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 findings were branded “astonishing” and prompted calls for an NHS trust boss to be sacked after the probe concluded victim’s families were “repeatedly let down… at all levels”.

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 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.

Inquiry chairman Sir Jonathan Michael told reporters this had not just been the case of a “rogue” employee, and families of his victims were “repeatedly let down by those at all levels whose responsibility it was to ensure that they were appropriately cared for and protected in the mortuary.”

At a press conference in Westminster, central London, on Tuesday, he said: “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.”

He highlighted “missed opportunities” over the years to question Fuller’s working practices, which included him carrying out unnecessary tasks in the mortuary.

Some of his crimes were committed during working hours when mortuary staff should have been on duty. He also used an admissions log book to select his victims and for reference to catalogue his crimes, a 300-page report said.

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.

Sallie Booth, from law firm Irwin Mitchell which is representing 18 families of victims abused by Fuller, said: “Whilst the families have yet to read the detail of the report, they expect all of those individuals who had responsibility for governance and management of the hospital to reflect seriously about their own failures, acknowledge those failings and take personal responsibility for them.”

David Fuller court case
Court artist sketch of David Fuller (Elizabeth Cook/PA)

The daughter of one of his victims told the inquiry: “They need to sack the CEO, as I can’t believe he’s still in the hospital.”

Miles Scott became the trust’s chief executive in 2018 – two years before Fuller’s arrest.

In a statement, he said 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”.

The trust did not respond when asked by the PA news agency if Mr Scott would resign over the matter.

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”.

More allegations made about Fuller in the 1990s, after he started working at the hospitals in 1989, were investigated but no evidence of more offences and victims have been identified.

The publication of the inquiry’s first tranche of findings was delayed by almost a year and the cost of the probe stands at £2 million so far.

The findings of the second and final phase of the inquiry – reviewing how people who have died are cared for around the country and scrutinising funeral directors as well as private mortuaries and ambulances – are now due to be published next year.