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The positive effect of public inquiries

Creating change for good.

Public inquiries play a prominent part in public life in the United Kingdom. They are a well-rehearsed mechanism to investigate matters of public concern. They are driven by a desire to learn lessons so that mistakes are not repeated, and changes are made for the better.  

This analysis will focus on how public inquiries seek to make recommendations that will change the UK landscape for the good. The article will focus its attention on a number of the positive changes brought about by historic public inquiries and will go on to consider some of the more recent recommendations emanating out of the Manchester Arena Inquiry and specifically how these recommendations, if adopted, may dramatically affect modern British society.

Public inquiries — learning lessons

Inquiries into matters of ‘public concern’, often emanating out of tragic circumstances, are used to establish facts, to restore public confidence, to determine accountability and importantly to learn lessons so that mistakes are not repeated in the future.

The learning of vital lessons is so often a prominent and determinative feature for those families who find themselves central to a public inquiry. For such families, demonstrating positive change out of circumstances that are so often nothing short of tragic, offers them the necessary reassurance that others will not have to suffer such similar anguish and that out of something so negative, positive change can be drawn.

Over the years, real and indelible change has been brought about as a result of a number of public inquiries and high profile inquests. Many of these changes will have positively impacted the general public in their every day lives, often in ways they are unaware of.

Inquests into the 7/7 bombings

On 7 July 2005, London became the target of the one of the deadliest terror attacks in the western world, when four suicide bombs were detonated on London’s transport system. 52 people were killed as a result of the attack and more than 700 were injured. On 11 October 2010, inquests were commenced into the deaths of those who lost their lives. Those inquests were presided over by The Right Honourable Lady Justice Hallet with evidence heard for a period just short of five months.

On 6 May 2011, at the conclusion of the inquests, Lady Justice Hallett issued a report under Rule 43 of the Coroners Rules 1984 (now referred to as Regulation 28 of the Coroners (Investigations) Regulations 2013) making nine recommendations for consideration by a number of organisations.

Whilst not emanating directly out of one of her formal recommendations, following the 7/7 bombings, the Hazardous Area Response Team (HART) capability was developed. HART are comprised of specially recruited personnel trained and equipped to provide the ambulance response to high-risk and complex emergency situations. HART teams work alongside the police and fire and rescue services within what is known as the ‘inner cordon’ or ‘hot’ and/or ‘warm zone’ of a major incident. Their job is to triage and treat casualties and to help save lives in very difficult circumstances and hazardous environments, bringing clinical care closer to the scene of the incident. The primary goal behind the initial development of HART was to ensure that casualties located within an ‘inner cordon’ at a major incident, like that which occurred at 7/7, receive timely live saving interventions.

The Francis Public Inquiry

The Francis Inquiry report was published on 6 February 2013 and examined the causes of the failings in care at Mid Staffordshire NHS Foundation Trust between 2005 and 2009.

One of the recommendations made by Sir Robert Francis KC (QC at that time), the Chair of that Inquiry, was that the National Institute of Clinical Excellence (NICE) needed to develop evidence-based tools for establishing the staffing needs of each service in the NHS, in terms of minimum staff numbers and skill mix, including nursing staff on wards, as well as clinical staff.

On 15 July 2014, NICE published its first ever guideline on the safe staffing levels of nursing staff in adult inpatient wards in acute hospital; a direct result of the Francis Report recommendations.   

Leveson Public Inquiry

The Leveson Inquiry, chaired by The Right Honourable Lord Justice Brian Leveson, was set up in response to the discovery that News International had been involved in a number of phone hacking scandals. Its purpose was to inquire into the culture, practices and ethics of the UK press, to examine their relationship with the police and politicians and suggest recommendations based upon its findings.

As a result of those recommendations, a Royal Charter on press regulation was granted on 30 October 2013. This incorporated key recommendations from the Leveson Report, allowing for one or more independent self-regulatory bodies for the press to be established. Any such body would be recognised and overseen by a Press Recognition Panel which came into being on 3 November 2014. Two legislative changes arising from the inquiry were also introduced to provide financial incentives to newspaper publishers to join a regulator recognised by the Press Recognition Panel.

Manchester Arena Public Inquiry

On 22 May 2017, 22 innocent people tragically lost their lives when a suicide bomber detonated his device at the conclusion of an Ariana Grande Concert at the Manchester Arena.

On 22 October 2019 the Home Secretary established the Manchester Arena Inquiry, its purpose to investigate the deaths of the victims of the 2017 Manchester Arena attack.

One of those victims was Martyn Hett. In the wake of the atrocity, Martyn’s mother, Figen Murray, sought to petition government that there should be a duty imposed that requires venues to take steps to improve public safety, with measures dependant on the size of the venue and the activity taking place.

The Manchester Arena Inquiry Volume One Report, which was published in June 2021, and focussed on the security arrangements at the arena, strongly recommended the introduction of a duty to improve the safety and security of public venues.  

On 19 December 2022 the Government announced details of the Protect Duty, now to be known as Martyn’s Law.  The draft Terrorism (Protection of Premises) Bill was published in early May of this year and is set to reform the Protect Duty thereby transforming it from a voluntary engagement for businesses into a compulsory duty. Read our guidance surrounding the evolution of Martyn's Law

A new duty for all employers?

In early November 2022, the Manchester Arena Inquiry Volume Two Report was published. This volume focussed its attention on the emergency response to the atrocity at the Arena, with the Chair making 149 recommendations.

Many of the recommendations made by the Chair in his Volume 2 Report affect organisations at a local, regional and national level. One of the recommendations that has potentially far-reaching consequences is the recommendation that “The Home Office should consider the introduction of a requirement into law, for example through regulations issued under the Health and Safety at Work etc. Act 1974, that employers train all employees, or certain categories of employees, in first responder interventions.”

Evidence heard at the Inquiry regarding the ‘care gap’ and the need for ‘zero responder’ help in the event of an atrocity such as that which occurred in Manchester offers some explanation as to why the Chair has issued such a wide-reaching and potentially onerous recommendation.

What is the 'care gap'?

The Care Gap was afforded its own chapter within the Inquiry’s Volume 2 Report and was defined within that chapter in the following terms:

In the event of a mass casualty incident, the public expect ambulances to travel to the scene quickly and in large numbers. The public also expect that, once on the scene, paramedics will attend to casualties immediately, with treatment starting within minutes of the incident occurring. The evidence demonstrates that, following the current approach, this is unlikely ever to be achieved. That is the case for at least four reasons.

First, the reality of the resourcing of ambulance services around the UK is that ambulances do not wait around for a Major Incident to occur. In the event of a mass casualty incident, it is inevitable that all, or at least most, ambulances in the geographical area of the incident will already be engaged in dealing with other events, leading to a time lapse to the deployment to scene of ambulance personnel.

Second, even when ambulance personnel begin to arrive at the scene of a mass casualty incident, the treatment of casualties is unlikely to commence immediately.  The first on scene have important duties to stand back from treating and instead assess the scene, establish command and control, liaise with commanders of other services and relay structured messages to control rooms.

Third, even once command is established, the expectation will be for patients to be triaged given the likelihood that the number of those needing treatment will almost certainly exceed the capacity of the healthcare resource initially available at scene. 

All of the above can be further exacerbated when there is a need to respond to a marauding or evolving major incident, where the scene of the incident is continually changing or expanding.  Witnesses and experts alike explained that the consequence of these factors is that, in a mass casualty incident, it is inevitable that there will be a delay in healthcare professionals commencing treatment on those that injured. During the Inquiry, this period was described as ‘the Care Gap’.

Bridging the 'care gap' — a recommendation for change

Established in 2016, citizenAID is a UK registered charity with a focused mission to prepare individuals, communities and organisations to help themselves and each other when there are multiple casualties, particularly from deliberate attacks. citizenAID helps the general public to stay safe and improvise effective treatment before emergency services are available to provide professional medical support; thereby filling the ‘care gap’.

It is initiatives like citizenAID that the Chair hopes can garner traction within the employment sector, such that at least some of the UK’s workforce can be properly and sufficiently trained to respond in the crucial minutes following a mass casualty atrocity such that lives can be saved.

It is the overarching concern about the impact of the ‘care gap’ that has ultimately led to the Chair recommending that the Home Office should consider the introduction of a legal duty, with potential criminal sanctions, that all employers train their employees, or certain categories of employees, in first responder interventions, such as applying a tourniquet or opening an airway.

If this recommendation is adopted by the Home Office, this will have far-reaching consequences for all employers. The Chair’s recommendation offers no distinction as to the types of employers that could have this legal duty imposed upon them and it could therefore be imposed not just upon those types of employer whose premises are deemed to be ‘high risk’, but also upon schools, shops, small businesses, charities, large corporate entities and so forth.

The recommendation is therefore clearly an ambitious one and if adopted and could see dramatic change across the entire UK workforce.

What does this mean for the future?

Over the years, the recommendations established by many public inquiries have brought about real positive change to the society within which we live.  

The Manchester Arena Inquiry will be no different. Hundreds of recommendations have been levelled at a number of national, regional and local level organisations by the Inquiry’s Chair in the hope that positive change can be brought to pass in the wake of such a devastating event. As considered within this analysis, some of the Chair’s recommendations, if adopted, could be far-reaching and place additional obligations upon the entire UK workforce.

Over the coming months, the response to the Chair’s recommendations from those to whom they were addressed will be made public and it will be at this stage that greater clarity is provided as to how the work of the Manchester Arena Inquiry is likely to shape the UK’s future.

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