone did not give a complete picture of mortuary standards, she said. 

She said the root cause of the problems is the lack of pathologists to carry out post-mortem work.

Ms Gall said: “A shortage of pathologists leads to delays which require the deceased to be stored for increasing periods of time.”

She said many of the shortfalls involve increased demand for refrigeration and storage of the deceased, as well as mortuaries using “temporary solutions” on a permanent basis because of increasing demand.

Other shortfalls have occurred because of a lack of investment, not just in the mortuary, as the financial pressure increases on the NHS, she added.

Dr Michael Osborne, of the Royal College of Pathologists, said the college was taking the increase “extremely seriously” and helping HTA “properly analyse the data”.

He stressed that experts need to “drill down into the figures” before any meaningful conclusions can be drawn.

Part of the analysis should focus on making sure the HTA standards are reasonable, and that they are achievable under the current circumstances the NHS finds itself in, he added.

“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.”

Last year, mortuaries across England, Wales, and Northern Ireland admitted more than 300,000 bodies and around 90,000 post mortems were performed.