Mortuary abuser David Fuller was able to offend without being caught because of “serious failings” at the hospitals where he worked, an inquiry has found.
Between 2007 and 2020, Fuller abused the bodies of at least 101 women and girls in Kent hospitals.
Inquiry chair Sir Jonathan Michael said “there were missed opportunities to question Fuller’s working practices”.
He added the abuse “had caused shock and horror across our country and beyond”.
The inquiry has made 17 recommendations to prevent “similar atrocities”.
These include installing CCTV cameras in mortuaries, ensuring non-mortuary staff are always accompanied and that bodies are not left out of fridges overnight.
Fuller, who is 69, was given two whole-life sentences in 2021 for murdering Wendy Knell and Caroline Pierce and jailed for a total of 16 years for abusing corpses, meaning he will die in prison.
As well as failures of management at Maidstone and Tunbridge Wells NHS Trust, Sir Jonathan said there had been a “failure to follow standard policies and procedures, together with a persistent lack of curiosity”.
“The senior management of the trust were aware of problems in the running of the mortuary from as early as 2008. But there is little evidence that effective action was taken to remedy these,” he said.
There had been “little regard” given to who was accessing the mortuary, with Fuller visiting 444 times in a year – something that had gone “unnoticed and unchecked”.
Sir Jonathan said: “In identifying such serious failings, it’s clear to me that there is the question of who should be held responsible.”
He said Fuller’s behaviour was not something that could easily be anticipated.
“It is out of the ordinary, but that is precisely why you have policies and procedures and protocols to pick up that which is out of the ordinary.”
SOURCE: BBC