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

17 shown (filtered)

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 →

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 →