Independent Inquiry into the issues raised by the David Fuller case

Maidstone and Tunbridge Wells NHS Trust must ensure that non-mortuary staff and contractors, including maintenance staff employed by the Trust's external facilities management provider, are always accompanied by another staff member when they visit the mortuary. For example, maintenance staff should undertake tasks in the mortuary in pairs.

In October 2024, Wes Streeting, Secretary of State for Health and Social Care, reported that Maidstone and Tunbridge Wells NHS Trust requires non-mortuary staff and contractors to always be accompanied by another staff member, with swipe-card controls in place and NHS England monitoring ongoing compliance (Wes Streeting response, Oct 2024). In February 2024, the Trust stated that it complied with the recommendation in full, as external contractors and maintenance staff are always accompanied by mortuary staff when visiting the mortuary (Maidstone and Tunbridge Wells NHS Trust response, Feb 2024). The record holds no update since the Secretary of State's response of October 2024 (Wes Streeting response, Oct 2024).

Maidstone and Tunbridge Wells NHS Trust must assure itself that all regulatory requirements and standards relating to the mortuary are met and that the practice of leaving deceased people out of mortuary fridges overnight, or while maintenance is undertaken, does not happen.

In October 2024, the Secretary of State for Health and Social Care, Wes Streeting, reported that Maidstone and Tunbridge Wells NHS Trust had set out its progress in an assurance statement, adding that NHS England would monitor ongoing compliance through regular oversight meetings (Wes Streeting response, Oct 2024). In its February 2024 statement, the Trust stated that it complies with the recommendation in full, having ceased the practice of leaving deceased people out of mortuary fridges in early 2021, formalised that prohibition in local policy, and addressed regulatory shortfalls identified by the Human Tissue Authority (Maidstone and Tunbridge Wells NHS Trust response, Feb 2024). The record holds no update since the Minister's response of October 2024 (Wes Streeting response, Oct 2024).

Maidstone and Tunbridge Wells NHS Trust must assure itself that it is compliant with its own current policy on criminal record checks and re-checks for staff. The Trust should ensure that staff who are employed by its facilities management provider or other contractors are subject to the same requirements.

In October 2024, the Secretary of State for Health and Social Care, Wes Streeting, reported that Maidstone and Tunbridge Wells NHS Trust had mandated contractors to renew security clearances every three years, with ongoing compliance monitored by NHS England (Wes Streeting response, Oct 2024). The Trust had stated in February 2024 that it "complies with this recommendation in full", reporting that internal reviews showed no staff had an outstanding check without actively engaging in renewal (Maidstone and Tunbridge Wells NHS Trust response, Feb 2024). The record holds no update since the Minister's response of October 2024 (Wes Streeting response, Oct 2024).

Maidstone and Tunbridge Wells NHS Trust must assure itself that its Mortuary Managers are suitably qualified and have relevant anatomical pathology technologist experience. The Mortuary Manager should have a clear line of accountability within the Trust's management structure and must be adequately managed and supported.

In October 2024, Wes Streeting reported that Maidstone and Tunbridge Wells NHS Trust had set out its progress in an assurance statement, with NHS England monitoring ongoing compliance (Wes Streeting response, Oct 2024). In that February 2024 statement, the Trust stated that it complied with the recommendation in full after establishing a Care After Death Directorate and setting qualification requirements for its Mortuary Manager (Maidstone and Tunbridge Wells NHS Trust response, Feb 2024). The record holds no update since the Department of Health and Social Care's response of October 2024 (Wes Streeting response, Oct 2024).

The role of Mortuary Manager at Maidstone and Tunbridge Wells NHS Trust should be protected as a full-time dedicated role, in recognition of the fact that this is a complex regulated service, based across two sites, that requires the appropriate level of management attention.

In October 2024, the Secretary of State for Health and Social Care, Wes Streeting, relayed Maidstone and Tunbridge Wells NHS Trust's February 2024 assurance statement, in which the Trust stated that it "complies with this recommendation in full" by maintaining the Mortuary Manager as a full-time dedicated role (Maidstone and Tunbridge Wells NHS Trust response, Feb 2024; Wes Streeting response, Oct 2024). In the same October 2024 statement, the Minister noted that NHS England would monitor ongoing compliance through regular regional oversight meetings (Wes Streeting response, Oct 2024). The record holds no update since the Department of Health and Social Care's response of October 2024 (Wes Streeting response, Oct 2024).

Maidstone and Tunbridge Wells NHS Trust must review its policies to ensure that only those with appropriate and legitimate access can enter the mortuary.

In October 2024, Wes Streeting reported that Maidstone and Tunbridge Wells NHS Trust controls mortuary access using swipe cards and requires non-mortuary staff and contractors to be accompanied by another staff member (Wes Streeting response, Oct 2024). The Trust had stated in February 2024 that it complies with the recommendation in full, having withdrawn general access cards and restricted mortuary entry to authorized personnel and trained porters (Maidstone and Tunbridge Wells NHS Trust response, Feb 2024). The record holds no update since the Department of Health and Social Care's response of October 2024 (Wes Streeting response, Oct 2024).

Maidstone and Tunbridge Wells NHS Trust must audit implementation of any resulting new policy and must regularly monitor access to restricted areas, including the mortuary, by all staff and contractors.

Wes Streeting, Secretary of State for Health and Social Care, reported in October 2024 that Maidstone and Tunbridge Wells NHS Trust was controlling mortuary access using swipe cards, requiring non-mortuary staff and contractors to be accompanied, and monitoring access with CCTV (Wes Streeting response, Oct 2024). The Trust had stated in February 2024 that it complied in full with the recommendation through weekly card deactivations and monthly access reviews, though a local standard operating procedure for mortuary access audits still required review (Maidstone and Tunbridge Wells NHS Trust response, Feb 2024). The record holds no update since the Department of Health and Social Care's response of October 2024 (Wes Streeting response, Oct 2024).

Maidstone and Tunbridge Wells NHS Trust should treat security as a corporate not a local departmental responsibility.

In October 2024, Wes Streeting, Secretary of State for Health and Social Care, informed Parliament that the Trust had set out its progress in a February 2024 assurance statement, and noted that NHS England had held monthly regional meetings to oversee compliance (Wes Streeting response, Oct 2024). In that February 2024 statement, Maidstone and Tunbridge Wells NHS Trust stated that it "now complies with this recommendation in full", having transferred executive responsibility for security to the Chief Operating Officer, appointed a Head of Security Management, and re-established a Trust Security Committee (Maidstone and Tunbridge Wells NHS Trust response, Feb 2024). The record holds no update since the Secretary of State for Health and Social Care's response of October 2024 (Wes Streeting response, Oct 2024).

Maidstone and Tunbridge Wells NHS Trust must install CCTV cameras in the mortuary, including the post-mortem room, to monitor the security of the deceased and safeguard their privacy and dignity.

In October 2024, the Secretary of State for Health and Social Care reported to Parliament that Maidstone and Tunbridge Wells NHS Trust had installed CCTV coverage monitoring access to and from mortuary areas, with ongoing compliance monitored by NHS England (Wes Streeting response, Oct 2024). The Trust had stated in February 2024 that it complied with the recommendation in full, having installed CCTV cameras across its mortuaries in 2020 and within the post-mortem room at Tunbridge Wells Hospital in 2021 (Maidstone and Tunbridge Wells NHS Trust response, Feb 2024). The record holds no update since the Secretary of State's response of October 2024 (Wes Streeting response, Oct 2024).

Maidstone and Tunbridge Wells NHS Trust must ensure that footage from the CCTV is reviewed on a regular basis by appropriately trained staff and examined in conjunction with swipe card data to identify trends that might be of concern.

In October 2024, Wes Streeting, Secretary of State for Health and Social Care, reported that Maidstone and Tunbridge Wells NHS Trust had controlled mortuary access using swipe cards and installed CCTV coverage, with NHS England monitoring ongoing compliance (Wes Streeting response, Oct 2024). The Trust had stated in February 2024 that it complies with the recommendation in full, detailing monthly swipe card checks against CCTV footage when anomalies occur, regular random CCTV reviews, and an extended 38-day image retention period (Maidstone and Tunbridge Wells NHS Trust response, Feb 2024). The record holds no update since the department's response of October 2024 (Wes Streeting response, Oct 2024).

Maidstone and Tunbridge Wells NHS Trust must proactively share Human Tissue Authority reports with organisations that rely on Human Tissue Authority licensing for assurance of the service provided by the mortuary.

In October 2024, the Secretary of State for Health and Social Care, Wes Streeting, reported that Maidstone and Tunbridge Wells NHS Trust had set out its progress in an assurance statement, and noted that NHS England would monitor ongoing compliance with the Inquiry's recommendations (Wes Streeting response, Oct 2024). In that February 2024 statement, the Trust stated that it "now complies with this recommendation in full" by proactively sharing Human Tissue Authority reports with Kent County Council, East Sussex County Council, and the Kent & Medway Integrated Care Board (Maidstone and Tunbridge Wells NHS Trust response, Feb 2024). The record holds no update since the Department of Health and Social Care's response of October 2024 (Wes Streeting response, Oct 2024).

We have illustrated throughout this Report how Maidstone and Tunbridge Wells NHS Trust relied on reassurance rather than assurance in monitoring its processes. The Board must review its governance structures and function in light of this.

In October 2024, the Secretary of State for Health and Social Care, Wes Streeting, reported that the board of Maidstone and Tunbridge Wells NHS Trust was providing greater oversight and assurance, noting that NHS England would monitor ongoing compliance through regular regional meetings (Wes Streeting response, Oct 2024). The Trust had stated in February 2024 that it complied with the recommendation in full, having agreed governance changes following an independent review by Deloitte (Maidstone and Tunbridge Wells NHS Trust response, Feb 2024). The record holds no update since the Minister's response of October 2024 (Wes Streeting response, Oct 2024).

Maidstone and Tunbridge Wells NHS Trust Board must have greater oversight of licensed activity in the mortuary. It must ensure that the Designated Individual is actively involved in reporting to the Board and is supported in this.

In October 2024, the Secretary of State for Health and Social Care, Wes Streeting, reported that Maidstone and Tunbridge Wells NHS Trust Board was providing greater oversight and assurance of legally regulated activity in the mortuary, with ongoing compliance monitored by NHS England (Wes Streeting response, Oct 2024). The Trust had stated in February 2024 that it complied with the recommendation in full, having established regular board reports and multiple direct reporting routes for the Designated Individual (Maidstone and Tunbridge Wells NHS Trust response, Feb 2024). The record holds no update since the Minister's response of October 2024 (Wes Streeting response, Oct 2024).

Maidstone and Tunbridge Wells NHS Trust should treat compliance with Human Tissue Authority standards as a statutory responsibility for the Trust, notwithstanding the fact that the formal responsibility under the Human Tissue Act 2004 rests with the Designated Individual. The Act will be subject to review in Phase 2 of the Inquiry's work.

In October 2024, Wes Streeting, Secretary of State for Health and Social Care, reported that Maidstone and Tunbridge Wells NHS Trust was providing greater board oversight of legally regulated mortuary activity, with NHS England monitoring ongoing compliance (Wes Streeting response, Oct 2024). The Trust had previously stated in February 2024 that it complied with the recommendation in full, noting that the Human Tissue Authority was satisfied all inspection shortfalls had been corrected (Maidstone and Tunbridge Wells NHS Trust response, Feb 2024). The record holds no update since the department's response of October 2024 (Wes Streeting response, Oct 2024).

The Chief Nurse should be made explicitly responsible for assuring the Maidstone and Tunbridge Wells NHS Trust Board that mortuary management is delivered in such a way that it protects the security and dignity of the deceased.

In October 2024, Wes Streeting, Secretary of State for Health and Social Care, reported that Maidstone and Tunbridge Wells NHS Trust was providing greater board oversight of mortuary activity, with NHS England monitoring ongoing compliance (Wes Streeting response, Oct 2024). The Trust had previously stated in February 2024 that it complied with the recommendation in full, having amended the Chief Nurse's job description to make mortuary assurance explicit and established a Care After Death workstream (Maidstone and Tunbridge Wells NHS Trust response, Feb 2024). The record holds no update since the Minister's response of October 2024 (Wes Streeting response, Oct 2024).

Maidstone and Tunbridge Wells NHS Trust must treat the deceased with the same due regard to dignity and safeguarding as it does its other patients.

In October 2024, Wes Streeting, Secretary of State for Health and Social Care, reported that Maidstone and Tunbridge Wells NHS Trust had strengthened mortuary access controls and board oversight, with NHS England monitoring ongoing compliance (Wes Streeting response, Oct 2024). The Trust had stated in February 2024 that it complied in full with the recommendation, having adopted a safeguarding definition for the deceased and introduced dignity measures including mortuary preparation packs (Maidstone and Tunbridge Wells NHS Trust response, Feb 2024). The record holds no update since the Department of Health and Social Care's response of October 2024 (Wes Streeting response, Oct 2024).