Seventeen recommendations made as a result of independent inquiry into David Fuller case

Chair Sir Jonathan Michael

In December 2021, Heathfield man David Fuller, an electrical maintenance supervisor with Maidstone and Tunbridge Wells NHS Trust, was convicted of the murders of Wendy Knell and Caroline Pierce in 1987. On his arrest, police officers conducted a search of his home address. This search uncovered printed photographs and video images, held on hidden computer hard drives of Fuller performing sexual acts on deceased people.

The subsequent police investigation found that Fuller had sexually abused at least 100 deceased women and girls in the mortuaries of the hospitals in which he had worked. His victims’ ages ranged from 9 to 100 years old. His offences took place between 2005 and 2020. Fuller was convicted of the mortuary offences under the Sexual Offences Act 2003, at the same time as his conviction for the murders of
Wendy and Caroline.

The Phase 1 Report of the inquiry to investigate how David Fuller was able to carry out inappropriate and unlawful actions in the mortuaries at Maidstone and Tunbridge Wells NHS Trust and why they went apparently unnoticed was published today. The inquiry will also consider if procedures and practices in other hospital and non-hospital settings, where the deceased are placed, safeguard the security and dignity of the deceased.

This phase of the Inquiry has been to establish what happened in the Maidstone and Tunbridge Wells NHS Trust to allow Fuller to commit such awful crimes and to understand how his offending remained undetected for so long.

The Inquiry held interviews with over 200 witnesses and reviewed more than 3,700 documents. Based on the evidence heard and reviewed by the Inquiry team, the report makes 17 recommendations with the aim of preventing any similar atrocities happening again in the Trust.

Sir Jonathan Michael, Chair of the Inquiry, said: “When I was asked to chair this Independent Inquiry, I was conscious of the responsibility of the role, as Fuller’s crimes had caused shock and horror across our country and beyond.

“The offences that Fuller committed were truly shocking, and he will never be released from prison. 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, and to do so for 15 years without ever being suspected or caught.

“I would like to reiterate my sincere thanks to the families of Fuller’s victims, for bravely sharing their feelings and experiences with us, and for their patience as we undertook the process of reviewing evidence and drafting this Report.”

Maidstone and Tunbridge Wells NHS Trust said in a statement that David Fuller’s depraved, calculated and devious criminal behaviour remains deeply shocking. That he murdered two young women in 1987 and went on to abuse his role in public service to pursue his criminal activities is equally shocking. At the time of his conviction two years ago the Trust offered its sincere apologies to the families of Fuller’s victims. Today we repeat that apology.

The Trust Chief Executive, Miles Scott, said: “On behalf of the Trust, and on behalf of the previous NHS organisations that Fuller worked for, I am deeply sorry for the pain and anguish the families have suffered. I know how devastating it has been for them to learn the extent of his crimes.”

We would like to thank Sir Jonathan Michael and his team for their detailed work. The Trust did not see the report in advance of publication, but clearly it contains important lessons for us.

It makes 16 recommendations for the Trust including the installation of further CCTV cameras, additional swipe card access on doors, and regular auditing of mortuary access records. The vast majority of these recommendations have already been actioned in the period since Fuller’s arrest, and we will be implementing the remaining recommendations as quickly as possible.

The Inquiry team told us if they came across any conduct of concern, such as potential disciplinary offences or breaches of professional codes of conduct, they would tell us. We have received no such notification, but we will be studying the report carefully to make our own assessment.

We have worked with Kent Police and Victim Support to help the families of Fuller’s victims in a number of ways and established a dedicated compensation scheme. Our commitment to the continuing support of these families is ongoing and will be open-ended.

Sir Jonathan Michael’s report covers a period of over 30 years. Fuller’s crimes were horrific, and the impact of these crimes will stay with the families of his victims forever. We now have a duty to ensure the lessons are learned.