Public Inquiry recommendations & the campaign for a National Oversight Mechanism

Baroness Hallet DBE (Chair of the UK Covid-19 Inquiry) published the Inquiry’s first final report and recommendations, following the Inquiry’s Module 1 investigation into resilience and pandemic emergency preparedness of the United Kingdom.

The report covers the state of the healthcare system, stockpiles of personal protective equipment (PPE), and planning in place ahead of the pandemic, and is the first of at least nine scheduled reports ranging from political decision-making to vaccines and impact on children.

This first report (Module 1) sets out the failures and weaknesses of the UK’s pandemic preparations. It reveals how the public were failed by a significant degree of under-preparation by the government, as well as years of insufficient investment and neglect, which in turn strained and created obstacles for death prevention efforts and the conservation of life. Importantly, as noted by the chair of BMA council Professor Philip Banfield, the report reveals that “lives could have been saved”.

Public and corporate bodies have a duty to keep people safe from harm and protect lives – relatedly, the purpose of a Public Inquiry is to establish how the deaths occurred and to recommend how to prevent them in the future. There are concerns, however, that too often recommendations produced by Public Inquiries are “left to gather dust”, forgotten or dismissed, and therefore not adequately acted upon.

These concerns have led to renewed calls, following the publication of the Module 1 Covid-19 Inquiry report, for the creation of an independent body to monitor recommendations from public inquiries, to ensure they are implemented accordingly and efficiently. The Covid-19 Bereaved Families For Justice, Grenfell United and Factor 8 (representing victims of the infected blood scandal), have joined the charity INQUEST and 36 other groups to urge the prime minister to create a National Oversight Mechanism.

INQUEST note that their work with families and lawyers to enhance the preventative potential of investigations into state-related deaths has highlighted how the possibility for prevention is undermined by the lack of a framework to monitor compliance with the findings and recommendations that emerge from post-death investigations.

The absence of a framework to monitor compliance is at the crux of INQUEST’s No More Deaths campaign, aimed at Learning, Action, and Accountability, which sets out in detail their case for a National Oversight Mechanism. Within this campaign, INQUEST conveys the frustrations of bereaved families at the absence of a centralised system to monitor the recommendations made and any progress made regarding future death prevention. This is juxtaposed by what INQUEST describe as an “institutional indifference to change”, displayed by many public bodies and their legal representatives who appear more concerned about reputational damage management than learning.

The obvious implication of this lack of candour and culture of defensiveness from state bodies towards change and learning is undermined trust and confidence of bereaved people who may have initially looked at these processes to deliver answers and accountability. This is particularly problematic as Deborah Coles (Director at INQUEST) explains that for many of the affected families “what actually gives meaning to these processes is the knowledge that other deaths may be prevented.” Having to engage in what oftentimes is a protracted, intrusive, and distressing process following a death in the hope of establishing the truth about their loved one's death and holding those responsible to account; only to then experience the system’s failure to enact meaningful change, can exacerbate further harm and trauma to the already suffering bereaved family.

INQUEST are therefore calling for the National Oversight Mechanism to be an independent public body responsible for collating, analysing and following up on recommendations arising from the following post-death processes:

• Investigations
• Inquests
• Public Inquiries
• Official Reviews

The campaign is being supported by various groups who have been affected by the different tragedies from recent decades (including Hillsborough, Grenfell and the Infected Blood scandal), which further evidences the fact that across-the-board findings from Public Inquiries and other similar post-death processes are not being acted upon adequately or in a manner that effectuates genuine change. It can be said that these failures are in danger of rendering these post-death investigations unfit for purpose, as recommendations and lessons learned are a crucial aspect and vital outcome of these processes.

Currently, there are ten public inquiries underway, including the Undercover Policing Inquiry, the Angiolini inquiry into Sarah Everard’s murder, the Lampard inquiry into the deaths of mental health patients in Essex and the Dawn Sturgess inquiry into her novichok poisoning, as well as the Post Office Horizon scandal, Grenfell and Covid-19. Concerns about whether recommendations are likely to be efficiently acted upon and addressed are pertinent to each of these investigations.

For example, the Grenfell Tower Inquiry is due to publish the report from the second stage of its investigation in September of this year, however, INQUEST point to the fact that “there are still recommendations in the first report that have not been implemented, five years after it was published”, including findings concerning the emergency of evacuation of people with disabilities.

Public Inquiries and Inquests constitute a significant expense to the Public Purse. In 2017 the Ministry of Justice spent £4.2million on Prison and Probation Service legal representation at Inquests into deaths in prison. It appears a great waste if lessons learned and recommendations from an Inquest or Public Inquiry are not acted upon. For example, INQUEST highlight the fact that The Grenfell Tower inquiry has cost £173 million of taxpayers money between August 2017 and March 2024 - significantly more than it would have cost to make Grenfell Tower safe.

The creation of a National Oversight Mechanism seems a reasonable and practical proposition to bring about more transparency and central responsibility to ensure actions are taken in response to key recommendations. Ignoring such a proposal or failure to properly consider it, would only further undermine the legitimacy of and public trust in the UK’s complex investigatory framework and wider public bodies. A National Oversight Mechanism would assist groups such as INQUEST who campaign to prevent state-related death, in holding the government to account. Finally, it is important to remember Public Inquiries such as the ongoing COVID-19 inquiry will only be as valuable as the policy changes it will bring about.