Necrophilia: The horrific case of a man who abused more than 100 bodies in British hospitals

The investigation made 17 recommendations to prevent “similar atrocities.”

These include installing cameras in morgues, ensuring that people who do not belong to funeral services are always accompanied and bodies are not left outside mortuaries overnight.

Fuller, 69, was sentenced to life in prison in 2021 for the murders of Wendy Knell and Carolyn Pierce, and was also sentenced to 16 years for abuse of corpses, meaning he will die in prison.

In addition to management failings in Maidstone and Tunbridge Wells, Jonathan said there had been a “failure to follow standard policies and procedures, coupled with a persistent lack of curiosity”.

According to him, the administration “has been aware of the problems obstructing the operation of the morgue since 2008. But there is little evidence that effective measures have been taken to address these problems.”

There was “little interest” in who arrived at the morgue, as Fuller visited it 444 times in one year – something that went “unnoticed and unattended”.

“By identifying such serious failings, it is clear to me that someone needs to be held accountable,” Jonathan said.

Fuller, originally from Heathfield in East Sussex, worked as a maintenance supervisor at Tunbridge Wells Hospitals in Kent for three decades.

He committed the crimes in morgues between 2007 and his arrest in 2020.

Fuller was able to access morgues using an employee’s magnetic card, choosing times when he knew employees had gone home and when areas were unattended.

There, he systematically assaulted at least 101 bodies, the youngest nine years old and the oldest 100 years old.

During his trial, the court heard how he visited “the same bodies over and over again”.

Responding to the investigation report, Miles Scott, chief executive of the trust that runs the hospital, said the findings contained “important lessons for us”.

He said the “vast majority” of the recommendations made by the investigation “have already been put into practice in the period following Fuller’s arrest, and we will implement the remaining recommendations as quickly as possible.”

In a written statement to Parliament, Health Minister Maria Caulfield said: “I want to deeply apologize on behalf of the Government and the NHS, and pledge to learn lessons.”

“We welcome the report and will ensure there is a full response to the recommendations in spring 2024, and that lessons are learned across the NHS so that no family has to go through this again.”

The second part of the investigation was launched in July to analyze the way people who died were treated across the country, focusing on conditions in private morgues, private ambulances and funeral homes.

Conclusions for this part of the investigation are expected in 2024.