The maintenance worker sexually abused the bodies of at least 101 women and girls aged between nine and 100 while employed at the now-closed Kent and Sussex Hospital and the Tunbridge Wells Hospital, in Pembury, between 2005 and 2020.
The 69-year-old, from Heathfield, was already serving a whole life sentence for the sexually motivated murders of Wendy Knell, 25, and Caroline Pierce, 20, in two separate attacks in Tunbridge Wells, Kent, in 1987, when police uncovered his systematic sexual abuse in hospital mortuaries.
The government launched an independent inquiry in 2021 to investigate how Fuller was able to carry out his crimes undetected, with the first phase of the probe looking at his employer, Maidstone and Tunbridge Wells NHS Trust.
Fuller was able to “offend undetected” amid failures in “management, governance” and because standard procedures were not followed, the inquiry found, while senior bosses were said to be “aware of problems in the running of the mortuary from as early as 2008″.
There was “little regard” given to who was accessing the mortuary, with Fuller visiting 444 times in a year – something that went “unnoticed and unchecked”, reporters were told.
At a press conference in Westminster, central London, on Tuesday, inquiry chairman Sir Jonathan Michael said: “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.
“Over the years, there were missed opportunities to question Fuller’s working practices.
“He routinely worked beyond his contracted hours, undertaking tasks in the mortuary that were not necessary or which should not have been carried out by someone with his chronic back problems. This was never properly questioned.”
Outlining 17 recommendations made in a bid to prevent similar atrocities, Sir Michael, a former NHS hospital consultant and chief executive, said: “In identifying such serious failings, it’s clear to me that there is the question of who should be held responsible.
“Although the failures took place over many years and during various management and regulatory regimes, I expect the current leadership of the Maidstone and Tunbridge Wells NHS Trust and those outside the trust charged with oversight and regulation, to reflect seriously and carefully on their responsibility for the weaknesses and failings that I have identified in this report and to implement my recommendations.”
The inquiry concluded the trust should install CCTV cameras in the mortuary and post-mortem room, that maintenance staff should always carry out tasks in those areas in pairs and the “practice of leaving deceased people out of mortuary fridges overnight” or while maintenance is carried out should end. It also called for a review of governance policies by the trust’s board.
An examination of Fuller’s computer hard drive at his home in Heathfield, East Sussex, revealed 818,051 images and 504 videos of his abuse as well as evidence of his “persistent interest” in rape, abuse and murder of women.
In 2021, Fuller admitted murdering Ms Knell and Ms Pierce, as well as pleading guilty to 44 charges relating to 78 women and girls between 2008 and November 2020.
He was sentenced to a further four years in prison last year, after pleading guilty to sexually abusing the bodies of 23 more women between 2007 and 2020.
Trust chief executive Miles Scott, who took on the role in 2018, said in a statement he was “deeply sorry for the pain and anguish” suffered by the families of Fuller’s victims, adding of the inquiry’s report: “Clearly it contains important lessons for us.”
While many of the recommendations were acted on in the wake of Fuller’s arrest, Mr Scott said the trust would be implementing the remainder “as quickly as possible”.
Health minister Maria Caulfield apologised on behalf of the government and the NHS, saying the report made for “harrowing reading” and vowed that “lessons will be learnt” so “no family has to go through this experience again”.
A second part of the inquiry was launched in July to review how people who have died are cared for around the country, focusing on safeguarding in private mortuaries, private ambulances and funeral directors.
The findings of this part of the inquiry are expected in 2024.
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