The investigation states that "regulation and supervision of care for people after death are incomplete, ineffective and, in significant areas, entirely lacking".
The case, which is the entire basis for the investigation, concerns a man who over several years assaulted at least 101 deceased persons, both underage girls and older women.
The now 70-year-old man worked for many years as an electrician at two mortuaries in Kent in southeastern Britain. By using his access card, he could easily gain access to the bodies. He chose specific times when he knew the staff had gone home. In some cases, he filmed his assaults.
Investigation leader Sir Jonathan Michaels says that the shortcomings in supervision are not specific to just the mortuaries where the necrophile worked, but that he has seen similar shortcomings at other hospitals around the country and therefore has come to the conclusion that similar necrophile crimes may very well be repeated.