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.

Live tracking hearings, witnesses and documents synced daily from the inquiry website Open live tracker Search evidence
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: 5 Feb 2026 (Claude)
How to read this

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

Full methodology

11 questions 16 statements since Feb 2022
Written Question Funerals: Regulation
Dame Caroline Dinenage (Conservative)
28 Aug 2026
Written Ministerial Statement Government update on Progress in responding to the Fuller Inquiry Phase 2 …
Baroness Merron (Labour)
15 Jul 2026
Written Ministerial Statement Government update on Progress in responding to the Fuller Inquiry Phase 2 …
Preet Kaur Gill (Labour)
15 Jul 2026
Written Question Cremation and Funerals: Local Government
Ayoub Khan (Independent)
29 Jun 2026
Written Question Cremation and Funerals
Ayoub Khan (Independent)
29 Jun 2026
View all 27 mentions →
All Activity (27)
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
08 Nov 2021
Independent inquiry into the David Fuller case announced

Commons statement by Sajid Javid MP, Secretary of State for Health and Social Care, replacing the Trust-commissioned investigation with an independent inquiry. Repeated as a Lords statement the following day, 9 Nov 2021.

Source
08 Nov 2021
Sir Jonathan Michael appointed Chair of the independent inquiry

Same statement as the announcement. Verbatim: "I have appointed Sir Jonathan Michael to chair this inquiry." Sir Jonathan had already been chairing the preceding Trust-commissioned investigation before it was converted into this independent inquiry.

Source
23 Feb 2022
Terms of Reference published

Date confirmed by the 2023 ToR Addendum's own text ("terms of reference that were published by the Inquiry on 23 February 2022") and independently by the Wayback Machine's first-capture timestamp for this PDF. Full ToR text also at https://web.archive.org/web/20220522063937/https://fuller.independent-inquiry.uk/terms-of-reference/

Source
28 Nov 2023
Phase 1 report published (HC 310)

Covers events at Maidstone and Tunbridge Wells NHS Trust. 17 recommendations (16 for the Trust, 1 for Kent County Council/East Sussex County Council), per Wes Streeting's 15 Oct 2024 statement. Referred to in the Terms of Reference as the "initial report".

Source
15 Oct 2024
Phase 2 interim report published (HC 260, funeral sector module)

gov.uk publication page states "Published: 15 October 2024", matching the same-day Hansard statement HCWS132. The Chair expedited this module ahead of the rest of Phase 2 following reports of neglect at a funeral home in Hull.

Source
15 Oct 2024
Government response to Phase 1 report recommendations (Wes Streeting statement, HCWS132)

Confirms the Trust published an assurance statement on implementation of the Phase 1 recommendations in February 2024; announced the same-day publication of the Phase 2 interim report.

Source
15 Jul 2025
Phase 2 (final) report published (HC 1092)

75 recommendations in total (19 for NHS trusts, 25 for local authorities, 31 for other settings). Same-day Hansard statement by Wes Streeting, HCWS824. Referred to in the Terms of Reference as the "final report".

Source
16 Dec 2025
Government interim update on progress responding to Phase 2 recommendations

Statement by Dr Zubir Ahmed, HCWS1173: "solid progress" on 54 of 75 recommendations (11 accepted in full, 43 relating to NHS/local authority mortuaries requiring further work, 21 still under consideration). Full government response due "Summer 2026" - not yet located as of this research (25 Aug 2026).

Source
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
- 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).
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
- 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).
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
- 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).
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
- 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).
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
- 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).
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
- 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).
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
- 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).
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
- 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).
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
- 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).
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
- 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).
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
- 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).
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
- 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).
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
- 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).
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
- 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).
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
- 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).
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
- 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).
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
- 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).
Maidstone and Tunbridge Wells NHS Trust (Primary)
View Details