Reports & recommendations
92 recommendations from 2 reports, each with the government response on the record. Filter by government response, report or delivery status.
Reports (3)
| Title | Volume | Publication Date | Recommendations | Links |
|---|---|---|---|---|
| Fuller Inquiry Phase 2 Interim Report – Funeral Sector | - | 15 Oct 2024 | 0 | |
| Fuller Inquiry Phase 1 Report | - | 28 Nov 2023 | 17 | |
| Fuller Inquiry Phase 2 Report | - | 15 Jul 2025 | 75 |
Recommendations (92)
Non-mortuary staff accompanied in mortuary
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 should undertake tasks in the mortuary in pairs.
In October 2024, Wes Streeting, Secretary of State for Health and Social Care, reported that Maidstone and Tunbridge Wells NHS Trust requires non-mortuary staff and contractors to always be accompanied by another staff member, with swipe-card controls in place and NHS England monitoring ongoing compliance (Wes Streeting response, Oct 2024). In February 2024, the Trust stated that it complied with the recommendation in full, as external contractors and maintenance staff are always accompanied by mortuary staff when visiting the mortuary (Maidstone and Tunbridge Wells NHS Trust response, Feb 2024). The record holds no update since the Secretary of State's response of October 2024 (Wes Streeting response, Oct 2024).
No deceased left out of fridges overnight
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 not happen.
In October 2024, the Secretary of State for Health and Social Care, Wes Streeting, reported that Maidstone and Tunbridge Wells NHS Trust had set out its progress in an assurance statement, adding that NHS England would monitor ongoing compliance through regular oversight meetings (Wes Streeting response, Oct 2024). In its February 2024 statement, the Trust stated that it complies with the recommendation in full, having ceased the practice of leaving deceased people out of mortuary fridges in early 2021, formalised that prohibition in local policy, and addressed regulatory shortfalls identified by the Human Tissue Authority (Maidstone and Tunbridge Wells NHS Trust response, Feb 2024). The record holds no update since the Minister's response of October 2024 (Wes Streeting response, Oct 2024).
Criminal record checks compliance
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 or other contractors are subject to the same requirements.
In October 2024, the Secretary of State for Health and Social Care, Wes Streeting, reported that Maidstone and Tunbridge Wells NHS Trust had mandated contractors to renew security clearances every three years, with ongoing compliance monitored by NHS England (Wes Streeting response, Oct 2024). The Trust had stated in February 2024 that it "complies with this recommendation in full", reporting that internal reviews showed no staff had an outstanding check without actively engaging in renewal (Maidstone and Tunbridge Wells NHS Trust response, Feb 2024). The record holds no update since the Minister's response of October 2024 (Wes Streeting response, Oct 2024).
Mortuary Managers qualified and supported
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 be adequately managed and supported.
In October 2024, Wes Streeting reported that Maidstone and Tunbridge Wells NHS Trust had set out its progress in an assurance statement, with NHS England monitoring ongoing compliance (Wes Streeting response, Oct 2024). In that February 2024 statement, the Trust stated that it complied with the recommendation in full after establishing a Care After Death Directorate and setting qualification requirements for its Mortuary Manager (Maidstone and Tunbridge Wells NHS Trust response, Feb 2024). The record holds no update since the Department of Health and Social Care's response of October 2024 (Wes Streeting response, Oct 2024).
Mortuary Manager as full-time dedicated role
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 level of management attention.
In October 2024, the Secretary of State for Health and Social Care, Wes Streeting, relayed Maidstone and Tunbridge Wells NHS Trust's February 2024 assurance statement, in which the Trust stated that it "complies with this recommendation in full" by maintaining the Mortuary Manager as a full-time dedicated role (Maidstone and Tunbridge Wells NHS Trust response, Feb 2024; Wes Streeting response, Oct 2024). In the same October 2024 statement, the Minister noted that NHS England would monitor ongoing compliance through regular regional oversight meetings (Wes Streeting response, Oct 2024). The record holds no update since the Department of Health and Social Care's response of October 2024 (Wes Streeting response, Oct 2024).
Review policies on mortuary access
Maidstone and Tunbridge Wells NHS Trust must review its policies to ensure that only those with appropriate and legitimate access can enter the mortuary.
In October 2024, Wes Streeting reported that Maidstone and Tunbridge Wells NHS Trust controls mortuary access using swipe cards and requires non-mortuary staff and contractors to be accompanied by another staff member (Wes Streeting response, Oct 2024). The Trust had stated in February 2024 that it complies with the recommendation in full, having withdrawn general access cards and restricted mortuary entry to authorized personnel and trained porters (Maidstone and Tunbridge Wells NHS Trust response, Feb 2024). The record holds no update since the Department of Health and Social Care's response of October 2024 (Wes Streeting response, Oct 2024).
Audit and monitor mortuary access
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.
Wes Streeting, Secretary of State for Health and Social Care, reported in October 2024 that Maidstone and Tunbridge Wells NHS Trust was controlling mortuary access using swipe cards, requiring non-mortuary staff and contractors to be accompanied, and monitoring access with CCTV (Wes Streeting response, Oct 2024). The Trust had stated in February 2024 that it complied in full with the recommendation through weekly card deactivations and monthly access reviews, though a local standard operating procedure for mortuary access audits still required review (Maidstone and Tunbridge Wells NHS Trust response, Feb 2024). The record holds no update since the Department of Health and Social Care's response of October 2024 (Wes Streeting response, Oct 2024).
Security as corporate responsibility
Maidstone and Tunbridge Wells NHS Trust should treat security as a corporate not a local departmental responsibility.
In October 2024, Wes Streeting, Secretary of State for Health and Social Care, informed Parliament that the Trust had set out its progress in a February 2024 assurance statement, and noted that NHS England had held monthly regional meetings to oversee compliance (Wes Streeting response, Oct 2024). In that February 2024 statement, Maidstone and Tunbridge Wells NHS Trust stated that it "now complies with this recommendation in full", having transferred executive responsibility for security to the Chief Operating Officer, appointed a Head of Security Management, and re-established a Trust Security Committee (Maidstone and Tunbridge Wells NHS Trust response, Feb 2024). The record holds no update since the Secretary of State for Health and Social Care's response of October 2024 (Wes Streeting response, Oct 2024).
CCTV in mortuary including post-mortem room
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.
In October 2024, the Secretary of State for Health and Social Care reported to Parliament that Maidstone and Tunbridge Wells NHS Trust had installed CCTV coverage monitoring access to and from mortuary areas, with ongoing compliance monitored by NHS England (Wes Streeting response, Oct 2024). The Trust had stated in February 2024 that it complied with the recommendation in full, having installed CCTV cameras across its mortuaries in 2020 and within the post-mortem room at Tunbridge Wells Hospital in 2021 (Maidstone and Tunbridge Wells NHS Trust response, Feb 2024). The record holds no update since the Secretary of State's response of October 2024 (Wes Streeting response, Oct 2024).
Regular CCTV review with swipe card data
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.
In October 2024, Wes Streeting, Secretary of State for Health and Social Care, reported that Maidstone and Tunbridge Wells NHS Trust had controlled mortuary access using swipe cards and installed CCTV coverage, with NHS England monitoring ongoing compliance (Wes Streeting response, Oct 2024). The Trust had stated in February 2024 that it complies with the recommendation in full, detailing monthly swipe card checks against CCTV footage when anomalies occur, regular random CCTV reviews, and an extended 38-day image retention period (Maidstone and Tunbridge Wells NHS Trust response, Feb 2024). The record holds no update since the department's response of October 2024 (Wes Streeting response, Oct 2024).
Share HTA reports with reliant organisations
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.
In October 2024, the Secretary of State for Health and Social Care, Wes Streeting, reported that Maidstone and Tunbridge Wells NHS Trust had set out its progress in an assurance statement, and noted that NHS England would monitor ongoing compliance with the Inquiry's recommendations (Wes Streeting response, Oct 2024). In that February 2024 statement, the Trust stated that it "now complies with this recommendation in full" by proactively sharing Human Tissue Authority reports with Kent County Council, East Sussex County Council, and the Kent & Medway Integrated Care Board (Maidstone and Tunbridge Wells NHS Trust response, Feb 2024). The record holds no update since the Department of Health and Social Care's response of October 2024 (Wes Streeting response, Oct 2024).
Local authorities examine contractual arrangements
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.
In October 2024, Wes Streeting, Secretary of State for Health and Social Care, reported that Kent County Council and East Sussex County Council had reviewed contractual arrangements with Maidstone and Tunbridge Wells NHS Trust and confirmed that the contracts require licensing and regulatory standards to be met to ensure the deceased are treated with dignity and respect (Wes Streeting response, Oct 2024). Earlier, in February 2024, the Trust stated that contract discussions were underway to ensure arrangements protect the deceased, including a requirement to share inspection reports from the Human Tissue Authority (Maidstone and Tunbridge Wells NHS Trust response, Feb 2024). The record holds no update since the Department of Health and Social Care's response of October 2024 (Wes Streeting response, Oct 2024).
Board review governance - assurance not reassurance
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.
In October 2024, the Secretary of State for Health and Social Care, Wes Streeting, reported that the board of Maidstone and Tunbridge Wells NHS Trust was providing greater oversight and assurance, noting that NHS England would monitor ongoing compliance through regular regional meetings (Wes Streeting response, Oct 2024). The Trust had stated in February 2024 that it complied with the recommendation in full, having agreed governance changes following an independent review by Deloitte (Maidstone and Tunbridge Wells NHS Trust response, Feb 2024). The record holds no update since the Minister's response of October 2024 (Wes Streeting response, Oct 2024).
Board oversight of licensed mortuary activity
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.
In October 2024, the Secretary of State for Health and Social Care, Wes Streeting, reported that Maidstone and Tunbridge Wells NHS Trust Board was providing greater oversight and assurance of legally regulated activity in the mortuary, with ongoing compliance monitored by NHS England (Wes Streeting response, Oct 2024). The Trust had stated in February 2024 that it complied with the recommendation in full, having established regular board reports and multiple direct reporting routes for the Designated Individual (Maidstone and Tunbridge Wells NHS Trust response, Feb 2024). The record holds no update since the Minister's response of October 2024 (Wes Streeting response, Oct 2024).
Treat HTA compliance as Trust statutory responsibility
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 Act will be subject to review in Phase 2 of the Inquiry's work.
In October 2024, Wes Streeting, Secretary of State for Health and Social Care, reported that Maidstone and Tunbridge Wells NHS Trust was providing greater board oversight of legally regulated mortuary activity, with NHS England monitoring ongoing compliance (Wes Streeting response, Oct 2024). The Trust had previously stated in February 2024 that it complied with the recommendation in full, noting that the Human Tissue Authority was satisfied all inspection shortfalls had been corrected (Maidstone and Tunbridge Wells NHS Trust response, Feb 2024). The record holds no update since the department's response of October 2024 (Wes Streeting response, Oct 2024).
Chief Nurse responsible for mortuary assurance
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.
In October 2024, Wes Streeting, Secretary of State for Health and Social Care, reported that Maidstone and Tunbridge Wells NHS Trust was providing greater board oversight of mortuary activity, with NHS England monitoring ongoing compliance (Wes Streeting response, Oct 2024). The Trust had previously stated in February 2024 that it complied with the recommendation in full, having amended the Chief Nurse's job description to make mortuary assurance explicit and established a Care After Death workstream (Maidstone and Tunbridge Wells NHS Trust response, Feb 2024). The record holds no update since the Minister's response of October 2024 (Wes Streeting response, Oct 2024).
Deceased treated with same dignity as patients
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.
In October 2024, Wes Streeting, Secretary of State for Health and Social Care, reported that Maidstone and Tunbridge Wells NHS Trust had strengthened mortuary access controls and board oversight, with NHS England monitoring ongoing compliance (Wes Streeting response, Oct 2024). The Trust had stated in February 2024 that it complied in full with the recommendation, having adopted a safeguarding definition for the deceased and introduced dignity measures including mortuary preparation packs (Maidstone and Tunbridge Wells NHS Trust response, Feb 2024). The record holds no update since the Department of Health and Social Care's response of October 2024 (Wes Streeting response, Oct 2024).
NHS trusts commission specialist security review
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.
In July 2026, Parliamentary Under-Secretary of State Preet Kaur Gill reported that NHS England had issued a national system letter setting out the actions expected of trusts to ensure improvements are delivered consistently (Preet Kaur Gill, Jul 2026). In June 2026, it had confirmed that new self-assessment questions reflecting inquiry recommendations were incorporated into the Premises Assurance Model, with submissions open until September 2026 (NHS England, Jun 2026). Earlier, in December 2025, the Department of Health and Social Care accepted the recommendation in principle subject to further work to determine its full impact (Department of Health and Social Care response, Dec 2025).
CCTV in all NHS mortuaries
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.
In July 2026, Parliamentary Under-Secretary of State Preet Kaur Gill reported that NHS England had issued a national system letter setting out expected actions for providers (Preet Kaur Gill, Jul 2026). In an annex to that letter issued in June 2026, it noted that mortuary building standards were updated in 2023 to improve security and CCTV, but stated it "will be providing further update during 2026 to provide additional guidance to NHS trusts" (NHS England, Jun 2026). Previously, the Department of Health and Social Care confirmed in December 2025 that the government had accepted the recommendation in principle subject to further work to determine its full impact (Department of Health and Social Care response, Dec 2025).
Audit access data for deceased storage
All NHS trusts should routinely audit the access data of all facilities used to store deceased people.
In July 2026, Parliamentary Under-Secretary of State Preet Kaur Gill reported that NHS England had issued a national system letter detailing actions expected of trusts to ensure consistent improvements (Preet Kaur Gill, Jul 2026). In its June 2026 letter, it mapped the recommendation to supporting guidance, including the Premises Assurance Model and relevant standards for mortuary facilities (NHS England, Jun 2026). Previously, the Department of Health and Social Care accepted the recommendation in principle in December 2025 "subject to further work to determine the full impact" (Department of Health and Social Care response, Dec 2025).
End shared swipe cards
The practice of using shared electronic swipe cards for specific staff groups should cease immediately.
In July 2026, Parliamentary Under-Secretary of State Preet Kaur Gill reported that NHS England had issued a national system letter setting out the actions expected of trusts and providers to ensure consistent improvements (Preet Kaur Gill, Jul 2026). In its June 2026 letter, it mapped this recommendation to supporting guidance, including the NHS Premises Assurance Model and mortuary facilities guidance (NHS England, Jun 2026). Earlier, in December 2025, the Department of Health and Social Care accepted the recommendation in principle, "subject to further work to determine the full impact" (Department of Health and Social Care response, Dec 2025).
Operational barriers including device restrictions
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.
In July 2026, Parliamentary Under-Secretary of State Preet Kaur Gill reported that NHS England had issued a national system letter setting out the actions expected of trusts and providers to ensure improvements are delivered consistently (Preet Kaur Gill, Jul 2026). In its June 2026 letter, it mapped this recommendation alongside others on mortuary security, access, and audit to supporting materials, including the Premises Assurance Model and Health Building Note 16-01 (NHS England, Jun 2026). The Department of Health and Social Care had earlier accepted the recommendation in principle in December 2025, "subject to further work to determine the full impact of these recommendations" (Department of Health and Social Care response, Dec 2025).
Security breaches reviewed by expert with action plans
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.
In July 2026, the Department of Health and Social Care's Parliamentary Under-Secretary of State, Preet Kaur Gill, reported that NHS England had issued a national system letter setting out actions expected of trusts to ensure consistent improvements (Preet Kaur Gill, Jul 2026). In its June 2026 letter, it mapped this recommendation to supporting guidance, including the NHS Premises Assurance Model, Health Building Note 16-01, and Human Tissue Authority guidance (NHS England, Jun 2026). Previously, the department stated in December 2025 that the government had agreed to accept the recommendation in principle "subject to further work to determine the full impact" (Department of Health and Social Care response, Dec 2025).
Body store security standards match HTA-licensed facilities
The NHS should ensure that the security standards required for body stores are the same as those required for facilities licensed by the Human Tissue Authority.
In July 2026, Parliamentary Under-Secretary of State Preet Kaur Gill reported that a national system letter had been issued setting out expected actions for NHS trusts to deliver improvements consistently (Preet Kaur Gill, Jul 2026). NHS England had previously mapped this recommendation in June 2026 to supporting guidance, including its Premises Assurance Model and Human Tissue Authority standards (NHS England, Jun 2026). In December 2025, the Department of Health and Social Care accepted the recommendation in principle "subject to further work to determine the full impact" (Department of Health and Social Care response, Dec 2025). Earlier, in July 2025, Dr Colin Sullivan of the regulator stated that it had piloted an assessment model for unlicensed body stores and set clear expectations on security measures (Dr Colin Sullivan, Jul 2025).
Swipe to exit for mortuaries
All NHS trusts should consider the installation of 'swipe to exit' for mortuary facilities. This would allow trusts to monitor and audit entry and exit, as well as time spent in the mortuary.
In July 2026, Parliamentary Under-Secretary of State for Health Innovation and Safety Preet Kaur Gill reported that NHS England had issued a national system letter detailing actions expected of trusts to deliver improvements consistently (Preet Kaur Gill, Jul 2026). In that June 2026 letter, it mapped this mortuary access recommendation to supporting guidance, including the Premises Assurance Model, Health Building Note 16-01, and Human Tissue Authority guidance (NHS England, Jun 2026). Previously, the Department of Health and Social Care accepted the recommendation in principle in December 2025, subject to further work to determine its full impact (Department of Health and Social Care response, Dec 2025).
Monitor and review staff access numbers
All NHS trusts should monitor the number of staff with access to the mortuary or body store and keep this under routine review.
In July 2026, Parliamentary Under-Secretary of State Preet Kaur Gill reported that NHS England had issued a national system letter setting out actions expected of trusts to ensure improvements are delivered consistently (Preet Kaur Gill, Jul 2026). In that June 2026 letter, it mapped the recommendation to supporting guidance, including the NHS Premises Assurance Model and Health Building Note 16-01 (NHS England, Jun 2026). Previously, in December 2025, the Department of Health and Social Care accepted the recommendation in principle "subject to further work to determine the full impact" (Department of Health and Social Care response, Dec 2025).
Designated Individuals adequate time and resource
NHS trusts should ensure that Designated Individuals have enough time and resource to fulfil their responsibilities, including time for learning and development.
In July 2026, Parliamentary Under-Secretary of State Preet Kaur Gill stated that NHS England had issued a national system letter setting out actions expected of trusts to ensure improvements are delivered consistently (Preet Kaur Gill, Jul 2026). In June 2026, it mapped this recommendation to third-party Human Tissue Authority guidance on the role of the Designated Individual (NHS England, Jun 2026). The Department of Health and Social Care had accepted the recommendation in principle in December 2025, "subject to further work to determine the full impact of these recommendations" (Department of Health and Social Care response, Dec 2025).
Senior managers understand DI role and accountability
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.
In July 2026, Parliamentary Under-Secretary of State Preet Kaur Gill reported that NHS England had issued a national system letter setting out the actions expected of trusts to ensure consistent improvements (Preet Kaur Gill, Jul 2026). In an annex to that letter in June 2026, it mapped this recommendation to Human Tissue Authority guidance covering the role of the Designated Individual (NHS England, Jun 2026). Previously, the Department of Health and Social Care agreed in December 2025 to accept the recommendation in principle "subject to further work to determine the full impact" (Department of Health and Social Care response, Dec 2025).
DI attendance at governance forums
NHS trusts should ensure that Designated Individuals attend the correct governance forums. This would allow them to escalate issues and risks, as well as reporting upwards when required.
In July 2026, Parliamentary Under-Secretary of State Preet Kaur Gill reported that NHS England had issued a national system letter setting out actions expected of trusts (Preet Kaur Gill, Jul 2026). In its June 2026 letter, it mapped the recommendation to Human Tissue Authority guidance regarding the role of the Designated Individual (NHS England, Jun 2026). The Department of Health and Social Care had earlier accepted the recommendation in principle in December 2025, subject to further work to determine its full impact (Department of Health and Social Care response, Dec 2025).
Mortuary Manager professional background prerequisite
A professional background in the field of mortuary services should be made a prerequisite for the post of Mortuary Manager.
In July 2026, Parliamentary Under-Secretary of State for Health Innovation and Safety Preet Kaur Gill stated that NHS England had issued a national system letter setting out actions expected of trusts to ensure consistent improvements (Preet Kaur Gill, Jul 2026). In its June 2026 letter, it mapped this recommendation on the mortuary manager role to supporting guidance covering local HR policies and resource allocations (NHS England, Jun 2026). Earlier, in December 2025, the Department of Health and Social Care recorded that the government had agreed to accept the recommendation in principle, "subject to further work to determine the full impact" (Department of Health and Social Care response, Dec 2025).
Mortuary Manager adequate resources and support
NHS trusts should assure themselves that the Mortuary Manager has adequate resources and support to perform their role effectively, including meeting any reporting requirements.
In July 2026, Parliamentary Under-Secretary of State for Health Innovation and Safety Preet Kaur Gill reported that NHS England had issued a national system letter setting out expected actions for trusts to ensure consistent improvements (Preet Kaur Gill, Jul 2026). In June 2026, it had mapped this recommendation to supporting guidance on local human resources policies and resource allocations (NHS England, Jun 2026). Previously, the Department of Health and Social Care agreed in December 2025 to accept the recommendation in principle, subject to further work to determine its full impact (Department of Health and Social Care response, Dec 2025).
Routine mortuary reporting to trust boards
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.
In July 2026, Parliamentary Under-Secretary of State Preet Kaur Gill of the Department of Health and Social Care stated that NHS England had issued a national system letter setting out expected actions for trusts (Preet Kaur Gill, Jul 2026). In that June 2026 letter, its Chief Nursing Officer Duncan Burton and Chief Operating Officer Sarah-Jane Marsh asked provider trusts managing mortuaries or post-death care to return a Board Assurance Statement by 31 July 2026 (Duncan Burton, Jun 2026). Previously, in December 2025, the department agreed to accept the recommendation in principle, subject to further work to determine its full impact (Department of Health and Social Care response, Dec 2025).
Trust boards assure recommendation implementation
Trust boards should assure themselves that the recommendations in this Report have been implemented.
In July 2026, Parliamentary Under-Secretary of State Preet Kaur Gill stated that NHS England had issued a national system letter setting out actions expected of trusts to ensure consistent delivery of improvements (Preet Kaur Gill, Jul 2026). In its June 2026 letter, it mapped the recommendation to supporting guidance, including the Insightful provider board guide (NHS England, Jun 2026). Previously, the Department of Health and Social Care accepted the recommendation in principle in December 2025, "subject to further work to determine the full impact of these recommendations" (Department of Health and Social Care response, Dec 2025).
Recommendations apply to temporary facilities
Trust boards should ensure that these recommendations and governance arrangements are applied to any temporary facilities used by trusts for the storage and care of deceased people.
In July 2026, Parliamentary Under-Secretary of State for Health Innovation and Safety Preet Kaur Gill reported that NHS England had issued a national system letter outlining actions expected of trusts, noting that the Department of Health and Social Care remained committed to providing a full response (Preet Kaur Gill, Jul 2026). In an annex to that June 2026 letter, it mapped recommendation 17 alongside related board assurance recommendations to supporting guidance on board capability and reporting (NHS England, Jun 2026). Previously, in December 2025, the department accepted the recommendation in principle "subject to further work to determine the full impact" (Department of Health and Social Care response, Dec 2025).
Mortuaries treated as regulated activity in governance
Trust boards should take note of the fact that mortuary services are subject to statutory regulation and should be treated with equivalent regard to other regulated activities within trust governance arrangements.
Preet Kaur Gill, Parliamentary Under-Secretary of State for Health Innovation and Safety, reported in July 2026 that NHS England had issued a national system letter setting out actions expected of trusts to ensure improvements are delivered consistently (Preet Kaur Gill, Jul 2026). In June 2026, it had mapped this recommendation to supporting board guidance, including "The Insightful provider board guide" and provider capability guidance (NHS England, Jun 2026). The Department of Health and Social Care had previously accepted the recommendation in principle in December 2025, subject to further work to determine its full impact (Department of Health and Social Care response, Dec 2025).
Deceased included in safeguarding training and policy
NHS trust boards should ensure that the security and dignity of deceased people are included in safeguarding training, policies and assurance.
In July 2026, Parliamentary Under-Secretary of State for Health Innovation and Safety Preet Kaur Gill stated that NHS England had issued a national system letter setting out actions expected of trusts to ensure improvements are delivered consistently (Preet Kaur Gill, Jul 2026). In that June 2026 letter, it mapped the recommendation to supporting guidance in the NHS Safeguarding Accountability and Assurance Framework (NHS England, Jun 2026). Previously, in December 2025, the Department of Health and Social Care accepted the recommendation in principle subject to further work to determine its full impact (Department of Health and Social Care response, Dec 2025).
Chief Nurse responsibility for deceased safeguarding
The remit of the Chief Nurse in NHS trusts should explicitly include executive responsibility for safeguarding the security and dignity of deceased people in NHS mortuaries and body stores.
In July 2026, Parliamentary Under-Secretary of State for Health Innovation and Safety Preet Kaur Gill reported that NHS England had issued a national system letter detailing actions expected of trusts to deliver improvements consistently (Preet Kaur Gill, Jul 2026). In that June 2026 letter, it mapped this recommendation to its Safeguarding Accountability and Assurance Framework as supporting guidance (NHS England, Jun 2026). The Department of Health and Social Care had previously accepted the recommendation in principle in December 2025, stating that acceptance was "subject to further work to determine the full impact of these recommendations" (Department of Health and Social Care response, Dec 2025).
NHS England incorporate deceased in safeguarding framework
NHS England should formally incorporate the safeguarding of deceased people into its safeguarding framework for NHS trusts.
In July 2026, Parliamentary Under-Secretary of State Preet Kaur Gill stated that NHS England had issued a national system letter setting out actions expected of trusts and providers (Preet Kaur Gill, Jul 2026). It reported in June 2026 that its safeguarding framework "was updated to include reference to the deceased" in April 2026 (NHS England, Jun 2026). Earlier, in December 2025, the Department of Health and Social Care accepted the recommendation in principle, noting that further work was required to determine the full impact (Department of Health and Social Care response, Dec 2025).
Independent sector SOPs for deceased patients
Independent sector healthcare providers should ensure that there are Standard Operating Procedures and policies in place to protect the security and dignity of any patients that die under their care. Wherever possible, deceased patients' rooms should be kept locked. Providers should also ensure that staff are aware of the need to protect the security and dignity of deceased patients and are able to assess and mitigate risks to this.
In June 2026, the Department of Health and Social Care reported that work on the recommendation was in progress following meetings with the Independent Healthcare Provider Network, whose members confirmed they had taken action on the report (Department of Health and Social Care, Jun 2026). The department stated that the network was considering how to ensure assurance against these actions, and that it had also engaged independent inpatient mental health providers to ensure they were aware of the recommendations and taking appropriate measures (Department of Health and Social Care, Jun 2026).
Independent sector accompanied access to deceased
Independent sector healthcare providers should ensure that only people who have a legitimate reason to access a room that contains a deceased patient do so, even if they are staff members, and that they are always accompanied.
In June 2026, the Department of Health and Social Care reported that work on the recommendation was in progress, noting that independent healthcare providers had confirmed taking action while the Independent Healthcare Provider Network was still "considering the vehicle to ensure assurance against the actions" (Department of Health and Social Care, Jun 2026). In December 2025, the department had accepted the recommendation in full and confirmed that it had engaged independent inpatient mental health providers alongside the network to ensure awareness and appropriate measures (Department of Health and Social Care response, Dec 2025).
Anatomical education security and dignity policies
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.
The Department of Health and Social Care stated in a June 2026 dashboard update that this recommendation on anatomical education security and dignity policies remained under consideration (Department of Health and Social Care, Jun 2026). In a June 2026 national system letter, NHS England reported that, where relevant to the health service, these actions had been reflected in its Premises Assurance Model (NHS England, Jun 2026).
Postgraduate training governance clarity
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.
The Department of Health and Social Care stated in a government dashboard update in June 2026 that this recommendation on postgraduate training governance remained "under consideration" (Department of Health and Social Care, Jun 2026). In June 2026, NHS England reported in a national system letter to health service trusts and integrated care boards that, where relevant to the NHS, these actions have been reflected in the NHS Premises Assurance Model (NHS England, Jun 2026).
HTA require anatomy adverse incidents reported as HTARIs
The Human Tissue Authority should change its guidance to require that relevant adverse incidents in the anatomy sector are formally reported as Human Tissue Authority Reportable Incidents (HTARIs).
In July 2026, the Human Tissue Authority stated in its annual report that it had "successfully implemented" the recommendation to extend its reportable incident system to the anatomy sector (Human Tissue Authority, Jul 2026). In a written statement that same month, Parliamentary Under-Secretary of State Preet Kaur Gill reported that the authority had instructed mortuaries to review internal records from the last ten years, with findings due to Ministers by 16 October 2026 (Preet Kaur Gill, Jul 2026). The Department of Health and Social Care previously noted in a June 2026 dashboard update that formal guidance had been issued and the updated system went live on 1 December (Department of Health and Social Care, Jun 2026).
Hospice security and access controls
Hospices that care for deceased people on their premises should: introduce auditable access control of the area where deceased people are kept; have Standard Operating Procedures regarding the care of deceased people, including security of and access to the areas where deceased people are kept; and minimise unaccompanied access to areas where deceased people are cared for, wherever possible.
In June 2026, the Department of Health and Social Care reported that work was in progress, noting that it had worked with Hospice UK to ask clinical leaders to review their practices and that sector guidance had been updated to incorporate security measures (Department of Health and Social Care, Jun 2026). Later that month, NHS England notified health service trusts operating hospice services with body stores of this updated guidance alongside revised Human Tissue Authority standards (NHS England, Jun 2026).
CQC guidance on hospice inspection scope
To avoid confusion over its remit, the Care Quality Commission should issue clear guidance to inspectors (and others) that hospice inspections should not include areas where deceased people are kept, other than to focus on the needs of bereaved relatives.
In June 2026, the Department of Health and Social Care reported that the recommendation remained in progress, noting that the Care Quality Commission had issued a rapid update and an internal bulletin to reiterate the limits of mortuary regulation to inspectors (Department of Health and Social Care, Jun 2026). The department stated at that time that the commission was still "working on revising guidance to inspectors" (Department of Health and Social Care, Jun 2026).
Hospices in scope for new regulatory regime
Hospices should be considered in scope for the regulatory measures recommended in Chapter 11.
The Department of Health and Social Care reported in June 2026, in progress entries published by the Cabinet Office, that "This recommendation is under consideration" (Department of Health and Social Care, Jun 2026). This maintained the position taken in the department's December 2025 interim update on progress responding to the phase 2 report, which listed the proposal among 21 recommendations that remained under consideration (Department of Health and Social Care response, Dec 2025).
Ambulance data on conveying deceased
Data on how often deceased patients are conveyed in ambulances, and the reasons for this, should be routinely collected and reported to NHS England, and monitored to assess risk.
NHS England stated in June 2026 that ambulance trusts are individually responsible for introducing operational policies as described in the recommendation and monitoring their use, with boards advised to assess compliance, and noted that a further government update was expected in summer 2026 (NHS England, Jun 2026). Earlier in June 2026, the Department of Health and Social Care reported that relevant data lines had been confirmed in the information standard, with the first routine collection expected to be rolled out in 2026 to 2027 (Department of Health and Social Care, Jun 2026).
Ambulance policy on crew position with deceased
Every NHS ambulance service should have a policy setting out where ambulance crew members should sit when conveying deceased patients. This should include reference to the risk of abuse of deceased patients, as well as training requirements.
In June 2026, NHS England stated that ambulance trusts are individually responsible for introducing operational policies as recommended and monitoring their use, adding that boards should assess compliance and that a further update was expected in summer 2026 (NHS England, Jun 2026). Also in June 2026, the Department of Health and Social Care reported that the Association of Ambulance Chief Executives was discussing with ambulance service leads to ensure all services review their policies on managing the deceased and introduce a clear policy if none currently exists (Department of Health and Social Care, Jun 2026).
Ambulance policies on deceased security and dignity
NHS ambulance services should also have policies regarding the security and dignity of the deceased, including when the deceased should be covered and/or secured. NHS England should monitor that such policies are in place.
In June 2026, NHS England stated that ambulance trusts are individually responsible for introducing operational policies on the security and dignity of the deceased and monitoring their use, and that boards should assess compliance (NHS England, Jun 2026). It also noted that a further update was expected in summer 2026, following a December 2025 report in which the Department of Health and Social Care stated that the Association of Ambulance Chief Executives was working with service leads to review or introduce relevant policies (Department of Health and Social Care response, Dec 2025; NHS England, Jun 2026).
Ambulance photography policies
Every NHS ambulance service must put policies in place regarding taking photographs of deceased patients, including any circumstances in which this may be required, and ensure that ambulance staff are aware of these and comply with them.
NHS England stated in June 2026 that individual ambulance trusts are responsible for introducing operational policies and monitoring their use, with boards expected to assess compliance, while a further government update was expected in summer 2026 (NHS England, Jun 2026). The Department of Health and Social Care previously reported in December 2025 that the Association of Ambulance Chief Executives was working with service leads to ensure all ambulance services review their policies and introduce clear guidance regarding the deceased (Department of Health and Social Care response, Dec 2025).
Recommendations apply to independent ambulances
The Inquiry has focused its investigations into ambulance services on NHS ambulance services. However, the Inquiry considers that these recommendations could also be applied to independent ambulance services, including private ambulances.
The Department of Health and Social Care recorded the recommendation as in progress in June 2026, noting that the Association of Ambulance Chief Executives had alerted the Independent Ambulance Association to the recommendations (Department of Health and Social Care, Jun 2026). It stated that independent ambulance services commissioned under NHS contracts must comply with relevant NHS policies and procedures (Department of Health and Social Care, Jun 2026). For providers operating outside NHS contracts where this requirement does not apply, the department explained that the association had committed to advocate for implementation across the wider sector, noting that it holds no regulatory authority (Department of Health and Social Care, Jun 2026).
Local authority mortuary access review
There should be a process to routinely review who is permitted to access the mortuary unsupervised.
Preet Kaur Gill, Parliamentary Under-Secretary of State for Health Innovation and Safety, stated in July 2026 that ongoing work includes "working with local authorities to support closer alignment with Human Tissue Authority standards on security, governance and audit" (Preet Kaur Gill, Jul 2026). Earlier, in December 2025, the Department of Health and Social Care reported that the government had accepted the recommendation in principle, subject to further work to determine its full impact (Department of Health and Social Care response, Dec 2025).
Local authority individualised access controls
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.
In a July 2026 written statement, Preet Kaur Gill, Parliamentary Under-Secretary of State for Health Innovation and Safety, reported that the government was "working with local authorities to support closer alignment with Human Tissue Authority standards on security, governance and audit" (Preet Kaur Gill, Jul 2026). The Department of Health and Social Care had previously stated in December 2025 that the recommendation was accepted in principle, subject to further work to determine its full impact (Department of Health and Social Care response, Dec 2025).
Local authority visitor supervision
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.
In a July 2026 written statement, Preet Kaur Gill, Parliamentary Under-Secretary of State for Health Innovation and Safety, stated that work included "working with local authorities to support closer alignment with Human Tissue Authority standards on security, governance and audit" (Preet Kaur Gill, Jul 2026). The Department of Health and Social Care had previously reported in an interim update in December 2025 that the government accepted the recommendation in principle, subject to further work to determine its full impact (Department of Health and Social Care response, Dec 2025).
Local authority lone working review
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.
In July 2026, Preet Kaur Gill, Parliamentary Under-Secretary of State for Health Innovation and Safety, stated in a written statement to the House of Commons that work included working with local authorities to support closer alignment with Human Tissue Authority standards on security, governance and audit (Preet Kaur Gill, Jul 2026). This followed an interim update in December 2025 by the Department of Health and Social Care, which recorded that the government had accepted the recommendation in principle "subject to further work to determine the full impact of these recommendations" (Department of Health and Social Care response, Dec 2025).
Local authority security audits
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.
In July 2026, Preet Kaur Gill, Parliamentary Under-Secretary of State for Health Innovation and Safety, stated that work was under way with local authorities to support closer alignment with Human Tissue Authority standards on security, governance and audit (Preet Kaur Gill, Jul 2026). The Department of Health and Social Care previously noted in December 2025 that the government accepted the recommendation in principle, subject to further work to determine its full impact (Department of Health and Social Care response, Dec 2025).
Local authority strategic security review
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.
In July 2026, Parliamentary Under-Secretary of State for Health Innovation and Safety Preet Kaur Gill stated that work includes "working with local authorities to support closer alignment with Human Tissue Authority standards on security, governance and audit" (Preet Kaur Gill, Jul 2026). The Department of Health and Social Care had previously accepted the recommendation in principle in December 2025, subject to further work to determine its full impact (Department of Health and Social Care response, Dec 2025).
No reliance on keys/keypads alone
There must be no reliance on keys and keypad codes alone to secure access to the mortuary.
In a July 2026 written statement, Preet Kaur Gill, Parliamentary Under-Secretary of State for Health Innovation and Safety, stated that work includes "working with local authorities to support closer alignment with Human Tissue Authority standards on security, governance and audit" (Preet Kaur Gill, Jul 2026). Previously, the Department of Health and Social Care reported in December 2025 that the government had agreed to accept the recommendation in principle subject to further work to determine its full impact (Department of Health and Social Care response, Dec 2025).
Lock fridges and freezers at all times
Fridges and freezers containing deceased people must be locked at all times, with appropriate key security in place.
In July 2026, Parliamentary Under-Secretary of State for Health Innovation and Safety Preet Kaur Gill reported in a written statement that the government was "working with local authorities to support closer alignment with Human Tissue Authority standards on security, governance and audit" (Preet Kaur Gill, Jul 2026). The Department of Health and Social Care previously stated in December 2025 that the government had accepted the recommendation in principle, subject to further work to determine its full impact (Department of Health and Social Care response, Dec 2025).
Local authority CCTV installation
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.
In a July 2026 written statement to the House of Commons, Preet Kaur Gill, Parliamentary Under-Secretary of State for Health Innovation and Safety, stated that ongoing work includes "working with local authorities to support closer alignment with Human Tissue Authority standards on security, governance and audit" (Preet Kaur Gill, Jul 2026). Previously, the Department of Health and Social Care reported in December 2025 that the government had accepted the recommendation in principle, subject to further work to determine its full impact (Department of Health and Social Care response, Dec 2025).
Local authority incident response SOPs
Arrangements for responding to incidents of unauthorised access must be reviewed and incorporated into Standard Operating Procedures.
In July 2026, Parliamentary Under-Secretary of State for Health Innovation and Safety Preet Kaur Gill stated that work includes "working with local authorities to support closer alignment with Human Tissue Authority standards on security, governance and audit" (Preet Kaur Gill, Jul 2026). Earlier, in December 2025, the Department of Health and Social Care reported that the government had accepted the recommendation in principle subject to further work to determine its full impact (Department of Health and Social Care response, Dec 2025).
Local authority single security SOP
All policies and procedures in relation to the security of the mortuary must be accurately and comprehensively reflected in a single security Standard Operating Procedure.
In July 2026, Parliamentary Under-Secretary of State for Health Innovation and Safety Preet Kaur Gill reported in a written statement that ongoing work included "working with local authorities to support closer alignment with Human Tissue Authority standards on security, governance and audit" (Preet Kaur Gill, Jul 2026). Previously, the Department of Health and Social Care stated in December 2025 that the government had accepted the recommendation in principle, subject to further work to determine its full impact (Department of Health and Social Care response, Dec 2025).
Local authority funding for security expedited
There must be a process to ensure that, where there is a requirement for funding to strengthen mortuary security, it is expedited and considered at the highest levels within the local authority.
In July 2026, Parliamentary Under-Secretary of State for Health Innovation and Safety Preet Kaur Gill stated that work includes "working with local authorities to support closer alignment with Human Tissue Authority standards on security, governance and audit", while noting that a full response remains committed once the leadership period for Prime Minister has concluded (Preet Kaur Gill, Jul 2026). Earlier, in December 2025, the Department of Health and Social Care reported that the government had accepted the recommendation in principle subject to further work to determine its full impact (Department of Health and Social Care response, Dec 2025).
Local authority security breach investigation
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.
In July 2026, Parliamentary Under-Secretary of State for Health Innovation and Safety Preet Kaur Gill reported that ongoing work includes "working with local authorities to support closer alignment with Human Tissue Authority standards on security, governance and audit" (Preet Kaur Gill, Jul 2026). Previously, in December 2025, the Department of Health and Social Care stated that the government accepted the recommendation in principle subject to further work to determine its full impact (Department of Health and Social Care response, Dec 2025).
Local authority annual SOP and HTA audits
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.
In July 2026, Preet Kaur Gill, Parliamentary Under-Secretary of State for Health Innovation and Safety, stated in a written statement to the House of Commons that work includes supporting local authorities towards closer alignment with Human Tissue Authority standards on security, governance and audit (Preet Kaur Gill, Jul 2026). Earlier, in December 2025, the Department of Health and Social Care recorded that the government had agreed to accept the recommendation in principle "subject to further work to determine the full impact" (Department of Health and Social Care response, Dec 2025).
Local authority DI management and oversight review
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.
In July 2026, Parliamentary Under-Secretary of State for Health Innovation and Safety Preet Kaur Gill stated that government action includes "working with local authorities to support closer alignment with Human Tissue Authority standards on security, governance and audit" (Preet Kaur Gill, Jul 2026). Previously, in December 2025, the Department of Health and Social Care reported that the government had accepted the recommendation in principle, subject to further work to determine its full impact (Department of Health and Social Care response, Dec 2025).
Local authority mortuary as regulated service
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.
In July 2026, Parliamentary Under-Secretary of State for Health Innovation and Safety Preet Kaur Gill reported that government action includes "working with local authorities to support closer alignment with Human Tissue Authority standards on security, governance and audit" (Preet Kaur Gill, Jul 2026). Earlier, in December 2025, the Department of Health and Social Care recorded that the government had accepted the recommendation in principle, noting that further work was required to determine the full impact of the measure (Department of Health and Social Care response, Dec 2025).
Local authority biennial audits and peer review
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.
In July 2026, Parliamentary Under-Secretary of State for Health Innovation and Safety Preet Kaur Gill stated that ongoing work includes "working with local authorities to support closer alignment with Human Tissue Authority standards on security, governance and audit" (Preet Kaur Gill, Jul 2026). The Department of Health and Social Care had previously reported in December 2025 that the government accepted the recommendation in principle, subject to further work to determine its full impact (Department of Health and Social Care response, Dec 2025).
Share mortuary reports with coroner service
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.
In July 2026, Preet Kaur Gill, Parliamentary Under-Secretary of State for Health Innovation and Safety, stated in a written statement to the House of Commons that ongoing work included "working with local authorities to support closer alignment with Human Tissue Authority standards on security, governance and audit" (Preet Kaur Gill, Jul 2026). The Department of Health and Social Care had previously reported in December 2025 that the government accepted the recommendation in principle, subject to further work to determine its full impact (Department of Health and Social Care response, Dec 2025).
Local authority report implementation to committee
The implementation of these recommendations must be reported to the relevant statutory committee.
In July 2026, Parliamentary Under-Secretary of State for Health Innovation and Safety Preet Kaur Gill stated that work includes "working with local authorities to support closer alignment with Human Tissue Authority standards on security, governance and audit" (Preet Kaur Gill, Jul 2026). The Department of Health and Social Care previously reported in December 2025 that the government accepted the recommendation in principle, subject to further work to determine its full impact (Department of Health and Social Care response, Dec 2025).
Local authority contingent body storage plans
Local authorities providing a coroner service must review plans for the provision and operation of contingent body storage, in collaboration with local organisations providing mortuary services.
In July 2026, Parliamentary Under-Secretary of State for Health Innovation and Safety Preet Kaur Gill stated in a written statement to Parliament that work was in progress, including working with local authorities to support closer alignment with Human Tissue Authority standards on security, governance and audit (Preet Kaur Gill, Jul 2026). Previously, the Department of Health and Social Care recorded in December 2025 that the government accepted the recommendation in principle, "subject to further work to determine the full impact of these recommendations" (Department of Health and Social Care response, Dec 2025).
Unlicensed body stores prepared for HTA compliance
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.
In July 2026, Parliamentary Under-Secretary of State for Health Innovation and Safety Preet Kaur Gill stated that the government was working with local authorities to support closer alignment with Human Tissue Authority standards on security, governance and audit (Preet Kaur Gill, Jul 2026). The Department of Health and Social Care had previously confirmed in December 2025 that the government accepted the recommendation in principle, subject to further work to determine its full impact (Department of Health and Social Care response, Dec 2025). Earlier, in July 2025, Dr Colin Sullivan, Chief Executive Officer of the authority, stated that it had piloted an assessment model for unlicensed settings such as body stores and stood ready to offer its expertise (Dr Colin Sullivan, Jul 2025).
Unlicensed body stores follow same standards
Where local authorities provide an unlicensed body store, they should do so in line with this Report's recommendations to local authority providers of licensed mortuaries.
In July 2026, Parliamentary Under-Secretary of State Preet Kaur Gill stated that the government was "working with local authorities to support closer alignment with Human Tissue Authority standards" on security, governance, and audit (Preet Kaur Gill, Jul 2026). The Department of Health and Social Care had previously accepted the recommendation in principle in December 2025, noting that further work was required to determine its full impact (Department of Health and Social Care response, Dec 2025). Prior to this, in July 2025, Human Tissue Authority Chief Executive Officer Dr Colin Sullivan reported that the regulator had piloted an assessment model for unlicensed settings and stood ready to offer its expertise (Dr Colin Sullivan, Jul 2025).
Local authority review third-party contracts
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.
In an interim update on government progress published in December 2025, the Department of Health and Social Care relayed that this recommendation, addressed to the Ministry of Housing, Communities and Local Government regarding local authority reviews of third-party contracts, remained under consideration (Department of Health and Social Care response, Dec 2025). The record holds no update since the department's response of December 2025 (Department of Health and Social Care response, Dec 2025).
Contractual incident notification requirement
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.
Relaying progress in December 2025 on recommendations addressed to the Ministry of Housing, Communities and Local Government, the Department of Health and Social Care stated that this recommendation remained "under consideration" (Department of Health and Social Care response, Dec 2025). The department noted in December 2025 that the proposal was among 21 recommendations that remain under consideration (Department of Health and Social Care response, Dec 2025). The record holds no update since the department's response of December 2025 (Department of Health and Social Care response, Dec 2025).
Local authority contractor governance assurance
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.
In an interim update on government progress published in December 2025, the Department of Health and Social Care stated that this recommendation addressed to the Ministry of Housing, Communities and Local Government remained "under consideration" alongside twenty other recommendations (Department of Health and Social Care response, Dec 2025). The record holds no update since the department's response of December 2025 (Department of Health and Social Care response, Dec 2025).
Care homes in scope for new regulatory regime
The regulatory measures recommended in Chapter 11 should apply to care homes in England. Regulation should cover both systems and professionals where staff are providing care to deceased people in care homes.
The Department of Health and Social Care reported in June 2026 that "this recommendation is under consideration" in a dashboard update published by the Cabinet Office (Department of Health and Social Care, Jun 2026). This reiterated the position taken in its interim update of December 2025, when the department noted that the proposal was among 21 recommendations from the inquiry that remained under consideration (Department of Health and Social Care response, Dec 2025).
Statutory regulation of funeral directors
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.
In September 2026, the Secretary of State for Health and Social Care, Yvette Cooper, stated that the Department of Health and Social Care is leading cross-government work to draw up detailed proposals to drive up standards, "including proper regulation of the funeral sector" (Yvette Cooper, Sep 2026). This followed a July 2026 statement by Parliamentary Under-Secretary of State Preet Kaur Gill that the government would update the House as soon as practicably possible on how it intends to take the recommendations forward (Preet Kaur Gill, Jul 2026). The department previously reported in June 2026 that the recommendation remained under consideration, having earlier indicated in October 2025 that a final response would be published by summer 2026 (Dr Zubir Ahmed, Oct 2025; Department of Health and Social Care, Jun 2026).
Regulations consider whole deceased journey
These regulations and standards should be considered within the overall care and journey of the deceased rather than applying in isolation to funeral directors.
In September 2026, Secretary of State for Health and Social Care Yvette Cooper stated that the government will "bring forward comprehensive proposals to ensure respect and dignity for the deceased in every setting" (Yvette Cooper, Sep 2026). In July 2026, Parliamentary Under-Secretary of State Preet Kaur Gill stated that the Department of Health and Social Care will update the House of Commons as soon as practicably possible on how it intends to take the recommendations forward (Preet Kaur Gill, Jul 2026). The department had previously recorded in a June 2026 dashboard update that the recommendation remained under consideration (Department of Health and Social Care, Jun 2026).
Mandatory information from funeral directors
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.
In September 2026, the Secretary of State for Health and Social Care, Yvette Cooper, stated that the government will "bring forward comprehensive proposals" to ensure respect and dignity for the deceased and address rogue operators in the funeral industry (Yvette Cooper, Sep 2026). Earlier, in July 2026, Parliamentary Under-Secretary of State Preet Kaur Gill informed the House of Commons that the department would update Parliament as soon as practicably possible on taking forward recommendations for the sector (Preet Kaur Gill, Jul 2026). In a June 2026 dashboard update, the department had recorded that this recommendation remained under consideration (Department of Health and Social Care, Jun 2026).
Direct cremation in scope for standards
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.
The Secretary of State for Health and Social Care, Yvette Cooper, announced in September 2026 that the government would "bring forward comprehensive proposals to ensure respect and dignity for the deceased in every setting" and address rogue funeral operators (Yvette Cooper, Sep 2026). In July 2026, Preet Kaur Gill, the Parliamentary Under-Secretary of State for Health Innovation and Safety, stated that Ministers would update the House of Commons as soon as practicably possible on taking these recommendations forward (Preet Kaur Gill, Jul 2026). Previously, in a June 2026 dashboard update published by the Cabinet Office, the department recorded that the recommendation was under consideration (Department of Health and Social Care, Jun 2026).
Funeral director regulation benefits outweigh difficulties
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.
In September 2026, the Secretary of State for Health and Social Care, Yvette Cooper, announced in a written ministerial statement that the government will bring forward "comprehensive proposals to ensure respect and dignity for the deceased in every setting" and drive rogue operators out of the funeral industry (Yvette Cooper, Sep 2026). Earlier, in July 2026, Preet Kaur Gill, Parliamentary Under-Secretary of State for Health Innovation and Safety, stated that the department would update the House of Commons as soon as practicably possible on how it intends to take these recommendations forward (Preet Kaur Gill, Jul 2026). In a dashboard update published in June 2026, the department recorded that the recommendation remained under consideration (Department of Health and Social Care, Jun 2026).
Funeral sector in scope for new regulatory regime
The funeral sector in England should be considered in scope for the broader regulatory measures recommended in Chapter 11.
In September 2026, the Secretary of State for Health and Social Care, Yvette Cooper, stated that the government will "bring forward comprehensive proposals" to regulate the funeral industry and ensure dignity for the deceased (Yvette Cooper, Sep 2026). In July 2026, Parliamentary Under-Secretary of State Preet Kaur Gill stated that the department would update the House as soon as practicably possible on how it intends to take these recommendations forward (Preet Kaur Gill, Jul 2026). In its June 2026 dashboard update, the department recorded that this recommendation remained under consideration (Department of Health and Social Care, Jun 2026).
Faith organisations share guidance on deceased care
All faith organisations should consider how to support their members to deliver high standards of care for the deceased, with a focus on the security and dignity of the deceased – for example, by sharing guidance.
In June 2026, the Department of Health and Social Care stated that this recommendation was "under consideration" in a progress update published on the Cabinet Office dashboard (Department of Health and Social Care, Jun 2026). The department had previously reported the same status in December 2025, when its interim response to the inquiry's phase 2 report listed the proposal among 21 recommendations that remained under consideration (Department of Health and Social Care response, Dec 2025).
Religious building security for deceased
Where deceased people are in a religious building overnight, measures should be taken to ensure that the building is secure, including, for example, CCTV and secure access control for the area in which they are kept.
In its May 2026 dashboard update, published by the Cabinet Office in June 2026, the Department of Health and Social Care recorded that this recommendation remains "under consideration" (Department of Health and Social Care, Jun 2026). This reiterated the position the department took in its December 2025 interim progress update, where it confirmed that this proposal was among 21 recommendations that remained under consideration (Department of Health and Social Care response, Dec 2025).
Formalise multi-organisation arrangements
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.
In June 2026, the Department of Health and Social Care reported in a Cabinet Office dashboard update that "This recommendation is under consideration" (Department of Health and Social Care, Jun 2026). In that same June 2026 update, the department recorded no specific delivery position, stating that it was not providing an update for that quarter (Department of Health and Social Care, Jun 2026). In December 2025, it had similarly stated in an interim progress report that the recommendation remained under consideration, publishing no individual text for it (Department of Health and Social Care response, Dec 2025).
Chief Coroner review practice consistency
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.
In its interim progress update published in December 2025, the Department of Health and Social Care stated that this recommendation addressed to the Ministry of Justice remained under consideration (Department of Health and Social Care response, Dec 2025). The department grouped the measure among 21 recommendations from the phase 2 report that were still being considered by the government, offering no specific commentary on this recommendation alone (Department of Health and Social Care response, Dec 2025). The record holds no update since the department's response of December 2025 (Department of Health and Social Care response, Dec 2025).
New Chief Inspector regulatory regime for deceased
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 June 2026, the Department of Health and Social Care recorded in a government dashboard that this recommendation remained "under consideration" (Department of Health and Social Care, Jun 2026). It had previously confirmed in its December 2025 interim update that the recommendation was still under consideration (Department of Health and Social Care response, Dec 2025). Earlier, in October 2025, Dr Zubir Ahmed, Parliamentary Under-Secretary of State at the department, stated in a written answer that the department would publish a final response by summer 2026 (Dr Zubir Ahmed, Oct 2025).
Interim Commissioner for Dignity of Deceased
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.
In June 2026, the Department of Health and Social Care recorded that "This recommendation is under consideration" in a dashboard update published by the Cabinet Office (Department of Health and Social Care, Jun 2026). The department had previously reported in December 2025 that the recommendation remained under consideration, including it without individual commentary among twenty-one recommendations from the inquiry that were still being evaluated (Department of Health and Social Care response, Dec 2025).
Amend HT Act for organisational responsibility
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 Department of Health and Social Care stated in June 2026 that "This recommendation is under consideration" in progress entries published on the Cabinet Office recommendations dashboard (Department of Health and Social Care, Jun 2026). This maintained the position set out in the department's interim update on government progress in December 2025, which listed this recommendation among 21 phase 2 recommendations that remained under consideration (Department of Health and Social Care response, Dec 2025).
HTA require suitable qualified staff with enforcement
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.
Relaying progress on the recommendation addressed to the Human Tissue Authority, the Department of Health and Social Care stated in December 2025 that the proposal remained under consideration (Department of Health and Social Care response, Dec 2025). In its interim update, the department recorded that this was among 21 recommendations that "remain under consideration", giving no separate detail on the licensing requirements (Department of Health and Social Care response, Dec 2025). The record holds no update since the department's response of December 2025 (Department of Health and Social Care response, Dec 2025).
Government responsible for implementation monitoring
The government should take responsibility for the implementation of all the recommendations we make in this Report, regardless of the primary organisation they are directed at, and make arrangements to monitor the progress of their implementation.
In July 2026, Parliamentary Under-Secretary of State for Health Innovation and Safety Preet Kaur Gill reported that the government has worked through a dedicated cross-government programme board with partner organisations to consider each recommendation and determine required action (Preet Kaur Gill, Jul 2026). The Department of Health and Social Care previously confirmed in June 2026, reiterating its December 2025 interim update, that it established the programme board in July 2025 to scope and progress recommendations across government and with other responsible organisations (Department of Health and Social Care response, Dec 2025; Department of Health and Social Care, Jun 2026).