An investigation concluded by the British police confirmed that employee David Fuller abused corpses in the hospitals where he worked and managed to act without being caught because of “serious failures” in the establishments.
Between 2007 and 2020, Fuller abused the bodies of at least 101 women and girls in Kent hospitals.
Inquiry chair Jonathan Michael said “there were missed opportunities to question Fuller’s working practices”.
He added that the abuse “caused shock and horror across our country and beyond”.
They include installing cameras in morgues, ensuring that people who do not belong to the funeral service are always accompanied and that bodies are not left out of refrigerators overnight.
Fuller, 69, was sentenced to two life sentences in 2021 for the murder of Wendy Knell and Caroline Pierce and sentenced to a total of 16 years in prison for abuse of corpses, meaning he will die in prison.
In addition to the management failures at Maidstone and Tunbridge Wells, Jonathan said there was a “failure to follow standard policies and procedures, coupled with a persistent lack of curiosity”.
According to him, management “was aware of problems in the functioning of the morgue since 2008. But there is little evidence that effective measures have been taken to remedy these problems,” he said.
There was “little attention” to who accessed the morgue, as Fuller visited it 444 times in one year – something that went “unnoticed and uncontrolled”.
Jonathan said: “By identifying such serious failings, it is clear to me that someone must be held accountable.”
Fuller, originally from Heathfield in East Sussex, worked as a maintenance supervisor at hospitals in Tunbridge Wells in Kent for three decades.
He committed the crimes in morgues between 2007 and his arrest in 2020.
Fuller gained access to morgues using his employee swipe card, choosing times when he knew employees had gone home, when the areas were unattended.
There, he systematically abused at least 101 corpses, the youngest of which was nine years old and the oldest 100 years old.
At his trial, the court heard how he visited “the same bodies over and over again”.
Responding to the inquiry report, the chief executive of the trust that runs the hospital, Miles Scott, said the findings contained “important lessons for us”.
He said “the vast majority” of the recommendations made by the inquiry “have already been put into practice in the period since Fuller’s arrest, and we will implement the remaining recommendations as quickly as possible”.
In a written statement to Parliament, Health Minister Maria Caulfield said: “I want to deeply apologize on behalf of the government and the NHS, and commit that lessons will be learned.”
“We welcome the report and will ensure there is a full response to the recommendations in spring 2024, and that lessons are learned across the NHS so that no family has to go through this experience again.”
A second part of the inquiry was launched in July to analyze the way people who have died are treated across the country, focusing on conditions in private morgues, private ambulances and funeral homes.
The conclusions of this part of the investigation are expected in 2024.