Regulatory alerts
Please find all the regulatory alerts and updates issued by the HTA below.
HTA regulatory alerts will be issued when immediate action may be required to protect patient safety. HTA regulatory updates will be issued about regulatory changes or activity requiring action or awareness.
Regulatory alerts published before 2018 can be found on our archive.
Issued 1 February 2023
Notice for
-
Licence contacts in the Organ Donation and Transplantation sector
-
Designated Individuals in the Human Application sector
Scope
This alert is being issued by the Human Tissue Authority (HTA) and includes information about microbial contamination/discolouration, particulate matter within solution and leakage of bags of Carnamedica Belzer UW® Cold Storage and Machine Perfusion solutions, imported by Bridge to Life.
Issue
The HTA has been made aware of an investigation by the Medicines and Healthcare products Regulatory Agency (MHRA) and Bridge to Life into the following issues:
- Discolouration of solution / microbial contamination and leaking bags
- Carnamedica Belzer UW® Cold Storage Solution, 1L size / BUWC1
- Carnamedica Belzer UW® Machine Perfusion Solution MPSC
- Particles in solution
- Carnamedica Belzer UW® Cold Storage Solution, 2L size / BUWC2
On 20 January 2023, Bridge to Life implemented a temporary voluntary suspension of supply of specific manufacturing lots of Belzer UW Cold Storage Solution and Belzer UW Machine Perfusion Solution to the UK.
The manufacturer is conducting an investigation on the following known impacted lot numbers: 010722, 022422, 030122, 030222, 030322, 030722, 061022, 081222, 090122, 110822,110922, 123021. The safety investigation is on-going - lot numbers not listed as impacted cannot be guaranteed to be unaffected by the issues identified to date. Findings will be reported to MHRA for review. Safety related communication on how to minimise the associated risk has been published on the MHRA website.
Action taken by the HTA
The HTA has issued this alert to all HTA-licensed establishments that handle human organs, tissues and cells in the solid organ transplantation and human application sectors for wider awareness.
Actions for establishments
Users of any of these products are advised to contact Bridge to Life for further advice and guidance and to review the Field Safety Notice issued by the company. A link to the Field Safety Notice is provided below:
Medicines and Healthcare products Regulatory Agency (filecamp.com)
Users are also advised to review the information published by the MHRA in relation to this matter and to follow the guidance that has been issued regarding reporting of incidents. A link to the MHRA’s guidance is provided below:
Issued 10 January 2023
Notice for the following role holders within the Post Mortem Sector:
• All Designated Individuals
• All Corporate Licence Holder Contacts
• All Persons Designate
Scope
This update is being issued by the Human Tissue Authority (HTA) to provide advice and guidance on managing mortuary capacity issues.
Please circulate this information to staff within your establishment undertaking activities under the Post Mortem Licence.
Issue
Excess deaths within the United Kingdom has inevitably resulted in mortuary capacity issues and service pressures.
Actions for establishments
Licensed establishments are encouraged to revisit existing HTA Guidance on contingency storage arrangements for the deceased:
If additional storage is required, please inform the HTA of this by email to: Licensing@hta.gov.uk
In particular, the following information should be supplied to the HTA:
• Address and postcode the unit will be located
• Number of additional capacity spaces (fridge and freezer)
• Proximity to the mortuary
• Who will have access (APTs / porters / FDs etc) and how will transfer to this unit be completed
• Will the deceased be released directly to funeral directors from this site / unit (if applicable)
• Details of security arrangements in place and whether there is any oversight of activity in this area by the public
• Temperature monitoring arrangements
• Traceability arrangements – bodies of same / similar name and location recording
• Approximate time it will be in use for
An extension of storage capacity and location(s) increases the risks which are associated with licensable activities. Establishments should therefore undertake risk assessments, ensure sufficient training is provided to staff and ensure current SOPs, policies and procedures reflect current practice. In respect of the risk of release of the wrong body, establishments should review existing guidance: https://www.hta.gov.uk/guidance-professionals/guidance-sector/post-mortem/release-wrong-body-incidents-post-mortem-sector
Where additional storage will be off-site and bodies are being held for a scheduled purpose, a HTA licence is required. Guidance on the HTA’s emergency mortuary licensing can be found at: https://www.hta.gov.uk/guidance-professionals/licences-roles-and-fees/licensing/applying-our-licences/emergency-mortuary
Establishments are reminded of their obligations to report to the HTA any incidents that fall within the categories outlined in our guidance that can be found at: https://www.hta.gov.uk/guidance-professionals/regulated-sectors/post-mortem/post-mortem-hta-reportable-incidents-htaris
Issued 31 January 2023
We’ve published an updated version of our Anatomy sector Licensing Standards and Guidance
The updated version was informed by an internal review and engagement with external stakeholders.
In making these updates, we have also taken into account the revisions that we made to the guidance that supports our Post Mortem sector licensing standards in 2022.
The updated guidance includes the following:
- staff training (C2 and GQ3 standards)
- expectations for documents and governance aspects (GQ1 standards)
- control and monitoring of access (GQ1 and GQ2 standards)
- having due regard to other legislation (GQ4 standards)
- examples of adverse events (GQ5 standards)
- examples of risk assessments (GQ6 standards)
- premises suitability and security (PFE1 standards)
- storage arrangements to maintain the dignity of the deceased (PFE2 standards)
Please note that we are not making any changes to the standards themselves, which are brought into force by our Codes of Practice and have to be approved by Parliament.
Issued 6 April 2023
Notice for
- Licence contacts in the Organ Donation and Transplantation sector
- Designated Individuals in the Human Application sector
The Medicines and Healthcare products Regulatory Agency (MHRA) has published an update on defects identified with Belzer solutions, manufactured by Carnamedica (UK Responsible Person Bridge to Life). Please read details here:
Updated 13 June 2023: Due to technical difficulties, circulating the sector questionnaires to individual establishments has been delayed. This is expected to be resolved shortly and we have extended the deadline to complete and submit to 7 July.
Issued 23 May 2023
Notice for
Corporate Licence Holder contacts, Designated Individuals, Named Contacts and Persons Designated.
Scope
We will be carrying out a data collection exercise from licensed establishments.
Establishments in the Anatomy, Post-Mortem, Research, Public Display and Organ Donation and Transplantation sectors will be asked to complete a short questionnaire with simplified answer options. The responses we receive will inform our assessment allocation and prioritisation. The data we receive will also inform our understanding of risks and activities within establishments and sectors.
In the Human Application sector, we will be requesting information relating to preparation processes for which a Preparation Process Dossier (PPD) has not been submitted. Establishments will not be required to submit PPDs as part of this exercise. Establishments that are licensed to store relevant material for use for a scheduled purpose under the Human Tissue Act 2004 will be asked to complete a Research data collection questionnaire.
Actions for establishments
The invitation to complete the questionnaire will be sent via email to Designated Individuals and Named Contacts from 1 June 2023. We require responses to be submitted via the HTA portal by 30 June 2023 at the latest.
It is a requirement under licensing conditions to report this data to us. We advise that all Designated Individuals and Named Contacts check that they are registered on the HTA portal with their current email address.
Action by the HTA
For each sector licensed under the Human Tissue Act 2004, we will analyse the data and provide a high-level overview of findings. For relevant establishments in the Human Application and Organ Donation & Transplantation sectors, this exercise will ensure our licensing records are accurate and up to date and we may contact you for further information
An updated version of Code F, Part two: Deceased organ and tissue donation has been published, including new Directions.
Code F, Part two was approved by Parliament and reflects the introduction of deemed consent for deceased organ and tissue donation for the purpose of transplantation in Northern Ireland.
Issue date 30 June 2023
Updated versions of the HTA’s Codes of Practice (except Code F, Part two: Deceased organ and tissue donation which was published on 1 June 2023), have been published including new Directions.
Minor changes have been made to the Codes of Practice to ensure they accurately reflect recent legislative changes and policy updates – such as the introduction of Deemed Consent in Northern Ireland – and include updated references and other minor changes.
Issue date 13 July 2023
Scope
This update is being issued by the Human Tissue Authority (HTA) to provide advice and guidance on managing storage facilities during a heat wave.
Please circulate this information to staff within your establishment undertaking activities under the post mortem licence.
Background
Last summer, we saw temperatures in the United Kingdom rise to over 40°C.
Between July and August 2022, there were 15 reports of ‘Major Equipment Failure’ in the post mortem sector directly associated with the heat waves. Where temperatures exceed the normal working range of most fridge and freezers, especially for extended periods of time, there are risks of the fridge and freezer units becoming overworked leading to failure. In such scenarios, there is a risk to establishments’ ability to maintain the dignity of the deceased.
Advice for establishments
Licensed establishments should consider the following to minimise the risk of equipment failure:
- Monitor room temperatures where fridges and freezer units are located Where temperatures exceed normal working conditions, cooling systems such as air conditioning units, room cooling equipment and fans should be considered.
- Where compressor units are internal, establishments should ensure there is sufficient air flow around them. Consider an alternative location, allowing more air flow if possible.
- Where there is potential for external compressor units to be in direct sunlight the use of reflective coverings should be explored.
- Regular temperature monitoring will help to identify trends and the extent of any variations in storage temperatures.
- Establishments should check their temperature alarm triggers to ensure they are set correctly and there is a process in place if they are activated outside of usual working hours or shifts. The settings should ensure that the condition of bodies and tissue is appropriately preserved.
- The frequency of alarm testing may be increased, and this testing should also cover out of hours call outs.
- Temporary storage facilities may be less efficient at maintaining internal temperatures, especially in hot weather. Where storage capacity is an ongoing issue, this should be escalated to the relevant Trust, Health Board or Local Authority.
- Establishments are advised to contact their servicing and maintenance suppliers and/or internal estates departments to discuss arrangements during periods of hot weather.
- Establishments should consider entering into mutual aid agreements with neighbouring organisations in order to provide and obtain support in case of capacity shortages.
Establishments should report to the HTA any incidents that fall within the categories outlined in our guidance. It can be found here: https://www.hta.gov.uk/guidance-professionals/regulated-sectors/post-mortem/post-mortem-hta-reportable-incidents-htaris
Issue Date 18 July 2023
Scope
This update is being issued by the Human Tissue Authority (HTA) to provide an update and guidance on living organ donation procedures.
Background
We are facing an increased risk of human trafficking for organ removal, necessitating heightened vigilance and adherence to robust processes.
Revised Guidance for transplant teams and Independent Assessors will be published by the end of 2023, and mandatory refresher training, including information on trafficking indicators, will be implemented for assessors by April 2024.
There has been a rise in complex cases with remote donor-recipient relationships, often lacking sufficient evidence. Delays may occur, so adherence to guidance is crucial.
Advice for living donation coordinators
Please read this update provided by the Head of Regulation for Organ Donation and Transplantation.
Issue date 18 July 2023
Scope
This update is being issued by the Human Tissue Authority (HTA) to provide an update and guidance on living organ donation procedures.
Background
We are facing an increased risk of human trafficking for organ removal, necessitating heightened vigilance and adherence to robust processes.
Revised Guidance for transplant teams and Independent Assessors will be published by the end of 2023, and mandatory refresher training, including information on trafficking indicators, will be implemented for assessors by April 2024.
There has been a rise in complex cases with remote donor-recipient relationships, often lacking sufficient evidence. Delays may occur, so adherence to guidance is crucial.
Advice for Independent assessor
Please read this update provided by the Head of Regulation for Organ Donation and Transplantation.
Issued 4 August 2023
Notice for
• Designated Individuals in the Human Application sector
• Licence contacts in the Organ Donation and Transplantation sector
Scope
This alert is being issued by the Human Tissue Authority (HTA) and includes information about a recent case of West Nile Virus (WNV) in Bordeaux, France
Please circulate this information to staff within your establishment undertaking activities which may be affected by this notice.
Issue
On 1 August 2023, the L’Agence Régionale de Santé Nouvelle-Aquitaine (France) issued a press release of the first autochthonous human case of WNV infection in a person residing in Bordeaux (Gare district), in the department of Gironde.
Action taken by the HTA
The HTA has issued this alert to all UK establishments that handle human tissues and cells for human application or are involved in solid organ transplantation to raise awareness of WNV cases in areas not normally associated with this virus.
Actions for establishments
This alert is to ensure that all establishments are aware of the recent reports of WNV and can review their donor selection and evaluation procedures accordingly.
Up-to-date information on cases of WNV in Europe can be found here.
Issued 28 September 2022
Notice for
• Designated Individuals in the Human Application sector
• Licence contacts in the Organ Donation and Transplantation sector
Scope
This alert is being issued by the Human Tissue Authority (HTA) and includes information about locally-acquired Dengue cases in France.
Please circulate this information to staff within your establishment undertaking activities which may be affected by this notice.
Issue
On 26 September 2022, the Agence Nationale de Securité du Médicament (ANSM) in France created an alert on the EU Rapid Alert on Substances of Human Origin platform detailing 36 locally-acquired human cases of Dengue, as follows:
In Occitania region:
- One case in the city of Perpignan, Pyrénées-Orientales with onset of symptoms in mid-June 2022.
- Four cases in the city of Andrest (situated close to Tarbes) and in the city of Rabastens (30 km from Toulouse), Hautes-Pyrénées with onset of symptoms in July-August 2022.
- Four cases in the city of Salvetat Saint Gilles (situated close to Toulouse) with onset of symptoms in the second half of August 2022.
In Provence-Alps-Cote d'Azur region:
- Six cases in the city of Fayence, Var with onset of symptoms between end of June and end of July 2022.
- Twenty-one cases in the cities of St Jeannet, Gattières, and Gaude (situated close to Nice), Alpes-Maritimes with onset of symptoms in August-September 2022.
The outbreaks in the cities of Perpignan and in Fayence are now considered to be over. For the other three outbreaks, additional cases might be detected.
Action taken by the HTA
The HTA has issued this alert to all UK establishments that handle human tissues and cells for human application or are involved in solid organ transplantation to raise awareness of these cases.
Actions for establishments
This alert is to ensure that all establishments are aware of the recent reports of Dengue and can review their donor selection and evaluation procedures accordingly.
Up-to-date information on cases of Dengue in Europe can be found on the ECDC website.
Issued 4 October 2022
We’ve published an updated version of Post-mortem Examination Licensing Standards and Guidance.
We completed a thorough internal review of the wording of, and guidance associated with the following overarching licensing standards: GQ1, GQ2, GQ4, GQ6, T1, PFE1, PFE2 and PFE3.
These standards are broadly concerned with effective control and monitoring of access, storage arrangements that maintain the dignity of the deceased, and oversight of visitors and contractors.
The updates are as follows:
Governance and quality systems
-
GQ1a): additional guidance on procedures taking account of both standard and out-of-hours arrangements.
-
GQ1b): additional guidance emphasises that bodies should not be held in unrefrigerated conditions for prolonged periods of time to ensure dignity, safety and to preserve evidence of cause of death.
-
GQ1d): includes guidance relating to regular reviews of SOPs.
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GQ2a): includes guidance on auditing of CCTV as well as records of mortuary access.
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GQ2b): includes guidance on implementing processes to ensure feedback of audit findings and embedding of up- to- date procedures.
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GQ4a): includes guidance on record management procedures to include records of access to the mortuary.
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GQ6a): Additional guidance to include risks to security within risk assessments.
Premises, facilities and equipment
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PFE1d): Additional guidance ensuring security arrangements are robust with effective mechanisms to strictly control access. CCTV is acknowledged to be an important security measure but should not be used in a way that compromises dignity. Systems should prevent inappropriate access or use of of images.
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PFE1e): Additional guidance on monitoring and documenting of entry into the mortuary or body storage facility; DI oversight in respect of lone working arrangements; and auditing of records relating to mortuary access.
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PFE2g): Guidance added to emphasise that shrouding practices should preserve the dignity of the deceased.
Issued 14 November 2022
Organ transplantation – quality and safety update
An updated version of The Quality and Safety of Organs Intended for Transplantation: A documentary framework has been published, to include new directions.
Under the new directions, where an organ is sent to an establishment for assessment or recovery purposes and a mechanical perfusion device is used, the establishment under whose licence this activity takes place must record and store any organ characterisation and traceability data generated by the establishment, for a period of 30 years.
Issued 17 February 2021
Notice for
• Designated Individuals in the Human Application sector
Scope
The HTA has issued this alert to all UK establishments that handle human tissues and cells for human application to raise awareness of the potential contamination risks to cryopreserved stem cells.
Please circulate this information to staff within your establishment undertaking activities which may be affected by this notice.
Issue
A Field Safety Notice (FSN) has been placed on the Medicines & Healthcare products Regulatory Agency’s (MHRA) website.
The notice concerns the leaking of graft into the "pocket” in the seam of the stem cell transplant freezing bag when the graft was mixed. There was also a hole in the pocket from which the graft leaked out and which posed a risk of contamination to the graft. A “pocket” was observed in other bags of the same LOT.
Action taken by the HTA
The HTA has issued this alert to ensure that all HTA-licensed establishments in the human application sector which undertake cryopreservation of haematopoietic stem cells are aware of the field safety notice.
The FSN can be found on the MHRA's website.
The product identified in the FSN is as follows:
Miltenyi CryoMACS Freezing Bag 750, Product code 200-074-403, LOT 720070537, EXP 2023-06-29.
Actions for establishments
Establishments using the product listed above should contact Miltenyi Norden Biotec AB, Sweden for further information:
- Miltenyi Biotec Norden AB, Medicon Village, Scheeletorget 1, 223 81 Lund, Sweden
- Phone: +46 46 280 7280
- Email: macs@miltenyibiotec.se
Please contact the HTA on 020 7269 1900 or email enquiries@hta.gov.uk if you would like any further advice on the above notice.
Issued 21 October 2020
Notice for
• Designated Individuals in the Human Application sector
• Licence contacts in the Organ Donation and Transplantation sector
Scope
This alert is being issued by the Human Tissue Authority (HTA) and includes information about a recent case of West Nile Virus (WNV) in an individual in the Netherlands.
Please circulate this information to staff within your establishment undertaking activities which may be affected by this notice.
Issue
On 21 October 2020, The Netherlands - Dutch Health Care Inspectorate created an alert on the EU Rapid Alert on Substances of Human Origin platform of one male confirmed case of locally acquired West Nile Virus infection. The case coincides with the discovery of WNV in birds and mosquitos in the Utrecht region in August and September 2020.
Action taken by the HTA
The HTA has issued this alert to all UK establishments that handle human tissues and cells for human application or are involved in solid organ transplantation to raise awareness of potential WNV transmission from donors to recipients.
Actions for establishments
This alert is to ensure that all establishments are aware of the recent reports of WNV and can review their donor selection and evaluation procedures accordingly.
Up-to-date information on cases of WNV in Europe can be found on the European Centre for Disease Prevention and Control’s website.
Information on updated JPAC guidance can be found on JPAC's website.
Issued 24 August 2020
Notice for
• Designated Individuals in the Human Application sector
• Licence contacts in the Organ Donation and Transplantation sector
Scope
This alert is being issued by the Human Tissue Authority (HTA) and includes information about recent cases of West Nile Virus (WNV) in individuals in Spain.
Please circulate this information to staff within your establishment undertaking activities which may be affected by this notice.
Issue
On 21 August 2020, the National Transplant Organization in Spain created an alert on the EU Rapid Alert on Substances of Human Origin platform confirming an outbreak of neuro-invasive West-Nile virus infection in the province of Seville (Andalucía region), Spain.
Action taken by the HTA
The HTA has issued this alert to all UK establishments that handle human tissues and cells for human application or are involved in solid organ transplantation to raise awareness of potential WNV transmission from donors to recipients.
Actions for establishments
This alert is to ensure that all establishments are aware of the recent reports of WNV and can review their donor selection and evaluation procedures accordingly.
Up-to-date information on cases of WNV in Europe can be found on the European Centre for Disease Prevention and Control's website.
Information on updated JPAC guidance can be found on JPAC's website.
Issued 3 October 2019
Notice for
• Designated Individuals in the Human Application sector
• Licence contacts in the Organ Donation and Transplantation sector
Scope
This alert is being issued by the Human Tissue Authority (HTA) and includes information about a recent case of Dengue in an individual in Spain.
Please circulate this information to staff within your establishment undertaking activities which may be affected by this notice.
Issue
On 2 October 2019, the Organización Nacional de Trasplantes (ONT) in Spain created an alert on the EU Rapid Alert on Substances of Human Origin platform confirming a case of Dengue in a person residing in a municipality of Santa Coloma de Gramanet (Barcelona) in the region of Catalonia. This case has been considered as a possible autochthonous case.
Action taken by the HTA
The HTA has issued this alert to all UK establishments that handle human tissues and cells for human application or are involved in solid organ transplantation to raise awareness of potential Dengue transmission from donors to recipients.
Actions for establishments
This alert is to ensure that all establishments are aware of the recent reports of Dengue and can review their donor selection and evaluation procedures accordingly.
Up-to-date information on cases of Dengue in Europe can be found on the ECDC website.
Issued 20 August 2019 – updated 13 September 2019
Notice for
• Designated Individuals in the Human Application sector
• Licence contacts in the Organ Donation and Transplantation sector
Scope
This alert is being issued by the Human Tissue Authority (HTA) and includes information about recent cases of West Nile Virus (WNV) in individuals in France, Austria and Romania.
Please circulate this information to staff within your establishment undertaking activities which may be affected by this notice.
Issue
On 5 August 2019, the Agence Nationale de Securité du Médicament (ANSM) in France created an alert on the EU Rapid Alert on Substances of Human Origin (RATC) platform confirming a case of neuro-invasive West-Nile virus infection in a person residing in Frejus (Var department) in southern France. The patient did not report any recent travel outside the Var department. Therefore, this case is considered autochthonous and most likely acquired in the city of Frejus.
On 20 August 2019, Austrian Agency for Health and Food Safety - Federal Office for Safety in Healthcare created an alert on the same platform advising of the first confirmed WNV case in the region of Lower Austria.
Update: On 13 September 2019, the Ministry of Health – Directorate of Public Health Control (Romania) created an alert on the RATC platform advising of eight confirmed cases of West Nile meningitis / encephalitis during the period 30 July 2019 – 1 September 2019. The confirmed cases are from Bucuresti (1), Constanta (3), Tulcea (2), Olt (1), and Buzau (1).
Action taken by the HTA
The HTA has issued this alert to all UK establishments that handle human tissues and cells for human application or are involved in solid organ transplantation to raise awareness of potential WNV transmission from donors to recipients.
Actions for establishments
This alert is to ensure that all establishments are aware of the recent reports of WNV and can review their donor selection and evaluation procedures accordingly.
Up-to-date information on cases of WNV in Europe can be found on the ECDC website.
Issued: 14 August 2018
Notice for:
• Designated Individuals in the Human Application sector
• Licence contacts in the Organ Donation and Transplantation sector
Scope
This alert is being issued by the Human Tissue Authority (HTA) and includes information about recent cases of West Nile Virus (WNV) in individuals in Romania and France.
Please circulate this information to staff within your establishment undertaking activities which may be affected by this notice.
Issue
On 3 August 2018, the Romanian Directorate of Public Health Control created an alert on the EU Rapid Alert on Substances of Human Origin platform advising that seven individuals in the counties of Braila, Bacau, Bucuresti, Ilfn, Botosani, Dolj and Olt had been diagnosed as infected with WNV.
On 11 August 2018, the Agence Nationale de Securité du Médicament (ANSM) in France created an alert on the same platform advising of 3 autochthonous human cases of WNV (1 confirmed and 2 probable) in the city of Nice in the Alpes-Maritimes department of France.
On 13 August, the European Centre for Disease Prevention and Control (ECDC) issued a rapid risk assessment relating to the early large increase in WNV infections reported in the EU/EEA and EU neighbouring countries.
On 15 August, the Joint United Kingdom (UK) Blood Transfusion and Tissue Transplantation Services Professional Advisory Committee (JPAC) updated the Geographical Disease Risk Index (GDRI) for France and Monaco.
Action taken by the HTA
The HTA has issued this alert to all UK establishments that handle human tissues and cells for human application or are involved in solid organ transplantation to raise awareness of potential WNV transmission from donors to recipients.
Actions for establishments
This alert is to ensure that all establishments are aware of the recent reports of WNV and can review their donor selection and evaluation procedures accordingly.
Up-to-date information on WNV and a copy of the rapid risk assessment produced by the ECDC can be found on their website. The GDRI information can be found on there's.