Public Inquiry Recommendations

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 …

1 Accepted in Part

Paterson Inquiry (2020)

Single consultant data repository

We recommend that there should be a single repository of the whole practice of consultants across England, setting out their practising privileges and other critical consultant performance data – for …

- The Department of Health and Social Care stated in December 2021 that it was improving data flows to the CQC and GMC to provide …

4 Accepted in Part

Paterson Inquiry (2020)

Reflection period for consent

We recommend that there should be a short period introduced into the process of patients giving consent for surgical procedures, to allow them time to reflect on their diagnosis and …

- The GMC revised its "Decision making and consent" guidance, effective 9 November 2020, which requires doctors to give patients time to consider information before …

6b Accepted in Part

Paterson Inquiry (2020)

Mandatory independent complaint resolution

We recommend that all private patients should have the right to mandatory independent resolution of their complaint.

- The government stated in December 2021 that it was considering whether legislative change is needed to make independent adjudication mandatory for all private healthcare …

10 Accepted in Part

Paterson Inquiry (2020)

Indemnity regulation reform

We recommend that the Government should, as a matter of urgency, reform the current regulation of indemnity products for healthcare professionals in light of the serious shortcomings identified by this …

- In March 2024, the government announced that Medical Defence Organisations (MDOs) intended to implement a sector-led Code of Practice for discretionary indemnity by the …

12b Accepted in Part

Paterson Inquiry (2020)

Information sharing between providers

We recommend that if the healthcare professional also works at another provider, any concerns about them should be communicated to that provider.

- The GMC updated its guidance to state that patient safety is paramount when deciding whether to share information about doctors with other providers (DHSC …

13 Accepted in Part

Paterson Inquiry (2020)

Independent sector provider responsibility

We recommend that the government addresses, as a matter of urgency, this gap in responsibility and liability.

- The Independent Healthcare Providers Network (IHPN) refreshed the Medical Practitioners Assurance Framework (MPAF) to clarify that independent providers are responsible for the quality of …

R2 Accepted in Part

Allitt Inquiry (1994)

Coroners to send post mortem reports to consultants

We recommend that in every case Coroners should send copies of post mortem reports to any consultant who has been involved in the patient's care prior to death whether or …

R4 Accepted in Part

Allitt Inquiry (1994)

No nursing employment where major personality disorder

We recommend that no candidate for nursing in whom there is evidence of major personality disorder should be employed in the profession (para 5.4.11)

R5 Accepted in Part

Allitt Inquiry (1994)

Health screening for newly qualified nurses

We recommend that nurses should undergo formal health screening when they obtain their first posts after qualifying (para 5.5.13).

R6 Accepted in Part

Allitt Inquiry (1994)

Sickness records available to occupational health

We recommend that the possibility be reviewed of making available to Occupational Health departments any records of absence through sickness from any institution which an applicant for a nursing post …

R7 Accepted in Part

Allitt Inquiry (1994)

Criteria for management referrals to occupational health

We recommend that procedures for management referrals to Occupational Health should make clear the criteria which should trigger such referrals (para 5.5.14).

R8 Accepted in Part

Allitt Inquiry (1994)

Apply ANHSOP Chairman's suggestion in practice

We recommend that further consideration be given to how the suggestion of the Chairman of the Association of NHS Occupational Physicians (see para 5.5.16) could be applied in practice (para …

R9 Accepted in Part

Allitt Inquiry (1994)

GP certification of fitness for NHS employment

We recommend that consideration be given to how General Practitioners might, with the candidate's consent, be asked to certify that there is nothing in the medical history of a candidate …