An electrician who had sex with more than 100 corpses over a 15-year period was able to do so without being detected due to serious failures of "management, governance, regulation and processes, and a persistent lack of curiosity," a new 300-plus page inquiry report found.

David Fuller, who was later convicted of murder, finally had his necrophilia spree uncovered in 2020 when police used DNA to tie him to the 1987 slayings of two women. During the investigation, they also discovered millions of images of sexual abuse in his home. These images included videos of him having sex with the dead bodies of women and girls in the mortuaries at two hospitals where he worked in southeast England.

"The offenses that David Fuller committed were truly shocking," the British government-ordered report said. "However, the 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.

Fuller, 69, is serving a life sentence with no chance of release after he pleaded guilty to two counts of murder of Wendy Knell, 25, and Caroline Pierce, 20, in two separate attacks in the town of Tunbridge Wells in 1987. He is also serving a concurrent 12-year term after admitting to dozens of instances of necrophilia.

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David Fuller

Undated handout file photo issued by Kent Police of David Fuller. A British government-ordered inquiry said Tuesday, Nov. 28, 2023 it found "serious failings" at hospitals where an electrician who was later convicted of murder had been able to have sex with more than 100 corpses over a 15-year period without being detected.  (Kent Police/PA via AP)

Fuller committed 140 violations against the bodies of at least 101 girls and women — with the youngest being aged 9 and the oldest being 100 — between 2005 and 2020, the inquiry found. Each instance had time-stamped photographic or video evidence, according to the report.

The case prosecutor said the level of necrophilia had never been seen on that scale before in a British court and an inquiry was launched to find out how Fuller was able to get away with it for so long — and to prevent such abuse from ever happening again.

Fuller was brazen in committing his crimes, taking risks during working hours when other employees were in the mortuary, the report said. The inquiry said it could not determine how he had been able to carry out the abuse during working hours without being caught.

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The electrician, who would occasionally have to perform maintenance on the refrigeration system in the mortuary, routinely entered the department — as many as 444 times in one year — without being properly questioned, the inquiry said.

"This is not solely the story of a rogue electrical maintenance supervisor. David Fuller’s victims and their relatives were repeatedly let down by those at all levels whose job it was to protect and care for them," the report found.

People walking in London

David Fuller's necrophilia was only discovered in 2020 after police used DNA to tie him to the 1987 slayings of two women.  (Rasid Necati Aslim/Anadolu Agency via Getty Images)

The inquiry ultimately determined that Fuller had a criminal record as a burglar that he never disclosed in work papers. He was then hired at the now-closed Kent and Sussex Hospital in 1989, two years after he killed Knell and Pierce. Those crimes went unsolved for 33 years, during which time he was employed at the Tunbridge Wells Hospital, in Pembury.

Jonathan Michael, a former NHS chief executive who led the inquiry, ultimately recommended surveillance cameras be installed in the mortuary and post-mortem room, and that non-mortuary workers and contractors be accompanied to the mortuary by another staff member.

Several family members of the victims who were interviewed by the inquiry but not identified in the report said they were stunned when they learned what had happened to their loved ones.

Buildings in London

British authorities discovered millions of images of sexual abuse in Fuller's home, including videos of him having sex with the dead bodies of women and girls in the mortuaries at two hospitals where he worked in southeast England.  (DANIEL LEAL/AFP via Getty Images)

One widower said memories of his wife are stained with the thoughts of what Fuller did to her body after her death. And, he couldn't bring himself to tell his family members about it.

"The impact on my family has been non-existent, because they don’t know," the man said. "It’s basically robbed me of 25 years of happy memories. … Anything that reminds me of my wife also reminds me of what David Fuller did to her."

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Miles Scott, who became chief executive of Maidstone and Tunbridge Wells NHS Trust in 2018, said in a statement he was "deeply sorry for the pain and anguish" of the families of Fuller’s victims. He also vowed to implement the 17 recommended changes to prevent such violations in the future.

The Associated Press contributed to this report.