Recommendation P1-7: Audit and monitor mortuary access

Today I am updating the House on the response to those recommendations. The Trust published an assurance statement in February 2024 on the implementation of the recommendations from the Phase 1 report. This sets out the progress made to implement the Inquiry’s recommendations.

The range of actions taken by the Trust include requiring that non-mortuary staff and contractors are always accompanied by another staff member when visiting the mortuaries; controlling access to mortuaries using swipe cards; mandating contractors to renew security clearances every three years; and installing CCTV coverage monitoring access to and from mortuary areas. The Trust Board is also providing greater oversight and assurance of legally regulated activity in the mortuary.

I am also reassured that NHS England’s South East regional team held monthly oversight meetings with the Trust between November 2023 and April 2024 (in partnership with Kent and Medway Integrated Care Board) to ensure progress against the Inquiry’s recommendations and to review evidence of the Trust’s progress in delivering their action plan. Ongoing compliance with the Inquiry's recommendations will be monitored by NHS England through regular regional oversight meetings with the Trust, and through other channels as appropriate.

The Trust now complies with this recommendation in full on the following basis:

• As referred to under Recommendation 6, the mortuary is a designated “restricted” area in the Trust’s current “Security policy and procedure”. Access to restricted areas may only be granted by the senior managers in the such areas.

• Any access/swipe card which has not been used on Trust premises for more than two months will be deactivated, with the ability to reactivate when required. Every week, Security Control Room staff conduct an audit on the respective sites’ access control systems to review which access control cards have not been used for two months. Any access control cards identified are temporarily disabled.

• Once a month, the Operational Security Manager provides an electronic record to the managers of restricted areas of staff accessing those areas with the dates and times of those visits. This allows the manager to check that only authorised staff are accessing the area, and that this access is appropriate. The managers scrutinise these records and report any unusual or unauthorised activity to the Operational Security Manager for investigation.

• For the mortuary, this audit is undertaken by the Head of Service for the Care After Death Directorate (who was formerly the Mortuary Manager). The data provided by the Operational Security Manager includes details of the access to specific doors (each door has a reference number) i.e. the individual who has accessed the door, the date, time of entry, and time of exit. The data also includes details of individuals who have attempted to gain access (via their swipe card) but have failed. Although the Security policy and procedure contains a high-level description of the audit process for restricted areas, the audit process for mortuary access is further described in a local SOP. That SOP therefore needs to be reviewed, to confirm that it accurately reflects the current process, and revised if necessary.

• Retention period for CCTV images have been extended from 31 days to 38 days to enable the audits of restricted areas that relate to the review of CCTV footage to continue to be undertaken monthly.

• CCTV has also been installed outside and in the Snowdrop room at Tunbridge Wells Hospital (see Recommendation 6).