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 …

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 …

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 …

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 …

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 …

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.

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.

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.

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.

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 …

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 …

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 …

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 …

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 …

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 …

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.

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. …

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 …

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).

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 …

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, …

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.

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 …

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 …

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 …

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 …

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 …