Public Inquiry

Independent Inquiry into the issues raised by the David Fuller case

Status: Completed Chair: Sir Jonathan Michael Established: Jun 2022 Report: Jul 2025 Commissioned by: Department of Health and Social Care

Inquiry into mortuary abuse by David Fuller at NHS hospitals. Fuller sexually abused the bodies of at least 101 deceased women and girls. Phase 1 examined Maidstone and Tunbridge Wells NHS Trust; Phase 2 examined nationwide safeguards for the deceased.

Response breakdown

92 recommendations total

30%

47%

23%

28 (30%) — Accepted

43 (47%) — Accepted in Part

21 (23%) — Under Review

Data last updated: 1 Dec 2025 · Data verified: 5 Feb 2026 (Claude)

Key facts

Duration: 3 years

Reports & milestones

Reports

29 Nov 2023 17 tracked recs Fuller Inquiry Phase 1 Report · Tracked recommendations · PDF

15 Jul 2025 75 tracked recs Fuller Inquiry Phase 2 Report · Tracked recommendations · PDF

Timeline

No milestones recorded.

Recommendations

92 shown

Code	Recommendation	Addressed to	Response
P1-1	Non-mortuary staff accompanied in mortuary Maidstone and Tunbridge Wells NHS Trust must ensure that non-mortuary staff and contractors, including maintenance staff employed by the Trust's external facilities …	Maidstone and Tunbridge Wells NHS Tru…	Accepted	View →
P1-2	No deceased left out of fridges overnight Maidstone and Tunbridge Wells NHS Trust must assure itself that all regulatory requirements and standards relating to the mortuary are met and …	Maidstone and Tunbridge Wells NHS Tru…	Accepted	View →
P1-3	Criminal record checks compliance Maidstone and Tunbridge Wells NHS Trust must assure itself that it is compliant with its own current policy on criminal record checks …	Maidstone and Tunbridge Wells NHS Tru…	Accepted	View →
P1-4	Mortuary Managers qualified and supported Maidstone and Tunbridge Wells NHS Trust must assure itself that its Mortuary Managers are suitably qualified and have relevant anatomical pathology technologist …	Maidstone and Tunbridge Wells NHS Tru…	Accepted	View →
P1-5	Mortuary Manager as full-time dedicated role The role of Mortuary Manager at Maidstone and Tunbridge Wells NHS Trust should be protected as a full-time dedicated role, in recognition …	Maidstone and Tunbridge Wells NHS Tru…	Accepted	View →
P1-6	Review policies on mortuary access Maidstone and Tunbridge Wells NHS Trust must review its policies to ensure that only those with appropriate and legitimate access can enter …	Maidstone and Tunbridge Wells NHS Tru…	Accepted	View →
P1-7	Audit and monitor mortuary access Maidstone and Tunbridge Wells NHS Trust must audit implementation of any resulting new policy and must regularly monitor access to restricted areas, …	Maidstone and Tunbridge Wells NHS Tru…	Accepted	View →
P1-8	Security as corporate responsibility Maidstone and Tunbridge Wells NHS Trust should treat security as a corporate not a local departmental responsibility.	Maidstone and Tunbridge Wells NHS Tru…	Accepted	View →
P1-9	CCTV in mortuary including post-mortem room Maidstone and Tunbridge Wells NHS Trust must install CCTV cameras in the mortuary, including the post-mortem room, to monitor the security of …	Maidstone and Tunbridge Wells NHS Tru…	Accepted	View →
P1-10	Regular CCTV review with swipe card data Maidstone and Tunbridge Wells NHS Trust must ensure that footage from the CCTV is reviewed on a regular basis by appropriately trained …	Maidstone and Tunbridge Wells NHS Tru…	Accepted	View →
P1-11	Share HTA reports with reliant organisations Maidstone and Tunbridge Wells NHS Trust must proactively share Human Tissue Authority reports with organisations that rely on Human Tissue Authority licensing …	Maidstone and Tunbridge Wells NHS Tru…	Accepted	View →
P1-12	Local authorities examine contractual arrangements Kent County Council and East Sussex County Council should examine their contractual arrangements with Maidstone and Tunbridge Wells NHS Trust to ensure …	Kent County Council	Accepted	View →
P1-13	Board review governance - assurance not reassurance We have illustrated throughout this Report how Maidstone and Tunbridge Wells NHS Trust relied on reassurance rather than assurance in monitoring its …	Maidstone and Tunbridge Wells NHS Tru…	Accepted	View →
P1-14	Board oversight of licensed mortuary activity Maidstone and Tunbridge Wells NHS Trust Board must have greater oversight of licensed activity in the mortuary. It must ensure that the …	Maidstone and Tunbridge Wells NHS Tru…	Accepted	View →
P1-15	Treat HTA compliance as Trust statutory responsibility Maidstone and Tunbridge Wells NHS Trust should treat compliance with Human Tissue Authority standards as a statutory responsibility for the Trust, notwithstanding …	Maidstone and Tunbridge Wells NHS Tru…	Accepted	View →
P1-16	Chief Nurse responsible for mortuary assurance The Chief Nurse should be made explicitly responsible for assuring the Maidstone and Tunbridge Wells NHS Trust Board that mortuary management is …	Maidstone and Tunbridge Wells NHS Tru…	Accepted	View →
P1-17	Deceased treated with same dignity as patients Maidstone and Tunbridge Wells NHS Trust must treat the deceased with the same due regard to dignity and safeguarding as it does …	Maidstone and Tunbridge Wells NHS Tru…	Accepted	View →
P2-1	NHS trusts commission specialist security review All NHS trusts with mortuaries and/or body stores should commission a specialist strategic review of the systems in place to protect deceased …	NHS England	Accepted in Part	View →
P2-2	CCTV in all NHS mortuaries All NHS trusts should install CCTV inside the mortuary, with cameras facing all doors and access points, the reception area and the …	NHS England	Accepted in Part	View →
P2-3	Audit access data for deceased storage All NHS trusts should routinely audit the access data of all facilities used to store deceased people.	NHS England	Accepted in Part	View →
P2-4	End shared swipe cards The practice of using shared electronic swipe cards for specific staff groups should cease immediately.	NHS England	Accepted in Part	View →
P2-5	Operational barriers including device restrictions All NHS trusts should consider putting in place systemic operational barriers that prevent the security and dignity of deceased people being compromised. …	NHS England	Accepted in Part	View →
P2-6	Security breaches reviewed by expert with action plans All NHS trusts should take every breach of security in a mortuary or body store extremely seriously. Each security incident should be …	NHS England	Accepted in Part	View →
P2-7	Body store security standards match HTA-licensed facilities The NHS should ensure that the security standards required for body stores are the same as those required for facilities licensed by …	NHS England	Accepted in Part	View →
P2-8	Swipe to exit for mortuaries All NHS trusts should consider the installation of 'swipe to exit' for mortuary facilities. This would allow trusts to monitor and audit …	NHS England	Accepted in Part	View →
P2-9	Monitor and review staff access numbers All NHS trusts should monitor the number of staff with access to the mortuary or body store and keep this under routine …	NHS England	Accepted in Part	View →
P2-10	Designated Individuals adequate time and resource NHS trusts should ensure that Designated Individuals have enough time and resource to fulfil their responsibilities, including time for learning and development.	NHS England	Accepted in Part	View →
P2-11	Senior managers understand DI role and accountability NHS trusts should ensure that senior managers, including the Chief Executive, have a clear understanding of the role of the Designated Individual, …	NHS England	Accepted in Part	View →
P2-12	DI attendance at governance forums NHS trusts should ensure that Designated Individuals attend the correct governance forums. This would allow them to escalate issues and risks, as …	NHS England	Accepted in Part	View →
P2-13	Mortuary Manager professional background prerequisite A professional background in the field of mortuary services should be made a prerequisite for the post of Mortuary Manager.	NHS England	Accepted in Part	View →
P2-14	Mortuary Manager adequate resources and support NHS trusts should assure themselves that the Mortuary Manager has adequate resources and support to perform their role effectively, including meeting any …	NHS England	Accepted in Part	View →
P2-15	Routine mortuary reporting to trust boards All NHS trusts should establish a routine reporting system for matters relating to mortuaries and body stores. This reporting system should include …	NHS England	Accepted in Part	View →
P2-16	Trust boards assure recommendation implementation Trust boards should assure themselves that the recommendations in this Report have been implemented.	NHS England	Accepted in Part	View →
P2-17	Recommendations apply to temporary facilities Trust boards should ensure that these recommendations and governance arrangements are applied to any temporary facilities used by trusts for the storage …	NHS England	Accepted in Part	View →
P2-18	Mortuaries treated as regulated activity in governance Trust boards should take note of the fact that mortuary services are subject to statutory regulation and should be treated with equivalent …	NHS England	Accepted in Part	View →
P2-19	Deceased included in safeguarding training and policy NHS trust boards should ensure that the security and dignity of deceased people are included in safeguarding training, policies and assurance.	NHS England	Accepted in Part	View →
P2-20	Chief Nurse responsibility for deceased safeguarding The remit of the Chief Nurse in NHS trusts should explicitly include executive responsibility for safeguarding the security and dignity of deceased …	NHS England	Accepted in Part	View →
P2-21	NHS England incorporate deceased in safeguarding framework NHS England should formally incorporate the safeguarding of deceased people into its safeguarding framework for NHS trusts.	NHS England	Accepted in Part	View →
P2-22	Independent sector SOPs for deceased patients Independent sector healthcare providers should ensure that there are Standard Operating Procedures and policies in place to protect the security and dignity …	Department of Health and Social Care	Accepted	View →
P2-23	Independent sector accompanied access to deceased Independent sector healthcare providers should ensure that only people who have a legitimate reason to access a room that contains a deceased …	Department of Health and Social Care	Accepted	View →
P2-24	Anatomical education security and dignity policies All organisations providing anatomical education and training using donors should make sure that policies and procedures are in place to ensure the …	Department of Health and Social Care	Under Consideration	View →
P2-25	Postgraduate training governance clarity Postgraduate training providers using donors should ensure clarity in their governance and information-sharing, in particular where the providers are linked to both …	Department of Health and Social Care	Under Consideration	View →
P2-26	HTA require anatomy adverse incidents reported as HTARIs The Human Tissue Authority should change its guidance to require that relevant adverse incidents in the anatomy sector are formally reported as …	Human Tissue Authority	Accepted	View →
P2-27	Hospice security and access controls Hospices that care for deceased people on their premises should: introduce auditable access control of the area where deceased people are kept; …	Department of Health and Social Care	Accepted	View →
P2-28	CQC guidance on hospice inspection scope To avoid confusion over its remit, the Care Quality Commission should issue clear guidance to inspectors (and others) that hospice inspections should …	CQC	Accepted	View →
P2-29	Hospices in scope for new regulatory regime Hospices should be considered in scope for the regulatory measures recommended in Chapter 11.	Department of Health and Social Care	Under Consideration	View →
P2-30	Ambulance data on conveying deceased Data on how often deceased patients are conveyed in ambulances, and the reasons for this, should be routinely collected and reported to …	NHS England	Accepted	View →
P2-31	Ambulance policy on crew position with deceased Every NHS ambulance service should have a policy setting out where ambulance crew members should sit when conveying deceased patients. This should …	NHS England	Accepted	View →
P2-32	Ambulance policies on deceased security and dignity NHS ambulance services should also have policies regarding the security and dignity of the deceased, including when the deceased should be covered …	NHS England	Accepted	View →
P2-33	Ambulance photography policies Every NHS ambulance service must put policies in place regarding taking photographs of deceased patients, including any circumstances in which this may …	NHS England	Accepted	View →
P2-34	Recommendations apply to independent ambulances The Inquiry has focused its investigations into ambulance services on NHS ambulance services. However, the Inquiry considers that these recommendations could also …	Department of Health and Social Care	Accepted	View →
P2-35	Local authority mortuary access review There should be a process to routinely review who is permitted to access the mortuary unsupervised.	Ministry of Housing, Communities and …	Accepted in Part	View →
P2-36	Local authority individualised access controls Where unsupervised access is permitted for a legitimate and unavoidable purpose, there should be individualised electronic access controls to enter the mortuary …	Ministry of Housing, Communities and …	Accepted in Part	View →
P2-37	Local authority visitor supervision Where people other than mortuary staff are visiting the mortuary during working hours, for example contractors, cleaners and other visitors: Access must …	Ministry of Housing, Communities and …	Accepted in Part	View →
P2-38	Local authority lone working review Where mortuary staff are permitted to work alone in the mortuary, there should be a review of lone working policies, including consideration …	Ministry of Housing, Communities and …	Accepted in Part	View →
P2-39	Local authority security audits Routine and regular audits of security must be conducted, encompassing both access to and exit from the mortuary and movement within it, …	Ministry of Housing, Communities and …	Accepted in Part	View →
P2-40	Local authority strategic security review Immediate steps must be taken to commission a specialist strategic review of the systems in place to protect the deceased, which should …	Ministry of Housing, Communities and …	Accepted in Part	View →
P2-41	No reliance on keys/keypads alone There must be no reliance on keys and keypad codes alone to secure access to the mortuary.	Ministry of Housing, Communities and …	Accepted in Part	View →
P2-42	Lock fridges and freezers at all times Fridges and freezers containing deceased people must be locked at all times, with appropriate key security in place.	Ministry of Housing, Communities and …	Accepted in Part	View →
P2-43	Local authority CCTV installation CCTV must be installed inside the mortuary facing all doors and access points, the reception area and the doors of all fridges …	Ministry of Housing, Communities and …	Accepted in Part	View →
P2-44	Local authority incident response SOPs Arrangements for responding to incidents of unauthorised access must be reviewed and incorporated into Standard Operating Procedures.	Ministry of Housing, Communities and …	Accepted in Part	View →
P2-45	Local authority single security SOP All policies and procedures in relation to the security of the mortuary must be accurately and comprehensively reflected in a single security …	Ministry of Housing, Communities and …	Accepted in Part	View →
P2-46	Local authority funding for security expedited There must be a process to ensure that, where there is a requirement for funding to strengthen mortuary security, it is expedited …	Ministry of Housing, Communities and …	Accepted in Part	View →
P2-47	Local authority security breach investigation There must be an investigation into the root cause of each security breach. Each incident, the investigation and action plan must be …	Ministry of Housing, Communities and …	Accepted in Part	View →
P2-48	Local authority annual SOP and HTA audits There must be audits of the mortuary Standard Operating Procedures and compliance with Human Tissue Authority requirements, undertaken annually as a minimum, …	Ministry of Housing, Communities and …	Accepted in Part	View →
P2-49	Local authority DI management and oversight review There must be a review of the management and oversight arrangements for the mortuary service, taking into consideration who is appointed as …	Ministry of Housing, Communities and …	Accepted in Part	View →
P2-50	Local authority mortuary as regulated service The mortuary service must be treated in the same way as other regulatory services within local authority reporting structures: The mortuary must …	Ministry of Housing, Communities and …	Accepted in Part	View →
P2-51	Local authority biennial audits and peer review The mortuary service must be reviewed by professional auditors at least biennially, with the results of the audit reported to a formal …	Ministry of Housing, Communities and …	Accepted in Part	View →
P2-52	Share mortuary reports with coroner service All relevant reports and incidents concerning the mortuary must be made known to the lead local authority manager for the coroner service …	Ministry of Housing, Communities and …	Accepted in Part	View →
P2-53	Local authority report implementation to committee The implementation of these recommendations must be reported to the relevant statutory committee.	Ministry of Housing, Communities and …	Accepted in Part	View →
P2-54	Local authority contingent body storage plans Local authorities providing a coroner service must review plans for the provision and operation of contingent body storage, in collaboration with local …	Ministry of Housing, Communities and …	Accepted in Part	View →
P2-55	Unlicensed body stores prepared for HTA compliance Local authorities providing an unlicensed body store must be prepared to comply with the Human Tissue Authority's standards and guidance where applicable, …	Ministry of Housing, Communities and …	Accepted in Part	View →
P2-56	Unlicensed body stores follow same standards Where local authorities provide an unlicensed body store, they should do so in line with this Report's recommendations to local authority providers …	Ministry of Housing, Communities and …	Accepted in Part	View →
P2-57	Local authority review third-party contracts Local authorities must review all contractual arrangements and agreements with third-party providers of services that care for and transport the deceased. This …	Ministry of Housing, Communities and …	Under Consideration	View →
P2-58	Contractual incident notification requirement There must be a contractual requirement to formally notify the contract manager and senior local authority officers of any incidents involving the …	Ministry of Housing, Communities and …	Under Consideration	View →
P2-59	Local authority contractor governance assurance Local authorities must ensure that the providers they contract or enter into agreements with have robust governance processes in place to oversee …	Ministry of Housing, Communities and …	Under Consideration	View →
P2-60	Care homes in scope for new regulatory regime The regulatory measures recommended in Chapter 11 should apply to care homes in England. Regulation should cover both systems and professionals where …	Department of Health and Social Care	Under Consideration	View →
P2-61	Statutory regulation of funeral directors The UK government should establish an independent statutory regulatory regime for funeral directors in England as a matter of urgency in order …	Department of Health and Social Care	Under Consideration	View →
P2-62	Regulations consider whole deceased journey These regulations and standards should be considered within the overall care and journey of the deceased rather than applying in isolation to …	Department of Health and Social Care	Under Consideration	View →
P2-63	Mandatory information from funeral directors The standards should include details of mandatory information to be given to customers by funeral directors to provide transparency about the care …	Department of Health and Social Care	Under Consideration	View →
P2-64	Direct cremation in scope for standards Direct cremation businesses should also be considered in this context, and mandatory standards to protect the security and dignity of the deceased …	Department of Health and Social Care	Under Consideration	View →
P2-65	Funeral director regulation benefits outweigh difficulties While the introduction of a proportionate statutory regulation and inspection regime may require significant adjustment by funeral director organisations, it is the …	Department of Health and Social Care	Under Consideration	View →
P2-66	Funeral sector in scope for new regulatory regime The funeral sector in England should be considered in scope for the broader regulatory measures recommended in Chapter 11.	Department of Health and Social Care	Under Consideration	View →
P2-67	Faith organisations share guidance on deceased care All faith organisations should consider how to support their members to deliver high standards of care for the deceased, with a focus …	Department of Health and Social Care	Under Consideration	View →
P2-68	Religious building security for deceased Where deceased people are in a religious building overnight, measures should be taken to ensure that the building is secure, including, for …	Department of Health and Social Care	Under Consideration	View →
P2-69	Formalise multi-organisation arrangements Where organisations work together to care for people after death, the arrangements should be formalised through contracts or service level agreements. This …	Department of Health and Social Care	Under Consideration	View →
P2-70	Chief Coroner review practice consistency The Chief Coroner should review the difference in practice between coronial areas as soon as possible to ensure that: All coroners are …	Ministry of Justice	Under Consideration	View →
P2-71	New Chief Inspector regulatory regime for deceased The UK government should establish an independent statutory regulatory regime, headed by a Chief Inspector, for those who store and care for …	Department of Health and Social Care	Under Consideration	View →
P2-72	Interim Commissioner for Dignity of Deceased In the interim, the government should immediately appoint a Commissioner for the Dignity of the Deceased who should immediately issue universal guidance …	Department of Health and Social Care	Under Consideration	View →
P2-73	Amend HT Act for organisational responsibility The government should amend the Human Tissue Act 2004 so that the organisation holding the licence has primary legal responsibility to ensure …	Department of Health and Social Care	Under Consideration	View →
P2-74	HTA require suitable qualified staff with enforcement The Human Tissue Authority, and/or the new inspectorate, should require the organisations it licenses to ensure that any individual who provides care …	Human Tissue Authority	Under Consideration	View →
P2-75	Government responsible for implementation monitoring The government should take responsibility for the implementation of all the recommendations we make in this Report, regardless of the primary organisation …	Department of Health and Social Care	Accepted	View →

Parliamentary activity

26 mentions since Feb 2022

10 questions 16 statements

15 Jul 2026 Written Ministerial Statement Government update on Progress in responding to the Fuller Inquiry Phase 2 …
Baroness Merron (Labour)

15 Jul 2026 Written Ministerial Statement Government update on Progress in responding to the Fuller Inquiry Phase 2 …
Preet Kaur Gill (Labour)

29 Jun 2026 Written Question Cremation and Funerals
Ayoub Khan (Independent)

29 Jun 2026 Written Question Cremation and Funerals: Local Government
Ayoub Khan (Independent)

View all 26 mentions →