Parliamentary activity

Answering body: Department of Health and Social Care

Today the report of the independent inquiry into the issues raised by the David Fuller case has been published. Sir Jonathan Michael has updated the victims’ families earlier today.

This report follows two years of work by the independent inquiry, led by Sir Jonathan, investigating David Fuller’s shocking and depraved actions in the mortuaries of Maidstone and Tunbridge Wells NHS Trust.

I am very grateful to all those who provided evidence to the independent inquiry, especially the families who found the courage to share their experience of what happened to their loved ones.

The report makes for harrowing reading. It sheds a light on the circumstances surrounding David Fuller’s abuse which regrettably meant that his crimes went undetected for a long period of time.

I want to profoundly apologise on behalf of the Government and the NHS and commit that lessons will be learnt. We fully welcome the report, and will ensure that there is a full response to the recommendations in Spring 2024, and that lessons are learned across the wider NHS so that no family has to go through this experience again.

A lot of work has already been done to review mortuary safety since these crimes were first revealed. NHS England required all NHS Trusts with either a mortuary or body store to review practices and ensure they are compliant with the requirements set out in the Human Tissue Authority’s standards and guidance. NHS Trusts were asked to take action to ensure all access points to mortuaries or body stores are controlled by swipe card security access, ensure there is effective CCTV coverage monitoring access to and from mortuary areas, undertake risk assessments of mortuary security and ensure consistent application of appropriate levels of DBS checks for all Trust and contracted employees.

However, we should not be complacent. It is important that the whole system remains alert and accountable at all levels and that any concerns are swiftly identified and escalated through the appropriate governance processes.

The report will be published on gov.uk and is available in the Vote Office (HC 310).

Answering body: Department of Health and Social Care

I wish to inform the House of the Government’s full response to the report of the independent review into the maternity and neonatal services at East Kent University NHS Foundation Trust, which will be published today on GOV.UK.

NHS England commissioned Dr Bill Kirkup CBE in February 2022 to undertake this review following concerns about the quality and outcomes of care. This inquiry was published in October 2022 with five recommendations for the healthcare system.

I want to once again express my thanks for the role the families have played in this review. I remain deeply sorry for the harm and pain that has been a result of the failings of the Trust to provide safe care and treatment.

The Government informed the House of its interim response on 7 March 2023 and the fuller response published today sets out in detail how each recommendation is being implemented. This response has been informed by extensive engagement with stakeholders from across the healthcare system and voluntary sector as well as by the insight and views from those families I met with in June, for which I am grateful.

Whilst the issues set out by Dr Kirkup were a result of an investigation into one Trust, many will resonate across the wider system. That is why our response sets out the existing work that is already underway to drive forward system wide improvements, such as the implementation of the Three Year Delivery Plan that was published in March 2023 by NHS England. This Plan is clear on how maternity and neonatal care will be made safer, more personalised, and more equitable for women, babies, and families. It will be an important supporting role in the implementation of the East Kent recommendations, and we recognise there is more that we can do.

Today, I want to draw the attention of the House to the key new action we are taking that will create the conditions needed for the improvements to be successful and sustainable.

I will chair the new National Oversight Group to bring together the key people from the NHS and other organisations to look across maternity and neonatal improvement programmes and the implementation of recommendations from this and other maternity reviews. At a local level in East Kent, I will convene a local forum bringing together the NHS, Care Quality Commission (CQC) and Members of Parliament whose constituents have been affected to share information and updates. I am also pleased to announce that Dr Bill Kirkup has been appointed to support Government action in relation to recommendations 2 and 3.

It is with a firm determination that we must learn the lessons from this inquiry, as well as those before it, to implement meaningful change to prevent further inquiries into failings in maternity and neonatal services across England being needed.

Answering body: Department of Health and Social Care

On 8 November 2021, the Government announced an independent inquiry to examine the circumstances surrounding the offences committed by David Fuller in Maidstone and Tunbridge Wells NHS Trust and the national implications of his offending.

Following my statement on 1 December 2022, when I announced the establishment of the compensation scheme to facilitate compensation payments to the family members of David Fuller’s victims, I also updated Parliament on the timescales of the inquiry. I advised that the report on matters relating to Maidstone and Tunbridge Wells NHS Trust was planned for the first half of 2023.

I now wish to update Parliament that earlier this year, the inquiry was provided with information that had been passed on to the Police in line with its terms of reference.

The Police have now completed their enquiries regarding the new information provided to them and have found no evidence of any further criminal offences.

The inquiry will now need to investigate the information received by the Police and expects that a report before the autumn will not be possible.

This delay is necessary to allow time for a thorough investigation of the information received and consideration of its impact on the inquiry.

The inquiry has notified families of David Fuller’s victims of the results of the assessment by the Police and the change in timescales. I will continue to keep Parliament updated with any substantial developments.

Answering body: Department of Health and Social Care

Following my statement on 16 December 2021, I am pleased to inform the House that a compensation scheme to facilitate compensation payments to the family members of David Fuller’s victims has been established today.

The scheme, which will be administered by NHS Resolution on behalf of Maidstone and Tunbridge Wells NHS Trust, will ensure that compensation is paid to relatives as soon as practicable. The scheme will operate on a tiered approach. All qualifying family members will receive a fixed amount of compensation. Increased payments will then be made for psychiatric trauma and/or financial loss, subject to evidence. Entry into the scheme is entirely voluntary and the scheme will be advertised nationally to help ensure all eligible family members are aware of it.

The scheme represents a highly co-operative effort between NHS Resolution, Maidstone and Tunbridge Wells NHS Trust and the families’ representatives and I would like to thank all those involved for their work in developing this compensation scheme for families.

I would also like to take the opportunity to update the House on the timescales of the inquiry. The inquiry is progressing well and due to the significant amount of evidence being received, the report on matters relating to Maidstone and Tunbridge Wells NHS Trust is now planned for the first half of 2023.

Answering body: Department of Health and Social Care

Following earlier statements by Department of Health and Social Care Ministers, I would like to inform the House that the Independent Inquiry into the issues raised by the David Fuller case has today published a progress update on its work to date. This can be found at: https://fuller.independent-inquiry.uk/announcements/

The progress update sets out the transition from a local, independent investigation initiated by the Maidstone and Tunbridge Wells NHS Trust to the current Independent Inquiry that the Secretary of State for Health and Social Care announced in November of last year. It describes how the work already undertaken as part of the independent investigation is feeding into the inquiry; as well as the important common themes that emerged from families / other interested parties which gave rise to amendments to the inquiry’s Terms of Reference. The Independent Inquiry published its final Terms of Reference on 23 February 2022.

Although the local investigation was constrained from taking evidence while the criminal prosecution of David Fuller was underway, Sir Jonathan Michael does set out some urgent, high-level themes and areas of concern arising from the investigation at the time in his progress update:

Responsibilities between NHS Trusts and contractors / subcontractors.

Security and access.

Policies and procedures versus practice.

Oversight of regulated activities.

Management of areas and services not covered by regulation.

These themes had been shared with the Trust in August 2021 and subsequently with NHS England and NHS Improvement. The Trust has been putting its own steps in place regarding its mortuary practices ahead of the substantive, initial report of the Inquiry. NHS England and NHS Improvement has continued to work with Trusts to provide assurances against current guidance from the Human Tissue Authority (HTA), and on the additional measures that have been taken to improve the effectiveness of security in place for all their mortuaries and post-mortem activities.

The progress update makes clear that the first phase of the Independent Inquiry is firmly underway and describes the rapid progress that it has so far achieved. Also, from the inquiry’s engagement with witnesses so far, it has experienced a high degree of co-operation and expects this to continue. Both are testament to the hard work of Sir Jonathan and his team.

The progress update also sets out the next steps, including a revised timing for the initial report on matters relating to Maidstone and Tunbridge Wells NHS Trust. Due to the volume of evidence that is emerging, the initial report will now be available later this year. This will be followed by a final report next year, looking at the broader national picture and the wider lessons for the NHS and for other settings. Whilst there is real urgency in understanding how Fuller was able to carry out his shocking and unlawful actions, and why these went unnoticed, the Inquiry must be allowed the time it needs to fully consider all of the relevant evidence and assemble its findings. The Inquiry continues to liaise with Kent Police to ensure that if it identifies possible criminal conduct, this is referred swiftly for further investigation, in line with its Terms of Reference.

The HTA was asked by the Secretary of State to provide advice on its regulatory framework following the conclusion of the murder trial of David Fuller and the public revelation of his sexual offending against bodies in a hospital mortuary at Maidstone and Tunbridge Wells NHS Trust.

The HTA advice, received in December 2021, along with a short progress update, has been published today. Both can be found at https://www.hta.gov.uk/news/december-2021-advice-published

The HTA has focused on three areas since December 2021; preparation for the Inquiry, working with stakeholders on licensed mortuary security, and starting the revision of HTA guidance for licensed mortuaries in the post-mortem sector, with implementation planned later this year.

Further details will be available on GOV.UK via the following link which will ‘go live’ from noon today.

https://www.gov.uk/government/news/the-fuller-inquiry-update-to-the-secretary-of-state-19-may-2022

Answering body: Department of Health and Social Care

It is normal practice, when a government department proposes to undertake a contingent liability in excess of £300,000 for which there is no specific statutory authority, for the Minister concerned to present a Departmental Minute to Parliament giving particulars of the liability created and explaining the circumstances; and to refrain from incurring the liability until fourteen sitting days after the issue of the Minute, except in cases of special urgency.

I have today laid a Departmental Minute proposing to provide an indemnity that is required urgently in respect of a Department of Health and Social Care established non-statutory, independent inquiry into the circumstances surrounding the offences committed by David Fuller (‘DF’) at the Maidstone and Tunbridge Wells NHS Trust, and their national implications.

The Inquiry will be split into two phases:

an initial report, on matters relating to Maidstone and Tunbridge Wells NHS Trust, reporting by the middle of 2022, and

a final report, looking at the broader national picture and the wider lessons for the NHS and for other settings, reporting by the middle of 2023.

It will review DF’s unlawful actions, how he was able to carry these out, why his actions went apparently unnoticed, and will make recommendations with the aim of preventing anything similar happening again. We expect the Inquiry to publish a progress update as soon as possible after Easter recess.

In November 2021, the Secretary of State for Health and Social Care announced the Inquiry (Volume 703, 8 November 2021) to be chaired by Sir Jonathan Michael. The Department of Health and Social Care will indemnify the Inquiry insofar that the Chair or any other member of the Inquiry who has acted honestly and in good faith will not have to meet out of his or her personal resources any personal civil liability, including costs, which is incurred in the execution or the purported execution of his or her Inquiry functions, save where the Inquiry member has acted recklessly. This indemnity will cover the entire duration of the Inquiry’s work, from November 2021 until when the Inquiry submits its final report, expected in 2023, and for an unlimited period after that date. However, we believe there is a low risk of the indemnity being called upon beyond five years of the Inquiry having reported. There will be no cap placed upon the indemnity, so the maximum exposure is strictly unlimited. However, any losses are not expected to exceed a value of £3 million based upon the best estimate currently available at this stage of the Inquiry’s work. If the liability is called, provision for any payment will be sought through the normal Supply procedure.

The Treasury has approved the proposal in principle which mirrors the standard indemnity for board members described in Managing Public Money. If, during the period of fourteen Parliamentary sitting days beginning on the date on which this Minute was laid before Parliament, a member signifies an objection by giving notice of a Parliamentary Question or by otherwise raising the matter in Parliament, final approval to proceed with incurring the liability will be withheld pending an examination of the objection. The indemnity is expected to come into force on 26 April 2022, subject to the approval of Parliament on this basis.

Copies of the Departmental Minute have been laid in both Houses.

Answering body: Department of Health and Social Care

Following my statement on 16 December 2021 I wish to update the House about the independent Inquiry which is investigating the circumstances surrounding the offences committed by David Fuller at Maidstone and Tunbridge Wells NHS Trust. The Inquiry will help us understand how these offences took place without detection, identify any areas where swift action is necessary and consider wider national issues, including for the NHS.

Sir Jonathan Michael, who chairs the independent Inquiry, developed draft terms of reference in January 2022 which set out the scope of the Inquiry. He has since sought the views of affected families on the draft terms of reference.

The Inquiry has today, 23 February 2022 published its final Terms of Reference which can be found at https://fuller.independent-inquiry.uk/terms-of-reference/. I have placed a copy of the Inquiry’s Terms of Reference in the Libraries of both Houses.

Answering body: Department of Health and Social Care

Yesterday, David Fuller was sentenced at Maidstone Crown Court for the murders of Wendy Knell and Caroline Pierce, as well as over 100 sexual offences in a mortuary, and several other sexual offences.

This is a profoundly distressing case and I would like to reiterate my apologies to the friends and families of all of David Fuller’s victims. While nothing can undo the damage that has been done, he has been brought to justice for his crimes.

I would like to provide an update on the steps we are taking to ensure something like this never happens again.

Firstly, all NHS Trusts have undertaken risk assessments on their mortuary and body store facilities and assured their practices against existing Human Tissue Authority guidance. NHS England and Improvement is working with all trusts to ensure that the additional steps already requested are in place early in the New Year, if they have not already been delivered.

Secondly, we have made good progress in establishing the independent inquiry chaired by Sir Jonathan Michael to look into the circumstances surrounding the offences committed at the hospital. It will help us understand how these offences took place without detection, identify any areas where swift action is necessary and consider wider national issues, including for the NHS. Sir Jonathan has developed draft terms of reference and will seek views on these from families who have been affected in the new year before they are published.

Next, Ministers have received initial advice from the Human Tissue Authority and they will be reviewing this carefully.

Finally, families have quite understandably approached the Trust seeking compensation. I have asked NHS Resolution to work with the Trust and engage on plans for providing settlements. More details will be set out on this soon.