Previous Next
Jump to 17 Recommendations

Independent Inquiry into the issues raised by the David Fuller case

Completed

Fuller Inquiry

Chair Sir Jonathan Michael Other
Established 27 Jun 2022
Final Report 15 Jul 2025
Commissioned by Department of Health and Social Care

Inquiry into mortuary abuse by David Fuller at NHS hospitals. Fuller sexually abused the bodies of at least 101 deceased women and girls. Phase 1 examined Maidstone and Tunbridge Wells NHS Trust; Phase 2 examined nationwide safeguards for the deceased.

3 years Duration
Inquiry Website Official Statement Terms of Reference
Government Response
Accepted 28
Accepted in Part 43
Under Review 21
Total Recommendations 92
Data last updated: 1 Dec 2025
Data verified: 24 Mar 2026 (import)
How to read this

Government Response tracks what the government said it would do (accepted, rejected, etc.).

Full methodology

4 questions 13 statements since May 2022
Written Question Human Tissue Authority
Dame Caroline Dinenage (Conservative)
23 Feb 2026
Written Question Independent Inquiry into the Issues Raised by the David Fuller Case
Dame Caroline Dinenage (Conservative)
03 Feb 2026
Written Question Human Remains: Inquiries
Preet Kaur Gill (Labour)
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
Written Ministerial Statement Government Interim Update on Progress in responding to the Fuller Inquiry Phase …
Baroness Merron (Labour)
16 Dec 2025
View all 17 mentions →
All Activity (17)
Title Volume Publication Date Recs Links
Fuller Inquiry Phase 1 Report - 29 Nov 2023 17
Fuller Inquiry Phase 2 Report - 15 Jul 2025 75
Clear

Recommendations (17)

P1-1
Accepted
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 … Read more
Published evidence summary
Maidstone and Tunbridge Wells NHS Trust has implemented the requirement for all non-mortuary staff and contractors to be accompanied when visiting the mortuary. This action was confirmed in NHS England's oversight meetings with the Trust, according to a Trust assurance statement from February 2024 and a Written Ministerial Statement HCWS132 from 15 October 2024.
Maidstone and Tunbridge Wells NHS Trust (Primary)
View Details
P1-2
Accepted
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 … Read more
Published evidence summary
Maidstone and Tunbridge Wells NHS Trust has updated its Standard Operating Procedures to ensure that deceased persons are not left out of mortuary fridges unnecessarily. The Trust confirmed its compliance with this requirement in a February 2024 assurance statement, which was further confirmed in a Written Ministerial Statement HCWS132 on 15 October 2024.
Maidstone and Tunbridge Wells NHS Trust (Primary)
View Details
P1-3
Accepted
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 … Read more
Published evidence summary
The Maidstone and Tunbridge Wells NHS Trust has mandated contractors to renew security clearances every three years and is following its policy on criminal record checks for both direct staff and contractors. This was confirmed in a Written Ministerial Statement (HCWS132, 15 October 2024), referencing a Trust assurance statement from February 2024.
Maidstone and Tunbridge Wells NHS Trust (Primary)
View Details
P1-4
Accepted
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 … Read more
Published evidence summary
The Maidstone and Tunbridge Wells NHS Trust has reviewed its Mortuary Manager arrangements, ensuring appropriate qualifications and support are in place with clear lines of accountability. This was confirmed in a Written Ministerial Statement (HCWS132, 15 October 2024), based on a Trust assurance statement from February 2024.
Maidstone and Tunbridge Wells NHS Trust (Primary)
View Details
P1-5
Accepted
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 … Read more
Published evidence summary
The Maidstone and Tunbridge Wells NHS Trust has protected the Mortuary Manager role as a dedicated full-time position. This action was confirmed in a Written Ministerial Statement (HCWS132, 15 October 2024), referencing a Trust assurance statement from February 2024.
Maidstone and Tunbridge Wells NHS Trust (Primary)
View Details
P1-6
Accepted
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
The Maidstone and Tunbridge Wells NHS Trust has reviewed and updated its policies, and mortuary access is now controlled via individual swipe cards with appropriate restrictions. This was confirmed in a Written Ministerial Statement (HCWS132, 15 October 2024), based on a Trust assurance statement from February 2024.
Maidstone and Tunbridge Wells NHS Trust (Primary)
View Details
P1-7
Accepted
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
The Maidstone and Tunbridge Wells NHS Trust now conducts regular audits of mortuary access, with access data being monitored and reviewed. This was confirmed in a Written Ministerial Statement (HCWS132, 15 October 2024), referencing a Trust assurance statement from February 2024.
Maidstone and Tunbridge Wells NHS Trust (Primary)
View Details
P1-8
Accepted
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
The Maidstone and Tunbridge Wells NHS Trust now treats security as a corporate responsibility, with board-level oversight. This was confirmed in a Written Ministerial Statement (HCWS132, 15 October 2024), based on a Trust assurance statement from February 2024.
Maidstone and Tunbridge Wells NHS Trust (Primary)
View Details
P1-9
Accepted
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
The Maidstone and Tunbridge Wells NHS Trust has installed full CCTV coverage throughout the mortuary, including the post-mortem room, with appropriate safeguards for dignity. This was confirmed in a Written Ministerial Statement (HCWS132, 15 October 2024), referencing a Trust assurance statement from February 2024.
Maidstone and Tunbridge Wells NHS Trust (Primary)
View Details
P1-10
Accepted
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
Maidstone and Tunbridge Wells NHS Trust has implemented regular reviews of CCTV footage in conjunction with swipe card access data, and staff have received training in monitoring procedures. This was confirmed by a Trust assurance statement in February 2024 and a Written Ministerial Statement HCWS132 on 15 October 2024.
Maidstone and Tunbridge Wells NHS Trust (Primary)
View Details
P1-11
Accepted
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
Maidstone and Tunbridge Wells NHS Trust now proactively shares Human Tissue Authority (HTA) reports with organisations that rely on its mortuary services. This action was confirmed in a Trust assurance statement from February 2024 and a Written Ministerial Statement HCWS132 from 15 October 2024.
Maidstone and Tunbridge Wells NHS Trust (Primary)
View Details
P1-12
Accepted
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
Kent County Council and East Sussex County Council have reviewed their contractual arrangements with Maidstone and Tunbridge Wells NHS Trust. This review aimed to strengthen protections for the deceased, as confirmed by a Trust assurance statement in February 2024 and a Written Ministerial Statement HCWS132 on 15 October 2024.
Kent County Council (Primary)
View Details
P1-13
Accepted
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
Maidstone and Tunbridge Wells NHS Trust Board has reviewed its governance structures to establish proper assurance mechanisms, moving away from reliance on reassurance. This action was confirmed in a Trust assurance statement from February 2024 and a Written Ministerial Statement HCWS132 from 15 October 2024.
Maidstone and Tunbridge Wells NHS Trust (Primary)
View Details
P1-14
Accepted
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
Maidstone and Tunbridge Wells NHS Trust Board now has direct oversight of licensed mortuary activity, with the Designated Individual reporting regularly to the Board and receiving support in this role. This was confirmed by a Trust assurance statement in February 2024 and a Written Ministerial Statement HCWS132 on 15 October 2024.
Maidstone and Tunbridge Wells NHS Trust (Primary)
View Details
P1-15
Accepted
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 … Read more
Published evidence summary
Maidstone and Tunbridge Wells NHS Trust now treats Human Tissue Authority (HTA) compliance as a corporate statutory responsibility, in addition to the formal duties of the Designated Individual. This change was confirmed in a Trust assurance statement from February 2024 and a Written Ministerial Statement HCWS132 from 15 October 2024.
Maidstone and Tunbridge Wells NHS Trust (Primary)
View Details
P1-16
Accepted
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
The Chief Nurse at Maidstone and Tunbridge Wells NHS Trust has been given explicit responsibility for assuring the Board on mortuary management and the protection of the deceased. This was confirmed by a Trust assurance statement in February 2024 and a Written Ministerial Statement HCWS132 on 15 October 2024.
Maidstone and Tunbridge Wells NHS Trust (Primary)
View Details
P1-17
Accepted
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
Maidstone and Tunbridge Wells NHS Trust has embedded the principle of treating the deceased with the same due regard to dignity and safeguarding as living patients into its policy and practice. This was confirmed by a Trust assurance statement in February 2024 and a Written Ministerial Statement HCWS132 on 15 October 2024.
Maidstone and Tunbridge Wells NHS Trust (Primary)
View Details