Inquiry Protocol


This document explains how we will go about our work. There will be two phases to the Inquiry:

  • Phase 1 – Focussing on matters relating to the Maidstone and Tunbridge Wells NHS Trust
  • Phase 2 – Looking at the broader national picture and the wider lessons for the NHS and other settings

Inquiry Independence

  • The Inquiry will be entirely independent in its work.  This means it will work independently from its sponsor, the Department of Health and Social Care and from any individual or organisation it investigates or liaises with to fulfil its terms of reference. 
  • As it is independent, it is for the Inquiry to determine how to undertake its work in order to fulfil its terms of reference.  The Inquiry is committed to act fairly and with the need to avoid any unnecessary cost.
  • The need to act fairly includes the fair treatment of individuals connected with the issues under investigation and all other parties whose interests are affected by its work.
  • The Inquiry will conduct its investigations and reach its conclusions with all due expedition in light of the public interest in it making its findings known as soon as possible.


  • The Inquiry will conduct its work in a way that preserves the anonymity and protects the dignity of those affected by David Fuller’s actions. The Inquiry’s interactions with those affected will be sensitive, supportive and compassionate.
  • During Phase 1, families who have been affected by David Fuller’s actions will be invited to share their experience with the Inquiry team. They will be offered a session to speak with two members of the Inquiry team, either in person at our Maidstone office or virtually.
  • The Inquiry will be as flexible as we can about when and where sessions take place. However, we anticipate that most sessions will be held at our Maidstone office or virtually.
  • We will ensure that counsellors are available, if required, to provide emotional support to enable families to engage safely with the Inquiry.  Families who wish to use this confidential service will be given details of how to contact counsellors.
  • Sessions will be audio recorded and families will be provided with a transcript of the recording. The Inquiry may use some of the information anonymously in the Inquiry’s reports to illustrate the human cost and impact of when things go wrong.
  • Where families do not wish to attend a session in person, the Inquiry Team will invite families to share their information as a written document.   The Inquiry may use some of the information provided in this way anonymously in the Inquiry’s reports.

Other interested parties/witnesses

  • During Phase 1, we will gather witness accounts from those who worked alongside David Fuller and those who held positions of authority and corporate responsibility, including Mitie (the facilities management sub-contractor who employed Fuller) and the NHS Trust.
  • Other organisations, where it is considered that they might have relevant evidence to provide, for example regulators, will be invited to speak with the Inquiry.  A list of organisations that the Inquiry intends to approach for witness accounts will be published on its website.
  • Attendance at interview sessions is voluntary.  Reasonable adjustments will be made to the interview process to help achieve best evidence if a witness is vulnerable or has particular needs.  If a witness fails to participate in or co-operate with the interview process the Inquiry will consider any further action to take.  This may include informing professional regulators and current employers.  The Inquiry may include criticism in its report(s) of any individual or organisation that does not participate in or co-operate with the interview process.
  • The Inquiry will write to interview participants prior to their session, letting them know areas and topics they will be asked about.   
  • These sessions will involve a panel of at least three people questioning those giving evidence. They will be chaired by a member of the Inquiry team.  Prior to the interview commencing, the Inquiry team will explain the structure and purpose of the interview.
  • The sessions will be audio recorded and a copy of the written transcript shared securely via email when it is ready following the interview.  The Inquiry will endeavour to provide transcripts within 10 days of the date of each interview session. Participants will be asked to confirm the factual accuracy of the transcript within 10 days of it being sent. If no comments are provided within that time period, the Inquiry will consider the contents of the transcript to be agreed and final.  The transcripts will then be analysed by the Inquiry team to inform key lines of enquiry and the Inquiry’s findings and recommendations.
  • Participants may bring a person to support them. We ask that participants confirm in advance if they are to be accompanied by a person to support them. It is important that the support person remains an observer and does not actively participate in the session.  
  • Save for exceptional reasons, legal advisors for a witness will not be permitted to attend an interview. In that situation, questions will be addressed to the participant, who, although permitted to seek the advice of their legal representative, will be expected to respond to the questions directly.
  • The Inquiry will offer the provision of emotional support to participants who have been particularly affected by the actions of David Fuller, where this cannot be provided by their current employer.  
  • The Inquiry will accept and consider any supporting written evidence provided by participants. However, written evidence cannot be provided in the place of attendance in person. Written evidence will not be published by the Inquiry but may be referenced in the Inquiry’s reports.

How the Inquiry will use information

  • Any information gathered from an interview session with a non-family member may be used in the Inquiry’s reports.
  • The Inquiry is not an investigative or prosecutorial public authority. If the Inquiry receives information during an interview session which comprises of an allegation of professional misconduct or criminality, or if it considers through subsequent analysis that such acts may have occurred or are likely to occur, then it will take whatever steps are appropriate in the circumstances including notifying the relevant public authorities. This will be reiterated to any participants at the start of the interview. The Inquiry has a policy for raising matters of concern if it is felt that a witness is not being forthcoming or co-operative or has acted inappropriately or in breach of their professional obligations. Where this is the case, the relevant employer and professional regulator (if applicable) will be informed.

Those who may have evidence to offer

  • The Inquiry welcomes any approach from anyone who has relevant evidence to provide, or who believes they may have relevant evidence but is unsure how relevant it is. Such persons are encouraged to make contact with the Inquiry at or on 020 7972 1444.
  • The Inquiry cannot guarantee that it will engage in interviews with all individuals who request to participate but will decide on the relevance of the information that an individual can provide to the Inquiry’s terms of reference and the necessity for an interview.  Each request will be considered on its merits.

Production and publication of reports

  • The Phase I and Phase 2 reports will be laid before Parliament as House of Commons papers and made available online.
  • The Inquiry wishes to be as open and transparent in its published reports as possible.  This will ensure that failings are brought to light and lessons learned for the future.  The Inquiry will consider the naming of any individual in its reports where there is good reason, and it is fair to do so, in particular because the Inquiry is satisfied that it is necessary to show a level of culpability or a failure in the matters under investigation.
  • Where it is proposed to publish a named individual or organisation in the report who will be subject to criticism, the Inquiry team will provide prior notice to named individuals.  The notice will set out any proposed critical findings of them in the report.  Named individuals or organisations whom it is proposed to criticise in the reports will be given a reasonable opportunity to respond to such criticisms in writing.
  • If information provided in an interview session with the Inquiry amounts to whistleblowing, the Inquiry will carefully consider how to handle this information in its report so that the anonymity of the interviewee is protected where that is necessary and in accordance with any legal requirements.

Inquiry policies

  • The Inquiry has a policy on how we will use people’s data. This is set out at the Privacy Information Notice on the website www.fuller.independent-inquiry.
  • Where this is the case, the relevant employer and professional regulator (if applicable) will be informed. Where the Inquiry receives information to suggest criminal behaviour has taken place, the Police will be notified. 
  • If we receive information or have reason to believe that someone engaging with the Inquiry is at risk of harm, we will decide if action is required. This could take the form of referral to immediate support from the counselling service, signposting to other psychological support, or raising a safeguarding alert with the relevant local authority.
  • We ask that people do not attend a session in person if they have tested positive for Covid-19 or are displaying symptoms. Hand sanitiser will be available. People that are clinically vulnerable are encouraged to contact the Inquiry Team to discuss arrangements.