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

21 shown (filtered)

Code	Recommendation	Addressed to	Response
P2-24	Anatomical education security and dignity policies All organisations providing anatomical education and training using donors should make sure that policies and procedures are in place to ensure the …	Department of Health and Social Care	Under Consideration	View →
P2-25	Postgraduate training governance clarity Postgraduate training providers using donors should ensure clarity in their governance and information-sharing, in particular where the providers are linked to both …	Department of Health and Social Care	Under Consideration	View →
P2-29	Hospices in scope for new regulatory regime Hospices should be considered in scope for the regulatory measures recommended in Chapter 11.	Department of Health and Social Care	Under Consideration	View →
P2-57	Local authority review third-party contracts Local authorities must review all contractual arrangements and agreements with third-party providers of services that care for and transport the deceased. This …	Ministry of Housing, Communities and …	Under Consideration	View →
P2-58	Contractual incident notification requirement There must be a contractual requirement to formally notify the contract manager and senior local authority officers of any incidents involving the …	Ministry of Housing, Communities and …	Under Consideration	View →
P2-59	Local authority contractor governance assurance Local authorities must ensure that the providers they contract or enter into agreements with have robust governance processes in place to oversee …	Ministry of Housing, Communities and …	Under Consideration	View →
P2-60	Care homes in scope for new regulatory regime The regulatory measures recommended in Chapter 11 should apply to care homes in England. Regulation should cover both systems and professionals where …	Department of Health and Social Care	Under Consideration	View →
P2-61	Statutory regulation of funeral directors The UK government should establish an independent statutory regulatory regime for funeral directors in England as a matter of urgency in order …	Department of Health and Social Care	Under Consideration	View →
P2-62	Regulations consider whole deceased journey These regulations and standards should be considered within the overall care and journey of the deceased rather than applying in isolation to …	Department of Health and Social Care	Under Consideration	View →
P2-63	Mandatory information from funeral directors The standards should include details of mandatory information to be given to customers by funeral directors to provide transparency about the care …	Department of Health and Social Care	Under Consideration	View →
P2-64	Direct cremation in scope for standards Direct cremation businesses should also be considered in this context, and mandatory standards to protect the security and dignity of the deceased …	Department of Health and Social Care	Under Consideration	View →
P2-65	Funeral director regulation benefits outweigh difficulties While the introduction of a proportionate statutory regulation and inspection regime may require significant adjustment by funeral director organisations, it is the …	Department of Health and Social Care	Under Consideration	View →
P2-66	Funeral sector in scope for new regulatory regime The funeral sector in England should be considered in scope for the broader regulatory measures recommended in Chapter 11.	Department of Health and Social Care	Under Consideration	View →
P2-67	Faith organisations share guidance on deceased care All faith organisations should consider how to support their members to deliver high standards of care for the deceased, with a focus …	Department of Health and Social Care	Under Consideration	View →
P2-68	Religious building security for deceased Where deceased people are in a religious building overnight, measures should be taken to ensure that the building is secure, including, for …	Department of Health and Social Care	Under Consideration	View →
P2-69	Formalise multi-organisation arrangements Where organisations work together to care for people after death, the arrangements should be formalised through contracts or service level agreements. This …	Department of Health and Social Care	Under Consideration	View →
P2-70	Chief Coroner review practice consistency The Chief Coroner should review the difference in practice between coronial areas as soon as possible to ensure that: All coroners are …	Ministry of Justice	Under Consideration	View →
P2-71	New Chief Inspector regulatory regime for deceased The UK government should establish an independent statutory regulatory regime, headed by a Chief Inspector, for those who store and care for …	Department of Health and Social Care	Under Consideration	View →
P2-72	Interim Commissioner for Dignity of Deceased In the interim, the government should immediately appoint a Commissioner for the Dignity of the Deceased who should immediately issue universal guidance …	Department of Health and Social Care	Under Consideration	View →
P2-73	Amend HT Act for organisational responsibility The government should amend the Human Tissue Act 2004 so that the organisation holding the licence has primary legal responsibility to ensure …	Department of Health and Social Care	Under Consideration	View →
P2-74	HTA require suitable qualified staff with enforcement The Human Tissue Authority, and/or the new inspectorate, should require the organisations it licenses to ensure that any individual who provides care …	Human Tissue Authority	Under Consideration	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 →