Independent Inquiry into the issues raised by the David Fuller case

All organisations providing anatomical education and training using donors should make sure that policies and procedures are in place to ensure the security and dignity of donors. These should include: security and access policies and the auditing of security and access measures such as swipe card access, CCTV and access to the locations where donors are kept; governance arrangements to ensure effective oversight of and accountability for the security and dignity of donors; a review of contracts or agreements with external organisations for the transfer of donors to or between facilities; and policies and processes on incident reporting, both within the organisation and to the Human Tissue Authority, that are clear and accessible to all students and staff.

The Department of Health and Social Care stated in a June 2026 dashboard update that this recommendation on anatomical education security and dignity policies remained under consideration (Department of Health and Social Care, Jun 2026). In a June 2026 national system letter, NHS England reported that, where relevant to the health service, these actions had been reflected in its Premises Assurance Model (NHS England, Jun 2026).

Postgraduate training providers using donors should ensure clarity in their governance and information-sharing, in particular where the providers are linked to both university and NHS settings. This clarity should include formal agreements, where relevant, including management, governance and Human Tissue Authority licensing arrangements for the organisations involved.

The Department of Health and Social Care stated in a government dashboard update in June 2026 that this recommendation on postgraduate training governance remained "under consideration" (Department of Health and Social Care, Jun 2026). In June 2026, NHS England reported in a national system letter to health service trusts and integrated care boards that, where relevant to the NHS, these actions have been reflected in the NHS Premises Assurance Model (NHS England, Jun 2026).

Hospices should be considered in scope for the regulatory measures recommended in Chapter 11.

The Department of Health and Social Care reported in June 2026, in progress entries published by the Cabinet Office, that "This recommendation is under consideration" (Department of Health and Social Care, Jun 2026). This maintained the position taken in the department's December 2025 interim update on progress responding to the phase 2 report, which listed the proposal among 21 recommendations that remained under consideration (Department of Health and Social Care response, Dec 2025).

Local authorities must review all contractual arrangements and agreements with third-party providers of services that care for and transport the deceased. This must include consideration of assurance mechanisms, such as key performance indicators, regular reporting, formal contract review meetings, site visits and stakeholder feedback.

In an interim update on government progress published in December 2025, the Department of Health and Social Care relayed that this recommendation, addressed to the Ministry of Housing, Communities and Local Government regarding local authority reviews of third-party contracts, remained under consideration (Department of Health and Social Care response, Dec 2025). The record holds no update since the department's response of December 2025 (Department of Health and Social Care response, Dec 2025).

There must be a contractual requirement to formally notify the contract manager and senior local authority officers of any incidents involving the deceased, as well as the outcome of inspections or other action by the Human Tissue Authority or others with an oversight role, such as the Health and Safety Executive.

Relaying progress in December 2025 on recommendations addressed to the Ministry of Housing, Communities and Local Government, the Department of Health and Social Care stated that this recommendation remained "under consideration" (Department of Health and Social Care response, Dec 2025). The department noted in December 2025 that the proposal was among 21 recommendations that remain under consideration (Department of Health and Social Care response, Dec 2025). The record holds no update since the department's response of December 2025 (Department of Health and Social Care response, Dec 2025).

Local authorities must ensure that the providers they contract or enter into agreements with have robust governance processes in place to oversee the services they provide. This should include Standard Operating Procedures that protect the security and dignity of the deceased and audits to ensure staff compliance with them, as well as the reporting of incidents.

In an interim update on government progress published in December 2025, the Department of Health and Social Care stated that this recommendation addressed to the Ministry of Housing, Communities and Local Government remained "under consideration" alongside twenty other recommendations (Department of Health and Social Care response, Dec 2025). The record holds no update since the department's response of December 2025 (Department of Health and Social Care response, Dec 2025).

The regulatory measures recommended in Chapter 11 should apply to care homes in England. Regulation should cover both systems and professionals where staff are providing care to deceased people in care homes.

The Department of Health and Social Care reported in June 2026 that "this recommendation is under consideration" in a dashboard update published by the Cabinet Office (Department of Health and Social Care, Jun 2026). This reiterated the position taken in its interim update of December 2025, when the department noted that the proposal was among 21 recommendations from the inquiry that remained under consideration (Department of Health and Social Care response, Dec 2025).

The UK government should establish an independent statutory regulatory regime for funeral directors in England as a matter of urgency in order to safeguard the security and dignity of the deceased. This regime should include a licensing scheme, mandatory standards against which funeral directors should be inspected regularly, and enforcement powers.

In September 2026, the Secretary of State for Health and Social Care, Yvette Cooper, stated that the Department of Health and Social Care is leading cross-government work to draw up detailed proposals to drive up standards, "including proper regulation of the funeral sector" (Yvette Cooper, Sep 2026). This followed a July 2026 statement by Parliamentary Under-Secretary of State Preet Kaur Gill that the government would update the House as soon as practicably possible on how it intends to take the recommendations forward (Preet Kaur Gill, Jul 2026). The department previously reported in June 2026 that the recommendation remained under consideration, having earlier indicated in October 2025 that a final response would be published by summer 2026 (Dr Zubir Ahmed, Oct 2025; Department of Health and Social Care, Jun 2026).

These regulations and standards should be considered within the overall care and journey of the deceased rather than applying in isolation to funeral directors.

In September 2026, Secretary of State for Health and Social Care Yvette Cooper stated that the government will "bring forward comprehensive proposals to ensure respect and dignity for the deceased in every setting" (Yvette Cooper, Sep 2026). In July 2026, Parliamentary Under-Secretary of State Preet Kaur Gill stated that the Department of Health and Social Care will update the House of Commons as soon as practicably possible on how it intends to take the recommendations forward (Preet Kaur Gill, Jul 2026). The department had previously recorded in a June 2026 dashboard update that the recommendation remained under consideration (Department of Health and Social Care, Jun 2026).

The standards should include details of mandatory information to be given to customers by funeral directors to provide transparency about the care of the deceased, including information on measures to protect their security and dignity, and what should be expected of funeral directors' services.

In September 2026, the Secretary of State for Health and Social Care, Yvette Cooper, stated that the government will "bring forward comprehensive proposals" to ensure respect and dignity for the deceased and address rogue operators in the funeral industry (Yvette Cooper, Sep 2026). Earlier, in July 2026, Parliamentary Under-Secretary of State Preet Kaur Gill informed the House of Commons that the department would update Parliament as soon as practicably possible on taking forward recommendations for the sector (Preet Kaur Gill, Jul 2026). In a June 2026 dashboard update, the department had recorded that this recommendation remained under consideration (Department of Health and Social Care, Jun 2026).

Direct cremation businesses should also be considered in this context, and mandatory standards to protect the security and dignity of the deceased should be applied to these businesses and to any emerging new models of delivery of care for the deceased.

The Secretary of State for Health and Social Care, Yvette Cooper, announced in September 2026 that the government would "bring forward comprehensive proposals to ensure respect and dignity for the deceased in every setting" and address rogue funeral operators (Yvette Cooper, Sep 2026). In July 2026, Preet Kaur Gill, the Parliamentary Under-Secretary of State for Health Innovation and Safety, stated that Ministers would update the House of Commons as soon as practicably possible on taking these recommendations forward (Preet Kaur Gill, Jul 2026). Previously, in a June 2026 dashboard update published by the Cabinet Office, the department recorded that the recommendation was under consideration (Department of Health and Social Care, Jun 2026).

While the introduction of a proportionate statutory regulation and inspection regime may require significant adjustment by funeral director organisations, it is the view of the Inquiry that the benefit to customers and the need for public confidence outweigh the difficulties that may be experienced by some businesses.

In September 2026, the Secretary of State for Health and Social Care, Yvette Cooper, announced in a written ministerial statement that the government will bring forward "comprehensive proposals to ensure respect and dignity for the deceased in every setting" and drive rogue operators out of the funeral industry (Yvette Cooper, Sep 2026). Earlier, in July 2026, Preet Kaur Gill, Parliamentary Under-Secretary of State for Health Innovation and Safety, stated that the department would update the House of Commons as soon as practicably possible on how it intends to take these recommendations forward (Preet Kaur Gill, Jul 2026). In a dashboard update published in June 2026, the department recorded that the recommendation remained under consideration (Department of Health and Social Care, Jun 2026).

The funeral sector in England should be considered in scope for the broader regulatory measures recommended in Chapter 11.

In September 2026, the Secretary of State for Health and Social Care, Yvette Cooper, stated that the government will "bring forward comprehensive proposals" to regulate the funeral industry and ensure dignity for the deceased (Yvette Cooper, Sep 2026). In July 2026, Parliamentary Under-Secretary of State Preet Kaur Gill stated that the department would update the House as soon as practicably possible on how it intends to take these recommendations forward (Preet Kaur Gill, Jul 2026). In its June 2026 dashboard update, the department recorded that this recommendation remained under consideration (Department of Health and Social Care, Jun 2026).

All faith organisations should consider how to support their members to deliver high standards of care for the deceased, with a focus on the security and dignity of the deceased – for example, by sharing guidance.

In June 2026, the Department of Health and Social Care stated that this recommendation was "under consideration" in a progress update published on the Cabinet Office dashboard (Department of Health and Social Care, Jun 2026). The department had previously reported the same status in December 2025, when its interim response to the inquiry's phase 2 report listed the proposal among 21 recommendations that remained under consideration (Department of Health and Social Care response, Dec 2025).

Where deceased people are in a religious building overnight, measures should be taken to ensure that the building is secure, including, for example, CCTV and secure access control for the area in which they are kept.

In its May 2026 dashboard update, published by the Cabinet Office in June 2026, the Department of Health and Social Care recorded that this recommendation remains "under consideration" (Department of Health and Social Care, Jun 2026). This reiterated the position the department took in its December 2025 interim progress update, where it confirmed that this proposal was among 21 recommendations that remained under consideration (Department of Health and Social Care response, Dec 2025).

Where organisations work together to care for people after death, the arrangements should be formalised through contracts or service level agreements. This should include joint Standard Operating Procedures. The parties to the contracts or service level agreements should ensure that the contracts or agreements are managed effectively, and that they seek assurance that the arrangements protect the security and dignity of people after death.

In June 2026, the Department of Health and Social Care reported in a Cabinet Office dashboard update that "This recommendation is under consideration" (Department of Health and Social Care, Jun 2026). In that same June 2026 update, the department recorded no specific delivery position, stating that it was not providing an update for that quarter (Department of Health and Social Care, Jun 2026). In December 2025, it had similarly stated in an interim progress report that the recommendation remained under consideration, publishing no individual text for it (Department of Health and Social Care response, Dec 2025).

The Chief Coroner should review the difference in practice between coronial areas as soon as possible to ensure that: All coroners are informed of the findings of this Inquiry. All coroners are aware of the prevalence of offending by David Fuller against deceased people who were formally under the control of the coroner. All coroners understand the importance of a consistent approach to ensuring the security and dignity of deceased people who are under their control. This is likely to require guidance from the Chief Coroner to ensure that there is a consistent approach nationally, and it should be considered an area for further training for all coroners and their staff.

In its interim progress update published in December 2025, the Department of Health and Social Care stated that this recommendation addressed to the Ministry of Justice remained under consideration (Department of Health and Social Care response, Dec 2025). The department grouped the measure among 21 recommendations from the phase 2 report that were still being considered by the government, offering no specific commentary on this recommendation alone (Department of Health and Social Care response, Dec 2025). The record holds no update since the department's response of December 2025 (Department of Health and Social Care response, Dec 2025).

The UK government should establish an independent statutory regulatory regime, headed by a Chief Inspector, for those who store and care for deceased people. The purpose of the regulatory regime should be to ensure that the security and dignity of deceased people are protected, in whichever institutions or locations they are cared for, examined or stored. The government should ensure that this role is adequately resourced to discharge its responsibilities and should provide it with powers to require information and enter premises and to take appropriate enforcement action (including against office holders in any organisation). Either the Human Tissue Authority should be required to work under the auspices of this new regime, or its remit should be formally expanded to comply with the statutory regime's requirements.

In June 2026, the Department of Health and Social Care recorded in a government dashboard that this recommendation remained "under consideration" (Department of Health and Social Care, Jun 2026). It had previously confirmed in its December 2025 interim update that the recommendation was still under consideration (Department of Health and Social Care response, Dec 2025). Earlier, in October 2025, Dr Zubir Ahmed, Parliamentary Under-Secretary of State at the department, stated in a written answer that the department would publish a final response by summer 2026 (Dr Zubir Ahmed, Oct 2025).

In the interim, the government should immediately appoint a Commissioner for the Dignity of the Deceased who should immediately issue universal guidance that applies to all those who store and care for deceased people. This guidance should set out expectations for the security and dignity of deceased people.

In June 2026, the Department of Health and Social Care recorded that "This recommendation is under consideration" in a dashboard update published by the Cabinet Office (Department of Health and Social Care, Jun 2026). The department had previously reported in December 2025 that the recommendation remained under consideration, including it without individual commentary among twenty-one recommendations from the inquiry that were still being evaluated (Department of Health and Social Care response, Dec 2025).

The government should amend the Human Tissue Act 2004 so that the organisation holding the licence has primary legal responsibility to ensure that: There is a suitable Designated Individual in place at their establishment. Suitable premises are provided and maintained. Suitable individuals are employed. All relevant legal and regulatory duties pertaining to the licence are met.

The Department of Health and Social Care stated in June 2026 that "This recommendation is under consideration" in progress entries published on the Cabinet Office recommendations dashboard (Department of Health and Social Care, Jun 2026). This maintained the position set out in the department's interim update on government progress in December 2025, which listed this recommendation among 21 phase 2 recommendations that remained under consideration (Department of Health and Social Care response, Dec 2025).

The Human Tissue Authority, and/or the new inspectorate, should require the organisations it licenses to ensure that any individual who provides care to deceased people is suitably qualified, experienced and supervised. The regulatory regime should set minimum standards on the qualifications likely to be considered sufficient to demonstrate 'suitability' for particular roles or levels of responsibility. Failure to ensure that suitable individuals are employed would be subject to regulatory enforcement.

Relaying progress on the recommendation addressed to the Human Tissue Authority, the Department of Health and Social Care stated in December 2025 that the proposal remained under consideration (Department of Health and Social Care response, Dec 2025). In its interim update, the department recorded that this was among 21 recommendations that "remain under consideration", giving no separate detail on the licensing requirements (Department of Health and Social Care response, Dec 2025). The record holds no update since the department's response of December 2025 (Department of Health and Social Care response, Dec 2025).