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CAVUHB apology for findings in Human Tissue Authority Inspection Report

Wednesday, 8 November 2017

Cardiff and Vale University Health Board has apologised unreservedly to families and fully accepts the findings of an inspection report from the Human Tissue Authority (HTA).

An inspection of the mortuary and cellular pathology facilities at University Hospital Wales (UHW) between 9-10 August 2017 identified failings in three critical areas, 14 major areas and nine minor areas. The Health Board has since been co-operating fully with the HTA to improve the areas identified and put things right.

Following the initial inspection, a subsequent audit requested by the HTA highlighted 42 cases where we had retained human tissue longer than necessary and we did not have permission from the families to continue to store the tissue.

We believe at the present time in 38 of these cases the family or the coroner provided instruction to lawfully dispose, and we are currently in the process of disposing of these materials.

In the remaining four cases, the relevant authority has attempted to contact the families involved. There are two cases where it remains unclear as to the instructions of the family’s wishes and they have yet to be resolved. One is in the process of being returned to the family in line with their wishes and the remaining case is a family that has been living abroad for several years and it has been difficult to establish contact.

Our initial audits have identified that all of the material  /human tissue was taken lawfully for legitimate reasons but we accept that as a Health Board we did not dispose of them within three months as required by the HTA code of practice for post mortem examinations.

Whilst there is no immediate evidence to suggest that we undertook any further activity on these cases, this is subject to ongoing detailed investigation.

A newly appointed ‘Designated Individual’ (DI) has already commenced work to ensure all areas for action are addressed.

The HTA had given the Health Board until 6 November 2017 to address all of the priority issues identified, and to date these have either been resolved or, with the agreement of the HTA, are on target to reach deadlines. The DI is working closely with the HTA and all of the partner agencies involved in the mortuary and cellular pathology laboratory services to ensure lessons are learned from the report.

The HTA understands that some of the actions will take time to complete. This will not adversely impact on current service performance.

We will publish the HTA report and the associated action plan in full on the Health Board website and the report and action plan will be considered and scrutinised by the Board.

Dr Graham Shortland, Medical Director and corporate HTA licence holder said: “We are deeply sorry for any unnecessary distress that the findings in the report may cause. We are taking the inspection report very seriously and have had teams of people working on putting right the areas identified.

“With the close working co-operation of the HTA, we have already instigated a significant area of multiagency improvement work with Cardiff University, local Police Forces and the coroners to develop joint protocols and processes to support effective and prompt communication in often complex and protracted cases.

“On a multiagency basis we have worked through the detail of the cases. We recognise that the delay in disposal may be distressful and upsetting for some families who are already dealing with the loss of a loved one. This additional distress was totally avoidable and for this we are deeply sorry.”

On 29 September 2017 the HTA revisited UHW mortuary to review the immediate improvements and the action plan to date and we have continued to work on the additional advice to ensure the Health Board and other agencies using the mortuary and the cellular laboratory services meet all of the statutory and regulatory compliance.

While the numbers of cases affected is very small we acknowledge that this may cause unnecessary distress for some families who have lost loved ones. If you believe you are affected we have set up a contact number on 0800 952 0055.

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