Public Inquiry Recommendations

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 …

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 …