A Welsh health board failed to correctly store the remains of babies, leading to 'traceability issues' an inspection report has found.
The report by the Human Tissue Authority looked at the mortuary services at the Royal Glamorgan Hospital in Llantrisant and Prince Charles Hospital in Merthyr Tydfil. These are the same hospitals, run by Cwm Taf health board, where there is an ongoing investigation into maternity services. The investigations include the review of maternity cases including the death and serious injury of babies.
The report states: "During the body audit at the PCH [Prince Charles Hospital] body store issues were identified with fetal remains. There were discrepancies with documentation and staff were unclear when some remains had been brought to the mortuary. Record keeping was inconsistent for the remains reviewed."
Concerns were also raised regarding staff training around training in seeking consent for post mortems on babies, fetuses and children. The report said: "Maternity department staff at RGH [Royal Glamorgan Hospital] could not remember when they had received training and stated there was no system in place to ensure that training was delivered and refreshed regularly."
As well as concerns around fetal remains, were those around the dignity of the deceased.
Investigators wrote in their report that "when the refrigerated body store reaches capacity, they place bodies on PM [post mortem] tables in the PM suite; this has happened on a number of occasions." It continues: "This practice does not provide dignified storage of the deceased."
The investigation also found health and safety risks to staff working in the mortuary at Prince Charles Hospital, such as "residual blood on the floor of the main PM suite... blood and small pieces of tissue in the drain of main PM suite."
Concerns were also raised that bodies could be seen by members of the public in surrounding buildings and therefore "may impact on the dignity of the deceased."
The chief executive of Cwm Taf health board, Allison Williams said: “Cwm Taf University Health Board has accepted all the findings raised by the Human Tissue Authority and is addressing its recommendations through a comprehensive action plan.
"A significant amount of work has already been done and we are continuing to work closely with the HTA to provide all the necessary assurance to ensure the agreed corrective actions are completed.
"We would like to offer our sincerest apologies for any distress caused. Should anyone have any wider concerns they can call our contact line from 9am to 5pm Monday to Friday on 08000 328999"