LONDON (AP) — A British government-ordered inquiry said Tuesday 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.

David Fuller’s necrophilia was uncovered in 2020 when police used DNA to tie him to the 1987 slayings of two women and also discovered millions of images of sexual abuse in his home. The 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 308-page inquiry 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.

“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.”

Fuller, 69, is serving a life sentence with no chance of release after pleading guilty to two counts of murder. He is serving a concurrent 12-year term after admitting dozens of instances of necrophilia that the prosecutor in the case said had never been seen on that scale before in a British court.

The 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, who had a criminal record as a burglar that he never disclosed in work papers, was hired at the now-closed Kent and Sussex Hospital two years after he killed Wendy Knell, 25, and Caroline Pierce, 20, in two separate attacks in the town of Tunbridge Wells in 1987. Those crimes wouldn’t be solved for 33 years, after he moved on to work at the Tunbridge Wells Hospital, in Pembury.

Fuller committed 140 violations against the bodies of at least 101 girls and women — aged 9 to 100 — between 2005 and 2020, the inquiry found. There was time-stamped photographic or video evidence of each instance.

The inquiry led by Jonathan Michael, a former NHS chief executive, made 17 recommendations including that surveillance cameras be installed in the mortuary and post-mortem room, and that non-mortuary workers and contractors be accompanied to the mortuary with another staff member.

Miles Scott, who became chief executive of Maidstone and Tunbridge Wells NHS Trust in 2018, said the vast majority of the report’s recommendations had been put in place and others would be accomplished soon. He said in a statement he was “deeply sorry for the pain and anguish” of the families of Fuller’s victims.

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.

“It remains hard to believe not only that he took the risk of offending during normal mortuary working hours but that this was unnoticed by the mortuary staff who, we are told, were actually present in the department,” the report said.

Fuller, 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.

Fuller said he selected his victims by viewing a logbook. He avoided those who died of an infection or something like COVID-19, the report said.

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 and discussed how difficult it had been to carry on afterwards.

One widower said 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.”

Many questioned how Fuller was able to get away with it when surveillance cameras are so prevalent throughout Britain. Some said they had lost trust in the NHS leadership with at least one family member calling for the CEO to be sacked.

“I know they’re not alive, but they are vulnerable individuals,” the daughter of one victim said. “So why on earth is someone who’s a subcontractor being allowed to go in and out of that building at all times a day without having some form of supervision? ... I find that an absolute disgraceful trust loss there.”