Out of sight, out of mind

A Guardian Service report based on the "Independent inquiry into the issues raised by the David Fuller case - Phase 1 report." Sir Jonathan Michael, Chair of the Inquiry

Foreword

David Fuller committed 140 offences between August 2005 and November 2020 in the mortuaries at Kent and Sussex Hospital and Tunbridge Wells Hospital. The phase 1 report of the independent inquiry into the case was published in November 2023. Whilst we need to wait for the phase 2 report to make final recommendations for the wider system, the findings so far present definite opportunities for learning.

The case is horrendous involving serious sexual offences committed over a number of years. As the Inquiry chairs states, it caused ‘shock and horror’ and unimaginable distress to the victim’s families. The Inquiry has been thorough in its investigation and clear in its recommendations. The report states starkly that “ … failures of management, governance, regulation and processes, and a persistent lack of curiosity, all contributed to the creation of the environment in which he was able to offend.” (Foreword, p iv).

Looking at the case through a ‘speaking up lens’ there are failings that are all too familiar.

Whilst we can only hope that the Fuller case is exceptional, we know that similar failings have led to other tragic events.

Based on the report, we are presenting six questions that should constantly be on the mind of senior leaders in any organisation:

• Where are the dark corners in my organisation?
• Where am I not being seen?
• Do I recognise speaking up when I hear it?
• Am I really being objective?
• Am I demonstrating that I have listened and taken action?
• Am I being curious?