Independent Inquiry into the issues raised by the David Fuller case

Independent sector healthcare providers should ensure that there are Standard Operating Procedures and policies in place to protect the security and dignity of any patients that die under their care. Wherever possible, deceased patients' rooms should be kept locked. Providers should also ensure that staff are aware of the need to protect the security and dignity of deceased patients and are able to assess and mitigate risks to this.

In June 2026, the Department of Health and Social Care reported that work on the recommendation was in progress following meetings with the Independent Healthcare Provider Network, whose members confirmed they had taken action on the report (Department of Health and Social Care, Jun 2026). The department stated that the network was considering how to ensure assurance against these actions, and that it had also engaged independent inpatient mental health providers to ensure they were aware of the recommendations and taking appropriate measures (Department of Health and Social Care, Jun 2026).

Independent sector healthcare providers should ensure that only people who have a legitimate reason to access a room that contains a deceased patient do so, even if they are staff members, and that they are always accompanied.

In June 2026, the Department of Health and Social Care reported that work on the recommendation was in progress, noting that independent healthcare providers had confirmed taking action while the Independent Healthcare Provider Network was still "considering the vehicle to ensure assurance against the actions" (Department of Health and Social Care, Jun 2026). In December 2025, the department had accepted the recommendation in full and confirmed that it had engaged independent inpatient mental health providers alongside the network to ensure awareness and appropriate measures (Department of Health and Social Care response, Dec 2025).

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 Reportable Incidents (HTARIs).

In July 2026, the Human Tissue Authority stated in its annual report that it had "successfully implemented" the recommendation to extend its reportable incident system to the anatomy sector (Human Tissue Authority, Jul 2026). In a written statement that same month, Parliamentary Under-Secretary of State Preet Kaur Gill reported that the authority had instructed mortuaries to review internal records from the last ten years, with findings due to Ministers by 16 October 2026 (Preet Kaur Gill, Jul 2026). The Department of Health and Social Care previously noted in a June 2026 dashboard update that formal guidance had been issued and the updated system went live on 1 December (Department of Health and Social Care, Jun 2026).

Hospices that care for deceased people on their premises should: introduce auditable access control of the area where deceased people are kept; have Standard Operating Procedures regarding the care of deceased people, including security of and access to the areas where deceased people are kept; and minimise unaccompanied access to areas where deceased people are cared for, wherever possible.

In June 2026, the Department of Health and Social Care reported that work was in progress, noting that it had worked with Hospice UK to ask clinical leaders to review their practices and that sector guidance had been updated to incorporate security measures (Department of Health and Social Care, Jun 2026). Later that month, NHS England notified health service trusts operating hospice services with body stores of this updated guidance alongside revised Human Tissue Authority standards (NHS England, Jun 2026).

To avoid confusion over its remit, the Care Quality Commission should issue clear guidance to inspectors (and others) that hospice inspections should not include areas where deceased people are kept, other than to focus on the needs of bereaved relatives.

In June 2026, the Department of Health and Social Care reported that the recommendation remained in progress, noting that the Care Quality Commission had issued a rapid update and an internal bulletin to reiterate the limits of mortuary regulation to inspectors (Department of Health and Social Care, Jun 2026). The department stated at that time that the commission was still "working on revising guidance to inspectors" (Department of Health and Social Care, Jun 2026).

Data on how often deceased patients are conveyed in ambulances, and the reasons for this, should be routinely collected and reported to NHS England, and monitored to assess risk.

NHS England stated in June 2026 that ambulance trusts are individually responsible for introducing operational policies as described in the recommendation and monitoring their use, with boards advised to assess compliance, and noted that a further government update was expected in summer 2026 (NHS England, Jun 2026). Earlier in June 2026, the Department of Health and Social Care reported that relevant data lines had been confirmed in the information standard, with the first routine collection expected to be rolled out in 2026 to 2027 (Department of Health and Social Care, Jun 2026).

Every NHS ambulance service should have a policy setting out where ambulance crew members should sit when conveying deceased patients. This should include reference to the risk of abuse of deceased patients, as well as training requirements.

In June 2026, NHS England stated that ambulance trusts are individually responsible for introducing operational policies as recommended and monitoring their use, adding that boards should assess compliance and that a further update was expected in summer 2026 (NHS England, Jun 2026). Also in June 2026, the Department of Health and Social Care reported that the Association of Ambulance Chief Executives was discussing with ambulance service leads to ensure all services review their policies on managing the deceased and introduce a clear policy if none currently exists (Department of Health and Social Care, Jun 2026).

NHS ambulance services should also have policies regarding the security and dignity of the deceased, including when the deceased should be covered and/or secured. NHS England should monitor that such policies are in place.

In June 2026, NHS England stated that ambulance trusts are individually responsible for introducing operational policies on the security and dignity of the deceased and monitoring their use, and that boards should assess compliance (NHS England, Jun 2026). It also noted that a further update was expected in summer 2026, following a December 2025 report in which the Department of Health and Social Care stated that the Association of Ambulance Chief Executives was working with service leads to review or introduce relevant policies (Department of Health and Social Care response, Dec 2025; NHS England, Jun 2026).

Every NHS ambulance service must put policies in place regarding taking photographs of deceased patients, including any circumstances in which this may be required, and ensure that ambulance staff are aware of these and comply with them.

NHS England stated in June 2026 that individual ambulance trusts are responsible for introducing operational policies and monitoring their use, with boards expected to assess compliance, while a further government update was expected in summer 2026 (NHS England, Jun 2026). The Department of Health and Social Care previously reported in December 2025 that the Association of Ambulance Chief Executives was working with service leads to ensure all ambulance services review their policies and introduce clear guidance regarding the deceased (Department of Health and Social Care response, Dec 2025).

The Inquiry has focused its investigations into ambulance services on NHS ambulance services. However, the Inquiry considers that these recommendations could also be applied to independent ambulance services, including private ambulances.

The Department of Health and Social Care recorded the recommendation as in progress in June 2026, noting that the Association of Ambulance Chief Executives had alerted the Independent Ambulance Association to the recommendations (Department of Health and Social Care, Jun 2026). It stated that independent ambulance services commissioned under NHS contracts must comply with relevant NHS policies and procedures (Department of Health and Social Care, Jun 2026). For providers operating outside NHS contracts where this requirement does not apply, the department explained that the association had committed to advocate for implementation across the wider sector, noting that it holds no regulatory authority (Department of Health and Social Care, Jun 2026).

The government should take responsibility for the implementation of all the recommendations we make in this Report, regardless of the primary organisation they are directed at, and make arrangements to monitor the progress of their implementation.

In July 2026, Parliamentary Under-Secretary of State for Health Innovation and Safety Preet Kaur Gill reported that the government has worked through a dedicated cross-government programme board with partner organisations to consider each recommendation and determine required action (Preet Kaur Gill, Jul 2026). The Department of Health and Social Care previously confirmed in June 2026, reiterating its December 2025 interim update, that it established the programme board in July 2025 to scope and progress recommendations across government and with other responsible organisations (Department of Health and Social Care response, Dec 2025; Department of Health and Social Care, Jun 2026).