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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.
The inquiry's chair, Sir Jonathan Michael, said "there were missed opportunities to question Fuller's working practices."
The report 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.
Sir Jonathan said he was conscious that Fuller's crimes "had caused shock and horror across our country and beyond".
As well as failures of management at Maidstone and Tunbridge Wells NHS Trust, he said there had been a "failure to follow standard policies and procedures, together with a persistent lack of curiosity".
He said: "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.
"Had the measures that I am recommending been in place when Fuller was working at the trust, I firmly believe his offending could have been prevented.
"The fact that the trust was apparently improving its overall performance does not in any way excuse the failings that allowed Fuller to offend.
"In identifying such serious failings, it's clear to me that there is the question of who should be held responsible."
'Same bodies repeatedly'
Fuller, a 68-year-old from Heathfield, East Sussex, worked as a maintenance supervisor at hospitals in Tunbridge Wells in Kent over three decades.
He committed the offences at mortuaries in the now-closed Kent and Sussex Hospital, and its successor, the Tunbridge Wells Hospital at Pembury, between 2007 until his arrest in 2020.
Fuller gained access to morgues using his employee swipe card, choosing times when he knew staff had gone home so the areas were left unattended.
There, he systematically abused at least 101 corpses, the youngest of which was aged 9 and the oldest 100 years old.
At his trial, the court heard how he would visit "the same bodies repeatedly".
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