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).

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).