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

43 shown (filtered)

Code	Recommendation	Addressed to	Response
P2-1	NHS trusts commission specialist security review All NHS trusts with mortuaries and/or body stores should commission a specialist strategic review of the systems in place to protect deceased …	NHS England	Accepted in Part	View →
P2-2	CCTV in all NHS mortuaries All NHS trusts should install CCTV inside the mortuary, with cameras facing all doors and access points, the reception area and the …	NHS England	Accepted in Part	View →
P2-3	Audit access data for deceased storage All NHS trusts should routinely audit the access data of all facilities used to store deceased people.	NHS England	Accepted in Part	View →
P2-4	End shared swipe cards The practice of using shared electronic swipe cards for specific staff groups should cease immediately.	NHS England	Accepted in Part	View →
P2-5	Operational barriers including device restrictions All NHS trusts should consider putting in place systemic operational barriers that prevent the security and dignity of deceased people being compromised. …	NHS England	Accepted in Part	View →
P2-6	Security breaches reviewed by expert with action plans All NHS trusts should take every breach of security in a mortuary or body store extremely seriously. Each security incident should be …	NHS England	Accepted in Part	View →
P2-7	Body store security standards match HTA-licensed facilities The NHS should ensure that the security standards required for body stores are the same as those required for facilities licensed by …	NHS England	Accepted in Part	View →
P2-8	Swipe to exit for mortuaries All NHS trusts should consider the installation of 'swipe to exit' for mortuary facilities. This would allow trusts to monitor and audit …	NHS England	Accepted in Part	View →
P2-9	Monitor and review staff access numbers All NHS trusts should monitor the number of staff with access to the mortuary or body store and keep this under routine …	NHS England	Accepted in Part	View →
P2-10	Designated Individuals adequate time and resource NHS trusts should ensure that Designated Individuals have enough time and resource to fulfil their responsibilities, including time for learning and development.	NHS England	Accepted in Part	View →
P2-11	Senior managers understand DI role and accountability NHS trusts should ensure that senior managers, including the Chief Executive, have a clear understanding of the role of the Designated Individual, …	NHS England	Accepted in Part	View →
P2-12	DI attendance at governance forums NHS trusts should ensure that Designated Individuals attend the correct governance forums. This would allow them to escalate issues and risks, as …	NHS England	Accepted in Part	View →
P2-13	Mortuary Manager professional background prerequisite A professional background in the field of mortuary services should be made a prerequisite for the post of Mortuary Manager.	NHS England	Accepted in Part	View →
P2-14	Mortuary Manager adequate resources and support NHS trusts should assure themselves that the Mortuary Manager has adequate resources and support to perform their role effectively, including meeting any …	NHS England	Accepted in Part	View →
P2-15	Routine mortuary reporting to trust boards All NHS trusts should establish a routine reporting system for matters relating to mortuaries and body stores. This reporting system should include …	NHS England	Accepted in Part	View →
P2-16	Trust boards assure recommendation implementation Trust boards should assure themselves that the recommendations in this Report have been implemented.	NHS England	Accepted in Part	View →
P2-17	Recommendations apply to temporary facilities Trust boards should ensure that these recommendations and governance arrangements are applied to any temporary facilities used by trusts for the storage …	NHS England	Accepted in Part	View →
P2-18	Mortuaries treated as regulated activity in governance Trust boards should take note of the fact that mortuary services are subject to statutory regulation and should be treated with equivalent …	NHS England	Accepted in Part	View →
P2-19	Deceased included in safeguarding training and policy NHS trust boards should ensure that the security and dignity of deceased people are included in safeguarding training, policies and assurance.	NHS England	Accepted in Part	View →
P2-20	Chief Nurse responsibility for deceased safeguarding The remit of the Chief Nurse in NHS trusts should explicitly include executive responsibility for safeguarding the security and dignity of deceased …	NHS England	Accepted in Part	View →
P2-21	NHS England incorporate deceased in safeguarding framework NHS England should formally incorporate the safeguarding of deceased people into its safeguarding framework for NHS trusts.	NHS England	Accepted in Part	View →
P2-35	Local authority mortuary access review There should be a process to routinely review who is permitted to access the mortuary unsupervised.	Ministry of Housing, Communities and …	Accepted in Part	View →
P2-36	Local authority individualised access controls Where unsupervised access is permitted for a legitimate and unavoidable purpose, there should be individualised electronic access controls to enter the mortuary …	Ministry of Housing, Communities and …	Accepted in Part	View →
P2-37	Local authority visitor supervision Where people other than mortuary staff are visiting the mortuary during working hours, for example contractors, cleaners and other visitors: Access must …	Ministry of Housing, Communities and …	Accepted in Part	View →
P2-38	Local authority lone working review Where mortuary staff are permitted to work alone in the mortuary, there should be a review of lone working policies, including consideration …	Ministry of Housing, Communities and …	Accepted in Part	View →
P2-39	Local authority security audits Routine and regular audits of security must be conducted, encompassing both access to and exit from the mortuary and movement within it, …	Ministry of Housing, Communities and …	Accepted in Part	View →
P2-40	Local authority strategic security review Immediate steps must be taken to commission a specialist strategic review of the systems in place to protect the deceased, which should …	Ministry of Housing, Communities and …	Accepted in Part	View →
P2-41	No reliance on keys/keypads alone There must be no reliance on keys and keypad codes alone to secure access to the mortuary.	Ministry of Housing, Communities and …	Accepted in Part	View →
P2-42	Lock fridges and freezers at all times Fridges and freezers containing deceased people must be locked at all times, with appropriate key security in place.	Ministry of Housing, Communities and …	Accepted in Part	View →
P2-43	Local authority CCTV installation CCTV must be installed inside the mortuary facing all doors and access points, the reception area and the doors of all fridges …	Ministry of Housing, Communities and …	Accepted in Part	View →
P2-44	Local authority incident response SOPs Arrangements for responding to incidents of unauthorised access must be reviewed and incorporated into Standard Operating Procedures.	Ministry of Housing, Communities and …	Accepted in Part	View →
P2-45	Local authority single security SOP All policies and procedures in relation to the security of the mortuary must be accurately and comprehensively reflected in a single security …	Ministry of Housing, Communities and …	Accepted in Part	View →
P2-46	Local authority funding for security expedited There must be a process to ensure that, where there is a requirement for funding to strengthen mortuary security, it is expedited …	Ministry of Housing, Communities and …	Accepted in Part	View →
P2-47	Local authority security breach investigation There must be an investigation into the root cause of each security breach. Each incident, the investigation and action plan must be …	Ministry of Housing, Communities and …	Accepted in Part	View →
P2-48	Local authority annual SOP and HTA audits There must be audits of the mortuary Standard Operating Procedures and compliance with Human Tissue Authority requirements, undertaken annually as a minimum, …	Ministry of Housing, Communities and …	Accepted in Part	View →
P2-49	Local authority DI management and oversight review There must be a review of the management and oversight arrangements for the mortuary service, taking into consideration who is appointed as …	Ministry of Housing, Communities and …	Accepted in Part	View →
P2-50	Local authority mortuary as regulated service The mortuary service must be treated in the same way as other regulatory services within local authority reporting structures: The mortuary must …	Ministry of Housing, Communities and …	Accepted in Part	View →
P2-51	Local authority biennial audits and peer review The mortuary service must be reviewed by professional auditors at least biennially, with the results of the audit reported to a formal …	Ministry of Housing, Communities and …	Accepted in Part	View →
P2-52	Share mortuary reports with coroner service All relevant reports and incidents concerning the mortuary must be made known to the lead local authority manager for the coroner service …	Ministry of Housing, Communities and …	Accepted in Part	View →
P2-53	Local authority report implementation to committee The implementation of these recommendations must be reported to the relevant statutory committee.	Ministry of Housing, Communities and …	Accepted in Part	View →
P2-54	Local authority contingent body storage plans Local authorities providing a coroner service must review plans for the provision and operation of contingent body storage, in collaboration with local …	Ministry of Housing, Communities and …	Accepted in Part	View →
P2-55	Unlicensed body stores prepared for HTA compliance Local authorities providing an unlicensed body store must be prepared to comply with the Human Tissue Authority's standards and guidance where applicable, …	Ministry of Housing, Communities and …	Accepted in Part	View →
P2-56	Unlicensed body stores follow same standards Where local authorities provide an unlicensed body store, they should do so in line with this Report's recommendations to local authority providers …	Ministry of Housing, Communities and …	Accepted in Part	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 →