Parliamentary activity

Answering body: Ministry of Housing, Communities and Local Government

The Government offers its deepest sympathies to all those affected by the events referred to in these questions.

Local authorities are independent employers, responsible for the recruitment and management of Environmental Health Officers to fulfil their statutory obligations. Environmental Health Officers have no statutory role relating to funeral homes.

The Department has not made an assessment or collected data on regulatory gaps, environmental health standards, or the merits of inspection relating to funeral directors, but are working closely with the Department of Health and Social Care (DHSC) who are leading the government response to the Fuller Inquiry. An interim update on the Inquiry’s Phase 2 recommendations was published in December 2025, and DHSC has committed to publishing the Government’s full response in summer 2026. That response will set out the Government’s position on any potential future changes to oversight or regulation of the funeral sector.

Answering body: Ministry of Housing, Communities and Local Government

The Government offers its deepest sympathies to all those affected by the events referred to in these questions.

Local authorities are independent employers, responsible for the recruitment and management of Environmental Health Officers to fulfil their statutory obligations. Environmental Health Officers have no statutory role relating to funeral homes.

The Department has not made an assessment or collected data on regulatory gaps, environmental health standards, or the merits of inspection relating to funeral directors, but are working closely with the Department of Health and Social Care (DHSC) who are leading the government response to the Fuller Inquiry. An interim update on the Inquiry’s Phase 2 recommendations was published in December 2025, and DHSC has committed to publishing the Government’s full response in summer 2026. That response will set out the Government’s position on any potential future changes to oversight or regulation of the funeral sector.

Answering body: Department of Health and Social Care

The Department has not made an assessment of the additional cost of requiring the Human Tissue Authority to regulate the care of the deceased throughout the death pathway, including in funeral homes.

The Government is considering the full range of options to strengthen and improve standards to safeguard the security and dignity of the deceased. In this context, an interim update on progress with our response to the Fuller Inquiry Phase 2 report was published 16 December 2025, and is available at the following link:

https://www.gov.uk/government/publications/fuller-inquiry-government-interim-update-on-phase-2-recommendations

We will provide a full response by summer 2026.

Answering body: Ministry of Justice

The Government is considering the full range of options to strengthen and improve standards to safeguard the security and dignity of the deceased, particularly in the context of a full response to the Fuller Inquiry Phase 2 report which will be provided by summer 2026.

Our consideration has included discussions about a potential role for a relevant partner organisation such as the Human Tissue Authority.

Answering body: Ministry of Justice

The Government recognises the urgency of concerns about the funeral sector and is committed to responding at pace to ensure that the highest standards are always upheld by funeral directors and others involved in the care of people that have died.

To that end, the Government is considering the full range of options to strengthen and improve standards to safeguard the security and dignity of the deceased. In this context, an interim update on progress with our response to the Fuller Inquiry Phase 2 report was published by the Department for Health and Social Care on 16 December 2025 (Fuller inquiry: government interim update on phase 2 recommendations - GOV.UK), and we will provide a full response by summer 2026.

Answering body: Department of Health and Social Care

The Government will publish a full response to the Inquiry’s recommendations in summer 2026, setting out progress and next steps on the 75 recommendations, including the 11 specified.

Answering body: Ministry of Justice

The Government recognises the urgency of concerns about the funeral sector and is committed to responding at pace to ensure that the highest standards are always upheld by funeral directors and others involved in the care of people that have died.

To that end, the Government is considering the full range of options to strengthen and improve standards to safeguard the security and dignity of the deceased. In this context, an interim update on progress with our response to the Fuller Inquiry Phase 2 report was published by the Department for Health and Social Care on 16 December 2025 (Fuller inquiry: government interim update on phase 2 recommendations - GOV.UK), and we will provide a full response by summer 2026.

Answering body: Department of Health and Social Care

On 16 December 2025, the Government published an Interim update on government progress in responding to the Fuller inquiry phase 2 report, which is available at the following link:

https://www.gov.uk/government/publications/fuller-inquiry-government-interim-update-on-phase-2-recommendations

The interim update set out the solid progress that has been made in taking forward recommendations. Of the 75 recommendations: 11 have been accepted in full; 43 accepted in principle; and 21 remain under consideration. Full details of the status of all recommendations are contained in the published update.

The Government will publish a full response to the inquiry’s recommendations in summer 2026.

Answering body: Department of Health and Social Care

I am today updating the House on the Government’s progress in responding to the recommendations of the Independent Inquiry into the serious issues raised by the appalling actions of David Fuller, including an accompanying interim update published alongside this statement.

The final report of the Fuller Inquiry, published on 15 July 2025, set out seventy-five recommendations to strengthen the security and dignity of people after death across a wide range of settings. The Inquiry’s findings were clear: current arrangements for the care of the deceased are partial, piecemeal, and not universally mandated. A dedicated cross-Government Programme Board was established in July and has met fortnightly since.

At this interim stage solid progress has been made on fifty-four of the Inquiry recommendations.

Eleven are accepted in full and work is already in progress to implement these recommendations (22, 23, 26, 27, 28, 30,31, 32, 33, 34 & 75) covering standards, data and operating procedures in the wider health sector. Implementation highlights include: the publication by the Human Tissue Authority (HTA) on 1st December of updated guidance to ensure adverse incidents in the anatomy sector are recorded (recommendation 26) with incidents already being reported; agreement by NHS England that data collection on the conveyancing of deceased patients will be rolled out in 2026/27 for the first time (recommendation 31). Further details are included in the interim update publication here.

Forty-three of the Inquiry’s recommendations relating to both NHS and Local Authority mortuaries require further work before they can be implemented. Those include nine recommendations (1-9) for the NHS estate, and NHS England continue to assess the recommendations and are working with NHS Trusts to develop actions at Trust Board level. A further twelve of the Inquiry’s recommendations (10-21) relate to governance, accountability and safeguarding in NHS Trusts. Analysis of the logistics and costings of these recommendations is currently being carried out by NHS England. Recommendations 35-56 relate to Local Authority Mortuaries, which include twenty-one HTA licensed mortuaries. MHCLG sought views via the Local Government Association (LGA) on the state of the estate, and there is an LGA led roundtable meeting in January. The LGA and HTA are also working together to assess how LA mortuaries current practices compare with the Inquiry’s recommendations, and existing HTA standards in the Post-Mortem sector. The HTA has reviewed these recommendations against their own standards and conclude that seven are fully covered by existing HTA standards, and has shared this analysis with the LGA.

There are a further twenty-one recommendations still under consideration. Seven of these are miscellaneous recommendations (24,25,67,68,69,70&73), and three are for LAs who contract with third party providers (57,58 & 59). A roundtable was held in November regarding the role of faith organisations (67 and 68) in the care for the deceased in these settings. Outputs of the roundtable will inform the response to these two recommendations. In addition, the Chief Coroner has notified all coroners of the inquiry’s conclusions, in response to recommendation 70.

No decisions have been made regarding the eleven Recommendations (29,60,61,62,63,64,65,66,69,71,72) relating to wider regulation in all settings that care for people after death. We are working closely with the NHS, Local Authorities, the Human Tissue Authority, the Care Quality Commission, and other partners to explore how we can ensure that robust and consistent standards are in place across all settings. This includes reviewing mortuary access controls, oversight arrangements, contractor vetting, and requirements for training and reporting.

The Government is committed to transparency and accountability as this work progresses. This update demonstrates that work is actively underway to consider and respond to the Inquiry’s recommendations, with action already being taken towards implementing fifty-four of seventy-five recommendations. Full details of the status of all recommendations are contained in the published update. A full response to the Inquiry’s recommendations will be published in Summer 2026.

Answering body: Department of Health and Social Care

My Honourable Friend the Parliamentary Under-Secretary of State for Health Innovation and Safety (Zubir Ahmed) 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 raised by the appalling actions of David Fuller, including an accompanying interim update published alongside this statement.

The final report of the Fuller Inquiry, published on 15 July 2025, set out seventy-five recommendations to strengthen the security and dignity of people after death across a wide range of settings. The Inquiry’s findings were clear: current arrangements for the care of the deceased are partial, piecemeal, and not universally mandated. A dedicated cross-Government Programme Board was established in July and has met fortnightly since.

At this interim stage solid progress has been made on fifty-four of the Inquiry recommendations.

Eleven are accepted in full and work is already in progress to implement these recommendations (22, 23, 26, 27, 28, 30,31, 32, 33, 34 & 75) covering standards, data and operating procedures in the wider health sector. Implementation highlights include: the publication by the Human Tissue Authority (HTA) on 1st December of updated guidance to ensure adverse incidents in the anatomy sector are recorded (recommendation 26) with incidents already being reported; agreement by NHS England that data collection on the conveyancing of deceased patients will be rolled out in 2026/27 for the first time (recommendation 31). Further details are included in the interim update publication here.

Forty-three of the Inquiry’s recommendations relating to both NHS and Local Authority mortuaries require further work before they can be implemented. Those include nine recommendations (1-9) for the NHS estate, and NHS England continue to assess the recommendations and are working with NHS Trusts to develop actions at Trust Board level. A further twelve of the Inquiry’s recommendations (10-21) relate to governance, accountability and safeguarding in NHS Trusts. Analysis of the logistics and costings of these recommendations is currently being carried out by NHS England. Recommendations 35-56 relate to Local Authority Mortuaries, which include twenty-one HTA licensed mortuaries. MHCLG sought views via the Local Government Association (LGA) on the state of the estate, and there is an LGA led roundtable meeting in January. The LGA and HTA are also working together to assess how LA mortuaries current practices compare with the Inquiry’s recommendations, and existing HTA standards in the Post-Mortem sector. The HTA has reviewed these recommendations against their own standards and conclude that seven are fully covered by existing HTA standards, and has shared this analysis with the LGA.

There are a further twenty-one recommendations still under consideration. Seven of these are miscellaneous recommendations (24,25,67,68,69,70&73), and three are for LAs who contract with third party providers (57,58 & 59). A roundtable was held in November regarding the role of faith organisations (67 and 68) in the care for the deceased in these settings. Outputs of the roundtable will inform the response to these two recommendations. In addition, the Chief Coroner has notified all coroners of the inquiry’s conclusions, in response to recommendation 70.

No decisions have been made regarding the eleven Recommendations (29,60,61,62,63,64,65,66,69,71,72) relating to wider regulation in all settings that care for people after death. We are working closely with the NHS, Local Authorities, the Human Tissue Authority, the Care Quality Commission, and other partners to explore how we can ensure that robust and consistent standards are in place across all settings. This includes reviewing mortuary access controls, oversight arrangements, contractor vetting, and requirements for training and reporting.

The Government is committed to transparency and accountability as this work progresses. This update demonstrates that work is actively underway to consider and respond to the Inquiry’s recommendations, with action already being taken towards implementing fifty-four of seventy-five recommendations. Full details of the status of all recommendations are contained in the published update. A full response to the Inquiry’s recommendations will be published in Summer 2026.

Answering body: Department of Health and Social Care

In July 2025 the Fuller Inquiry’s phase 2 final report was published, which looked at the wider national lessons for hospital and non-hospital settings where the deceased are cared for. It examined whether procedures and practices safeguard the security and dignity of the deceased across the range of settings and made 75 recommendations in total.

This final report recommended the introduction of a statutory regulatory regime for those caring for the deceased. The Department will publish an interim update in winter 2025 and a final response by summer 2026. This will include updates on recommendations for the funeral sector and standards to protect the security and dignity of the deceased in all settings.

Answering body: Department of Health and Social Care

The Digital Markets, Competition and Consumers Act 2024 prohibits unfair commercial practices. These include misleading actions and omissions, that are likely to impact the average consumer’s transactional decisions. Traders who engage in commercial practices that are misleading omissions, or misleading actions, may be committing a criminal offence.

In July 2025, the final report of the independent inquiry into the issues raised by the David Fuller case recommended the introduction of a statutory regulatory regime for those caring for the deceased. The Department will publish an interim update on progress in winter 2025 and a final response by summer 2026. This will include updates on the recommendations for the funeral sector which set out that direct cremation businesses should also be considered in this context, and mandatory standards to protect the security and dignity of the deceased should be applied to these businesses and to any emerging new models of delivery of care for the deceased.

Answering body: Department of Health and Social Care

Today, the independent inquiry into the issues raised by the actions of David Fuller has published its Phase 2 and final report. It focuses on whether procedures and practices in hospital and non-hospital settings sufficiently safeguard the security and dignity of the deceased and would prevent a recurrence of the issues identified by the inquiry, as well as considering the role of regulation.

I wish to pass my thanks on to any individual or organisation who has provided evidence to this important independent inquiry. I extend my heartfelt condolences to the families of the victims and assure them that we are committed to learning from these events.

In 2023, the independent Inquiry, chaired by Sir Jonathon Michael, published its Phase 1 report, which set out how Fuller was able to commit such shocking crimes, undetected for so long at Maidstone and Tunbridge Wells NHS Trust. The Trust set out its progress implementing all the Inquiry’s recommendations via an assurance statement in February 2024.

A Phase 2 interim report was published in October 2024. The Inquiry’s chair expedited the Inquiry’s work on the funeral sector in light of reports of cases of neglect. The interim report presented preliminary findings and recommendations on the funeral sector in England. the Government committed to responding to these recommendations as part of the final phase two Government response.

The overall conclusion of today’s final report is that current arrangements for the care of people after death are partial, ineffective and in some areas, completely lacking. The overarching recommendation for Government is that there should be statutory regulation to protect the security and dignity of people after death, regardless of the setting or institution.

Today’s report makes 75 detailed recommendations in total, including 19 for Trusts and 25 for Local Authorities focusing on access, dignity, security and wider processes and procedures to protect deceased individuals. A smaller number of recommendations (31) focus on independent hospitals, medical education, hospices, Ambulance services, care homes, the funeral sector and faith organisations, making specific recommendations to improve the care of the deceased. This includes recommendations for UK Government to establish an independent statutory regulatory regime for the funeral sector.

Every deceased individual deserves to receive the highest standard of care and dignity. The Government will work to ensure this is the case, across all settings, be that in the NHS or other settings including Local Authority mortuaries, hospices, ambulance services, care homes, funeral homes, and faith organisations.

The Government recognises the urgency of the concerns raised by the Inquiry’s recommendations and will respond at pace. This will include an interim update on progress this year and a final response by Summer 2026.

Answering body: Department of Health and Social Care

My Rt Hon. Friend the Secretary of State for Health and Social Care (Wes Streeting MP) made the following Statement:

Today, the independent inquiry into the issues raised by the actions of David Fuller has published its Phase 2 and final report. It focuses on whether procedures and practices in hospital and non-hospital settings sufficiently safeguard the security and dignity of the deceased and would prevent a recurrence of the issues identified by the inquiry, as well as considering the role of regulation.

I wish to pass my thanks on to any individual or organisation who has provided evidence to this important independent inquiry. I extend my heartfelt condolences to the families of the victims and assure them that we are committed to learning from these events.

In 2023, the independent Inquiry, chaired by Sir Jonathon Michael, published its Phase 1 report, which set out how Fuller was able to commit such shocking crimes, undetected for so long at Maidstone and Tunbridge Wells NHS Trust. The Trust set out its progress implementing all the Inquiry’s recommendations via an assurance statement in February 2024.

A Phase 2 interim report was published in October 2024. The Inquiry’s chair expedited the Inquiry’s work on the funeral sector in light of reports of cases of neglect. The interim report presented preliminary findings and recommendations on the funeral sector in England. the Government committed to responding to these recommendations as part of the final phase two Government response.

The overall conclusion of today’s final report is that current arrangements for the care of people after death are partial, ineffective and in some areas, completely lacking. The overarching recommendation for Government is that there should be statutory regulation to protect the security and dignity of people after death, regardless of the setting or institution.

Today’s report makes 75 detailed recommendations in total, including 19 for Trusts and 25 for Local Authorities focusing on access, dignity, security and wider processes and procedures to protect deceased individuals. A smaller number of recommendations (31) focus on independent hospitals, medical education, hospices, Ambulance services, care homes, the funeral sector and faith organisations, making specific recommendations to improve the care of the deceased. This includes recommendations for UK Government to establish an independent statutory regulatory regime for the funeral sector.

Every deceased individual deserves to receive the highest standard of care and dignity. The Government will work to ensure this is the case, across all settings, be that in the NHS or other settings including Local Authority mortuaries, hospices, ambulance services, care homes, funeral homes, and faith organisations.

The Government recognises the urgency of the concerns raised by the Inquiry’s recommendations and will respond at pace. This will include an interim update on progress this year and a final response by Summer 2026.

Answering body: Cabinet Office

Since 2005, His Majesty’s Government has established 18 non-statutory inquiries.

The Cabinet Office collects data on the duration and cost of inquiries from departments, inquiries’ own reports, and other publicly available information. We do not centrally hold data on the projected costs of each inquiry as each Government Department is responsible for the inquiries they sponsor.

We have provided details on all non statutory inquiries established since 2005 in the table below. In the table below, “unknown” means that it is not known by Cabinet Office.

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Inquiry

Legislative Basis

Year established

Duration in months (from announcement to publication of final report)

Reported final costs where publicly available

Manston Inquiry

Non-Statutory

2025

Ongoing

Pending

Cranston Inquiry

Non-statutory

2023

Ongoing

Pending

Andrew Malkinson Inquiry

Non-statutory

2023

Ongoing

Pending

Fuller Inquiry

Non-statutory

2022

Ongoing

Pending

Angiolini Inquiry

Non-statutory

2022

Ongoing

Pending

The Independent Medicines and Medical Devices Safety Review

Non-statutory

2018

29

£1.7m

Independent Inquiry into the issues raised by Ian Paterson

Non-statutory

2018

26

£1.9m

Independent inquiry into the award of the Magnox decommissioning contract by the Nuclear Decommissioning Authority (NDA) and its subsequent termination

Non-statutory

2017

48

Unknown

Gosport Independent Panel

Non-statutory

2014

42

£13m

Harris Review / Independent review of self-inflicted deaths of young adults in custody aged between 18 and 24

Non-statutory

2014

17

£0.2m

The Morecambe Bay Maternity and Neonatal Services Investigation

Non-statutory

2013

18

£1.1m

Daniel Morgan Independent Panel

Non-statutory

2013

97

£17.6m

The Detainee Inquiry

Non-statutory (Committee of Privy Counsellors)

2010

45

£2.3m (exc. VAT)

The Hillsborough Independent Panel

Non-statutory

2009

33

Less than £5m

Independent Inquiry into care provided by Mid Staffordshire NHS Foundation Trust January 2001 – March 2009

Non-statutory

2009

7

Unknown

The Iraq Inquiry / The Chilcot Inquiry

Non-statutory (Committee of Privy Counsellors)

2009

85

£13.1m

Inquiry into Human Tissue Analysis in UK Nuclear Facilities / Redfern Inquiry

Non-statutory

2007

43

Unknown

Contaminated Blood and Blood Products Inquiry

Non-statutory

2007

48

£75k

</tbody>

Answering body: Home Office

Further to my previous response, the Government will lay out a clear timetable before Easter on how we will take forward the 20 recommendations from the final report of the Independent Inquiry into Child Sexual Abuse. We will also set up a new panel to ensure victims' and survivors' voices are prioritised in future policy making.

We have been clear that local authorities, who are responsible for delivering local services, are best placed to commission local inquiries, and we stand ready to support as we can. That is why the Home Secretary announced to Parliament on the 6 and 16 January 2025 a range of measures, including stronger national backing for local inquiries and funding provisions to help local councils set up their own reviews. The Home Office will develop a new effective framework for victim-centred, locally-led inquiries, and work with Oldham Council and four other pilot areas to implement it. Additionally, local councils which are yet to hold regional investigations where the group-based sexual offences have been more prevalent will be urged to conduct their own reviews to prevent offending happening again.

I refer the Rt Hon Member to the Home Secretary's statement made on 16 January, which set out the actions the Government is taking forward to improve our response to, and understanding of, child sexual exploitation and abuse, including group-based abuse This includes improving the data available on the perpetration of these crimes and the Home Secretary has asked the Child Sexual Exploitation Police Taskforce to expand the ethnicity data it collects and publishes - gathering data from the end of the investigation when a fuller picture is available.

The Home Secretary is also appointing Baroness Louise Casey to lead an audit to improve our understanding of the scale, nature and drivers of group-based child sexual exploitation and abuse at a national and local level, including what is known about the demographics of perpetrators and victims, and to make recommendations on what additional action is needed to improve our response.

Answering body: Home Office

Further to my previous response, the Government will lay out a clear timetable before Easter on how we will take forward the 20 recommendations from the final report of the Independent Inquiry into Child Sexual Abuse. We will also set up a new panel to ensure victims' and survivors' voices are prioritised in future policy making.

We have been clear that local authorities, who are responsible for delivering local services, are best placed to commission local inquiries, and we stand ready to support as we can. That is why the Home Secretary announced to Parliament on the 6 and 16 January 2025 a range of measures, including stronger national backing for local inquiries and funding provisions to help local councils set up their own reviews. The Home Office will develop a new effective framework for victim-centred, locally-led inquiries, and work with Oldham Council and four other pilot areas to implement it. Additionally, local councils which are yet to hold regional investigations where the group-based sexual offences have been more prevalent will be urged to conduct their own reviews to prevent offending happening again.

I refer the Rt Hon Member to the Home Secretary's statement made on 16 January, which set out the actions the Government is taking forward to improve our response to, and understanding of, child sexual exploitation and abuse, including group-based abuse This includes improving the data available on the perpetration of these crimes and the Home Secretary has asked the Child Sexual Exploitation Police Taskforce to expand the ethnicity data it collects and publishes - gathering data from the end of the investigation when a fuller picture is available.

The Home Secretary is also appointing Baroness Louise Casey to lead an audit to improve our understanding of the scale, nature and drivers of group-based child sexual exploitation and abuse at a national and local level, including what is known about the demographics of perpetrators and victims, and to make recommendations on what additional action is needed to improve our response.

Answering body: Home Office

Further to my previous response, the Government will lay out a clear timetable before Easter on how we will take forward the 20 recommendations from the final report of the Independent Inquiry into Child Sexual Abuse. We will also set up a new panel to ensure victims' and survivors' voices are prioritised in future policy making.

We have been clear that local authorities, who are responsible for delivering local services, are best placed to commission local inquiries, and we stand ready to support as we can. That is why the Home Secretary announced to Parliament on the 6 and 16 January 2025 a range of measures, including stronger national backing for local inquiries and funding provisions to help local councils set up their own reviews. The Home Office will develop a new effective framework for victim-centred, locally-led inquiries, and work with Oldham Council and four other pilot areas to implement it. Additionally, local councils which are yet to hold regional investigations where the group-based sexual offences have been more prevalent will be urged to conduct their own reviews to prevent offending happening again.

I refer the Rt Hon Member to the Home Secretary's statement made on 16 January, which set out the actions the Government is taking forward to improve our response to, and understanding of, child sexual exploitation and abuse, including group-based abuse This includes improving the data available on the perpetration of these crimes and the Home Secretary has asked the Child Sexual Exploitation Police Taskforce to expand the ethnicity data it collects and publishes - gathering data from the end of the investigation when a fuller picture is available.

The Home Secretary is also appointing Baroness Louise Casey to lead an audit to improve our understanding of the scale, nature and drivers of group-based child sexual exploitation and abuse at a national and local level, including what is known about the demographics of perpetrators and victims, and to make recommendations on what additional action is needed to improve our response.

Answering body: Ministry of Justice

Funeral directors have a profound responsibility to treat those who have died with the utmost dignity and respect and the majority of funeral directors conduct themselves in accordance with the high standards expected of them. However, the Government recognises that there are some significant concerns about certain practices within the funeral sector, as evidenced by the incident in Hull.

This is a complex and sensitive matter that demands careful consideration to ensure a response that effectively safeguards the public. It is crucial to protect the rights and dignity of those who have died and their grieving families, while implementing measures that are proportionate.

For that reason, the Government is thoroughly evaluating all potential next steps to ensure that the high standards upheld by many within the funeral director sector are consistently reflected throughout the entire industry. This includes the possibility of introducing suitable and proportionate regulation for funeral directors. Further updates on the next steps will be provided in due course and the Government will respond to the Fuller Inquiry when its part two report is published.

Answering body: Department of Health and Social Care

My Rt Hon Friend the Secretary of State for Health and Social Care (Wes Streeting MP) has made the following statement:

On 28 November 2023, the report of Phase 1 of the Fuller Independent Inquiry was published. Phase 1 of the Inquiry looked into how David Fuller’s appalling crimes in the mortuaries at Maidstone and Tunbridge Wells NHS Trust remained undetected for so long.

I wish to express my deepest sympathies to the victims’ families and reassure them that lessons will be learnt.

The Inquiry found highly concerning failings in the Trust’s running, management, and oversight of the mortuaries, and that it was due to this uncontrolled environment that David Fuller was able to offend undetected. Management, governance and regulation failures, alongside poor compliance to standard policies and procedures, and a persistent lack of curiosity, all contributed to the creation of the environment in which David Fuller was able to offend for 15 years without ever being suspected or caught.

The 17 recommendations - 16 for the Trust and the remaining one for Kent County Council and East Sussex County Council - made by the Inquiry in Phase 1 aim to prevent anything similar happening again at the Trust.

Today I am updating the House on the response to those recommendations. The Trust published an assurance statement in February 2024 on the implementation of the recommendations from the Phase 1 report. This sets out the progress made to implement the Inquiry’s recommendations.

The range of actions taken by the Trust include requiring that non-mortuary staff and contractors are always accompanied by another staff member when visiting the mortuaries; controlling access to mortuaries using swipe cards; mandating contractors to renew security clearances every three years; and installing CCTV coverage monitoring access to and from mortuary areas. The Trust Board is also providing greater oversight and assurance of legally regulated activity in the mortuary.

I am also reassured that NHS England’s South East regional team held monthly oversight meetings with the Trust between November 2023 and April 2024 (in partnership with Kent and Medway Integrated Care Board) to ensure progress against the Inquiry’s recommendations and to review evidence of the Trust’s progress in delivering their action plan. Ongoing compliance with the Inquiry's recommendations will be monitored by NHS England through regular regional oversight meetings with the Trust, and through other channels as appropriate.

Kent County Council and East Sussex County Council have reviewed contractual arrangements with the Trust and confirmed that the contracts include terms requiring that licensing and regulatory requirements are met to ensure the deceased are at all times treated with dignity and respect.

Phase 2 of the Independent Inquiry will consider whether procedures and practices in hospital and non-hospital settings, where deceased people are kept, are sufficient to safeguard the security and dignity of the deceased.

In light of the disturbing events in Hull earlier this year, which brought into sharp focus the lack of regulation and oversight in the funeral sector, we have agreed that the Inquiry will today publish an interim report on the findings from their funeral sector module. This will provide recommendations on safeguarding the security and dignity of the deceased in that sector.

The Government is committed to preventing any similar atrocities happening again and ensuring that the deceased are safeguarded and treated with dignity.

Answering body: Department of Health and Social Care

On 28 November 2023, the report of Phase 1 of the Fuller Independent Inquiry was published. Phase 1 of the Inquiry looked into how David Fuller’s appalling crimes in the mortuaries at Maidstone and Tunbridge Wells NHS Trust remained undetected for so long.

I wish to express my deepest sympathies to the victims’ families and reassure them that lessons will be learnt.

The Inquiry found highly concerning failings in the Trust’s running, management, and oversight of the mortuaries, and that it was due to this uncontrolled environment that David Fuller was able to offend undetected. Management, governance and regulation failures, alongside poor compliance to standard policies and procedures, and a persistent lack of curiosity, all contributed to the creation of the environment in which David Fuller was able to offend for 15 years without ever being suspected or caught.

The 17 recommendations - 16 for the Trust and the remaining one for Kent County Council and East Sussex County Council - made by the Inquiry in Phase 1 aim to prevent anything similar happening again at the Trust.

Today I am updating the House on the response to those recommendations. The Trust published an assurance statement in February 2024 on the implementation of the recommendations from the Phase 1 report. This sets out the progress made to implement the Inquiry’s recommendations.

The range of actions taken by the Trust include requiring that non-mortuary staff and contractors are always accompanied by another staff member when visiting the mortuaries; controlling access to mortuaries using swipe cards; mandating contractors to renew security clearances every three years; and installing CCTV coverage monitoring access to and from mortuary areas. The Trust Board is also providing greater oversight and assurance of legally regulated activity in the mortuary.

I am also reassured that NHS England’s South East regional team held monthly oversight meetings with the Trust between November 2023 and April 2024 (in partnership with Kent and Medway Integrated Care Board) to ensure progress against the Inquiry’s recommendations and to review evidence of the Trust’s progress in delivering their action plan. Ongoing compliance with the Inquiry's recommendations will be monitored by NHS England through regular regional oversight meetings with the Trust, and through other channels as appropriate.

Kent County Council and East Sussex County Council have reviewed contractual arrangements with the Trust and confirmed that the contracts include terms requiring that licensing and regulatory requirements are met to ensure the deceased are at all times treated with dignity and respect.

Phase 2 of the Independent Inquiry will consider whether procedures and practices in hospital and non-hospital settings, where deceased people are kept, are sufficient to safeguard the security and dignity of the deceased.

In light of the disturbing events in Hull earlier this year, which brought into sharp focus the lack of regulation and oversight in the funeral sector, we have agreed that the Inquiry will today publish an interim report on the findings from their funeral sector module. This will provide recommendations on safeguarding the security and dignity of the deceased in that sector.

The Government is committed to preventing any similar atrocities happening again and ensuring that the deceased are safeguarded and treated with dignity.

Answering body: Cabinet Office

The Cabinet Office collects data on the duration and cost of inquiries from departments, inquiries’ own reports, and other publicly available information.

We have provided details on all statutory and non-statutory inquiries established since 2005 in the table below.

In some cases, information in the table below has come from reports from outside the Government. We have not included the costs for ongoing inquiries, which are published at different frequencies on inquiry or departmental websites, and we have not included the details for any investigations commissioned by NHS England (some of which were counted in the total number of non-statutory inquiries in our previous response, answered on 8th February 2024, UIN HL1937). It has been noted where the publicly available information provides the cost excluding VAT.

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Inquiry

Sponsor Department

Legislative Basis

Year established

Duration in months (from announcement to publication of final report)

Reported final costs where publicly available

Jalal Uddin Inquiry

HO

Inquiries Act 2005

2023

Ongoing

-

Cranston Inquiry

DfT

Non-statutory

2023

Ongoing

-

Andrew Malkinson Inquiry

MoJ

Non-statutory

2023

Ongoing

-

Thirlwall Inquiry

DHSC

Inquiries Act 2005

2023

Ongoing

-

Inquiry into the preventability of the Omagh bombing

NIO

Inquiries Act 2005

2023

Ongoing

-

Independent inquiry relating to Afghanistan

Ministry of Defence

Inquiries Act 2005

2022

Ongoing

-

Dawn Sturgess Inquiry

HO

Inquiries Act 2005

2022

Ongoing

-

Fuller Inquiry

DHSC

Non-statutory

2022

Ongoing

-

Angiolini Inquiry

HO

Non-statutory

2022

Ongoing

-

UK Covid-19 Inquiry

Cabinet Office

Inquiries Act 2005

2022

Ongoing

-

Lampard Inquiry

DHSC

Inquiries Act 2005

2021

Ongoing

-

Jermaine Baker inquiry

HO

Inquiries Act 2005

2020

29

£4.1m

Post Office Horizon IT inquiry

DBT

Inquiries Act 2005

2020

Ongoing

-

Manchester Arena inquiry

HO

Inquiries Act 2005

2019

41

£35.6m

Brook House Inquiry

HO

Inquiries Act 2005

2019

46

£18.7m

The Independent Medicines and Medical Devices Safety Review

Department of Health

Non-statutory

2018

29

£1.7m

Independent Inquiry into the issues raised by Ian Paterson

Department of Health

Non-statutory

2018

26

£1.9m

Grenfell Tower Inquiry

Cabinet Office

Inquiries Act 2005

2017

Ongoing

-

Infected Blood Inquiry

Cabinet Office

Inquiries Act 2005

2017

Ongoing

-

Independent inquiry into the award of the Magnox decommissioning contract by the Nuclear Decommissioning Authority (NDA) and its subsequent termination

BEIS

Non-statutory

2017

48

[unknown]

Anthony Grainger Inquiry

HO

Inquiries Act 2005

2016

40

£2.6m

The Independent Inquiry into Child Sexual Abuse

HO

Inquiries Act 2005

2015

99

£192.7m (as of Dec 2022)

Undercover Policing Inquiry

HO

Inquiries Act 2005

2015

Ongoing

-

Gosport Independent Panel

Department of Health

Non-statutory

2014

42

£13m

The Litvinenko Inquiry

HO, FCO and 3 x Intelligence Agencies

Inquiries Act 2005

2014

18

£2.4m (exc. VAT)

Harris Review / Independent review of self-inflicted deaths of young adults in custody aged between 18 and 24

MoJ

Non-statutory

2014

17

£0.2m

The Morecambe Bay Maternity and Neonatal Services Investigation

Department of Health

Non-statutory

2013

18

£1.1m

Daniel Morgan Independent Panel

HO

Non-statutory

2013

97

£17.6m

The Leveson Inquiry

DCMS and HO

Inquiries Act 2005

2011

16

£5.4m

The Azelle Rodney Inquiry

MoJ

Inquiries Act 2005

2010

40

£2.6m

Mid Staffordshire NHS Foundation Trust Inquiry 2013 / The Francis Inquiry

Department of Health

Inquiries Act 2005

2010

36

£13.7m

The Detainee Inquiry

Cabinet Office

Non-statutory (Committee of Privy Counsellors)

2010

45

£2.3m (exc. VAT)

The Hillsborough Independent Panel

HO

Non-statutory

2009

33

Less than £5m

The Al Sweady Inquiry

MoD

Inquiries Act 2005

2009

61

£24.9m (exc. VAT)

Independent Inquiry into care provided by Mid Staffordshire NHS Foundation Trust January 2001 – March 2009

Department of Health

Non-statutory

2009

7

-

The Iraq Inquiry / The Chilcot Inquiry

Cabinet Office, FCO, DfID

Non-statutory (Committee of Privy Counsellors)

2009

85

£13.1m

The Bernard (Sonny) Lodge Inquiry

MoJ

Inquiries Act 2005

2009

10

£0.4m

The Baha Mousa Inquiry

MoD

Inquiries Act 2005

2008

39

£13m

Inquiry into Human Tissue Analysis in UK Nuclear Facilities / Redfern Inquiry

DTI - BERR - DECC

Non-statutory

2007

43

-

Contaminated Blood and Blood Products Inquiry

Department of Health

Non-statutory

2007

48

£75k

</tbody>

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

My Hon. Friend. the Parliamentary Under Secretary of State (Minister for Mental Health and Women’s Health Strategy) (Maria Caulfield) has made the following written statement:

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

My Hon friend the Parliamentary Under Secretary of State (Minister for Mental Health and Women’s Health Strategy) (Maria Caulfield) has made the following Written Statement:

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.