An inquiry into the case of necrophiliac hospital worker David Fuller has warned that “offences such as those committed by David Fuller could happen again” due to widespread regulatory failures across England’s death care system.
The independent inquiry found that “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”. Fuller, 70, was able to sexually abuse at least 101 corpses over 15 years at Kent hospitals without detection due to “serious failings”.
Phase 2 of the inquiry, which examined the broader national picture beyond Fuller’s crimes, concluded that weaknesses in mortuary security and management are not confined to where Fuller operated. Sir Jonathan Michael, who chairs the inquiry, said he found examples of poor practice “across the country” that could enable similar offences.
Decade of Undetected Abuse
Fuller was given a whole-life prison term in December 2021 for the murders of Wendy Knell and Caroline Pierce in Tunbridge Wells, Kent, in 1987. Police investigating the murders discovered he had systematically abused corpses whilst working as a maintenance supervisor at Kent and Sussex Hospital and Tunbridge Wells Hospital.
His victims ranged in age from nine to 100. Fuller entered one mortuary 444 times in a single year “unnoticed and unchecked”, according to phase 1 of the inquiry, which found deceased people were routinely left out of fridges overnight during working hours.
The maintenance worker recorded himself committing the offences between 2005 and 2020. Police uncovered the evidence when searching his home following his arrest for the historical murders.
National Regulatory Gaps
Presenting the phase 2 findings on Tuesday, Sir Jonathan said: “This is the first time that the security and dignity of people after death has been reviewed so comprehensively. Inadequate management, governance and processes helped create the environment in which David Fuller was able to offend for so long.”
He emphasised these weaknesses extended far beyond the hospitals where Fuller worked. I have asked myself whether there could be a recurrence of the appalling crimes committed by David Fuller. I have concluded that yes, it is entirely possible that such offences could be repeated, particularly in those sectors that lack any form of statutory regulation.”
The inquiry examined procedures in NHS and private hospitals, funeral directors, private mortuaries, ambulances, local authority mortuaries, medical schools and hospices. It found significant gaps in regulation across multiple sectors.
Call for Statutory Protection
Sir Jonathan called for urgent establishment of statutory regulation to “protect the security and dignity of people after death”. The inquiry’s interim report on the funeral sector, published in October 2024, had already recommended independent statutory regulation for funeral directors in England.
“Current arrangements for the regulation and oversight of the care of people after death are partial, ineffective and in significant areas completely absent,” the report stated. This leaves the deceased vulnerable to abuse or neglect across various settings.
The Human Tissue Authority currently licenses and inspects larger hospital mortuaries that conduct post-mortems. However, its regulatory powers do not extend to other mortuaries without post-mortem facilities, either in hospitals or those run by local authorities.
Hospital Security Failures
Phase 1 of the inquiry, published in November 2023, revealed shocking security lapses at the hospitals where Fuller worked. There was “virtually no on-site supervision, limited oversight and limited assurance” at the mortuaries, creating a culture where standard procedures were ignored.
A two-year delay occurred in installing CCTV at Tunbridge Wells Hospital mortuary after the manager requested it. The report concluded that “earlier installation of CCTV at the Tunbridge Wells Hospital mortuary, providing the correct coverage and operated with trained staff who were monitoring it, would have provided a significant barrier to David Fuller’s offending.”
Fuller routinely worked beyond his contracted hours, undertaking unnecessary tasks in the mortuary that should not have been performed by someone with his chronic back problems. Yet there was a persistent “lack of curiosity” among colleagues who never questioned his presence.
Family Trust Destroyed
More than half the families who gave evidence to the inquiry said they no longer trust Maidstone and Tunbridge Wells NHS Trust or the wider NHS. Some 60 per cent believed the trust failed to protect their loved ones when they were most vulnerable.
Miles Scott, chief executive of Maidstone and Tunbridge Wells NHS Trust, said he was “deeply sorry for the pain and anguish” suffered by victims’ families. The trust has implemented immediate security improvements including ensuring non-mortuary staff are always accompanied.
The inquiry was formally established in January 2022 following an announcement by then Health Secretary Sajid Javid. Sir Jonathan Michael was appointed to chair the investigation, with Rebecca Chaloner as secretary.
Widespread Vulnerabilities
The inquiry’s findings extend beyond hospitals to multiple sectors handling the deceased. Many bodies are held by funeral directors where there is no regulation comparable to that governing hospital mortuaries.
“Failures of management, of governance, of regulation, failure to follow standard policies and procedures, together with a persistent lack of curiosity, all contributed to the creation of the environment in which he was able to offend,” Sir Jonathan said.
The phase 2 report represents the first comprehensive review of security and dignity provisions for the deceased across England. It highlights how regulatory gaps leave multiple sectors vulnerable to potential abuse.
Fuller’s crimes were discovered only when police investigated him for the 1987 murders, for which DNA evidence had been available since 2007. A match was finally made in 2020, leading to his arrest and the subsequent discovery of his mortuary offences.
The inquiry continues to investigate allegations of inappropriate behaviour at Kent and Sussex Hospital mortuary in the late 1990s, having received new information requiring further examination.
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