Hospital ignored repeated warnings over corpses decomposing in corridors - report
Exclusive - An unpublished report reveals that management at University Hospital Waterford knew that human remains were being kept in unrefrigerated conditions since 2012 but failed to act despite warnings that it posed a risk to public health
The Irish Mirror today reveals exclusive details of a shocking report on mortuary services at University Hospital Waterford, which was commissioned following allegations that corpses had been left on trolleys in corridors, leaking bodily fluids onto the floor.
At the time of the allegations in 2019, hospital management said there was “no evidence” to substantiate the gruesome claims made by consultant pathologists in relation to the mortuary.
However, the damning report – which was never published by the HSE – reveals that top managers were already in possession of a building survey from 2012, which found that decomposing bodies were “often” kept in unrefrigerated conditions, spreading odours throughout the facility.
The report, which the Irish Mirror obtained through a Freedom of Information (FOI) request, contains disturbing details in relation to conditions at the mortuary before it was replaced by a new building in July 2021.
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The families of two deceased individuals even had to be offered counselling by the hospital after they complained about their experience at the facility in 2019.
A previous inspection found fungus growing in the post-mortem room, and there was no filter in place to stop material from human bodies being washed down the drains.
The refrigeration system was considered to be “at the end of its life” in 2012, and was “wholly inadequate” in terms of its capacity.
“This often results in a situation where decomposed remains cannot be kept in a cold environment, and odours emanate throughout the whole building,” the report said.
The facility did not meet infection control guidelines, and the ventilation system was “a major cause of concern” as it “did not meet any standard” in terms of air filtration, and “may pose a risk to the public”.
The review group criticised poor record-keeping at the mortuary, including in relation to organ retention, and it noted that body bags were not used as standard until May 2019.
The authors of the report were scathing in their criticism of hospital management in relation to the mortuary, finding no evidence that it had taken any action to address issues despite a series of “risk alerts” that should have prompted a response dating back to 2007.
The mortuary had been placed on the HSE’s own “risk register” with a risk rating of 25, which is the highest level and applies where an adverse outcome is “almost certain”, and the impact of such an outcome was rated as “extreme”.
The review group said it would have expected hospital management to take a number of actions to control or mitigate the issue based on the sequence of risk alerts, but it could find no evidence that any such actions were taken.
These alerts dated back to 2007, when a business case for a new mortuary had highlighted the inadequacy of the existing facility. They also included the 2012 building survey, and a letter from a consultant in 2016.
The tragic death of a child at the hospital in 2017 also prompted another consultant to contact management in relation to the “unsafe” facilities at the mortuary.
There did not appear to be any evidence of action at management level until after the conditions at the mortuary were reported by the media in April 2019. This prompted hospital management to commission an independent review.
The report said management seemed to think the matter was dealt with when it commissioned the review, and noted that the review team were therefore surprised that managers failed to engage properly with the process.
It criticised the “slow and sometimes partial” supply of documentation by management, and discovered in December 2019 that they had withheld a letter from a service provider who had complained about human remains discharging bodily fluids in a hallway at the mortuary.
The omission was considered so serious that the review group complained to the HSE national director of acute operations – going over the heads of the people who had commissioned the report.
This prompted an “internal examination” and the national director cut local hospital management out of the process by assuming the role of commissioner of the review and instructing the team to report directly to him.
The review, which had been delayed as a result of the Covid-19 pandemic, was finally completed in May 2021, by which time work had already commenced on a new mortuary at University Hospital Waterford.
Sinn Féin health spokesman and TD for Waterford David Cullinane described the report as “a damning indictment of management” at the hospital, and criticised “an absolute lack of transparency” from the health authorities.
“It is outrageous that the report has never been published. This demonstrates an absolute lack of transparency and is unacceptable,” he said.
“The report itself outlines a litany of failures, including failures to respond to extreme risks and complaints relating to the storage of bodies.
“This is a scathing report and a damning indictment of management and governance failures over a long number of years. Complaints, reports and risk assessments were not responded to appropriately,” he said.
Mr Cullinane said the contents of the report would be distressing for many families, and called for “absolute transparency and accountability” in relation to the matter.
The HSE did not answer questions asking why hospital management had not provided certain documents to the review group, or what the outcome was following the “internal examination” of its failure to do so.
However a spokesman for the HSE told the Sunday Mirror: “The purpose of the review into the mortuary services at UHW was to provide assurance around compliance with best practice, health and safety and legislative requirements for the day-to-day management and the governance and oversight of the facility from both a clinical and non-clinical perspective and to ensure that the facility is safe and satisfactory for use by deceased, relatives, staff and other key stakeholders,” said a spokeswoman.
“During the review process, the review group worked in collaboration with the hospital to implement a range of short-term improvements to the overall facility and the day-to-day functioning of the mortuary service.
"Additional recommendations set out in the review have been addressed by the construction of the new facility and the hospital continues to monitor and improve its mortuary and pathology service.”
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