Necrophiliac killer David Fuller was able to offend for 15 years without being suspected or caught due to “serious failings” at the hospitals where he worked, an inquiry has found.

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 was already serving a whole life sentence for the murders of Wendy Knell, 25, and Caroline Pierce, 20, in two separate attacks in Tunbridge Wells, in 1987, when police uncovered his systematic sexual abuse in hospital mortuaries.

The government launched an independent inquiry two years ago 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.

The report found Fuller was able to “offend undetected” amid failures in “management, governance” and because standard procedures were not followed, 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 today (November 28) 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.”

The inquiry heard from staff at the hospital that they did not believe there to be a requirement to supervise Fuller, who was an electrical maintenance supervisor, when he was in the post-mortem room to undertake maintenance tasks, as they were under the impression that it was part of his role.

Designated individual for the trust, Dr Dominic Chambers, said: “[T]here are not enough of you to just have someone standing there constantly making sure that that is what they are doing. You have to trust, you have to trust people, don’t you?”

The inquiry found that there was a “lack of curiosity” about Fuller among colleagues and they did not question his role or presence in the mortuary.

The investigation also said that there was “virtually no on-site supervision, limited oversight and limited assurance” at the mortuary which allowed a culture to develop where standard procedures were not followed.

The report added: “This culture created an environment in which David Fuller offended.”

Security measures at Tunbridge Wells Hospital also came under scrutiny, with a two-year delay in CCTV being installed at the mortuary after it was requested by the manager.

The report concluded: “Earlier installation of CCTV at the Tunbridge Wells Hospital mortuary, providing the correct coverage and operated with trained staff who were monitoring it, would have provided a significant barrier to David Fuller’s offending.”

It also said that the trust “failed to put in place adequate security systems to monitor staff access to the mortuary”, such as reviewing the use of access cards which Fuller had for his job.

The inquiry concluded he was able to sexually abuse the bodies of women and girls in both hospitals because he was allowed “unaccompanied access”.

This was despite it not being compliant with the Human Tissue Authority rules or the conditions of KCC’s contract with the trust for post-mortem services.

It recommended that the trust ensures that any non-mortuary staff and contractors “are always accompanied by another staff member when they visit the mortuary.”

The inquiry also found that the bodies of deceased people were left out of fridges overnight which would have increased Fuller’s opportunities to offend.

More than half of the families who gave evidence to the inquiry said they no longer trust Maidstone and Tunbridge Wells NHS Trust or the wider NHS after what happened to their relatives.

Some 60% believed the fault was with the trust for failing to protect their loved ones when they were at their most vulnerable.

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.

He added: “I know how devastating it has been for them to learn the extent of his crimes.”

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” and said the report “contains important lessons”.

The statement continued: “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.”

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.

An important part of the hearings is to "afford families who have been affected by David Fuller's actions to be heard".

Previously, families of Fuller's victims were upset about a lack of communication between the inquiry team.

Solicitors representing some of the families took legal action last year by calling for a judicial review in their campaign to get a public inquiry.