Driving change from public inquiries: the challenges and solutions to implementing learning

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.

An analysis of some of the positive change that has arisen out of previous public inquiries.

Despite some of their previous success however, public inquiries often face significant hurdles in ensuring that 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. This article seeks to explore how change comes about, sometimes because of the inquiry and sometimes due to forces outside of the inquiry itself; and whether oversight or even regulation is required to ensure learning and improvements are implemented.

Change through the scope of inquiry hearings

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 reforms to 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 and organisations to take measures to improve public safety was born out of the recommendations of the Manchester Arena Volume One Report. However, the momentum behind this 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.

More information on Martyn's Law

Manchester Arena Inquiry Chair, Sir John Saunders, sought to hold the Government to account repeatedly during the course of the inquiry, calling Government witnesses to provide updates to him and the public via the televised evidential hearings on progress with the legislative changes, but crucially, the inquiry itself had no power to direct the Government to make the necessary changes. Whilst Martyn’s Law has progressed to draft legislation in the form of the Terrorism (Protection of Premises) Bill 2023, as has been reported in the media only recently, Martyn’s Law has not yet been formally enacted.

Effecting change after the inquiry process ends

In October 2022, Chair of the long running and wide ranging Independent Inquiry into Child Sexual Abuse, Professor Alexis Jay, published her final report making recommendations to “better protect children from sexual abuse”, informed by the voices of victims and survivors. Since the report’s publication, Professor Jay has talked publicly of her concerns that those recommendations have not been adopted and implemented in the way that was intended within her report.

In a joint statement, released in May 2023, Professor Jay and the Victims and Survivors Consultative Panel said: “We are deeply disappointed that the government has not accepted the full package of recommendations made in the final report. In some instances, the government has stated that a number of them will be subject to consultations, despite the extensive research and evidence-taking which the Inquiry carried out over seven years. The package announced by the government will not provide the protection from sexual abuse that our children deserve. We ask the government to reconsider and accept and enact all our recommendations in full.”

Save for publicly voicing such concern, Professor Jay has no legal power to mandate that her recommendations be enacted in full or at all. In accordance with The Inquiries Act 2005, the responsibility of an inquiry essentially ends when its final report is published and notification is given to a government minister that the inquiry’s terms of reference have been fulfilled. As such, Professor Jay has resorted to public statements and media appearances rather than the use of any legal powers to express her concerns.

Similarly, the Chair of the Manchester Arena Inquiry, Sir John Saunders, at the closing of the inquiry made the following comments: “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 it is a limitation of the public inquiry 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 importance of factors outside of the legal process

In the absence of any such legal power at the hands of public inquiries, it is so often the case that campaigns to elicit change are often driven by the media, campaign groups or the impacted and affected families themselves, sometimes using ongoing inquiries as a necessary platform to have their voices heard.

In light of the growing concern that learning and recommendations are not being implemented by those to whom they are directed, charity organisation INQUEST have been campaigning for a ‘National Oversight Mechanism’ consisting of a new independent public body which would be responsible for collating, analysing and following up on recommendations arising from inquests, inquiries, official reviews and investigations into state-related deaths. INQUEST maintain 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.

Public inquiries do play a prominent part in public life in the United Kingdom. They are a well-rehearsed mechanism to investigate matters of public concern and are driven by a desire to learn lessons so that mistakes are not repeated, and changes are made for the better. However what is clear from studying the progress of learning lessons following public inquiries in recent years is that without a change to their statutory function and powers, public inquiries cannot work in isolation as the sole instrument for positive change to take effect.