Non-mortuary staff accompanied in mortuary
Fuller Inquiry · Fuller Inquiry Phase 1 Report · Issued 29 November 2023 · Addressed to: Maidstone and Tunbridge Wells NHS Trust
Source — verbatim from the inquiry
●Inquiry recommendation
Maidstone and Tunbridge Wells NHS Trust must ensure that non-mortuary staff and contractors, including maintenance staff employed by the Trust's external facilities management provider, are always accompanied by another staff member when they visit the mortuary. For example, maintenance staff should undertake tasks in the mortuary in pairs.
Fuller Inquiry, Fuller Inquiry Phase 1 Report · 29 Nov 2023 Source PDF →
Published evidence summary
Publicly available evidence relating to this recommendation:
- The government noted in October 2024 that the Trust had actioned the "vast majority" of Phase 1 recommendations (Written Statement HCWS132, 15 October 2024).
Sources
Response — verbatim from government
●Maidstone and Tunbridge Wells NHS Trust — initial response
Implemented. The Trust has implemented this requirement. All non-mortuary staff and contractors must be accompanied when visiting the mortuary. This was confirmed in NHS England's oversight meetings with the Trust. (Source: Trust assurance statement, February 2024; confirmed in Written Ministerial Statement HCWS132, 15 October 2024)
Maidstone and Tunbridge Wells NHS Trust · 1 Feb 2024
●Department of Health and Social Care — follow-up
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.
(Source: Written Ministerial Statement HCWS132, 15 October 2024)
Department of Health and Social Care · 15 Oct 2024 Written response →
Evidence trail — what's actually happened since
No published activity has been recorded against this recommendation yet.
Each entry above links to a primary source — gov.uk written statement, consultation response document, or inspection report. The Index does not characterise government intent; it tracks what has been published.
How this page is built
Source and Response are verbatim from primary documents. The Evidence trail records published activity since — written statements, consultation outcomes, inspection findings, parliamentary references. The Index does not paraphrase or characterise intent; it tracks what has been published. Where the evidence is the absence of action (a missed deadline, a slipped timetable), that absence is documented from primary sources rather than inferred.
This recommendation's data is verified periodically against primary sources. The Index is monitored for staleness weekly.