Public Inquiry Recommendations

P2-34 Accepted

Fuller Inquiry (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 …

- The government stated in December 2025 that this recommendation on extending standards to independent ambulance services was accepted in full. Full government response due …

P2-35 Accepted in Part

Fuller Inquiry (2025)

Local authority mortuary access review

There should be a process to routinely review who is permitted to access the mortuary unsupervised.

- The government stated in December 2025 that this recommendation on reviewing access controls in local authority mortuaries was accepted in principle. The government is …

P2-36 Accepted in Part

Fuller Inquiry (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 …

- The government stated in December 2025 that this recommendation on electronic access controls in local authority mortuaries was accepted in principle. Full government response …

P2-37 Accepted in Part

Fuller Inquiry (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 …

- The government stated in December 2025 that this recommendation on restricting visitor access to local authority mortuaries was accepted in principle. Full government response …

P2-38 Accepted in Part

Fuller Inquiry (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, …

- The government stated in December 2025 that this recommendation on ending lone working practices in local authority mortuaries was accepted in principle. Full government …

P2-39 Accepted in Part

Fuller Inquiry (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 …

- The government stated in December 2025 that this recommendation on regular audits of local authority mortuary security was accepted in principle. Full government response …

P2-40 Accepted in Part

Fuller Inquiry (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 …

- The government stated in December 2025 that this recommendation on a strategic review of local authority mortuary provision was accepted in principle. Full government …

P2-41 Accepted in Part

Fuller Inquiry (2025)

No reliance on keys/keypads alone

There must be no reliance on keys and keypad codes alone to secure access to the mortuary.

- The government stated in December 2025 that this recommendation on ending reliance on keys and keypads in local authority mortuaries was accepted in principle. …

P2-42 Accepted in Part

Fuller Inquiry (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.

- The government stated in December 2025 that this recommendation on individual fridge locks in local authority mortuaries was accepted in principle. Full government response …

P2-43 Accepted in Part

Fuller Inquiry (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 …

- The government stated in December 2025 that this recommendation on CCTV in local authority mortuaries was accepted in principle. Full government response due Summer …

P2-44 Accepted in Part

Fuller Inquiry (2025)

Local authority incident response SOPs

Arrangements for responding to incidents of unauthorised access must be reviewed and incorporated into Standard Operating Procedures.

- The government stated in December 2025 that this recommendation on incident response procedures in local authority mortuaries was accepted in principle. Full government response …

P2-45 Accepted in Part

Fuller Inquiry (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.

- The government stated in December 2025 that this recommendation on standard operating procedures for local authority mortuaries was accepted in principle. Full government response …

P2-46 Accepted in Part

Fuller Inquiry (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 …

- The government stated in December 2025 that this recommendation on funding for local authority mortuary improvements was accepted in principle. The government acknowledged the …

P2-47 Accepted in Part

Fuller Inquiry (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 …

- The government stated in December 2025 that this recommendation on incident investigation in local authority mortuaries was accepted in principle. Full government response due …

P2-48 Accepted in Part

Fuller Inquiry (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 …

- The government stated in December 2025 that this recommendation on compliance audits for local authority mortuaries was accepted in principle. Full government response due …

P2-49 Accepted in Part

Fuller Inquiry (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 …

- The government stated in December 2025 that this recommendation on management oversight of local authority mortuaries was accepted in principle. Full government response due …

P2-50 Accepted in Part

Fuller Inquiry (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 …

- The government stated in December 2025 that this recommendation on governance arrangements for local authority mortuaries was accepted in principle. Full government response due …

P2-51 Accepted in Part

Fuller Inquiry (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 …

- The government stated in December 2025 that this recommendation on professional audits of local authority mortuaries was accepted in principle. Full government response due …

P2-52 Accepted in Part

Fuller Inquiry (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 …

- The government stated in December 2025 that this recommendation on coroner reporting to local authorities on mortuary standards was accepted in principle. Full government …

P2-53 Accepted in Part

Fuller Inquiry (2025)

Local authority report implementation to committee

The implementation of these recommendations must be reported to the relevant statutory committee.

- The government stated in December 2025 that this recommendation on local authorities reporting on implementation of mortuary standards was accepted in principle. Full government …

P2-54 Accepted in Part

Fuller Inquiry (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.

- The government stated in December 2025 that this recommendation on contingency planning for local authority mortuary capacity was accepted in principle. Full government response …

P2-55 Accepted in Part

Fuller Inquiry (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 …

- The government stated in December 2025 that this recommendation on bringing unlicensed body stores into compliance was accepted in principle. Full government response due …

P2-56 Accepted in Part

Fuller Inquiry (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.

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

P2-57 Under Consideration

Fuller Inquiry (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 …

- The government stated in December 2025 that this recommendation on local authority oversight of mortuary contractors was under consideration. Full government response due Summer …

P2-58 Under Consideration

Fuller Inquiry (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 …

- The government stated in December 2025 that this recommendation on contractual standards for mortuary service contractors was under consideration. Full government response due Summer …

P2-59 Under Consideration

Fuller Inquiry (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 …

- The government stated in December 2025 that this recommendation on due diligence requirements for local authority mortuary contractors was under consideration. Full government response …

P2-60 Under Consideration

Fuller Inquiry (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 …

- The government stated in December 2025 that this recommendation on regulation of care home mortuaries was under consideration. Full government response due Summer 2026 …

P2-61 Under Consideration

Fuller Inquiry (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 …

- The government stated in December 2025 that this recommendation on statutory regulation of the funeral sector was under consideration. Full government response due Summer …

P2-62 Under Consideration

Fuller Inquiry (2025)

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.

- The government stated in December 2025 that this recommendation on security standards for funeral director premises was under consideration. Full government response due Summer …

P2-63 Under Consideration

Fuller Inquiry (2025)

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 …

- The government stated in December 2025 that this recommendation on DBS checks for funeral sector staff was under consideration. Full government response due Summer …

P2-64 Under Consideration

Fuller Inquiry (2025)

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 …

- The government stated in December 2025 that this recommendation on training requirements for funeral sector staff was under consideration. Full government response due Summer …

P2-65 Under Consideration

Fuller Inquiry (2025)

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 …

- The government stated in December 2025 that this recommendation on a code of practice for the funeral sector was under consideration. Full government response …

P2-66 Under Consideration

Fuller Inquiry (2025)

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.

- The government stated in December 2025 that this recommendation on a complaints mechanism for the funeral sector was under consideration. Full government response due …

P2-67 Under Consideration

Fuller Inquiry (2025)

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 …

- The government stated in December 2025 that this recommendation on faith organisations and the care of deceased persons was under consideration. Full government response …

P2-68 Under Consideration

Fuller Inquiry (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 …

- The government stated in December 2025 that this recommendation on coroner oversight of mortuary standards was under consideration. Full government response due Summer 2026 …

P2-69 Under Consideration

Fuller Inquiry (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 …

- The government stated in December 2025 that this recommendation on coroner powers in relation to mortuary security was under consideration. Full government response due …

P2-70 Under Consideration

Fuller Inquiry (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 …

- The government stated in December 2025 that this recommendation on coroner reporting on the treatment of the deceased was under consideration. Full government response …

P2-71 Under Consideration

Fuller Inquiry (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 …

- The government stated in December 2025 that this recommendation on establishing an independent statutory regulatory regime with a Chief Inspector of Mortuaries was under …

P2-72 Under Consideration

Fuller Inquiry (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 …

- The government stated in December 2025 that this recommendation on appointing an interim Commissioner for the Dignity of the Deceased was under consideration. Full …

P2-73 Under Consideration

Fuller Inquiry (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 …

- The government stated in December 2025 that this recommendation on amending the Human Tissue Act 2004 was under consideration. The government noted the complexity …

P2-74 Under Consideration

Fuller Inquiry (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 …

- The government stated in December 2025 that this recommendation on the HTA setting minimum qualification standards for mortuary staff was under consideration. Full government …

P2-75 Accepted

Fuller Inquiry (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 …

- The government stated in December 2025 that this recommendation on the government taking responsibility for overseeing implementation of all Fuller Inquiry recommendations was accepted …