The importance of public inquiries for learning lessons

Out-Law Analysis | 11 Jun 2020 | 2:08 pm | 3 min. read

Public inquiries have an essential role to play in identifying procedural weaknesses and spurring reform that can protect the public from potential harm.

The outcomes of the Shipman inquiry serve as an example of the benefits that rigorous public inquiries can deliver at a time when demand is growing for public inquiries into the UK government's handling of the coronavirus crisis.

What is a public inquiry?

Public inquiries are investigations, convened by a government minister, which deal with issues of public concern. In recent years there have been a range of public inquiries focussing on number of different areas such as terrorist attacks, the war in Iraq, sexual abuse, and the 'foot and mouth' outbreak. Whatever the focus of the inquiry, the purpose of all inquiries remains the same – to find out what happened, why it happened, and to try and prevent a recurrence of the events.

Public inquiries are conducted by a senior official, often a judge, who will review documents, hear witness evidence and evidence from experts, and draw conclusions and make recommendations.

A fundamental difference between traditional court proceedings and an inquiry is that court proceedings are adversarial – there's a winner and a loser – whereas inquiries are designed to investigate a situation and establish the facts.

Inquiries can be long running and extensive, and must be rigorous and thorough in order to engender confidence in the final conclusions. The Bloody Sunday inquiry took 12 years to complete, cost over £195 million, and the final reports ran to more than 5,000 pages.

The Shipman inquiry

In January 2000 Harold Shipman was found guilty of the murder of 15 patients under his care. A public inquiry subsequently found that he had killed more than 200 patients over a 24 year period.

The system of death and cremation certification in place at the time had failed to detect that Shipman had killed any of his victims. In July 2003 Dame Janet Smith DBE published her third Shipman inquiry report. The report concluded that the death and crematorium system was almost completely dependent upon the professional integrity and competence of the medical profession. The Shipman case had shown that the procedures failed to protect the public from the risk that, in certifying a death without reporting it to the coroner, a doctor might successfully conceal homicide, medical error or neglect leading to death, and as a result certification of the cause of death by a single doctor was no longer acceptable.

The inquiry, and the recommendations proposed, led to an overhaul of the death certification process to protect the public from a repeat of the Shipman case, and is still used to this day. It clearly demonstrates the essential role that public inquiries can play in terms of learning lessons and protecting the public.

Public inquiries and the coronavirus pandemic

With the death rate from Covid-19 falling in the UK and the worst of the 'first wave' of the crisis seemingly behind the country, there are growing calls to convene a number of public inquiries in relation to the pandemic. For example, many public figures have called for an inquiry into why there is a higher death rate for people from ethnic minority backgrounds, and more recently there has been a call for an inquiry into the provision of personal protective equipment (PPE) for care home workers. It is very likely that many more issues and decisions that will be subject to a public inquiry.

One of the issues gaining traction in the media and within the public consciousness more generally in the UK is the difference between death rates reported by different countries. One of the main reasons for this is because England is reporting a much higher death rate than other countries. An issue for an inquiry to consider is why the death rate is higher – whether it is due to the fact that the lockdown was implemented too late, as some critics of government assert,  or whether it is because the UK has a different way of recording deaths.

England, as a result of the Shipman inquiry, has a strict system for recording and reporting deaths. Belgium, which also has a higher death rate than many others, reports all Covid-19 related deaths including those outside hospital, and records those deaths where Covid-19 is merely suspected and has not been confirmed. Other countries operate less stringent systems making it difficult to compare like with like. The reasons behind the higher death rates in the UK may in time become the subject of a public inquiry.

It will take years for all the Covid-19 related inquiries to be completed, but the outcomes and recommendations will be vital in ensuring that the country is as well prepared as possible to cope with any future pandemic.

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