Inspectors have warned of mixed-up bodies, weak security and a lack of dignity in the morgue of Norfolk's biggest hospital.
Major shortfalls were revealed at the Norfolk and Norwich Hospital mortuary by officials from the Human Tissue Authority (HTA), prompting an extensive revamp of the facility due to be completed next month.
The HTA is a public body which regulates organisations that work with bodies in contexts such as anatomical examinations, post-mortems, organ donations and transplants.
They were set in 2005 after hospitals were found to be removing and keeping organs and tissue without authorisation in the 1990s.
Inspectors from the HTA said in transferring the deceased from the main mortuary at the N&N to six temporary storage units, there was a risk of misidentification, which could lead to visiting relatives viewing the wrong bodies at the Norwich facility.
A report from the HTA published after the April inspection revealed: “The establishment has insufficient capacity for storage of bodies.
"Six temporary units are erected and in permanent use, including one in the post-mortem room, which is blocking body store doors and a fire exit, posing safety risks.”
RISK OF BODY MIX-UPS
Despite warnings from the HTA, mix-ups have occurred due to failings at the facility.
In October last year, bosses at the N&N apologised after staff released the wrong body from the mortuary.
The corpse was collected from the hospital by undertakers who thought it belonged to someone else and took it to a funeral parlour in North Walsham.
It remained there for four days before N&N staff realised the blunder and the body was returned to the mortuary before being collected by the correct funeral directors in Norwich.
HTA inspectors had previously said the practises seen at the hospital could result in bodies being mixed up.
They noted: “To manage capacity mortuary staff transfer bodies from the main mortuary body store to the temporary and external body storage units on a daily basis.
“This increases the risk of: losing traceability and misidentification of bodies, accidental damage to bodies and musculoskeletal injuries to staff.”
It was found staff were not checking bodies thoroughly enough prior to relatives viewing the deceased.
They observed: “Mortuary staff do not routinely check a minimum of three identifiers on the deceased with details provided by relatives before a viewing takes place.
"This poses a risk of viewing a wrong body.”
The problems with storage had been on the trust's risk register since May 2020.
MORTUARY OVERHAUL
Hospital officials say they have taken steps to transform the mortuary facility and are no longer using temporary units permanently.
Dr Bernard Brett, medical director, said the hospital is taking the inspection report “extremely seriously”.
He added: “Since the HTA inspection, unused temporary units have been removed and are now deployed only when required during high-pressure periods. The HTA has confirmed it is content with this approach.
“We began a refurbishment of the mortuary and post-mortem room in July 2025 and this will be completed, on schedule, in late February 2026. The post-mortem work and wider mortuary activity has remained unaffected by the extensive refurbishment.
“We have a range of effective operational controls in place and there have been no patient safety incidents associated with storage capacity since the risk was first recorded.
“We are carrying out a comprehensive retrospective audit of post-mortem consent and testing documentation.
"An action plan has been submitted to the HTA and this will be incorporated into our regular audit schedule.”
He also said steps have been taken to improve the security level at the hospital morgue.
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