What chairing the COVID People’s Inquiry taught me about how a public inquiry should be designed and run

An effective UK COVID-19 public inquiry means those who have been bereaved must come to believe their loved ones did not die in vain. But what kind of inquiry is most likely to achieve the lasting systemic changes this requires?

Michael Mansfield

Chairing the People’s COVID Inquiry – which we launched in the autumn of 2020, in response to the UK Government’s repeated refusal to agree to a public inquiry – has left me certain about what the tens of thousands of bereaved families want, above all else, from a UK COVID public inquiry which, even now, is only in the earliest stages of development. While there is understandable talk of accountability and catharsis, what those who lost relatives and friends to the pandemic told us above all else was: ‘We don’t ever want this to happen again.’

An effective inquiry – which, crucially, must also mean effective implementation of its recommendations – will serve as a memorial to all who lost their lives during the pandemic. Those who have been bereaved must come to believe their loved ones did not die in vain. But what kind of inquiry is most likely to achieve the lasting systemic changes this demands?

My first recommendation is to stand back and say: ‘There is no one-size-fits-all inquiry model.’ Given the unprecedented scale of this inquiry, you’ve got to start by thinking laterally about how to accommodate all the very different elements – without compromising the need for speed where it matters most.

The public inquiry needs a fast-track element

The biggest gripe that most people have with judicial inquiries is that by their very nature, they take a long time. Major public inquiries are measured in years, if not longer. By the time they eventually come up with recommendations, they risk feeling irrelevant and redundant.

Of course, public inquiries come in many shapes and sizes – ranging from a one-incident inquiry such as the Stephen Lawrence Inquiry to an historic set of circumstances such as Bloody Sunday. In certain cases, such as the Hillsborough disaster and now with COVID-19, there is a pressing need to carry out a rapid analysis of what happened and why, because change is required to limit the ongoing risk of further casualties. The UK COVID Public Inquiry therefore needs a fast-track element.

Lord Taylor’s inquiry was up-and-running within a month of the incident at Hillsborough football stadium in April 1989. He did a very quick initial inquiry, during which he ascertained the immediate cause of the 96 deaths – the worst sporting disaster in British history. The immediate issue – the fact that spectators were trapped inside the stadium pen and crushed to death – had to be addressed before the new football season started, so he brought in all-seater stadiums. Other questions, about the decisions made by the police overseeing the FA Cup semi-final that day, were addressed later in a second phase of the Inquiry, which was less successful.

Similarly, we were up-and-running with the People’s COVID Inquiry very quickly after we realised, in autumn 2020, that things were dangerously out of sync, in terms of the UK Government’s mixed messages to the public regarding the virus. Our inquiry was set up very quickly – indeed, I think it is the only people’s inquiry that has been held entirely online.

A key point for us was that ‘you don’t start at the beginning of the pandemic’; we knew we also had to look at decisions that had been taken long before that. We brought together experts from a range of disciplines plus the bereaved family groups and many other stakeholders over an intensive three-month period. As soon as possible, we came up with our interim recommendations.

In all, our inquiry took just under a year from start to finish, which is unusual. But if we could do it – unrecognised and unfunded by the UK Government – then others can do the same. In short, it can be done if you set your mind to it.

Several investigations at the same time

That’s not to underestimate the challenge of staging a UK COVID public inquiry. Clearly, there need to be several investigations going on at the same time. Alongside the fast-track group looking at the most pressing needs, you could have another group doing a social analysis, and another group listening to the bereaved families.

You also need a separate body looking into pandemics in general, the history of this virus, and the global repercussions, because ‘if it’s anywhere, it’s everywhere’. The People’s Inquiry didn’t have the resources to look at the global picture properly, but it does need a group of experts – if you like, another commission – working alongside the others, looking at the wider medical repercussions of what’s happened.

The question of how to address the needs of bereaved families is a huge task, and an absolutely vital one. Alongside the part of the inquiry racing ahead in order to prevent this crisis happening again, you need to know what the bereaved feel about how it might be prevented – because they’ve all got very strong ideas. So you either need a parallel investigation or to commission an inquiry that is focused on them. The conclusions they come to can be fed into the main inquiry if and when they are ready.

While some suggest that building an element of catharsis into the inquiry could take too long, I think there is still a way of achieving this – indeed, we did it in the People’s Inquiry. We had representatives who spoke on behalf of the bereaved, and we also made sure we heard from medical workers in order to just say how they felt. ‘Moral fatigue’ was one of the terms that was most frequently used. People on the frontline were exhausted; they needed to be able to express how they felt.

Furthermore, these days it is perfectly possible to ensure that every single person who has died is named on a virtual wall of remembrance. In an inquest they are called ‘pen portraits’, when a family is entitled to come along and tell the story of their dead relative or friend. In the wake of the Grenfell Tower fire, we saw a huge array of photographs, poems and other tributes – it was very moving. Of course, the numbers of dead relating to COVID-19 are huge – but that doesn’t mean it can’t be done, and it should be done. The bereaved families need their moment, and we know their representatives were really angry that the Prime Minister didn’t even want to meet them.

Conclusion: we need a new approach for all public inquiries

The refrain when anything goes majorly wrong these days is ‘we want a judicial inquiry’. Well fine, but without the correct framework, there is no guarantee that such an inquiry will achieve the desired results – let alone one on the scale of the UK COVID Public Inquiry.

That’s why I think it’s time to establish a standing commission that is ready to go into action whenever a public inquiry is established – a whole body of people, and an associated network, that stands ready to act quickly, to address the situation and ‘size it up’. If the particular challenges of COVID aren’t enough to bring this about, I’m not sure what will.

Furthermore, there should be a national oversight mechanism to closely monitor the implementation stage of any inquiry – this will be a key factor for the Grenfell Tower Inquiry too. Here again, I think you need a standing body whose function is to monitor the recommendations of inquest X or inquiry Y, then periodically ask: ‘Excuse me Minister, what have you done about any of these?’ The government officials must report back to this standing group regularly, and if they don’t do their job, there should be sanctions and repercussions.

A notable precedent here is what happened after the Lawrence Inquiry. In this case, the implementation of its recommendations was monitored not by government but by Doreen and Neville Lawrence, who held meetings in Central Hall Westminster every year at which they asked, basically, ‘what have you done on any of this?’ And the Police Commissioner was suitably embarrassed from time to time, and said: ‘Sorry, we’ve done this, but we haven’t done that…’

But a formal oversight group is critical to ensure all the time spent working out what needs to be done is not wasted – especially when a government says, ‘We entirely accept the recommendations of this inquiry’, without any real intention of following them up. A key legacy of the COVID-19 pandemic must be to ensure those in the corridors of power deliver the changes that are needed to fulfil what all the bereaved families most want – that we never again see such a disastrous and uncoordinated response to a major crisis.

Michael Mansfield QC chaired the Peoples’ COVID Inquiry. He is head of chambers at Nexus Chambers.