No Lessons Learned: Peers Condemn Culture of Brushing Damning Inquiry Findings Under the Carpet

A damning new report has condemned the “inexcusable” failure by successive governments to learn live-saving lessons from a series of major public inquiries which cost tens of millions of pounds.

The House of Lords cites two high profile inquiries – the Grenfell Tower inquiry – and the 2013 investigation into multiple hospital deaths in Mid Staffordshire – which, it says, may have never had to be held if recommendations from a previous inquest into a fire in a tower block and a previous inquiry into hospital deaths had been properly implemented.

The Grenfell Tower fire came four years after a fire at Lakanal House in Southwark where six people died. The coroner, a judge, made 43 recommendations including drawing attention to the spread of the fire because the panels in the building were not fire resistant.

Four years later 72 people died at Grenfell Tower where the cladding was substandard. The chairman of the inquiry, Sir Martin Moore-Blick said last week all the deaths had been avoidable.

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The Mid Staffordshire inquiry under Sir Robert Francis, came 13 years after another inquiry into the deaths of 29 babies at Bristol Royal Infirmary. The 529 page report at the time was so wide ranging it was described as a blueprint to reform practices in the NHS.

Yet between 2005 and 2008 between 400 and 1200 people died in Mid Staffordshire replicating the same issues raised in the Bristol case.

The Lords report states: “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.”

The report goes on to suggest that the Mid Staffordshire and Grenfell Tower deaths were less likely to have happened if action had been taken following the two previous reports.

Chair of the House of Lords Statutory Inquiries Committee, Lord Norton of Louth, 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.”

The report calls for a major reform of the present inquiry system. This includes strengthening the Cabinet Office Inquiry Unit, creating a new Parliamentary committee to monitor recommendations and an accessible online tracker detailing where this happens.

This year alone there are 18 public inquiries taking place – from high profile ones like the Post Office Horizon inquiry and the infected blood inquiry, to inquiries into individual murders like Iman Jalal Uddin in Rochdale.

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A large number of them are expensive, take place many years after the original events and are sometimes accused of “re- inventing the wheel”.  The committee is in favour of expanding non statutory inquiries, which can report earlier, cost less, are based on a panel of experts and involved families of the victims of injustice more closely with the procedure.

The special select committee, took evidence from Bishop James Jones, who chaired the Hillsborough and the Gosport War Memorial Hospital independent panel inquiries, emphasised the need for empathy with the victims families. He pointed out when the judge led Grenfell Inquiry first started the room was full of lawyers with the bereaved families, at the back of the room or in an overflow room. This was changed during the inquiry.

Sir Brian Leveson, who gave written evidence to the inquiry, said there were too many inquiries and they were running out of judges who could chair them because of how long they take to complete. He also was in favour of other experts chairing inquiries. He also pressed the committee to reform the Maxwellisation” procedures as it can be used to delay publication of inquiries.

Alexis Jay, chair of the child sexual abuse inquiry, in written evidence expressed disappointment with the government’s response to her recommendations, which set no timetable for implementation. She has suggested to ministers that there should be a monitoring group set up to review the progress but had no response.

A Government spokesperson said, “We remain absolutely committed to righting past wrongs and working to ensure justice is delivered for victims.

“We thank the committee for its report and will take the time to consider its findings and recommendations.”