Human Tissue Authority

The regulator for human tissue and organs

Post Mortem HTA Reportable Incidents closed in Q4 2020/21 – Details

Licence Number

Organisation

Case Number

Incident Classification

Brief summary of HTARI

12554

Manchester University

NHS Foundation Trust -

Central Hospitals

CAS-57522-G9W9

Accidental damage to a body

Human error led to minor damage

to a body during

post-mortem

examination.

12554

Manchester University

NHS Foundation Trust -

Central Hospitals

CAS-57624-N9S0

Accidental damage to a body

Human error led to

minor damage to a

body during

post-mortem

examination.

12337

Leicester Royal Infirmary

CAS-57047-T2B3

Accidental damage to a body

Human error led to

minor damage to a body.

12224

Royal Stoke University Hospital

CAS-54719-M1Y0

Loss of an organ or tissue

Communication error

led to loss of an organ.

12034

Derriford Hospital

CAS-56572-Z1S6

Any incident not

listed here that

could result in

adverse publicity

that may lead to damage in

public confidence

Procedural and

communication error

led to a complaint

from the family.

12232

Royal Berkshire Hospital

CAS-56416-B3G3

Loss, disposal or retention

of a whole

fetus or fetal tissue

(gestational

age less than 24 weeks) against

the express wishes

of the family

Human error led

to loss of

traceability

of a fetus.

12342

The Royal Oldham

Hospital

CAS-57579-W5S9

Release of the wrong body

Human error led to

short-term release

of

the wrong body.

12003

Great

Western Hospital

CAS-57218-Z4C6

Post-mortem examination

conducted

was not in line with

the consent given

or the post-mortem examination

proceeded with inadequate consent

Communication error

led

to a full post-mortem

examination being

conducted that

was not in line with the Coroner’s

authorisation for a

limited examination.

12034

Derriford Hospital

CAS-57113-N4K9

Discovery of an

organ or tissue following

post-mortem examination and

release of body

Procedural error

led to discovery of

additional tissue

following release

of a body.

12362

Basingstoke and North

Hampshire Hospital

CAS-58070-V1K2

Accidental damage to a body

Human error led

to

minor damage to a

body.

12034

Derriford Hospital

CAS-57348-J2K0

Disposal or retention of an organ or

tissue against the express wishes

of the family

Communication error

led to inadvertent

retention

of post mortem

tissue.

12323

Wexham Park Hospital

CAS-57828-V9H1

Major equipment failure

Equipment failure

impacted

on service

delivery.

12318

Addenbrooke's Hospital

CAS-57508-Y1K2

Accidental damage to a body

Human error led to

minor damage to a

body

during post-mortem examination.

12037

Royal Preston Hospital

CAS-57784-Y2R4

Accidental damage to a body

Procedural error led to

damage to a body.

11104

Colchester General Hospital

CAS-57247-B1G9

Accidental damage to a body

Procedural error led to deterioration

in the condition

of a body.

11068

Southend Hospital

CAS-56259-Y7C2

Disposal or

retention of an

organ or tissue

against the

express wishes of

the family

Communication

error

led to inadvertent

retention of

post mortem tissue.

12043

Whiston Hospital

CAS-57877-G5H5

Any incident not

listed here that

could result in

adverse publicity

that may lead to

damage in public confidence

Complaint received

about mortuary

services.

12086

Pinderfields Hospital

CAS-58309-T5R9

Accidental damage to a body

Human error led to

damage to a body.

12052

John Radcliffe Hospital

CAS-58097-N6R2

Post-mortem examination

conducted was

not in line with

the consent given

or the post-mortem

examination

proceeded with inadequate consent

Human error led to

a post-mortem

examination

being commenced

that

was not in line

with

the consent given.

12337

Leicester Royal Infirmary

CAS-57907-J7W0

Accidental damage

to a body

Human error led to

damage

to a body.

12117

East Surrey Hospital

CAS-56164-W7M1

Any incident not

listed here that

could result in

adverse publicity

that may lead to

damage in public confidence

Complaint received

about mortuary

services.

12083

Somerset NHS Foundation Trust

CAS-55108-Z3W4

Release of the wrong body

Human error led

to

short-term release

of

the wrong body.

12554

Manchester University

NHS Foundation

Trust - Central Hospitals

CAS-57164-G1S2

Loss of an organ or tissue

Procedural error led to

loss of

tissue traceability.

12554

Manchester University

NHS Foundation Trust -

Central Hospitals

CAS-57615-G0P3

Accidental damage to a body

Procedural error led

to minor damage

to a body.

12013

Royal Free Hospital

CAS-56313-L5L5

Major equipment failure

Major equipment failure

led to inappropriate

storage temperature.

12102

Walsall Manor Hospital

CAS-57312-W6N0

Release of the wrong body

Human error led to

short-term release

of the wrong body.

12554

Manchester University

NHS

Foundation Trust -

Central Hospitals

CAS-57625-M0B9

Accidental damage to a body

Human error led

to minor damage

to a body.

12170

Hull Royal Infirmary

CAS-57805-F2B7

Accidental damage to a body

Human error led

to minor damage

to a body during

post-mortem examination.

12411

Macclesfield District

General Hospital

CAS-58220-F8P8

Accidental damage to a body

Human error led to

minor damage to a body.

12258

Queen's

Medical Centre

CAS-57971-R9Z5

Accidental damage to a body

Human error led

to minor damage

to a body.

12054

UCL Hospitals NHS

Foundation Trust

CAS-57899-P2N8

Serious security breach

An unauthorised

individual gained

access to the

mortuary premises.

12224

Royal Stoke University Hospital

CAS-56439-Y6B7

Serious security breach

Procedural error led

to a breach of histology

security processes.

Last updated on: 19 Apr 2021