Independent Inquiry into the issues raised by the David Fuller Case publishes Phase 2 final report

The Inquiry was established to consider issues raised by the case of David Fuller who committed offences on the bodies of at least 100 deceased women and children at the Maidstone and Tunbridge Well NHS Trust mortuaries.   Phase 1 of the Inquiry considered what happened at the Trust and how Fuller’s offending remained undetected for so long. Phase 2 inquired into the wider national picture considering care of the deceased in both hospital and non-hospital contexts including local authority mortuaries, funeral directors, the NHS ambulance service, medical schools, temporary mortuaries, care homes and hospices.  Jonathan Landau acted as Counsel to the Inquiry in Phase 2 with a particular focus on advising the Inquiry about the relevant regulatory and legislative frameworks

The Inquiry analysed the full range of legal frameworks and oversight concerning the deceased and the legal status of the deceased taking evidence from organisations through statements and interviews, and by means of a seminar facilitated by Jonathan.  The Inquiry found that the protection of the deceased was partial, ineffective and in significant cases completely lacking with no system of regulation or oversight with the principal objective of protecting the security and dignity of the deceased.   It made 75  recommendations including introducing statutory regulation to protect the security of the deceased regardless of the setting they are in.

The Phase 2 report, which completes the Inquiry’s work, follows an interim report published by the Inquiry in October 2024 calling for an independent statutory regulatory regime for the funeral sector.  That followed further reports of abuse of deceased persons nationally during the course of the Inquiry’s work.  Currently, there is neither a mandatory nor a statutory regulatory regime for the sector in England and Wales.

The Inquiry’s Chair noted that it is currently possible that there could be a recurrence of the crimes committed by Fuller, particular in sectors that lack statutory regulation.  It will accordingly be of great interest how the government responds to the recommendations.

The phase 2 report is available on the Inquiry website here: Independent Inquiry into the issues raised by the David Fuller case – Phase 2 report

Jonathan Landau acts as Counsel to the Inquiry and Core Participants in Inquiries, for Coroners, police forces and other public authorities in claims for judicial review, for a broad range of clients in inquests, and for health and social care providers in healthcare regulatory matters.