Public Inquiry Recommendations

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 …

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 …

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.

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.

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 …

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 …

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.

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 …

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.

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.

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 …

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.

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.

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.

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 …

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.

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.

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 …

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.

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.

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.

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.

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 …

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 …

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, …

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 …

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 …

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.

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.

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 …

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.

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.

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 …

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 …

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 …

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 …

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 …

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 …

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 …

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.

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.

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 …

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.