Policy paper

Interim update on government progress in responding to the Fuller inquiry phase 2 report

Published 16 December 2025

Applies to England

Introduction and background

In November 2021, the then Secretary of State for Health and Social Care, the Rt Hon Sir Sajid Javid, announced an independent inquiry into the issues raised by the actions of David Fuller. Fuller, an electrical maintenance supervisor, committed appalling sexual offences against over 100 deceased women and girls in mortuaries at Kent and Sussex Hospital and Tunbridge Wells Hospital between 2005 and 2020.

The inquiry, chaired by Sir Jonathan Michael, was established as a non-statutory, independent inquiry and conducted in 2 phases. Sir Jonathan was determined to provide an opportunity for those families and staff who were directly affected by the actions of Fuller to share their experiences and information with the inquiry in ways that were sensitive and supportive.

Phase 1 report

Phase 1 examined the circumstances at Maidstone and Tunbridge Wells NHS Trust and its system partners. The resulting phase 1 report, published in November 2023, made 17 recommendations - 16 for the trust and one for Kent County Council and East Sussex County Council.

The government responded in October 2024 in a written statement to Parliament outlining the progress made by the trust and councils.

The trust implemented all their actions putting in place procedures:

• requiring that non-mortuary staff and contractors are always accompanied by another staff member when visiting the mortuaries
• controlling access to mortuaries using swipe cards
• mandating contractors to renew security clearances every 3 years
• installing CCTV coverage monitoring access to and from mortuary areas

The trust board also provided greater oversight and assurance of legally regulated activity in the mortuary.

Ongoing compliance with the recommendations was monitored by NHS England through regular regional oversight meetings with the trust and through other channels as appropriate.

The county councils responded to their recommendation by reviewing contractual arrangements with the trust and confirming that the contracts included terms requiring that licensing and regulatory requirements are met to ensure the deceased are at all times treated with dignity and respect.

Phase 2 report

The settings the inquiry considered in its phase 2 work included:

• NHS hospitals
• independent hospitals
• medical education settings
• hospices
• ambulances
• local authority mortuaries and body stores
• care homes
• the funeral sector

It also considered how different faith organisations safeguard the security and dignity of the deceased when facilitating burials or funerary ceremonies.

The inquiry’s work was expedited in light of cases of neglect of the deceased in some funeral homes. An interim report on the funeral sector was published in October 2024.

The phase 2 interim report on the funeral sector included preliminary findings and recommendations for this sector.

The phase 2 report, published on 15 July 2025, presented findings and recommendations aimed at preventing future abuse or neglect of the deceased. The chair’s overall conclusion was that the current arrangements in England for the regulation and oversight of the care of people after death are partial, ineffective and, in significant areas, completely lacking.

The inquiry’s phase 2 report is split into modules, covering specific sectors and settings that are involved in the care and management of the deceased. The 75 recommendations made in the final report by Sir Jonathan Michael aim to protect the security and dignity of people after death. Some of the recommendations are to specific sectors and others are wider reaching.

Recommendations: government interim update

The phase 2 report’s 75 recommendations are grouped below by whether the government:

• has accepted the recommendation in full (11)
• has accepted the recommendation in principle (43)
• is still considering the recommendation (21)

Recommendations accepted in full

The Department of Heath and Social Care (DHSC), working with relevant partner organisations, has accepted in full 11 of the recommendations.

Work in progress or completed is outlined below.

Recommendations 22 and 23

Ensuring standard operating procedures for patients who die, and ensuring only appropriate access to the deceased, in independent hospitals.

DHSC officials have met twice with the Independent Healthcare Provider Network (IHPN), which engaged with its members in September 2025. Members have confirmed they have taken action on the report. IHPN is now considering how to ensure assurance against the actions. DHSC has engaged independent inpatient mental health providers to ensure they are also aware of the inquiry’s recommendations and take any appropriate measures.

Recommendation 26

Human Tissue Authority to ensure adverse incidents in the anatomy sector are routinely reported.

The Human Tissue Authority, in its role as regulator, has expanded the scope of its adverse events and reportable incidents system in the post-mortem sector to include the anatomy sector. It has drafted guidance to ensure that adverse incidents in the anatomy sector are routinely reported, and the updated reporting system was implemented on 1 December 2025.

Recommendation 27

Hospices that care for deceased people on their premises should strengthen access controls where they are kept.

DHSC has worked with Hospice UK to ask its clinical leaders group network to urgently review their clinical practices against the recommendations. Hospice UK has already updated its Care After Death guidance for the hospice sector recommending that standard operating procedures regarding care of the deceased includes security measures to protect their dignity and safety, which may include CCTV monitoring. Any temporary or externally commissioned body store should meet these same security and governance standards.

The guidance also highlights the inquiry’s recommendations suggesting the introduction of auditable access control to the area where deceased people are kept and minimise unaccompanied access of non-permitted staff or contractors if possible. 

Recommendation 28

The Care Quality Commission (CQC) should issue clear guidance to inspectors that hospice inspections should not include areas where deceased people are kept.

CQC issued a rapid update to reiterate to inspectors the limits of their regulation in relation to mortuaries, and a further update through its internal bulletin to inspectors. CQC is currently working on revising guidance to inspectors. 

Recommendation 30

Data on how often deceased patients are conveyed in ambulances should be routinely collected and reported to NHS England.

NHS England has confirmed that relevant data lines are in the information standard. The first routine collection is expected to be rolled out in 2026 to 2027.

Recommendations 31 to 33

Introducing policies regarding the security and dignity of the deceased in NHS ambulances services.

The Association of Ambulance Chief Executives (AACE) has written to DHSC setting out the work they are doing to implement recommendations 31 to 33. This includes discussing with ambulance service leads to ensure all ambulance services review their policies around managing the deceased and introduce a clear policy if there is none currently.

AACE suggests that policies include specific wording around care of the deceased and contain detail and guidance around security and dignity in private or public locations.

Recommendation 34

Applying policies in recommendations 31 to 33 to independent ambulance services including private ambulances.

AACE has made the Independent Ambulance Association (IAA) aware of the inquiry recommendations. Where ambulance services have contractual agreements with independent ambulance services, those commissioned services must comply with the relevant NHS policies and procedures.

This requirement does not apply where independent ambulance providers operate outside of NHS contracts. For these providers, IAA has committed to advocate for the implementation of recommendations among its members and the wider sector, noting that IAA does not hold regulatory authority.

Recommendation 75

The UK government to take responsibility for the implementation of all the inquiry’s recommendations.

As part of the government’s commitment to responding to the inquiry’s recommendations, DHSC, as the inquiry sponsor, established a programme board in July 2025 to work across government and with other responsible organisations to scope and progress recommendations.

Recommendations accepted in principle

The government has agreed to accept in principle 43 recommendations subject to further work to determine the full impact of these recommendations.

Recommendations 1 to 21: NHS hospitals

Recommendation 1

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 of the potential breaches of security that could occur. The review should include an assessment of:

• the systems in place to identify any unauthorised access to the facility
• the strength and effectiveness of barriers to prevent unauthorised access to the facilities
• the systems in place to identify any access to deceased people for unauthorised purposes
• how CCTV is used, including its monitoring and any audits undertaken

Recommendation 2

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 and dignity of deceased people by implementing the appropriate safeguards. Where double-ended fridges also open into the post-mortem room, NHS trusts should install CCTV cameras inside the post-mortem room that focus on the doors to the fridges.

Recommendation 3

All NHS trusts should routinely audit the access data of all facilities used to store deceased people.

Recommendation 4

The practice of using shared electronic swipe cards for specific staff groups should cease immediately.

Recommendation 5

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 a rule that prevents electronic devices such as phones or cameras being taken into a mortuary, other than for approved reasons.

Recommendation 6

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 to identify any systemic security issues associated with the incident. A detailed action plan should be developed for each security breach, no matter how minor trusts regard such breaches to be. All security breaches occurring in mortuaries should be incorporated into security reports provided to trust boards or relevant subcommittees, in line with security breaches in other vulnerable areas.

Recommendation 7

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.

Recommendation 8

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 in the mortuary.

Recommendation 9

All NHS trusts should monitor the number of staff with access to the mortuary or body store and keep this under routine review.

Recommendation 10

NHS trusts should ensure that designated individuals have enough time and resource to fulfil their responsibilities, including time for learning and development.

Recommendation 11

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 responsibility associated with being a designated individual.

Recommendation 12

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.

Recommendation 13

A professional background in the field of mortuary services should be made a prerequisite for the post of mortuary manager.

Recommendation 14

NHS trusts should assure themselves that the mortuary manager has adequate resources and support to perform their role effectively, including meeting any reporting requirements.

Recommendation 15

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 accountable executive director, to the trust board on a routine basis. The accountable executive director should prepare and present to the trust board a formal annual report, similar to the annual safeguarding report. The report should include:

• staffing matters
• security incidents
• all serious incidents
• Human Tissue Authority reports (where applicable)
• all security audits, including audits of access and any access breaches

Recommendation 16

Trust boards should assure themselves that the recommendations in the report have been implemented.

Recommendation 17

Trust boards should ensure that these recommendations and government arrangements are applied to any temporary facilities used by trusts for the storage and care of deceased people.

Recommendation 18

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 arrangements.

Recommendation 19

NHS trust boards should ensure that the security and dignity of deceased people are included in safeguarding training, policies and assurance.

Recommendation 20

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.

Recommendation 21

NHS England should formally incorporate the safeguarding of deceased people into its safeguarding framework for NHS trusts.

Recommendations 35 to 56: local authorities

Recommendations 35 to 56 relate to local authorities.

Recommendation 35

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

Recommendation 36

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 mortuary, such as the post-mortem room. There should be a requirement to ‘swipe to exit’ to ensure that all activity is auditable. There should be no shared electronic access controls.

Recommendation 37

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 purposes of their work or visit
• they must be supervised when working in areas where there is access to deceased people, for example in the fridge or post‑mortem rooms
• their attendance must be recorded and audited

Recommendation 38

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, alongside mitigations that can be put in place to safeguard the security and dignity of the deceased, such as CCTV.

Recommendation 39

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 reconciled against CCTV footage. Audits must be reported to the designated individual and head of service or equivalent.

Recommendation 40

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 breaches of security that could occur. The review should include an assessment of:

• the systems in place to identify unauthorised access to the facility
• the strength and effectiveness of barriers to prevent unauthorised access to the facility
• the systems in place to identify any inappropriate access to the deceased
• how CCTV is used, including its monitoring and any audits undertaken

Recommendation 41

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

Recommendation 42

Fridges and freezers containing deceased people must be locked at all times, with appropriate key security in place.

Recommendation 43

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 from within the post-mortem room. Local authorities must put appropriate safeguards in place to maintain the security and dignity of the deceased in relation to the monitoring of CCTV. CCTV footage should be regularly reviewed. This should be done by mortuary staff where it is of a sensitive nature.

Recommendation 44

Arrangements for responding to incidents of unauthorised access must be reviewed and incorporated into standard operating procedures.

Recommendation 45

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.

Recommendation 46

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 local authority.

Recommendation 47

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 as a minimum. Serious security breaches must also be reported to the relevant cabinet member and/or committee of elected members.

Recommendation 48

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 designated individual, head of service or equivalent. Audits of staff compliance with the standard operating procedures must be undertaken at least annually, with the results of the audits reported to the designated individual and head of service or equivalent.

Recommendation 49

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 mortuary, level of influence within the local authority, and attendance at governance forums. In particular:

• local authorities must ensure that the designated individual has enough time and resource to fulfil their statutory responsibilities, including time for learning and development
• the designated individual must have access to director-level officers in the local authority. The designated individual must also be able to directly raise issues in relation to the mortuary at the highest level within the local authority if they deem it is necessary
• where the designated individual is non‑technically trained, a senior anatomical pathology technologist must fulfil the mortuary manager role to ensure that there is sufficient technical experience within the mortuary
• the designated individual must attend regular, documented meetings at mortuary level. The designated individual must also attend governance forums where the mortuary is discussed and scrutinised
• in line with Human Tissue Authority guidance, the named licence holder must be at a more senior level than the designated individual (for example, director level or higher) and have a clear understanding of the Human Tissue Authority’s statutory requirements and the role of the designated individual

Recommendation 50

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 committee, with regular reporting
• key performance indicators must be identified and must include the results of audits of compliance with Human Tissue Authority requirements
• inspections by the Human Tissue Authority and Human Tissue Authority Reportable Incidents (HTARIs) must be reported to the relevant statutory committee, and actions to achieve compliance monitored

Recommendation 51

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 authorities must arrange a peer review of the mortuary service at least every 3 years.

Recommendation 52

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 see these reports). Local authorities that are not the lead authority for the coroner service must also share these reports and incidents with the coroner service lead in that coroner area.

Recommendation 53

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

Recommendation 54

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.

Recommendation 55

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 licence is required to enable activities outside Human Tissue Authority licensing exemptions.

Recommendation 56

Where local authorities provide an unlicensed body store, they should do so in line with the report’s recommendations to local authority providers of licensed mortuaries.

Recommendations under consideration

For the remaining 21 recommendations, these remain under consideration.

The government will continue to work on its response to the recommendations and provide a full response to the Fuller inquiry phase 2 report by summer 2026.

Recommendation 24

All organisations providing anatomical education and medical training using donors should make sure that other clinical policies and procedures are in place to ensure the security and dignity of donors. These should include:

• security and access policies and the auditing of security and access measures such as swipe card access, CCTV and access to the locations where donors are kept
• governance arrangements to ensure effective oversight of and accountability for the security and dignity of donors
• a review of contracts or agreements with external organisations for the transfer of donors to or between facilities
• policies and processes on incident reporting, both within the organisation and to the Human Tissue Authority, that are clear and accessible to all students and staff

Recommendation 25

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 formal agreements, where relevant, including management, governance and Human Tissue Authority licensing arrangements for the organisations involved.

Recommendation 29

Hospices should be considered in scope for the regulatory measures in chapter 11 (of the phase 2 report).

Recommendation 57

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 key performance indicators, regular reporting, formal contract review meetings, site visits and stakeholder feedback.

Recommendation 58

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 or other action by the Human Tissue Authority or others with an oversight role, such as the Health and Safety Executive.

Recommendation 59

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 operating procedures that protect the security and dignity of the deceased and audits to ensure staff compliance with them, as well as the reporting of incidents.

Recommendation 60

The regulatory measures recommended in chapter 11 (of the phase 2 report) should apply to care homes in England. Regulation should cover both systems and professionals where staff are providing care to deceased people in care homes.

Recommendation 61

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 deceased. This regime should include a licensing scheme, mandatory standards against which funeral directors should be inspected regularly, and enforcement powers.

Recommendation 62

These regulations and standards should be considered within the overall care and journey of the deceased rather than applying in isolation to funeral directors.

Recommendation 63

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 protect their security and dignity, and what should be expected of funeral directors’ services.

Recommendation 64

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 any emerging new models of delivery of care for the deceased.

Recommendation 65

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 customers and the need for public confidence outweigh the difficulties that may be experienced by some businesses.

Recommendation 66

The funeral sector in England should be considered in scope for the broader regulatory measures recommended in chapter 11 (of the phase 2 report).

Recommendation 67

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 - for example, by sharing guidance.

Recommendation 68

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 area in which they are kept.

Recommendation 69

Where organisations work together to care for the people after death, the arrangements should be formalised through contracts or service level agreements. This should include joint standard operating procedures. The parties to the contracts or service level agreements should ensure that the contracts or agreements are managed effectively, and that they seek assurance that the arrangements protect the security and dignity of people after death.

Recommendation 70

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 coroners are aware of the prevalence of offending by David Fuller against deceased people who were formally under the control of the coroner
• all coroners understand the importance of a consistent approach to ensuring the security and dignity of deceased people who are under their control

This is likely to require guidance from the chief coroner to ensure that there is a consistent approach nationally, and it should be considered an area for further training for all coroners and their staff.

Recommendation 71

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 should be to ensure that the security and dignity of deceased people are protected, in whichever institutions or locations they are cared for, examined or stored.

The government should ensure that this role is adequately resourced to discharge its responsibilities and should provide it with powers to require information and enter premises and to take appropriate enforcement action (including against office holders in any organisation). Either the Human Tissue Authority should be required to work under the auspices of this new regime, or its remit should be formally expanded to comply with the statutory regime’s requirements.

Recommendation 72

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 care for deceased people. This guidance should set out expectations for the security and dignity of deceased people.

Recommendation 73

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 place at their establishment
• suitable premises are provided and maintained
• suitable individuals are employed
• all relevant legal and regulatory duties pertaining to the licence are met

Recommendation 74

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 supervised. The regulatory regime should set minimum standards on the qualifications likely to be considered sufficient to demonstrate suitability for particular roles or levels of responsibility. Failure to ensure that suitable individuals are employed would be subject to regulatory enforcement.