A coalition of people affected by the worst disasters and scandals of the past decade is calling on Keir Starmer to create an independent body to monitor recommendations from public inquiries so that they cannot be “left to gather dust”.
The Covid-19 Bereaved Families For Justice, Grenfell United and Factor 8, which represents victims of the infected blood scandal, have joined the charity Inquest and 36 other groups to urge the prime minister to act. Others include campaigners on Hillsborough, mental health deaths and disabilities.
Inquiries aim to establish how deaths occurred and recommend how to prevent them. Yet no one is responsible for tracking whether this happens. It means that bereaved families lose faith in public inquiries, as well as inquests, investigations and official reviews, said Deborah Coles, director of Inquest.
“There is a repeated failure to enact changes identified through these legal processes,” Coles said. “There is real frustration from families that there’s no centralised system where you can go and actually look at what recommendations were made, and what progress there has been.
“That really undermines trust and confidence, particularly of bereaved people who have looked at those processes to deliver answers and accountability … And what families tell us, time and time again, is that what actually gives meaning to these processes is the knowledge that other deaths may be prevented.”
Ten public inquiries are under way, 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, which issued its first report last week.
The Covid inquiry chair, Heather Hallett, made a series of recommendations, and Susie Flintham of Covid-19 Bereaved Families For Justice said the group would like to see implementation of “red team” experts tasked with challenging official plans.
“We’d also like to see a minister for resilience,” Flintham said. “A national oversight mechanism would bake in accountability. The fact that we’ve had to team up with Hillsborough and Grenfell and infected blood shows that inquiries haven’t been acted on.”
Lady Hallett has said she will monitor responses to her recommendations. John Saunders extended the Manchester Arena bombing inquiry to review whether his recommendations were implemented. In 2023 he said there was an “ongoing problem” of “making sure recommendations from inquiries are implemented and not forgotten”.
Coles said the report from the second stage of the Grenfell inquiry was due to be published in September. “But there are still recommendations in the first report that have not been implemented, five years after it was published, such as around the emergency evacuation of people with disabilities,” she said.
Natasha Elcock, chair of Grenfell United, said that six years after the fire that killed 72 people in Kensington, west London, they knew every death could have been prevented, adding: “So little has changed. “
“Bereaved and survivors should not have to fight to hold government to account to ensure learning and change and that history is not repeated.”
Smaller inquiries are even easier for authorities to ignore, Coles said. Coroners can issue prevention of future death reports, – there were 440 in England and Wales in 2021 – but an analysis using Oxford University’s preventable deaths tracker showed only 33% of such reports resulted in published responses.
Richard Caseby, a communications consultant from London, lost his son Matthew after a psychotic episode, having no history of mental illness. The 23-year-old was detained at the Priory Woodbourne hospital in Birmingham in 2020 but escaped over a fence three days later and was hit by a train.
Caseby campaigned for the Priory to be prosecuted over his son’s death and in March it was fined £650,000 after pleading guilty to breaches of the Health and Social Care Act. “The key issue was that Matthew escaped over a dangerously low fence while left unattended and yet there is no government regulation for the height of fences at acute psychiatric units,” he said. The coroner called for a regulation to be introduced, and Caseby did his own survey of NHS mental health units, but found months later that nothing had been done.
The Right Rev James Jones, former bishop of Liverpool and chair of the Hillsborough Independent Panel, said: “It is a waste of an inquest or inquiry if lessons learned are not acted upon. But there is no national mechanism to make that happen. At last, the charity Inquest has come up with a practical proposal to set one up. The government must not ignore it.”
A government spokesperson said: “Public inquiries are an important mechanism to allow the government to learn lessons for the future and right injustices. All government departments take inquiries’ recommendations seriously.”
