Public Inquiry Recommendations

P1-1 Accepted

Fuller Inquiry (2023)

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 …

- MTW Trust stated in February 2024 that it had implemented accompaniment requirements for non-mortuary staff and contractors visiting the mortuary (MTW Trust Assurance Statement, …

P1-2 Accepted

Fuller Inquiry (2023)

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 …

- MTW Trust stated in February 2024 that it had strengthened procedures to ensure regulatory requirements are met and that the deceased are not left …

P1-3 Accepted

Fuller Inquiry (2023)

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 …

- MTW Trust stated in February 2024 that it had implemented enhanced criminal record checks for mortuary staff, including DBS checks at the appropriate level …

P1-4 Accepted

Fuller Inquiry (2023)

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 …

- MTW Trust stated in February 2024 that it had reviewed the qualifications required for the Mortuary Manager role and ensured the post-holder meets the …

P1-5 Accepted

Fuller Inquiry (2023)

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 …

- MTW Trust stated in February 2024 that it had established the Mortuary Manager as a full-time dedicated role (MTW Trust Assurance Statement, February 2024). …

P1-6 Accepted

Fuller Inquiry (2023)

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.

- MTW Trust stated in February 2024 that it had implemented a comprehensive mortuary access policy restricting entry to authorised personnel only (MTW Trust Assurance …

P1-7 Accepted

Fuller Inquiry (2023)

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.

- MTW Trust stated in February 2024 that it had implemented audit procedures to monitor access to restricted areas within the mortuary (MTW Trust Assurance …

P1-8 Accepted

Fuller Inquiry (2023)

Security as corporate responsibility

Maidstone and Tunbridge Wells NHS Trust should treat security as a corporate not a local departmental responsibility.

- MTW Trust stated in February 2024 that mortuary security had been elevated to a corporate responsibility with board-level oversight (MTW Trust Assurance Statement, February …

P1-9 Accepted

Fuller Inquiry (2023)

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.

- MTW Trust stated in February 2024 that CCTV had been installed in the mortuary covering all areas where the deceased are stored or examined …

P1-10 Accepted

Fuller Inquiry (2023)

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 …

- MTW Trust stated in February 2024 that it had implemented regular review of CCTV footage from the mortuary as part of routine security procedures …

P1-11 Accepted

Fuller Inquiry (2023)

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 …

- MTW Trust stated in February 2024 that HTA inspection reports are now shared with relevant Trust boards and governance committees (MTW Trust Assurance Statement, …

P1-12 Accepted

Fuller Inquiry (2023)

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 …

- MTW Trust stated in February 2024 that it had reviewed contracts with Kent County Council and East Sussex County Council for mortuary services (MTW …

P1-13 Accepted

Fuller Inquiry (2023)

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 …

- MTW Trust stated in February 2024 that it had strengthened board governance to ensure "assurance not reassurance" in relation to mortuary operations (MTW Trust …

P1-14 Accepted

Fuller Inquiry (2023)

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 …

- MTW Trust stated in February 2024 that the Designated Individual now has protected time for oversight duties and reports directly to the Trust Board …

P1-15 Accepted

Fuller Inquiry (2023)

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 …

- MTW Trust stated in February 2024 that HTA compliance is now treated as a statutory responsibility at board level (MTW Trust Assurance Statement, February …

P1-16 Accepted

Fuller Inquiry (2023)

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 …

- MTW Trust stated in February 2024 that the Chief Nurse had been assigned responsibility for mortuary services within the Trust executive structure (MTW Trust …

P1-17 Accepted

Fuller Inquiry (2023)

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.

- MTW Trust stated in February 2024 that it had reinforced the principle that the deceased must be treated with the same dignity and respect …

P2-1 Accepted in Part

Fuller Inquiry (2025)

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 …

- The government stated in December 2025 that this recommendation on conducting a strategic review of NHS mortuary security was accepted in principle. Work to …

P2-2 Accepted in Part

Fuller Inquiry (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 …

- The government stated in December 2025 that this recommendation on installing CCTV in all NHS mortuaries was accepted in principle. The government noted that …

P2-3 Accepted in Part

Fuller Inquiry (2025)

Audit access data for deceased storage

All NHS trusts should routinely audit the access data of all facilities used to store deceased people.

- The government stated in December 2025 that this recommendation on auditing access to NHS mortuaries was accepted in principle. Standards and guidance to be …

P2-4 Accepted in Part

Fuller Inquiry (2025)

End shared swipe cards

The practice of using shared electronic swipe cards for specific staff groups should cease immediately.

- The government stated in December 2025 that this recommendation on ending shared swipe cards and generic access credentials in NHS mortuaries was accepted in …

P2-5 Accepted in Part

Fuller Inquiry (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 …

- The government stated in December 2025 that this recommendation on implementing operational barriers to restrict access within NHS mortuaries was accepted in principle. Full …

P2-6 Accepted in Part

Fuller Inquiry (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 …

- The government stated in December 2025 that this recommendation on recording and investigating security incidents in NHS mortuaries was accepted in principle. Full government …

P2-7 Accepted in Part

Fuller Inquiry (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.

- The government stated in December 2025 that this recommendation on minimum standards for body stores in NHS mortuaries was accepted in principle. Full government …

P2-8 Accepted in Part

Fuller Inquiry (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 …

- The government stated in December 2025 that this recommendation on requiring swipe-to-exit controls in NHS mortuaries was accepted in principle. Full government response due …

P2-9 Accepted in Part

Fuller Inquiry (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.

- The government stated in December 2025 that this recommendation on monitoring staff access patterns in NHS mortuaries was accepted in principle. Full government response …

P2-10 Accepted in Part

Fuller Inquiry (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.

- The government stated in December 2025 that this recommendation on ensuring Designated Individuals have adequate time and resources for their HTA oversight role was …

P2-11 Accepted in Part

Fuller Inquiry (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 …

- The government stated in December 2025 that this recommendation on ensuring senior managers understand the Designated Individual role was accepted in principle. Full government …

P2-12 Accepted in Part

Fuller Inquiry (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.

- The government stated in December 2025 that this recommendation on establishing DI governance forums was accepted in principle. Full government response due Summer 2026 …

P2-13 Accepted in Part

Fuller Inquiry (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.

- The government stated in December 2025 that this recommendation on minimum qualifications for Mortuary Managers was accepted in principle. Full government response due Summer …

P2-14 Accepted in Part

Fuller Inquiry (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.

- The government stated in December 2025 that this recommendation on ensuring Mortuary Managers have adequate resources was accepted in principle. Full government response due …

P2-15 Accepted in Part

Fuller Inquiry (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 …

- The government stated in December 2025 that this recommendation on routine board reporting on mortuary operations was accepted in principle. Full government response due …

P2-16 Accepted in Part

Fuller Inquiry (2025)

Trust boards assure recommendation implementation

Trust boards should assure themselves that the recommendations in this Report have been implemented.

- The government stated in December 2025 that this recommendation on board assurance of implementation of mortuary standards was accepted in principle. Full government response …

P2-17 Accepted in Part

Fuller Inquiry (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.

- The government stated in December 2025 that this recommendation on standards for temporary mortuary facilities was accepted in principle. Full government response due Summer …

P2-18 Accepted in Part

Fuller Inquiry (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 …

- The government stated in December 2025 that this recommendation on treating the mortuary as a regulated service within the NHS was accepted in principle. …

P2-19 Accepted in Part

Fuller Inquiry (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.

- The government stated in December 2025 that this recommendation on safeguarding training for staff with access to deceased persons was accepted in principle. Full …

P2-20 Accepted in Part

Fuller Inquiry (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.

- The government stated in December 2025 that this recommendation on assigning Chief Nurse responsibility for mortuary services was accepted in principle. Full government response …

P2-21 Accepted in Part

Fuller Inquiry (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.

- The government stated in December 2025 that this recommendation on NHS England developing a safeguarding framework for the deceased was accepted in principle. Full …

P2-22 Accepted

Fuller Inquiry (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. …

- The government stated in December 2025 that this recommendation on standard operating procedures for independent sector mortuaries was accepted in full. The HTA is …

P2-23 Accepted

Fuller Inquiry (2025)

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 …

- The government stated in December 2025 that this recommendation on access controls for independent sector mortuaries was accepted in full. The HTA is working …

P2-24 Under Consideration

Fuller Inquiry (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: …

- The government stated in December 2025 that this recommendation on security of body donors in anatomical examination facilities was under consideration. Full government response …

P2-25 Under Consideration

Fuller Inquiry (2025)

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 …

- The government stated in December 2025 that this recommendation on governance of postgraduate anatomy training was under consideration. Full government response due Summer 2026 …

P2-26 Accepted

Fuller Inquiry (2025)

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).

- The government stated in December 2025 that this recommendation on HTA adverse incident reporting for anatomy was accepted in full and completed. The HTA …

P2-27 Accepted

Fuller Inquiry (2025)

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 …

- The government stated in December 2025 that this recommendation on security measures for hospice mortuaries was accepted in full. Work is being taken forward …

P2-28 Accepted

Fuller Inquiry (2025)

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, …

- The government stated in December 2025 that this recommendation on CQC updating its hospice inspection guidance to include mortuary security was accepted in full. …

P2-29 Under Consideration

Fuller Inquiry (2025)

Hospices in scope for new regulatory regime

Hospices should be considered in scope for the regulatory measures recommended in Chapter 11.

- The government stated in December 2025 that this recommendation on bringing hospice mortuaries into the HTA regulatory scope was under consideration. Full government response …

P2-30 Accepted

Fuller Inquiry (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.

- The government stated in December 2025 that this recommendation on ambulance services collecting data on conveyance of deceased persons was accepted in full. NHS …

P2-31 Accepted

Fuller Inquiry (2025)

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 …

- The government stated in December 2025 that this recommendation on ambulance seating policies to protect the dignity of deceased persons was accepted in full. …

P2-32 Accepted

Fuller Inquiry (2025)

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 …

- The government stated in December 2025 that this recommendation on ambulance services adopting dignity policies for the deceased was accepted in full. Full government …

P2-33 Accepted

Fuller Inquiry (2025)

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 …

- The government stated in December 2025 that this recommendation on prohibiting photography of deceased persons by ambulance staff was accepted in full. Full government …