Independent Inquiry into the issues raised by the David Fuller case

All organisations providing anatomical education and training using donors should make sure that policies and procedures are in place to ensure the security and dignity of donors. These should include: security and access policies and the auditing of security and access measures such as swipe card access, CCTV and access to the locations where donors are kept; governance arrangements to ensure effective oversight of and accountability for the security and dignity of donors; a review of contracts or agreements with external organisations for the transfer of donors to or between facilities; and policies and processes on incident reporting, both within the organisation and to the Human Tissue Authority, that are clear and accessible to all students and staff.

Postgraduate training providers using donors should ensure clarity in their governance and information-sharing, in particular where the providers are linked to both university and NHS settings. This clarity should include formal agreements, where relevant, including management, governance and Human Tissue Authority licensing arrangements for the organisations involved.

Local authorities must review all contractual arrangements and agreements with third-party providers of services that care for and transport the deceased. This must include consideration of assurance mechanisms, such as key performance indicators, regular reporting, formal contract review meetings, site visits and stakeholder feedback.

There must be a contractual requirement to formally notify the contract manager and senior local authority officers of any incidents involving the deceased, as well as the outcome of inspections or other action by the Human Tissue Authority or others with an oversight role, such as the Health and Safety Executive.

Local authorities must ensure that the providers they contract or enter into agreements with have robust governance processes in place to oversee the services they provide. This should include Standard Operating Procedures that protect the security and dignity of the deceased and audits to ensure staff compliance with them, as well as the reporting of incidents.

The UK government should establish an independent statutory regulatory regime for funeral directors in England as a matter of urgency in order to safeguard the security and dignity of the deceased. This regime should include a licensing scheme, mandatory standards against which funeral directors should be inspected regularly, and enforcement powers.

The standards should include details of mandatory information to be given to customers by funeral directors to provide transparency about the care of the deceased, including information on measures to protect their security and dignity, and what should be expected of funeral directors' services.

Direct cremation businesses should also be considered in this context, and mandatory standards to protect the security and dignity of the deceased should be applied to these businesses and to any emerging new models of delivery of care for the deceased.

While the introduction of a proportionate statutory regulation and inspection regime may require significant adjustment by funeral director organisations, it is the view of the Inquiry that the benefit to customers and the need for public confidence outweigh the difficulties that may be experienced by some businesses.

Where organisations work together to care for people after death, the arrangements should be formalised through contracts or service level agreements. This should include joint Standard Operating Procedures. The parties to the contracts or service level agreements should ensure that the contracts or agreements are managed effectively, and that they seek assurance that the arrangements protect the security and dignity of people after death.

The Chief Coroner should review the difference in practice between coronial areas as soon as possible to ensure that: All coroners are informed of the findings of this Inquiry. All coroners are aware of the prevalence of offending by David Fuller against deceased people who were formally under the control of the coroner. All coroners understand the importance of a consistent approach to ensuring the security and dignity of deceased people who are under their control. This is likely to require guidance from the Chief Coroner to ensure that there is a consistent approach nationally, and it should be considered an area for further training for all coroners and their staff.

The UK government should establish an independent statutory regulatory regime, headed by a Chief Inspector, for those who store and care for deceased people. The purpose of the regulatory regime should be to ensure that the security and dignity of deceased people are protected, in whichever institutions or locations they are cared for, examined or stored. The government should ensure that this role is adequately resourced to discharge its responsibilities and should provide it with powers to require information and enter premises and to take appropriate enforcement action (including against office holders in any organisation). Either the Human Tissue Authority should be required to work under the auspices of this new regime, or its remit should be formally expanded to comply with the statutory regime's requirements.

In the interim, the government should immediately appoint a Commissioner for the Dignity of the Deceased who should immediately issue universal guidance that applies to all those who store and care for deceased people. This guidance should set out expectations for the security and dignity of deceased people.

The government should amend the Human Tissue Act 2004 so that the organisation holding the licence has primary legal responsibility to ensure that: There is a suitable Designated Individual in place at their establishment. Suitable premises are provided and maintained. Suitable individuals are employed. All relevant legal and regulatory duties pertaining to the licence are met.

The Human Tissue Authority, and/or the new inspectorate, should require the organisations it licenses to ensure that any individual who provides care to deceased people is suitably qualified, experienced and supervised. The regulatory regime should set minimum standards on the qualifications likely to be considered sufficient to demonstrate 'suitability' for particular roles or levels of responsibility. Failure to ensure that suitable individuals are employed would be subject to regulatory enforcement.