For two days in January the Bedford hospital trust "bodies in the chapel" scandal gripped the nation after several newspapers published pictures of seven corpses stored in a hospital "chapel".
There was public shock, ministerial outrage and retribution in the form of a sacked manager. An inquiry was launched and pledges were made that such an outrage should never happen again.
But now the media storm has blown over, what really happened? What did the inquiry, which reported last week, discover? And what happened next?
How did the scandal emerge?
Bedfordshire on Sunday and the Sunday Telegraph (followed by several other newspapers) published photographs on January 14 that showed seven bodies wrapped in sheets lying on the floor of the "chapel" of rest. The story was generally presented as evidence of an NHS in crisis, and an affront to human dignity.
Why were the bodies in the chapel?
The door of a temporary mortuary storage facility was inaccessible due to a defective door. The storage capacity of the main mortuary had become "increasingly inadequate" over the past decade, partly because of closure of old facilities and because of under investment in new facilities. Last winter, despite leasing an additional refrigerated body store facility, at one time more than 20 bodies were placed at on the floor of the chapel.
Who knew that the chapel was being used in this way?
Trust chief executive Ken Williams told the inquiry he was aware that the practice of temporarily placing bodies in the chapel had been taking place "for at least five years". Porters and mortuary workers knew, as did local Unison official Willy White, to whom union members had reported the problem. The trust board was unaware of the practice.
Isn't treating bodies in this way obviously bad practice?
The coroner was not overtly shocked. He told the inquiry that "use of the chapel area (in this way) was not in itself wrong at times of particular pressure, provided that it was used appropriately and with due regard for the dignity of the diseased". Similarly, pathology consultants at the trust on the whole "did not see (this practice) as untoward".
Why didn't the chaplain complain about the use of his chapel?
The chapel of rest is not a place of religious worship but an unrefrigerated, carpeted annexe of the main mortuary used to allow relatives to view a deceased relative (but not when bodies were stored there). It is a secure area, and not normally accessible to the public.
Why didn't Unison contact the trust board about the bodies in the chapel, rather than contacting the local newspaper?
Mr White said there was "a culture in the hospital which had prevented people feeling able to raise their concerns internally". The inquiry report says that, while this may have been true for "blue collar" staff, the majority of professional staff felt the culture of the trust was "friendly and open". The trust had a whistleblowing policy in place but it had never been used.
Was this just Unison settling old scores?
Managers and medical staff told the inquiry the incident could be traced to a bitter management-Unison feud over the dismissal of a staff member last year, and that the taking of the photographs was "a deliberate act" in a campaign to discredit the chief executive "by any means". Mr White said he was simply raising a serious issue of malpractice at the trust.
If the mortuary is "secure", how did a photographer gain access?
There were two sets of mortuary keys, one in the porter's lodge and one in the casualty department. No trust employee interviewed would admit to allowing the journalists access to the mortuary. The inquiry concludes that it "was unable to establish who had breached security and more importantly patient confidentiality by using their access to these keys".
If bodies are wrapped in sheets before being placed in the chapel, how was one of the bodies identified from pictures in the newspapers?
Part of the face and legs of one of the bodies was exposed on one of the bodies, which could have been an accident or could have been posed. The inquiry says that most staff "refused to believe that the photographs could have been obtained except by tampering with the bodies and their coverings beforehand". The director and photographer of the Bedfordshire on Sunday stated categorically that they "did not touch or interfere with the bodies".
Why did the faulty mortuary door take so long to fix?
A management mix-up meant that neither the estates manager nor the maintenance manager would take responsibility for the matter. Middle managers in pathology and the resource directorate also ignored the problems and failed to alert senior managers. The inquiry found that some staff felt that if they raised concerns about such matters they were ignored, "so they did not bother and adopted a make-do-and-mend' philosophy".
Who is to blame for the scandal?
The report concludes that "failings in the management processes and management accountability at the trust" were principally to blame, and as a result Mr Williams resigned. It also noted how staff shortages, historical underfunding of capital projects at the hospital, and poor procurement practice relating to the temporary mortuary also contributed. The inquiry was clearly angry at the role of both Mr White and the Bedfordshire on Sunday, although it did not directly apportion blame.
Was trust chief executive Ken Williams sacked, or did he resign?
Formally, he resigned, although many managers believe he was pushed. Mr Williams was on local television on the Sunday saying it was not a resigning issue. Less than 24 hours later, after stories had appeared in the national papers relating that health secretary Alan Milburn had "hit the roof" over the affair, Mr Williams met regional officials. After this meeting, he resigned. Regional director Peter Houghton told the press: "Being an honourable man, Ken Williams agreed he should stand down (our emphasis)." Technically the health secretary has no powers to directly "sack" NHS trust managers - although he will acquire these powers when the health and social care bill becomes law.
What has happened since?
The practice of storing bodies in the chapel has ceased. Relatives have been sent a letter of apology with the offer of a meeting with the trust to receive a full explanation, and counselling. There is now only one set of mortuary keys, to which access is now restricted. The mortuary doors have now been fixed, and a CCTV system has been installed. The trust is considering increasing mortuary capacity, and is seeking to hire another mortician. The coroner is seeking a detailed explanation from the trust as to how the breach of security happened. The trust and Unison are to meet to "rebuild relationships".
