Learning from mistakes and implementing change from public inquiries – the recurring calls to plug the gap

The Grenfell Tower Public Inquiry chaired by Sir Martin Moore-Bick (the “Inquiry”) Phase 2 Report (the “Report”) was published on 4 September 2024. The Report follows closely behind other recent landmark inquiry reports from other statutory public inquiries, and this article considers the recurring themes that bind those reports.

Key takeaway points:

1. The Report notably includes recommendation 113.40 which suggests that a formal system be put in place to monitor whether and/or how Inquiry recommendations are implemented.
2. This ties into calls from other public inquiries and would represent a significant de facto change in the effective power Inquiries have when making recommendations.
3. There is growing support for this change and would make an evolution of public inquiries – we will be watching with interest whether this recommendation is implemented.

Contained within the Report were a number of recommendations intended to realise positive change for the future.

One such recommendation, whilst framed within the findings of the Inquiry specifically, struck a chord with an ongoing wider discussion about how inquiries provoke meaningful change and is of particular significance to inquiry lawyers and public bodies alike. Recommendation 113.40 states:

“We recommend that it be made a legal requirement for the government to maintain a publicly accessible record of recommendations made by select committees, coroners and public inquiries together with a description of the steps taken in response. If the government decides not to accept a recommendation, it should record its reasons for doing so. Scrutiny of its actions should be a matter for Parliament, to which it should be required to report annually”.

This connects to a recurring theme of concerns raised by inquiry chairs around the need to implement change from inquiries. 

Change from inquiries - the mixed picture of success

In recent years, the recommendations established by many public inquiries and large scale inquests have seen positive change to the society within which we live. Inquiries such as Leveson, Francis and the inquests into the 7/7 bombings all resulted in recommendations that led to substantial change that has positively impacted society. The positive impact of inquiries to effect change is proven by key changes such as the implementation of safe staffing levels for nursing, the introduction of a statutory Duty of Candour in the healthcare sector and the development of specialist emergency service teams work under joint operating principles. 

Despite some previous success, however, public inquiries often face significant hurdles in ensuring their recommendations are accepted and changes thereafter implemented. A challenge that is made somewhat more difficult in the absence of any legal power on the part of the inquiry to insist that organisations, be that locally, regionally or nationally, make any attempt to take action in response to their recommendations. Furthermore, some chairs of public inquiries have taken to monitoring recommendations from previous reports whilst the inquiry remains ongoing. The chair can exert pressure on those who can make change by requesting evidence and call a responsible person to give evidence to account for actions taken. However, such a strategy is time-limited by the duration of the inquiry itself, with the power to monitor the recommendations extinguishing when the inquiry’s terms of reference have been met and the chair’s report placed before parliament. 

Recommendation 113.40 – the recurring theme of inaction on change

In the context of the Inquiry, the specific concern on which this recommendation was prefaced was that the Inquiry had identified that some important recommendations affecting fire safety were ignored by the government in the years leading up to the devastating fire at Grenfell Tower on 14 June 2017 (the “Fire”). Notably, recommendations made by the Select Committee in 1999 were not implemented and the response to the recommendations made by the Lakanal House coroner were inadequate. There was no system for recording recommendations made by public bodies or keeping track of the response to them. The Inquiry confirmed that to their mind this was “obviously unsatisfactory”. 

It is noticeable that this recommendation appears in the Report at the end of the Inquiry marking the end of the chair’s remit. Whilst a public inquiry is ongoing, the momentum of those proceedings, as well as the public scrutiny very often played out within the media, assists with ensuring change takes effect as the inquiry and wider public would anticipate. One good example of this is the Protect Duty, known as Martyn’s Law. Named after one of the 22 victims of the Manchester Arena attack, Martyn Hett, the recommendation to introduce a compulsory duty on businesses to take measures to improve public safety was born out of the recommendations of the Manchester Arena Volume One Report.  However, the momentum behind the change was and continues to be driven largely by the tireless campaigning of Martyn’s mother, Figen Murray, who was instrumental in ensuring the government recognised the important changes needed in this area.

The Inquiry recommendation also marks the third inquiry in quick succession to touch upon the need to ensure recommendations from inquiries are actioned. In the summer of 2023, when concluding the Manchester Arena Inquiry, the chair - Sir John Saunders - made the following comments and published his comments on the inquiry website as his final act:

I am particularly concerned to ensure, now the Inquiry has come to an end, the continuation of the monitoring of the recommendations I made. There have been reports of occasions when an inquiry has made detailed findings and recommendations only for that work to be side-lined and the important learning from that inquiry lost, until another disaster or tragedy leading to another inquiry causes the same issues to be examined again. I had direct experience of this problem myself, in that failings identified in the 7/7 Prevention of Future Deaths Report had not been adequately addressed and reoccurred on 22 May 2017. I have been determined that does not happen here. It was an important reason for monitoring recommendations during the course of this Inquiry and doing so publicly.

Sir John Saunders’ comments serve to demonstrate that the limitation of the process that the inquiry has no legal power to mandate that where learning and recommendations are yet to be fully implemented, that that work continues and is completed as hoped. The inquiry itself had no power to direct the government, or any other organisation, to make the necessary changes. There is no defined route or mechanism for the overview or monitoring of inquiry recommendations once the inquiry’s functions are defunct.

The chair of the Infected Blood Inquiry, Sir Brian Langstaff, adopted a different approach to trying to secure a legacy of change from inquiry recommendations. On 20 May 2024, the Infected Blood Inquiry published its final report. Despite the inquiry lasting six years, covering a period of many decades and producing a report running into 2,700 pages, the chair made only 12 recommendations. His rationale was simple and logical:

There is a danger in Inquiries making too many recommendations; it becomes difficult to see whether action is truly being taken to avoid the errors of the past being repeated.

If there is no oversight or ongoing monitoring of recommendations, this represents one possible strategy to overcome the challenge is to distil the key learning into a limited number of laser-focused recommendations. However, such an approach of limiting recommendations to increase their likely effectiveness is the exception to the general trend of recent inquiry reports. It is a strategy to try and work around the problem of a lack of monitoring rather than address the problem itself.  

The campaign for improving effectiveness

Recommendation 113.40 from the Inquiry seems to have landed at a poignant moment, one that has seen a national garnering of support for the introduction of a system that would monitor the response to recommendations made at inquiries and inquests. 

Charity organisation INQUEST, have been campaigning for some time for a ‘National Oversight Mechanism’ consisting of a new independent public body who would be responsible for collating, analysing and following-up on recommendations arising from inquests, inquiries, official reviews and investigations into state-related deaths. It mirrors neatly the type of monitoring recommended by Sir Martin Moore-Bick. INQUEST maintains that such change is required as hundreds of vital recommendations are made following inquests and inquiries, yet there is no system in place to oversee them or ensure changes are made. INQUEST believe that potentially life-saving recommendations are too often forgotten, dismissed or simply not implemented, which leads to yet more preventable deaths and harms. Sir Brian Langstaff’s rationale around the recommendations for the Infected Blood Inquiry would seem to support INQUEST’s own rationale. 

INQUEST’s campaign has now gathered traction and a group of more than 40 organisations, including Criminal Justice Alliance, Liberty and Grenfell United have rallied in offering their support to the suggestion of a national oversight mechanism. Additionally, the House of Lords’ Statutory Inquiries Committee was set up this year to consider whether the Inquiries Act 2005 provides an effective framework for public inquiries. With some 18 inquiries taking place this year alone, a report published by the committee in September this year said:

Too often, inquiries are failing to meet their aims because inquiry recommendations are not subsequently implemented, despite being accepted by the government. This is inexcusable, as it risks the recurrence of a disaster and undermines the whole purpose of holding an inquiry in the first place.

This report calls for a new joint parliamentary public inquiries committee that would publish inquiry reports and government responses in one place, monitor implementation of accepted inquiry and inquest recommendations and scrutinise the government’s response. This is exactly what Recommendation 113.40 of the Inquiry also suggests should happen. It is in many ways an irony that the Inquiry have issued a recommendation that governments should monitor the completion of recommendations on the basis that recommendations have not been adequately completed historically.

Conclusion - what does the government do?

If the government acknowledge what appears to be an increasing mountain of support for the proposition outlined by this recommendation, it might well see the introduction of additional powers to those judges who preside over inquiries and inquests, which would allow recommendations to be monitored, with the potential for sanctions to be imposed for those who fail to comply. 

Whilst however the exact mechanism with respect to enacting Recommendation 113.40 or indeed whether it will be enacted at all remains to be seen, what is clear is that the Inquiry is amongst a growing number of concerned individuals and organisations who have identified the need for greater oversight when it comes to learning lessons.

The significance of this recommendation was aptly summarised by House of Lords Statutory Inquiries Committee Chair Lord Norton of Louth when he said:

‘Lessons learned’ is an entirely vacuous phrase if lessons aren’t being learned because inquiry recommendations are ignored or delayed. Furthermore, it is insulting and upsetting for victims, survivors and their families who frequently hope that, from their unimaginable grief, something positive might prevail.”

Whilst the new government’s legislative agenda does include important changes around new duties of candour and public funding for certain inquests and inquiries, the issue of monitoring recommendations and learning is not (yet at least) covered. 

The ongoing question will be whether the raft of recent reports together with the ongoing campaigning provide sufficient momentum to garner the political will to introduce a monitoring process. This, we will be monitoring with interest.

This article forms part of a wider analysis of the Report by Weightmans.