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An inspection at a mortuary where David Fuller abused dead women raises further questions over his access to the morgue.
A former public body report into the hospital mortuaries at Maidstone and Tunbridge Wells, found three major and 11 minor shortfalls, including bodies being "doubled up" during one winter, a lack of CCTV and comprehensive risk assessments.
On November 4, Fuller, 67, of Heathfield, East Sussex, admitted to the murders of Wendy Knell, 25, and Caroline Pierce, 20 in 1987, in Tunbridge Wells.
After his arrest for their murders in December 2020, video footage was found in Fuller's home, showing him abusing the bodies of at least 100 dead women in the mortuaries of hospitals where he worked, between 2008 and November 2020.
The killer first started working at the now closed Kent and Sussex Hospital in 1989 in electrical maintenance roles. In 2010 he began work at Tunbridge Wells Hospital, and became a supervisor, remaining there until his arrest.
In 2011 his job was transferred to Interserve and just three days before his arrest, the company Mitie took over the facilities management side of Interserve.
Mitie confirmed Fuller's previous employment, but will not comment further at this time.
In 2015 and 2018, the Human Tissue Authority (HTA), a non-departmental public body, inspected Tunbridge Wells Hospital mortuary, with Maidstone Hospital morgue also inspected in 2018.
The HTA was set up in 2005 and regulates organisations that remove, store and use human tissue for research, medical treatment and post-mortem examination.
The 2015 report found that Tunbridge Wells Hospital had met the majority of HTA standards. However, two minor shortfalls were found, with more work needed on standard operation procedures and several risk assessments limited in scope.
The report also revealed that mortuary staff worked well together and their efforts were even recognised by Maidstone and Tunbridge Wells NHS Trust, through an award.
The 2018 document said the Tunbridge Wells Hospital mortuary had met the majority of HTA standards, then goes on to explain the shortfalls.
The 2018 report is much more detailed and extensive than the 2015 document, giving an insight into how the mortuary was run and its issues.
It also raises questions about whether's Fuller's access to the mortuary was disclosed to inspectors.
As of 2018, the Tunbridge Wells Hospital had four members of staff, including a mortuary manager who was based at Maidstone.
Around 556 post-mortem examinations were carried out a year, and there were 65 refrigerated body storage spaces, as well as temporary, contingency storage.
The report reads: "The entrance to the Tunbridge Wells Hospital mortuary from the hospital is secured by swipe card access, which is limited to trained mortuary and trained portering staff and there is a video intercom system in place."
During their investigation, police discovered that David Fuller, as a maintenance supervisor, had full access all areas in the hospital.
Explaining this in a police briefing, Det Supt Ivan Beasley said: "He had access to all areas. He could go anywhere because that's what his job allowed him to do. That does include the mortuary."
He added that Fuller had "no specific role within the mortuary".
In court it emerged that Fuller had access to the mortuary with his swipe card.
However, the report does not refer to any staff, other than mortuary staff and trained portering staff, accessing the site.
This raises questions over whether Fuller's access was disclosed to the HTA, which has standards including: "The premises are secured (for example there is controlled access to the body storage area(s) and post-mortem room and the use of CCTV to monitor access)."
Another standard says: "Security arrangements protect against unauthorized access and ensure oversight of visitors and contractors who have a legitimate right of access."
Fuller generally worked 11am-7pm, while the mortuary staff worked 7am-4pm, meaning there were times Fuller could have been alone in the mortuary.
Kent Police have also confirmed that Fuller's swipe card records demonstrate he spent a "significant amount of time" outside his planned shift pattern in the mortuary at Tunbridge Wells Hospital.
The police were able to sift through his swipe card records going back to the winter of 2019. Fuller's last offence was committed in November 2020.
It is understood that maintenance staff generally have access to mortuaries in hospitals, in order to fix and check equipment.
However, the level of access, such as the regularity and procedures around access, are decided by the hospital.
Maidstone and Tunbridge Wells NHS Trust was asked by KentOnline why the report does not mention that maintenance staff or supervisors, such as Fuller, had access to the mortuary.
KentOnline also asked whether any other staff, apart from Fuller, and those referenced in the report had access.
In response, the trust referred to a previous statement from its chief executive, Miles Scott, which said: "I am confident that our mortuary today is safe and secure. But I am determined to see if there are any lessons to be learned or systems to be improved."
The trust says they'll be able to say more once the public inquiry into how Fuller's actions went undetected, and wider lessons for the NHS, has been carried out.
The Human Tissue Authority says it does not comment further on public reports, when asked whether they were told about staff, apart from those mentioned in the report, accessing the mortuary.
But, in a comment, the body said it welcomes the inquiry and is "ready to advise" Health Secretary Sajid Javid, who ordered it.
One major shortfall related to security at Maidstone Hospital mortuary, which is smaller than Tunbridge Wells, with 48 refrigerated spaces, and does not carry out post-mortem examination.
David Fuller never worked at Maidstone Hospital, Maidstone and Tunbridge Wells NHS Trust has previously confirmed.
The 2018 report reads: "There is no mortuary or hospital CCTV within, or at access points to the mortuary and there is no audio-visual intercom system at Maidstone Hospital."
Staff are only able to verify who is requesting access by opening the entrance doors to the mortuary.
This could pose a potential risk to the security of the staff and premises, especially as there is only one member of staff lone working there, the report adds.
"He could go anywhere because that's what his job allowed him to do..."
During the visit, inspectors were told that Tunbridge Wells Hospital does not have sufficient capacity for storing bodies for extended periods during the winter months.
"Last winter, the mortuary staff had to 'double-up' bodies in refrigerated storage due to insufficient capacity.
"This is not considered suitable practice and disregards the dignity of the deceased," the report adds.
Inspectors were told funds may be available in the future to increase storage, but it was not guaranteed.
The hospital trust was asked by KentOnline if there is now CCTV and an intercom system at Maidstone Hospital mortuary, and when these were installed. It was also asked whether lone working at Maidstone mortuary is still frequent.
The trust was also asked if more storage capacity has been created and when.
The organisation did not answer these questions, instead referring to its previous statement, already quoted.
A third major shortfall centred on bodies being released to funeral directors and being seen by family, without them giving three separate identifiers, in order to establish which body is needed.
Funeral directors did not bring paperwork with them for release, so the mortuary was releasing bodies on a verbal request of name only.
This presents a risk of releasing and viewing of the wrong body, the report says.
Minor shortfalls include standard operating procedures which were out of date or lacking in detail, and incomplete audits.
Some risk assessments were past their review date and did not consider all potential hazards.
When risks were identified, many of them as well as the control measures did not accurately reflect procedures and practices.
Concluding, the report said some areas of strength and good practice were observed, describing the mortuary staff as a "cohesive, long-standing and experienced team".
They also demonstrated "a sensitive and dedicated approach to their work".
Following the revelations of Fuller's acts in the mortuary, Maidstone and Tunbridge Wells NHS Trust announced it's own investigation, which would be independently chaired, into how he was able to commit the violations.
However, within the week, Health Secretary Sajid Javid announced a public inquiry, replacing the trust's investigation.
He said: "The inquiry will look into the circumstances surrounding the offences committed at the hospital and their national implications.
"It will help us understand how these offences took place without detection in the trust."
The inquiry will report to Mr Javid and will be split into two parts. The first will be an interim report which Mr Javid has asked to be published early in the New Year, and the second, a final report looking at wider lessons for the NHS.
An HTA spokesman said: "We are deeply shocked by these crimes and the distressing impact they will have on families and friends of the victims. Protecting the dignity of the deceased is a guiding principle of our work at the HTA.
"Understanding how these crimes were able to take place is now critical, so any lessons can be learned for all those involved.
"The HTA is ready to advise the Secretary of State and we welcome the announcement of the Independent Inquiry."
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