Assessors found “evidence of active ongoing risks and significant areas of concern” at a hospital mortuary, five months after the wrong bodies were released to two bereaved families.
As a result, the UK’s national accreditation service has partially suspended its official recognition of mortuary activities at the Grange University Hospital, in Cwmbran.
Aneurin Bevan University Health Board said it has put in safeguards against any further incidents, and is working with the mortuary staff to “deliver continued improvements”.
The two separate incidents occurred at the hospital in November 2023, triggering an internal investigation, as well as inspections by the Human Tissue Authority (HTA), which licenses the health board’s post mortem procedures.
News of the second incident also prompted an unannounced visit from the UK Accreditation Service (UKAS) in early April.
UKAS is not a regulatory body, but acts as a government-recognised, independent organisation commissioned to “assess against nationally and internationally agreed standards”.
At the Grange, its assessors found “evidence of a lack of standardisation” in the procedures for patient release, five months after the two “serious” incidents.
Deceased patients arriving at the mortuary from the community have different identification tags and paperwork from those who arrive there from the hospital, and there is also “inconsistency” with information added into the mortuary register, they said.
UKAS also raised concerns about a “lack of security measures in place”, including CCTV coverage, and no list of personnel with access to the facility.
In all, UKAS found seven “areas of improvement” and decided to partially suspend its accreditation of the Grange’s mortuary service, subject to review, over what an assessor called “serious concerns on security and safe patient management”.
A spokesman for Aneurin Bevan University Health Board said the two “unprecedented” incidents at the mortuary “were found to have the same root cause”.
He said the health board launched its own investigation, audited the department, and introduced safeguards against repeat incidents – and has to date completed 17 of 19 recommendations made by its own investigators.
Five further corrective actions mandated by licensing agency the HTA had been “met satisfactorily across the health board”, he added.
“It is important to note that UKAS is not a regulatory body, and that UKAS accreditation is not a mandatory requirement, but we voluntarily ask them to review our services to maintain good practice,” the spokesman said.
The health board is now making changes at the mortuary, based on several of the investigations’ findings.
“Enhanced CCTV is being implemented”, said the spokesman, adding that “all our mortuary sites are secure, with swipe card access in place”.
“In addition, all relevant procedures have been updated and staff have been given further training to provide additional assurance,” he said.
“We continue to address all recommendations from the HTA and UKAS, and a transformational team is working alongside our mortuary staff to deliver continued improvements.”