Overview

• The inquiry’s Phase 2 report concludes that England lacks a single regulator with authority over post-death care, describing current arrangements as partial, ineffective and in significant areas absent.
• Sir Jonathan Michael warns that without legally enforceable standards, offences like David Fuller’s necrophilia could recur across hospitals, care homes and funeral services.
• The report issues 75 recommendations, including mandatory CCTV in mortuaries, a unified oversight framework and statutory registration and inspection of funeral directors.
• Existing bodies such as the Human Tissue Authority and Care Quality Commission hold limited mandates that exclude control over mortuary security or body storage, leaving critical governance gaps.
• David Fuller abused over 100 bodies between 2005 and 2020 at Kent and Sussex and Tunbridge Wells hospitals, making 444 unchecked mortuary visits in a single year.