Independent Inquiry into the issues raised by the David Fuller case
CompletedFuller 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.
3 years
Duration
Parliamentary Activity 19 Click to expand
5 questions
14 statements
since Feb 2022
Written Question
Independent Inquiry into the Issues Raised by the David Fuller Case
Mike Wood (Conservative)
10 Apr 2026
Mike Wood (Conservative)
23 Feb 2026
Written Question
Independent Inquiry into the Issues Raised by the David Fuller Case
Dame Caroline Dinenage (Conservative)
03 Feb 2026
Dame Caroline Dinenage (Conservative)
12 Jan 2026
Written Ministerial Statement
Government Interim Update on Progress in responding to the Fuller Inquiry Phase …
Dr Zubir Ahmed (Labour)
16 Dec 2025
Dr Zubir Ahmed (Labour)
Reports (2) Click to expand
| Title | Volume | Publication Date | Tracked recs | Links |
|---|---|---|---|---|
| Fuller Inquiry Phase 1 Report | - | 29 Nov 2023 | 17 | |
| Fuller Inquiry Phase 2 Report | - | 15 Jul 2025 | 75 |
Recommendations (17)
Non-mortuary staff accompanied in mortuary
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 …
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Published evidence summary
- MTW Trust stated in February 2024 that it had implemented accompaniment requirements for non-mortuary staff and contractors visiting the mortuary (MTW Trust Assurance Statement, February 2024).
- The government noted in October 2024 that the Trust had actioned the "vast majority" of Phase 1 recommendations (Written Statement HCWS132, 15 October 2024).
- The government noted in October 2024 that the Trust had actioned the "vast majority" of Phase 1 recommendations (Written Statement HCWS132, 15 October 2024).
Maidstone and Tunbridge Wells NHS Trust
(Primary)
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No deceased left out of fridges overnight
Recommendation
Maidstone and Tunbridge Wells NHS Trust must assure itself that all regulatory requirements and standards relating to the mortuary are met and that the practice of leaving deceased people out of mortuary fridges overnight, or while maintenance is undertaken, does …
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Published evidence summary
- MTW Trust stated in February 2024 that it had strengthened procedures to ensure regulatory requirements are met and that the deceased are not left out of refrigerated storage unnecessarily (MTW Trust Assurance Statement, February 2024).
- The government noted in October 2024 that the Trust had actioned the "vast majority" of Phase 1 recommendations (Written Statement HCWS132, 15 October 2024).
- The government noted in October 2024 that the Trust had actioned the "vast majority" of Phase 1 recommendations (Written Statement HCWS132, 15 October 2024).
Maidstone and Tunbridge Wells NHS Trust
(Primary)
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Criminal record checks compliance
Recommendation
Maidstone and Tunbridge Wells NHS Trust must assure itself that it is compliant with its own current policy on criminal record checks and re-checks for staff. The Trust should ensure that staff who are employed by its facilities management provider …
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Published evidence summary
- MTW Trust stated in February 2024 that it had implemented enhanced criminal record checks for mortuary staff, including DBS checks at the appropriate level (MTW Trust Assurance Statement, February 2024).
- The government noted in October 2024 that the Trust had actioned the "vast majority" of Phase 1 recommendations (Written Statement HCWS132, 15 October 2024).
- The government noted in October 2024 that the Trust had actioned the "vast majority" of Phase 1 recommendations (Written Statement HCWS132, 15 October 2024).
Maidstone and Tunbridge Wells NHS Trust
(Primary)
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Mortuary Managers qualified and supported
Recommendation
Maidstone and Tunbridge Wells NHS Trust must assure itself that its Mortuary Managers are suitably qualified and have relevant anatomical pathology technologist experience. The Mortuary Manager should have a clear line of accountability within the Trust's management structure and must …
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Published evidence summary
- MTW Trust stated in February 2024 that it had reviewed the qualifications required for the Mortuary Manager role and ensured the post-holder meets the appropriate professional standards (MTW Trust Assurance Statement, February 2024).
- The government noted in October 2024 that the Trust had actioned the "vast majority" of Phase 1 recommendations (Written Statement HCWS132, 15 October 2024).
- The government noted in October 2024 that the Trust had actioned the "vast majority" of Phase 1 recommendations (Written Statement HCWS132, 15 October 2024).
Maidstone and Tunbridge Wells NHS Trust
(Primary)
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Mortuary Manager as full-time dedicated role
Recommendation
The role of Mortuary Manager at Maidstone and Tunbridge Wells NHS Trust should be protected as a full-time dedicated role, in recognition of the fact that this is a complex regulated service, based across two sites, that requires the appropriate …
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Published evidence summary
- MTW Trust stated in February 2024 that it had established the Mortuary Manager as a full-time dedicated role (MTW Trust Assurance Statement, February 2024).
- The government noted in October 2024 that the Trust had actioned the "vast majority" of Phase 1 recommendations (Written Statement HCWS132, 15 October 2024).
- The government noted in October 2024 that the Trust had actioned the "vast majority" of Phase 1 recommendations (Written Statement HCWS132, 15 October 2024).
Maidstone and Tunbridge Wells NHS Trust
(Primary)
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Review policies on mortuary access
Recommendation
Maidstone and Tunbridge Wells NHS Trust must review its policies to ensure that only those with appropriate and legitimate access can enter the mortuary.
Published evidence summary
- MTW Trust stated in February 2024 that it had implemented a comprehensive mortuary access policy restricting entry to authorised personnel only (MTW Trust Assurance Statement, February 2024).
- The government noted in October 2024 that the Trust had actioned the "vast majority" of Phase 1 recommendations (Written Statement HCWS132, 15 October 2024).
- The government noted in October 2024 that the Trust had actioned the "vast majority" of Phase 1 recommendations (Written Statement HCWS132, 15 October 2024).
Maidstone and Tunbridge Wells NHS Trust
(Primary)
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Audit and monitor mortuary access
Recommendation
Maidstone and Tunbridge Wells NHS Trust must audit implementation of any resulting new policy and must regularly monitor access to restricted areas, including the mortuary, by all staff and contractors.
Published evidence summary
- MTW Trust stated in February 2024 that it had implemented audit procedures to monitor access to restricted areas within the mortuary (MTW Trust Assurance Statement, February 2024).
- The HTA introduced unannounced inspections of post-mortem sector facilities from September 2024, which include assessment of access controls (Human Tissue Authority, Strengthening Regulatory Oversight, 2024).
- The HTA introduced unannounced inspections of post-mortem sector facilities from September 2024, which include assessment of access controls (Human Tissue Authority, Strengthening Regulatory Oversight, 2024).
Maidstone and Tunbridge Wells NHS Trust
(Primary)
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Security as corporate responsibility
Recommendation
Maidstone and Tunbridge Wells NHS Trust should treat security as a corporate not a local departmental responsibility.
Published evidence summary
- MTW Trust stated in February 2024 that mortuary security had been elevated to a corporate responsibility with board-level oversight (MTW Trust Assurance Statement, February 2024).
- The government noted in October 2024 that the Trust had actioned the "vast majority" of Phase 1 recommendations (Written Statement HCWS132, 15 October 2024).
- The government noted in October 2024 that the Trust had actioned the "vast majority" of Phase 1 recommendations (Written Statement HCWS132, 15 October 2024).
Maidstone and Tunbridge Wells NHS Trust
(Primary)
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CCTV in mortuary including post-mortem room
Recommendation
Maidstone and Tunbridge Wells NHS Trust must install CCTV cameras in the mortuary, including the post-mortem room, to monitor the security of the deceased and safeguard their privacy and dignity.
Published evidence summary
- MTW Trust stated in February 2024 that CCTV had been installed in the mortuary covering all areas where the deceased are stored or examined (MTW Trust Assurance Statement, February 2024).
- The HTA introduced unannounced inspections of post-mortem sector facilities from September 2024, which include assessment of physical security measures including CCTV (Human Tissue Authority, Strengthening Regulatory Oversight, 2024).
- The HTA introduced unannounced inspections of post-mortem sector facilities from September 2024, which include assessment of physical security measures including CCTV (Human Tissue Authority, Strengthening Regulatory Oversight, 2024).
Maidstone and Tunbridge Wells NHS Trust
(Primary)
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Regular CCTV review with swipe card data
Recommendation
Maidstone and Tunbridge Wells NHS Trust must ensure that footage from the CCTV is reviewed on a regular basis by appropriately trained staff and examined in conjunction with swipe card data to identify trends that might be of concern.
Published evidence summary
- MTW Trust stated in February 2024 that it had implemented regular review of CCTV footage from the mortuary as part of routine security procedures (MTW Trust Assurance Statement, February 2024).
- The government noted in October 2024 that the Trust had actioned the "vast majority" of Phase 1 recommendations (Written Statement HCWS132, 15 October 2024).
- The government noted in October 2024 that the Trust had actioned the "vast majority" of Phase 1 recommendations (Written Statement HCWS132, 15 October 2024).
Maidstone and Tunbridge Wells NHS Trust
(Primary)
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Share HTA reports with reliant organisations
Recommendation
Maidstone and Tunbridge Wells NHS Trust must proactively share Human Tissue Authority reports with organisations that rely on Human Tissue Authority licensing for assurance of the service provided by the mortuary.
Published evidence summary
- MTW Trust stated in February 2024 that HTA inspection reports are now shared with relevant Trust boards and governance committees (MTW Trust Assurance Statement, February 2024).
- The government noted in October 2024 that the Trust had actioned the "vast majority" of Phase 1 recommendations (Written Statement HCWS132, 15 October 2024).
- The government noted in October 2024 that the Trust had actioned the "vast majority" of Phase 1 recommendations (Written Statement HCWS132, 15 October 2024).
Maidstone and Tunbridge Wells NHS Trust
(Primary)
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Local authorities examine contractual arrangements
Recommendation
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.
Published evidence summary
- MTW Trust stated in February 2024 that it had reviewed contracts with Kent County Council and East Sussex County Council for mortuary services (MTW Trust Assurance Statement, February 2024).
- The government noted in October 2024 that the Trust had actioned the "vast majority" of Phase 1 recommendations (Written Statement HCWS132, 15 October 2024).
- The government noted in October 2024 that the Trust had actioned the "vast majority" of Phase 1 recommendations (Written Statement HCWS132, 15 October 2024).
Kent County Council
(Primary)
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Board review governance - assurance not reassurance
Recommendation
We have illustrated throughout this Report how Maidstone and Tunbridge Wells NHS Trust relied on reassurance rather than assurance in monitoring its processes. The Board must review its governance structures and function in light of this.
Published evidence summary
- MTW Trust stated in February 2024 that it had strengthened board governance to ensure "assurance not reassurance" in relation to mortuary operations (MTW Trust Assurance Statement, February 2024).
- The government noted in October 2024 that the Trust had actioned the "vast majority" of Phase 1 recommendations (Written Statement HCWS132, 15 October 2024).
- The government noted in October 2024 that the Trust had actioned the "vast majority" of Phase 1 recommendations (Written Statement HCWS132, 15 October 2024).
Maidstone and Tunbridge Wells NHS Trust
(Primary)
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Board oversight of licensed mortuary activity
Recommendation
Maidstone and Tunbridge Wells NHS Trust Board must have greater oversight of licensed activity in the mortuary. It must ensure that the Designated Individual is actively involved in reporting to the Board and is supported in this.
Published evidence summary
- MTW Trust stated in February 2024 that the Designated Individual now has protected time for oversight duties and reports directly to the Trust Board on HTA compliance (MTW Trust Assurance Statement, February 2024).
- The government noted in October 2024 that the Trust had actioned the "vast majority" of Phase 1 recommendations (Written Statement HCWS132, 15 October 2024).
- The government noted in October 2024 that the Trust had actioned the "vast majority" of Phase 1 recommendations (Written Statement HCWS132, 15 October 2024).
Maidstone and Tunbridge Wells NHS Trust
(Primary)
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Treat HTA compliance as Trust statutory responsibility
Recommendation
Maidstone and Tunbridge Wells NHS Trust should treat compliance with Human Tissue Authority standards as a statutory responsibility for the Trust, notwithstanding the fact that the formal responsibility under the Human Tissue Act 2004 rests with the Designated Individual. The …
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Published evidence summary
- MTW Trust stated in February 2024 that HTA compliance is now treated as a statutory responsibility at board level (MTW Trust Assurance Statement, February 2024).
- The HTA introduced unannounced inspections of post-mortem sector facilities from September 2024, providing an additional layer of regulatory scrutiny (Human Tissue Authority, Strengthening Regulatory Oversight, 2024).
- The HTA introduced unannounced inspections of post-mortem sector facilities from September 2024, providing an additional layer of regulatory scrutiny (Human Tissue Authority, Strengthening Regulatory Oversight, 2024).
Maidstone and Tunbridge Wells NHS Trust
(Primary)
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Chief Nurse responsible for mortuary assurance
Recommendation
The Chief Nurse should be made explicitly responsible for assuring the Maidstone and Tunbridge Wells NHS Trust Board that mortuary management is delivered in such a way that it protects the security and dignity of the deceased.
Published evidence summary
- MTW Trust stated in February 2024 that the Chief Nurse had been assigned responsibility for mortuary services within the Trust executive structure (MTW Trust Assurance Statement, February 2024).
- The government noted in October 2024 that the Trust had actioned the "vast majority" of Phase 1 recommendations (Written Statement HCWS132, 15 October 2024).
- The government noted in October 2024 that the Trust had actioned the "vast majority" of Phase 1 recommendations (Written Statement HCWS132, 15 October 2024).
Maidstone and Tunbridge Wells NHS Trust
(Primary)
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Deceased treated with same dignity as patients
Recommendation
Maidstone and Tunbridge Wells NHS Trust must treat the deceased with the same due regard to dignity and safeguarding as it does its other patients.
Published evidence summary
- MTW Trust stated in February 2024 that it had reinforced the principle that the deceased must be treated with the same dignity and respect as living patients (MTW Trust Assurance Statement, February 2024).
- The government noted in October 2024 that the Trust had actioned the "vast majority" of Phase 1 recommendations (Written Statement HCWS132, 15 October 2024).
- The government noted in October 2024 that the Trust had actioned the "vast majority" of Phase 1 recommendations (Written Statement HCWS132, 15 October 2024).
Maidstone and Tunbridge Wells NHS Trust
(Primary)
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