UK COVID-19 Inquiry: in the context of previous inquiries

As the COVID-19 Inquiry reaches Module 2 of its timeline and it turns its attention to the political and administrative decisions made at the height of the pandemic, Shoosmiths looks at the history of public inquiries to reflect on their purpose and effectiveness in preventing future mistakes of the same kind. Reviewing previous public inquiries may inform us about the likely trajectory of the COVID-19 Inquiry. 

Background to the inquiry

In May 2021, Boris Johnson committed to holding a public inquiry into COVID-19. The UK COVID-19 Inquiry is an independent public inquiry set up by the Government to examine the UK’s response to and impact of the COVID-19 pandemic, and to learn lessons for the future. 

Since the May 2021 announcement, the Right Honourable Baroness Heather Hallett has been made Inquiry Chair, the Terms of Reference have been agreed and released, and the inquiry was officially opened with Module 1 in July 2022. As we prepare for substantive hearings to commence, it is important to remind ourselves of the reasons for this inquiry and what we, as the public, want to see happen as a result. 

What is the purpose of public inquiries?

Public inquiries are major investigations convened by a Government minister that have special powers to compel witnesses to appear before court and the release of other forms of evidence. The only requirement for a public inquiry is the existence of public concern in relation to an event that has transpired. 

The main purpose of a public inquiry is to prevent recurrence of the event at hand. 

Jason Beer KC, recognised as an eminent UK public inquiry lawyer, says the main function is to address three critical questions:

  1. What happened?
  2. Why did it happen and who is to blame?
  3. What can be done to prevent this happening again?

All inquiries therefore begin by looking at the evidence, and then draw on experts to help form recommendations for the future. These are intended to guide the Government to make changes that will prevent recurrence. Between 1990 and 2017, 46 inquiries led to 2,791 recommendations. 

Previous inquiries 

Historically, inquiries have been slow moving, taking an average of two years from start to completion. The shortest took 45 days and the longest – the inquiry into Hyponatraemia-related deaths – took 13 years and three months to complete. 

Given the amount of time and a considerable sum of money being spent, the public will be keen to know that the outcome is worth it. To see the potential outcome and effect of a public inquiry, it is vital to look at historic inquiries to see the result of the expense and the effect their recommendations have held on preventing future events of the same kind. 

The Bloody Sunday Inquiry 

Also known as the ‘Saville Inquiry’, the Bloody Sunday Inquiry was established in 1998 after campaigns were held by the families of those killed in Derry on Sunday, 30 January 1972, during the peak of the Troubles. When the report was finalised in 2010, the total costs were £200 million.  

The outcome of the inquiry was to establish the truth about what happened on the day. The main recommendations and conclusions were as follows:

  • The soldiers should have been deployed as an arrest force in the event of rioting and there was no justification for firing at the victims.  
  • Orders were not followed from higher officers to determine peaceful protestors and rioters thus there was no separation for arrests to be made easier.
  • Better communication between officers would have informed senior officers of what had been done on the scene and may have led to calling off the arrest operation due to the danger to the public. This lack of communication meant that soldiers were not informed of the limits of how far they should go, leading to no governance over the armed men. 
  • Exoneration of the victims and a wide acceptance that they were unarmed civilians, a view that was of significance for the families of the victims who aimed to make this known to the public.

The outcomes, as defined specifically in the terms of reference, were met in this instance. However, a downside of this inquiry comes from the time it took for the families to reach any form of justice. Since the inquiry, the innocence of the victims has been widely known and publicised in connection with the inquiry.  

2005 South Wales E. coli O157 Outbreak Inquiry

In 2005, the largest outbreak of E. coli in Wales, and the second largest outbreak in the UK occurred in South Wales. 157 cases were identified, 31 were hospitalised and one child died. The cause was found to be a vacuum packaging machine used to wrap raw and cooked meat without being cleaned between batches. The meat supplier, who catered to local schools, was convicted for manslaughter and spent a year in prison. 

The inquiry was to establish the circumstances that had led to the outbreak and to consider the implications for the future and make recommendations accordingly. The findings were:

  • All food businesses must ensure that their systems and procedures are capable of preventing contamination or cross-contamination of food with E.coli O157.
  • Additional resources should be made available to ensure that all food businesses in Wales put in place an effective food safety management system. 
  • Regulatory and enforcement bodies should employ more robust checks.
  • All inspections must be unannounced unless, exceptionally, there are specific and justifiable circumstances or reasons why a pre-arranged visit is necessary.
  • Businesses contracting for the supply of high-risk foods, such as raw and cooked meats, to public sector organisations, must be subject to independent food hygiene audits.
  • All councils in Wales should review their policies, procedure and systems against issues raised in the report.

Since this inquiry, there have been no widespread E.coli breakouts in Wales. As this incident was identified as being a preventable outbreak, the recommendations were extremely important in ensuring the prevention of another similar situation. 

Penrose Inquiry

The Penrose Inquiry looked into the hepatitis C and HIV infections from NHS Scotland’s treatment. This mainly affected people with haemophilia. The inquiry only looked into the events in Scotland and was set up by the Scottish Government. 

Taking roughly six years and costing £12 million to complete, the inquiry committee concluded with just one recommendation:

The Scottish Government takes all reasonable steps to offer a hepatitis C virus test to everyone in Scotland who has had a blood transfusion before September 1991 and who has not been tested for hepatitis C. 

The outcome of this inquiry was not looked upon well due to the lack of recommendations or guidance for the future. Though the inquiry justified its decision by saying that detection of those who were infected hepatitis C is the only respect in which the inquiry can recommend action to prevent more suffering from occurring, organisations and individuals involved believed the inquiry was a failure.

A factor in this was that the powers and terms of reference were limited. Though the systems and procedures in Scotland were scrutinised, the inquiry did not have the power to compel witnesses outside of Scotland to attend. This drawback was crucial as health policy prior to 1999 was controlled by politicians and civil servants based in England. 

A working group was set up by the Scottish government to look at the effect of the inquiry and whether uptake of blood tests had increased since publication or if further action was needed. The group concluded there were still a small number of people who remained undiagnosed and alive in Scotland. The backlash of this inquiry and many other factors have led the UK government to launch a UK-wide inquiry. This inquiry will review the situation and evidence for the Scottish victims and will have implications if new verdicts are found. However, the background of the disasters varies widely and the time it will take for a UK-wide inquiry is likely to be extensive. 

King’s Cross Fire Inquiry 

In 1987, 31 people died and 100 were left injured after a wooden escalator caught fire in King’s Cross underground station. The tragedy led to a public inquiry the following year to determine the cause of the fire and prevent another from occurring in this way again. 

The inquiry lasted from February to June 1988 and despite this short timeframe, was exceedingly effective in bringing change in order to prevent similar incidents in the future.  The inquiry aimed to find the cause of the fire and consequently recommend preventative measures.

In determining the cause, extensive research was conducted. This included investigators replicating the fire and a computer simulation to look at how the flashover occurred, and subsequently discover a new phenomenon now known as the trench effect. 

Though smoking on underground trains had been banned three year prior, the inquiry determined that when members of the public light cigarettes on the escalators on their way out, they would discard their lit matches within the station. In this case, on the tracks of the wooden escalator. Evidence showed this had happened before, but the fires had burnt out before escalating. However, through thorough investigation it was noted that the presence of grease and other fibrous materials from day-to-day use of the escalators had allowed the flame to ignite and hold. The angle of the escalators enabled the trench effect to cause a flashover into the ticket hall where majority of the fatalities occurred. 

In response to these determinations from the inquiry investigation, a report was published with several recommendations including:

  • The removal of wooden panelling from escalators.
  • Heat detectors and sprinklers to be fitted beneath escalators.
  • Radio communication systems and staff emergency training improvement.
  • A ban of smoking on all underground stations including escalators.
  • An investigation into passenger flow and congestion in stations and remedial action to be taken.

In response to the report published, resignations were submitted by senior management of London Underground and London Regional Transport. Wooden panelling was removed from escalators and most notably, the Fire Precautions (Sub-surface Railway Stations) Regulations 1989 were introduced. By 1997 the majority of the recommendations had been implemented including improvements to firefighter’s equipment and clothing. The legacy of the inquiry also led in later years to the upgrade and expansion of King’s Cross, Tottenham Court Road and London Bridge stations. 

The Chilcot Report 

Also known as the Iraq Inquiry, the Chilcot Report was a public inquiry into the UK’s involvement in Iraq. It covers the run up to the conflict, the military action and its aftermath. 

The key findings were substantial in nature and included noteworthy admissions such as:

  • The invasion was chosen before all peaceful options were exhausted.
  • The threat by Saddam Hussein was deliberately exaggerated and was not imminent.
  • British intelligence agencies produced flawed information. 
  • The UK military were ill-equipped for the task. 
  • UK-US relations would not have been harmed if the UK stayed out of the war. 
  • The Government had no post-war invasion strategies. 
  • The Government did not try hard enough to keep a tally of Iraqi civilian casualties. 

The report, published in 2016, seven years after the inquiry was announced, was different in many ways from any other kind of inquiry. It looked at why the invasion happened which in effect would prevent the same mistakes and lapse in judgements from occurring in leadership again. 

Though the inquiry was able to answer many questions, it was a highly controversial and sparked much criticism of the Government’s decision. When conflicts of this magnitude occur and a public inquiry is called, the importance is grounded on holding those responsible accountable and highlighting on any failures in the decision-making process, in order to learn from the same in the future. 

The Stafford Hospital Inquiry

This inquiry concerned the poor care and high mortality rates of patients at the Stafford Hospital during the years 2000-2010. The discovery of such issues within the hospital was made by a campaign called Cure the NHS, started by a woman whose mother had died at the hospital in 2007. After gaining support of local forums and trust, the Healthcare Commission investigated the hospital and found serious neglect by hospital staff.

The inquiry raised over a million pages of evidence alongside in person witnesses and culminated in 290 recommendations.  Key points raised for the future included:

  • A single regulator for financial and care quality.
  • Higher powers to suspend or prosecute boards or individuals. 
  • A duty of candour for all healthcare organisations and those working for them. 
  • A prevention of gagging orders. 
  • Ensuring only registered individuals care for patients. 

As a consequence of the inquiry, many nurses and midwives were struck off the register or suspended. Those who were found in later years to have knowingly given false evidence were referred to the Crown Prosecution Service or forced to resign. 

However, the recommendations have been heavily criticised with some arguing that micro-regulation within the NHS can produce serious unintended consequences and that the crucial questions asked by the families of the victims remained unanswered. The report noted that the events have most probably occurred elsewhere and will be repeated unless the recommendations were followed but the enforcement of these recommendations will be ineffective if authorities fail to identify the warning signs of a similar situation.

Next steps 

With Module 2 of the COVID-19 Inquiry underway, looking at previous inquiries is instructive. Learning from the mistakes made and aspiring for a better outcome can only be achieved by understanding the significance of the recommendations and the factors that make them successful in achieving their outcomes. 

Inquiries often work hand in hand with tragic events that affect members of the public for years to come and so the report published bears a significant weight. In order to reduce the damage caused by similar events, in the future, it is imperative that the country is informed of their significance and the importance of each stage that their involvement can affect the outcome. It is crucial that recommendations are taken seriously and enforced. 

Further Reading

COVID-19 Inquiry Terms of Reference Terms of Reference - UK Covid-19 Inquiry ( 

Overview of Module 2 and how to become a core participant - UK Covid-19 Public Inquiry ( 

Shoosmiths’ view on the ‘four nations’ approach to the COVID-19 Inquiry - The pressure of running a 'four nations' Covid-19 inquiry, Michael Vallance (


This information is for educational purposes only and does not constitute legal advice. It is recommended that specific professional advice is sought before acting on any of the information given. © Shoosmiths LLP 2024.


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