Independent Inquiry into the issues raised by the David Fuller case
Completed
· Chair: Sir Jonathan Michael
· Established November 2021
· Commissioned by Department of Health and Social Care
Inquiry into mortuary abuse by David Fuller at NHS hospitals.
More about this inquiry
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.
Noted · No statement from Kent County Council found
Recommended
Kent County Council and East Sussex County Council should examine their contractual arrangements with Maidstone and Tunbridge Wells NHS Trust to ensure that they are effective in protecting the safety and dignity of the deceased.
Since then (summary written by this site)
In October 2024, Wes Streeting, Secretary of State for Health and Social Care, reported that Kent County Council and East Sussex County Council had reviewed contractual arrangements with Maidstone and Tunbridge Wells NHS Trust and confirmed that the contracts require licensing and regulatory standards to be met to ensure the deceased are treated with dignity and respect (Wes Streeting response, Oct 2024). Earlier, in February 2024, the Trust stated that contract discussions were underway to ensure arrangements protect the deceased, including a requirement to share inspection reports from the Human Tissue Authority (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).
Sir Jonathan Michael appointed Chair of the independent inquiry
Same statement as the announcement. Verbatim: "I have appointed Sir Jonathan Michael to chair this inquiry." Sir Jonathan had already been chairing the preceding Trust-commissioned investigation before it was converted into this independent inquiry.
Independent inquiry into the David Fuller case announced
Commons statement by Sajid Javid MP, Secretary of State for Health and Social Care, replacing the Trust-commissioned investigation with an independent inquiry. Repeated as a Lords statement the following day, 9 Nov 2021.
Covers events at Maidstone and Tunbridge Wells NHS Trust. 17 recommendations (16 for the Trust, 1 for Kent County Council/East Sussex County Council), per Wes Streeting's 15 Oct 2024 statement. Referred to in the Terms of Reference as the "initial report".
Phase 2 interim report published (HC 260, funeral sector module)
gov.uk publication page states "Published: 15 October 2024", matching the same-day Hansard statement HCWS132. The Chair expedited this module ahead of the rest of Phase 2 following reports of neglect at a funeral home in Hull.
Government response to Phase 1 report recommendations (Wes Streeting statement, HCWS132)
Confirms the Trust published an assurance statement on implementation of the Phase 1 recommendations in February 2024; announced the same-day publication of the Phase 2 interim report.
75 recommendations in total (19 for NHS trusts, 25 for local authorities, 31 for other settings). Same-day Hansard statement by Wes Streeting, HCWS824. Referred to in the Terms of Reference as the "final report".
Government interim update on progress responding to Phase 2 recommendations
Statement by Dr Zubir Ahmed, HCWS1173: "solid progress has been made on fifty-four of the Inquiry recommendations", eleven "accepted in full and work is already in progress to implement these recommendations (22, 23, 26, 27, 28, 30,31, 32, 33, 34 & 75)", forty-three relating to NHS and local authority mortuaries requiring further work, and "a further twenty-one recommendations still under consideration". The companion gov.uk policy paper published the same day groups the 75 as "has accepted the recommendation in full (11)", "has accepted the recommendation in principle (43)" and "is still considering the recommendation (21)": that is the source of the widely quoted "accepted in principle" wording (https://www.gov.uk/government/publications/fuller-inquiry-government-interim-update-on-phase-2-recommendations). The statement promised a full response in Summer 2026; see the 15 July 2026 milestone, which defers it again.
Government update on progress responding to Phase 2 recommendations (HCWS261)
Statement by Preet Kaur Gill, Parliamentary Under-Secretary of State for Health Innovation and Safety; made in the Lords the same day by Baroness Merron as HLWS268. Marks one year since the Phase 2 report. NO numeric breakdown is given: it states only that "Government has accepted in full the majority of Sir Jonathan Michael recommendations", with "a further group of recommendations where the Government agrees with the intent and direction of travel, but where further consideration is needed". The 11/43/21 split is from the December 2025 interim update, not from this statement. This is NOT the promised full response: the Government "remains committed to providing a full response to Sir Jonathan Michael's report once the leadership period for Prime Minister has concluded". New commitments cited: NHS England has issued a national system letter (PRN02500, 26 June 2026) requiring a Board Assurance Statement from every trust with a mortuary by 31 July 2026 (https://www.england.nhs.uk/long-read/nottingham-maternity-review-findings-on-post-death-care-and-key-actions-required-following-the-fuller-inquiry/); and the Human Tissue Authority has instructed all mortuaries to review 10 years of internal records, reporting to Ministers by 16 October 2026. Links the work to the Independent Review of Maternity Services at Nottingham University Hospitals NHS Trust.
Written QuestionHouse of CommonsLizzi Collinge · Labour
Asked: To ask the Secretary of State for Health and Social Care, when the Government intends to provide a full response to the Fuller Inquiry's recommendations.
Written Ministerial StatementHouse of LordsBaroness Merron · Labour
Statement: My Right Honourable Friend the Secretary of State for Health and Social Care (Yvette Cooper MP) has made the following statement:I wish to update the House on the Government’s proposals for formal regulation of the funeral sector, announced this summer following the sentencing of criminal …
Written Ministerial StatementHouse of CommonsYvette Cooper · Labour
Statement: I wish to update the House on the Government’s proposals for formal regulation of the funeral sector, announced this summer following the sentencing of criminal funeral director Robert Bush. These proposals will seek to crack down on rogue operators in the funeral sector and ensure …
Written QuestionHouse of CommonsNadia Whittome · Labour
Asked: To ask the Secretary of State for Health and Social Care, (a) what steps she is taking to implement the recommendations of the Fuller Inquiry, particularly in relation to a statutory regulatory scheme for funeral directors; and (b) what consideration has been given to the …
Answered by Department of Health and Social Care: I refer the Hon Member to the Written Ministerial Statement made by my Rt Hon. Friend, the Secretary of State for Health and Social Care, on 1 September, available at the following link: https://questions-statements.parliament.uk/written-statements/detail/2026-09-01/hcws295 We will provide further updates in due course, including on progress in implementing the recommendations in the Fuller Inquiry Phase 2 report.
Written QuestionHouse of CommonsDame Caroline Dinenage · Conservative
Asked: To ask the Secretary of State for Health and Social Care, pursuant to the Fuller Inquiry Phase 2 Report: Government Interim Update on Progress, when he plans to respond to recommendations 29, 60, 61, 62, 63, 64, 65, 66, 69, 71 and 72.
Answered by Department of Health and Social Care: I refer the Hon Member to the Written Ministerial Statement made by my Rt Hon. Friend, the Secretary of State for Health and Social Care, on 1 September, available at the following link: https://questions-statements.parliament.uk/written-statements/detail/2026-09-01/hcws295 We will provide further updates in due course, including on progress in implementing the recommendations in the Fuller Inquiry Phase 2 report.
Written Ministerial StatementHouse of LordsBaroness Merron · Labour
Statement: My Honourable Friend the Parliamentary Under-Secretary of State (Preet Kaur Gill MP) has made the following statement:I am today updating the House on the Government’s progress in responding to the recommendations of the independent inquiry into the serious issues arising from the appalling actions of …
Written Ministerial StatementHouse of CommonsPreet Kaur Gill · Labour
Statement: I am today updating the House on the Government’s progress in responding to the recommendations of the independent inquiry into the serious issues arising from the appalling actions of David Fuller. The Inquiry’s final report, published on 15 July 2025, made seventy-five recommendations to strengthen …
Written QuestionHouse of CommonsAyoub Khan · Independent
Asked: To ask the Secretary of State for Housing, Communities and Local Government, what information his Department collects annually from Local Authorities on the provision of cremation and burial services; and if he will publish that data.
Answered by Ministry of Housing, Communities and Local Government: The Government does not collect this information and has therefore not done any assessments. The Department of Health and Social Care is leading the cross-government response to the Fuller Inquiry and will publish a full response to the Inquiry’s recommendations, including consideration of the funeral sector, by summer 2026.