Independent Inquiry into the issues raised by the David Fuller case

All NHS trusts with mortuaries and/or body stores should commission a specialist strategic review of the systems in place to protect deceased people, which should include a detailed risk assessment of the potential breaches of security that could occur. The review should include an assessment of: the systems in place to identify any unauthorised access to the facility; the strength and effectiveness of barriers to prevent unauthorised access to the facilities; the systems in place to identify any access to deceased people for unauthorised purposes; and how CCTV is used, including its monitoring and any audits undertaken.

All NHS trusts should install CCTV inside the mortuary, with cameras facing all doors and access points, the reception area and the doors of body fridges, while maintaining the security and dignity of deceased people by implementing the appropriate safeguards. Where double-ended fridges also open into the post-mortem room, NHS trusts should install CCTV cameras inside the post-mortem room that focus on the doors to the fridges.

All NHS trusts should consider putting in place systemic operational barriers that prevent the security and dignity of deceased people being compromised. An example of this would be implementation of a rule that prevents electronic devices such as phones or cameras being taken into a mortuary, other than for approved reasons.

All NHS trusts should take every breach of security in a mortuary or body store extremely seriously. Each security incident should be reviewed by a security expert who is able to identify any systemic security issues associated with the incident. A detailed action plan should be developed for each security breach, no matter how minor trusts regard such breaches to be. All security breaches occurring in mortuaries should be incorporated into security reports provided to trust boards or relevant subcommittees, in line with security breaches in other vulnerable areas.

NHS trusts should ensure that senior managers, including the Chief Executive, have a clear understanding of the role of the Designated Individual, their lines of accountability, and the individual legal responsibility associated with being a Designated Individual.

All NHS trusts should establish a routine reporting system for matters relating to mortuaries and body stores. This reporting system should include the presentation of a formal report, by the accountable executive director, to the trust board on a routine basis. The accountable executive director should prepare and present to the trust board a formal annual report, similar to the annual safeguarding report. The report should include: staffing matters; security incidents; all serious incidents; Human Tissue Authority reports (where applicable); and all security audits, including audits of access and any access breaches.

Where unsupervised access is permitted for a legitimate and unavoidable purpose, there should be individualised electronic access controls to enter the mortuary and restrict access to specific areas of the mortuary, such as the post-mortem room. There should be a requirement to 'swipe to exit' to ensure that all activity is auditable. There should be no shared electronic access controls.

Where people other than mortuary staff are visiting the mortuary during working hours, for example contractors, cleaners and other visitors: Access must be limited to specific areas required for the purposes of their work or visit. They must be supervised when working in areas where there is access to deceased people, for example in the fridge or post-mortem rooms. Their attendance must be recorded and audited.

Where mortuary staff are permitted to work alone in the mortuary, there should be a review of lone working policies, including consideration of activities involving direct handling of the deceased, alongside mitigations that can be put in place to safeguard the security and dignity of the deceased, such as CCTV.

Routine and regular audits of security must be conducted, encompassing both access to and exit from the mortuary and movement within it, including the post-mortem room. Access data must be reconciled against CCTV footage. Audits must be reported to the Designated Individual and head of service or equivalent.

Immediate steps must be taken to commission a specialist strategic review of the systems in place to protect the deceased, which should include a detailed risk assessment of the potential breaches of security that could occur. The review should include an assessment of: the systems in place to identify unauthorised access to the facility; the strength and effectiveness of barriers to prevent unauthorised access to the facility; the systems in place to identify any inappropriate access to the deceased; and how CCTV is used, including its monitoring and any audits undertaken.

CCTV must be installed inside the mortuary facing all doors and access points, the reception area and the doors of all fridges containing deceased people, including where these are accessible from within the post-mortem room. Local authorities must put appropriate safeguards in place to maintain the security and dignity of the deceased in relation to the monitoring of CCTV. CCTV footage should be regularly reviewed. This should be done by mortuary staff where it is of a sensitive nature.

There must be an investigation into the root cause of each security breach. Each incident, the investigation and action plan must be reported to director level within the local authority as a minimum. Serious security breaches must also be reported to the relevant cabinet member and/or committee of elected members.

There must be audits of the mortuary Standard Operating Procedures and compliance with Human Tissue Authority requirements, undertaken annually as a minimum, with a clear record of authorisation by the Designated Individual, head of service or equivalent. Audits of staff compliance with the Standard Operating Procedures must be undertaken at least annually, with the results of the audits reported to the Designated Individual and head of service or equivalent.

There must be a review of the management and oversight arrangements for the mortuary service, taking into consideration who is appointed as the Designated Individual, their direct contact with the mortuary, level of influence within the local authority, and attendance at governance forums. In particular: Local authorities must ensure that the Designated Individual has enough time and resource to fulfil their statutory responsibilities, including time for learning and development. The Designated Individual must have access to director-level officers in the local authority. The Designated Individual must also be able to directly raise issues in relation to the mortuary at the highest level within the local authority if they deem it is necessary. Where the Designated Individual is non-technically trained, a senior anatomical pathology technologist must fulfil the Mortuary Manager role to ensure that there is sufficient technical experience within the mortuary. The Designated Individual must attend regular, documented meetings at mortuary level. The Designated Individual must also attend governance forums where the mortuary is discussed and scrutinised. In line with Human Tissue Authority guidance, the named Licence Holder must be at a more senior level than the Designated Individual (e.g. director level or higher) and have a clear understanding of the Human Tissue Authority's statutory requirements and the role of the Designated Individual.

The mortuary service must be treated in the same way as other regulatory services within local authority reporting structures: The mortuary must be visible to scrutiny at the relevant statutory committee, with regular reporting. Key performance indicators must be identified and must include the results of audits of compliance with Human Tissue Authority requirements. Inspections by the Human Tissue Authority and Human Tissue Authority Reportable Incidents (HTARIs) must be reported to the relevant statutory committee, and actions to achieve compliance monitored.

The mortuary service must be reviewed by professional auditors at least biennially, with the results of the audit reported to a formal committee regardless of the level of assurance. Local authorities must arrange a peer review of the mortuary service at least every three years.

All relevant reports and incidents concerning the mortuary must be made known to the lead local authority manager for the coroner service (and the Senior Coroner if they wish to see these reports). Local authorities that are not the lead authority for the coroner service must also share these reports and incidents with the coroner service lead in that coroner area.

Local authorities providing an unlicensed body store must be prepared to comply with the Human Tissue Authority's standards and guidance where applicable, in the event that a Human Tissue Authority licence is required to enable activities outside Human Tissue Authority licensing exemptions.