Review policies on mortuary access

Today I am updating the House on the response to those recommendations. The Trust published an assurance statement in February 2024 on the implementation of the recommendations from the Phase 1 report. This sets out the progress made to implement the Inquiry’s recommendations.

The range of actions taken by the Trust include requiring that non-mortuary staff and contractors are always accompanied by another staff member when visiting the mortuaries; controlling access to mortuaries using swipe cards; mandating contractors to renew security clearances every three years; and installing CCTV coverage monitoring access to and from mortuary areas. The Trust Board is also providing greater oversight and assurance of legally regulated activity in the mortuary.

I am also reassured that NHS England’s South East regional team held monthly oversight meetings with the Trust between November 2023 and April 2024 (in partnership with Kent and Medway Integrated Care Board) to ensure progress against the Inquiry’s recommendations and to review evidence of the Trust’s progress in delivering their action plan. Ongoing compliance with the Inquiry's recommendations will be monitored by NHS England through regular regional oversight meetings with the Trust, and through other channels as appropriate.

The Trust now complies with this recommendation in full on the following basis:

• All access points to the mortuaries at Tunbridge Wells Hospital and Maidstone Hospital are controlled by swipe card access.

• There are no longer any ‘access all areas’ access/swipe cards in circulation.

• The mortuary is one of the designated “restricted” areas in the Trust’s current “Security policy and procedure”.

• In relation to the mortuary, the Head of Service for the Care After Death Directorate confirmed which roles should have the required access. Access is only granted to the mortuary staff, Bereavement team, the Bereavement Midwife, trained porters (see below), and security staff. Moreover, the security staff are not provided access to the doors within the mortuary that still have a digi-lock or key-lock in place (i.e. in addition to a swipe card activation). The porters are provided with the relevant digi-lock code in order to be able to access the fridges.

• At the Tunbridge Wells Hospital mortuary, there is differential access between the mortuary perimeter and the specific rooms within that perimeter. For example, portering staff cannot access the post mortem room.

• Estates staff (i.e. Mitie staff at Tunbridge Wells Hospital and the in-house team at Maidstone Hospital) and the Site Team are not given access to the mortuaries via their swipe cards. They are therefore expected to undertake any duties in the mortuary when mortuary staff are present, and can only access the mortuary out-of-hours if they attend with someone onsite who has been authorised to have swipe card access, or contact the on-call member of the mortuary team who would attend to authorise such access.

• All porters are required to attend a 90-minute training session with mortuary staff, and be deemed competent, before they are authorised to access the mortuary with a swipe card. The key aspects are as follows:

o The training covers security; patients contact; ‘do’s and don’ts'; the Human Tissue Authority (HTA); HTA Reportable Incidents (HTARIs) and how to report an incident; moving and handling; and wellbeing.

o The porter’s competency is assessed at the end of the training (by an Anatomical Pathology Technologist (APT)) to ensure they have understood the requirements.

o The training records are held by the mortuary

• When a porter is deemed competent, they are granted swipe card access to specific areas of the mortuary for 12 months. Their swipe card access will automatically deactivate after 12 months unless they receive the training again within that 12-month period. If they are deemed competent again, they will be granted swipe card access for a further 12 months. The mortuary team hold a record of each porter’s training, and will prompt a porter to schedule their further training as their 12-month period is approaching.

• As a further security measure, in addition to the access control of entry points, the mortuary has an intruder alarm system in place. This requires those who access the mortuary to ‘tap’, upon entry, a pad located on the wall within the main entrance area of the mortuary with an electronic key fob, to deactivate the alarm. If the key fob is not deployed within a certain time period, the alarm is activated. The intruder alarm process is managed by the security team (who issue the key fobs to the required staff).

• Swipe card access has also been installed inside and out of the Snowdrop room at Tunbridge Wells Hospital. This room is used to store the bodies of any babies that die on the delivery suite, in three refrigerated cots, and is therefore considered a ‘satellite’ to the main mortuary at Tunbridge Wells Hospital (and is thus covered by the Trust’s HTA licence).

No statement on delivery from Maidstone and Tunbridge Wells NHS Trust has been found in the sources searched. This is separate from the response above.