In her opening remarks as counsel to the Thirlwall inquiry last week, Rachel Langdale KC recalled three sudden deaths of children at Grantham Hospital in 1991. A fourth baby died not long after being allowed home.
Doctors realised that this was unusual but thought the deaths could be explained on the basis of each child’s medical history. However, a blood test showed that one of the babies had been wrongly injected with insulin.
In 1993, Beverly Allitt was convicted of murdering four babies, three attempted murders and six other charges of causing grievous bodily harm. The former nurse was sentenced to life imprisonment on each charge, with a minimum term of 30 years.
An independent inquiry was commissioned “to ensure that the NHS learned any lessons it could to prevent similar events in future”. But 25 years later, said Langdale, “another nurse working in another hospital killed and harmed babies in her care”.
And that’s not the first time. A House of Lords committee was told recently that the patient deaths investigated by the Mid-Staffordshire Hospitals Inquiry in 2013 might have been less likely if recommendations from the inquiry into deaths at the Bristol Royal Infirmary in 2001 been implemented. And if changes had been made as recommended in 2013 after the inquest into a fire at Lakanal House in London, the Grenfell Tower fire might have been prevented.
Failure to implement inquiry recommendations once they have been accepted by the government is “inexcusable”, the Lords statutory inquiries committee says in a report published this morning. “It risks the recurrence of a disaster and undermines the whole purpose of holding an inquiry in the first place.”
The committee is chaired by Lord Norton of Louth, professor of government and director of the centre for legislative studies at the University of Hull. I have been discussing its findings with him for my latest podcast, available to subscribers here.
What, I asked him, is the purpose of holding an inquiry into inquiries? After all, another House of Lords committee did precisely that a decade ago and published its report in February 2014.
That committee made 33 recommendations to the government about how to change the Inquiries Act 2005 and governance structure for public inquiries. Of these, 19 recommendations were accepted by the government in June 2014 and 14 were rejected.
Of those the government accepted, how many have been put into effect during the past decade? Precisely none, as far the Lords committee could find out. But one recommendation that was rejected by the government in 2014 has since been implemented, although in a different form. As this flow-chart1 indicates, today’s report calls for all but six of the remaining recommendations to be given effect:
Little surprise, then, that Norton and his colleagues want to make sure that future inquiry recommendations are followed up and put into effect. The Lords committee recommends that a new, independent committee of parliament — ideally, a joint committee of MPs and peers — is set up to
conduct oversight of public inquiries;
monitor the publication of and government responses to inquiry recommendations; and
hold the government to account so that the inquiry recommendations it accepts are actually implemented.
The one recommendation made in 2014 that has been acted on is to set up an inquiries unit in the Cabinet Office that can share best practice and make sure that inquiries are run appropriately. Even though it dates back to 2019, it has no online presence and little seems to be known about it.
“It is telling and unfortunate that around 10 witnesses recommended to us that an inquiries unit should be established, because this implies that they are not aware that it in fact exists,” Norton’s committee observed. “There remains a perception that new inquiries are continuing to ‘reinvent the wheel’ and that opportunities to learn from shared best practice are being missed.”
The Cabinet Office inquiries unit has written a guide for inquiry chairs and secretaries. There is no link to it in today’s report because the only version of it that can be found online dates back to 2012. That appears to be the photocopied draft that I have previously linked to. “A more recent copy must be made available in a form for the public,” the committee says.
Peers commended the inquires unit for the work it has done within government but the committee is disappointed that it has failed to engage with academic experts.
Its report includes some important recommendations:
Inquiry terms of reference should contain an obligation on chairs and secretaries to produce (at a minimum) a lessons-learnt paper (on legal and policy challenges) and a working paper (on logistics), detailing what went well for the inquiry and what could be improved in the future. This requirement should also be included in the chair’s terms of appointment so that their full salary cannot be paid until the documents have been presented.
The reports should be written as the inquiry progresses and submitted with the inquiry report, so that they can be considered by the inquiries unit and shared at the regular meetings of inquiry practitioners. This way, best practice would be disseminated and avoidable mistakes averted.
They should also be supplied to (but not published by) the new public inquiries committee of parliament, so the committee can make undertake meta-analyses of the successes and failures common to inquiries and make recommendations for improvement.
The inquiries unit in the Cabinet Office should be sufficiently resourced, so it can establish a wider “community of practice” for public inquiries, which includes more non-governmental experts. There should be a forum so that inquiry chairs can also share best practice, as well as inquiry secretaries.
A form of the handbook for inquiry chairs and secretaries should be publicly available. The unit should also use policy-making and civil service expertise to support chairs in making practicable recommendations.
But what makes Norton think these recommendations will be put into effect when those made a decade ago have fallen by the wayside?
“I think they’re more focussed,” he tells me in the podcast interview. “They’re more directed to the key problems.” And a new parliamentary committee would have the resources to monitor the implementation of inquiry recommendations. It could call ministers to account if necessary.
That strikes me as an excellent idea. Best of all, it could be implemented whether the government likes it or not.
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A Sankey diagram, I’m told.
As Emily Dickinson had it:”Hope is a feathered thing that perches in the soul”. There is as I believe an obligation to hope and there is a serious mischief to be countered when the cynics or more charitable the sceptics demand to know of your evidence to justify hope. That is, again in my view, to miss the point. If the need arising is of a pressing and vital kind in the public interest then everyone with the relevant skills and convictions has a clear duty to strive for better. To be frank, I have so far been impressed by the judge or former judge chairmanship of the current handful or more high profile inquiries. The Lords Committee under Lord Norton seems to be on very much the right track and governments really must be held to account if remaining inactive notwithstanding sound recommendations and especially ones that have been accepted by them- or their successors. Some auditing mechanism and some heavy influencing or even compelling measure should be on the agenda.
Surely the idea is either a demonstration of the oft claimed definition of insanity or a demonstration of just how gullible Government (of all persuasions) assumes people are. Your comments suggest the first possibility? Perhaps it is the latter relying on the public's tendency towards gullibility allowing problems to be shifted to some undefined future date when the public outcry/demand for change will be replaced by the next outrage? Should I be worried by the hint at optimism found in this write-up notwithstanding your obvious concern about the history of inquiries?