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

28 shown (filtered)

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 →
P2-22	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 →
P2-26	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 →
P2-30	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 →
P2-75	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 →