Problems with after-death care came to light after the parents of Harriet Hawkins, who was stillborn at NUH in 2016, discovered her body had been allowed to decompose so badly that it had to be triple-bagged for her funeral.

A subsequent investigation found 17 areas of concern and prompted an examination by the independent maternity review into the after-death care provided to 16 other babies and one mother.

They found that one early gestation baby had been disposed of as clinical waste, the wrong baby had been passed to funeral directors and a mother who died had deteriorated so badly that her family were advised not to see her prior to her funeral.

"The Review found evidence of recurring examples of failure to protect the dignity of the deceased… including inadequate arrangements for undertaking paediatric post-mortems," Ockenden said in her report.

The problems prompted the Human Tissue Authority (HTA), which regulates mortuary care in England, Wales and Northern Ireland, to examine the trust's services.

In an unannounced inspection, external it found three critical, six major and one minor shortfalls against its standards at the two hospitals run by the trust, the QMC and City Hospital.

The HTA found lack of freezer space at both Nottingham hospitals meant some bodies had been put in a refrigerated area instead.

Eight of the bodies were showing "advanced deterioration" because they had not been transferred to a freezer in time.

Instead of being conducted in a post-mortem suite, some baby post-mortem examinations were carried out in a lab that was inadequately ventilated, with support staff who had not been trained in mortuary care, the HTA found.

An accompanying audit found just more than half of the 145 recorded incidents that should have been escalated to the regulator were not.