Eight bodies were found in a state of 'advanced deterioration' at the mortuary of a scandal-hit NHS trust after hospitals ran out of freezer space.

Inspectors from the Human Tissue Authority (HTA) also found staff at Nottingham University Hospitals NHS Trust failed to check wristbands - increasing the risk of the wrong bodies being released to families.

It comes after a report into maternity services at the trust published on Wednesday found more than 500 mothers and babies died or were harmed due to 'deeply embedded systemic failures' at the 'toxic' organisation where women were routinely ignored and mistakes covered up.

The review that exposed the biggest maternity scandal in NHS history also found a culture of bullying, where ‘speaking up was dangerous’ and bosses’ responses were ‘shaped by self protection rather than patient safety’.

When families did complain about care at the Nottingham trust they were met with an ‘intimidating, male-dominated’ panel who were ‘dismissive of non-medical voices’.

It found the poor treatment continued after death: one baby was placed in a mortuary space already occupied by an unknown and unrelated deceased adult while an early gestation baby was disposed of as ‘clinical waste’.

Sarah and Jack Hawkins, whose baby Harriet died in 2016 after significant failings later found her body had been allowed to decompose so badly by NUH, it had to be triple-bagged for her funeral.

Speaking on BBC Women's Hour on Thursday, Mrs Hawkins said: 'Harriet's first and last walk was in her tiny white coffin and we took some comfort in that so to find out later she was decomposed in the coffin - I can't even begin to describe the emotional toll.'

In the unannounced mortuary inspection which was carried out in March but only published this week, inspectors found three critical shortfalls. 

The report said: 'Due to the lack of freezers, it has become routine practice to use hermetically sealed bags, or body bags, to store the deteriorating deceased within a refrigerated ‘isolation’ area.

'The inspection team noted that this had a detrimental effect on the condition and dignity of the deceased.

'During the body audit, the inspection team identified eight bodies that were showing advanced deterioration due to not being transferred to a freezer within a sufficient timeframe.'

The HTA report also found problems relating to the bodies of babies. It found perinatal post-mortem examinations were not being conducted within the mortuary post-mortem suite and were taking place in a non-mortuary laboratory area that does not meet HTA standards.

Two men have been arrested by Nottinghamshire police 'in connection with operating practices in the mortuary service' provided by the trust.

Ms Ockenden’s report into the trust was heavily critical of the trust’s mortuary services.

She found examples of dehumanising language by clinicians; and poor mortuary care, including failure to comply with legal requirements. 

In one case, the wrong baby was released to a funeral director and in another, a stillborn baby girl remained in a fridge when she should have been taken to the mortuary.

Trust chief executive Anthony May apologised for the mortuary failings. 'The dignity and respect of people in death matters just as much as it does during their lives,' he said.

'This initially came to my attention after one of the maternity families found something in one of their subject access requests about the way we’d cared for their daughter.'

It comes as bereaved families warned more babies and mothers would die if the government did not act immediately on recommendations in the Ockenden report.

Ms Ockenden called for a series of “immediate and essential” measures to improve maternity safety.

But James Murray, the Health Secretary, said the Government would wait until the end of the year to develop an action plan.

His comments drew a scathing response from Ms Ockenden. She said: 'How much more harm may happen in this country? We don’t have the luxury of six months.'

Urging ministers to act sooner, she said: 'I’m really disappointed that what Government seem to be suggesting is they’re going to take six months to develop an action plan.

'In six months, how many obstetricians are going to walk away and say I can’t do this anymore… How many more midwives are going to hang up their uniforms and say ‘Enough, I can’t do it’?'

Mrs Hawkins said: 'I find that frankly insulting...what we are talking about is babies dying, mothers dying... is it ok to take six months to do something?'

Maternal deaths are now at a 20-year high, despite a succession of scandals across the country and 59 major reports in the decade to 2023.

The NHS now spends as much on legal claims for maternity blunders as it spends on maternity care.