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A recent review led by Donna Ockenden has uncovered extensive failings in the Nottingham University Hospitals (NUH) NHS Trust, marking it as the largest maternity scandal in NHS history. While the report initially focused on cases where mothers and babies experienced potentially preventable harm, it also revealed serious defects in the trust’s mortuary services. Among the distressing incidents reported were examples of babies being treated without dignity—one infant was discarded as clinical waste, another was placed in a mortuary chamber that was already occupied by a deceased adult, and in a separate instance, a baby was mistakenly released to the wrong funeral directors. These issues are not merely historical; in March this year, eight bodies were discovered in a state of severe decomposition at the trust’s mortuary due to a lack of freezer space.
The impact on bereaved families has been profound. Natalie and David Needham, whose son Kouper died shortly after birth, were further traumatized when they received a disc containing graphic post-mortem photographs along with an itemized letter detailing the costs associated with Kouper’s care and death. Natalie expressed how deeply painful this was, stating, “I’d always wanted my last image of Kouper to be when I was holding him in hospital while he was still breathing. That was taken away from me – because my last image of him now is those mortuary pictures.” The letter, addressed to “Dear Doctor” rather than to her, included charges ranging from incubation tubes to ambulance transport, culminating in a cost assigned for informing her of her son’s death.
Following this incident, NUH faced criticism for its handling of the post-mortem information. When Natalie contacted the hospital upon receiving the letter, she was pressured to return the documents but refused, and the trust threatened court action to reclaim them. NUH did not directly respond to inquiries about this episode. Later, in discussions with NUH’s chief executive Anthony May, Natalie was told that the documents were sent as part of her subject access request (SAR) under data protection laws. However, both Ockenden’s team and NUH acknowledged that the way these materials were disclosed was “completely unacceptable,” highlighting deficiencies in quality assurance. Despite this, Natalie remains unconvinced that the documents were sent legitimately as part of her SAR and suspects purposeful wrongdoing. NUH chief nurse Tracy Pilcher issued an apology and confirmed that thorough investigations led to improved processes to prevent a recurrence.
The origin of concerns about mortuary care dates back to 2016 when Jack and Sarah Hawkins raised issues surrounding the handling of their stillborn daughter Harriet. Ockenden described their case as an “exemplar” that instigated the wider review into post-death care at NUH. The Hawkins family had been misled to believe Harriet’s body was preserved for further examination; instead, it had decomposed so severely that it required triple-bagging for the funeral. More recently, after eight bodies were found in a state of advanced decay, NUH’s chief executive Anthony May accepted full responsibility for these failures. This triggered an investigation by the Human Tissue Authority, with whom NUH has engaged to address concerns and improve practices. The trust has implemented a daily mortuary capacity meeting and expanded storage to manage corpse preservation better. Meanwhile, Nottinghamshire Police have arrested two men associated with the mortuary on suspicion of misconduct in public office, although this is separate from an ongoing corporate manslaughter inquiry into NUH. Amid these developments, Natalie Needham continues her fight for accountability, emphasizing the need for clear answers to prevent the enduring anguish caused by unanswered questions
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