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

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

19 mentions since Feb 2022

5 questions 14 statements

10 Apr 2026 Written Question Independent Inquiry into the Issues Raised by the David Fuller Case
Mike Wood (Conservative)

23 Feb 2026 Written Question Human Tissue Authority
Dame Caroline Dinenage (Conservative)

03 Feb 2026 Written Question Independent Inquiry into the Issues Raised by the David Fuller Case
Dame Caroline Dinenage (Conservative)

12 Jan 2026 Written Question Human Remains: Inquiries
Preet Kaur Gill (Labour)

16 Dec 2025 Written Ministerial Statement Government Interim Update on Progress in responding to the Fuller Inquiry Phase …
Dr Zubir Ahmed (Labour)

View all 19 mentions →