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July 9, 2024

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Is it time to learn lessons from UK public inquiries?

Erin Shoesmith, Partner at Addleshaw Goddard discusses public inquiries and what impact, if any, comes from their recommendations. 

Erin Shoesmith, Partner at Addleshaw Goddard.

Public inquiries are engrained in modern political culture. They have a prominent role in investigating major public events and tragedies.

The issues they investigate have been front and centre in recent months following the ITV’s depiction of Mr Bates v The Post Office and the publication of the report following the Infected Blood Inquiry.

But do public inquiries bring about meaningful improvements?

In some cases, Inquiries do provide the necessary motivation for change. The Manchester Arena Inquiry was the catalyst for Martyn’s law, which featured in the King’s Speech last year and for which the draft Bill is being introduced for parliamentary scrutiny this year. The aim of Martyn’s law is to ensure stronger protections against terrorism in public places. The Grenfell Tower Inquiry inspired the Building Safety Act 2022 and associated regulations, which introduce a more rigorous building safety regime.

The number of public inquiries taking place and the media interest they attract continues to rise. Between 1990 and 2017, central and devolved governments have spent at least £638.9 million on 68 public inquiries[1]. However, very few inquiries are followed up to check recommendations have been implemented.

Barriers to implementing change

  • Public inquiries are perceived as slow. Between 1990 and 2017, the average inquiry took two and a half years to publish its final report[2]. The risk with delay is that similar incidents may arise in the interim period before lessons are learned and implemented. Slow progress also means there is a real risk that the findings and recommendations come too late, often rendering them redundant.

The Edinburgh Tram Inquiry was the subject of this very criticism. The aims of the Inquiry included to examine why the Edinburgh Tram project incurred delays and cost more than originally budgeted. However, it only concluded on 19 September 2023, over nine years after the inquiry was announced. Its conclusion and recommendations came after expansion to the Edinburgh trams scheme, which opened its first new route in June 2023.

  • The final report of a public inquiry sets out relevant findings and recommendations, but those recommendations have no legal effect and are not binding. There is no current system for the Chair of an Inquiry to monitor and review the implementation of learning points arising from an Inquiry. There is also no standard process for the government to follow up on the recommendations.

The shortcomings of this approach are clear from the Thirlwall Inquiry’s review into recommendations from previous healthcare type inquiries published on 15 May 2024.[3]  In the Royal Liverpool Children’s Hospital Inquiry, only 4 out of the 67 recommendations were effectively implemented, with a further 22 recommendations lacking clear evidence of any implementation. Additionally, the Shipman Inquiry, established to investigate the activities of general practitioner and serial killer Harold Shipman in 2002, saw a mere four of its 33 recommendations implemented. Overall, the review starkly shows “across 30 inquiries, dating back to 1967, just 302 out of more than 1,400 key recommendations had been adopted”[4].  It is astonishing that nearly 80% of recommendations have either been rejected, there is insufficient evidence of implementation or the implementation is incomplete.

Scope for improvement

Court room.What would improve the effectiveness of public inquiries?

This is what the House of Lords Statutory Inquiries Committee is grappling with, and has heard evidence from the Chairs of the Manchester Arena Inquiry and the Brook House Inquiry as well as Counsel to the ICCSA about the effectiveness of public inquiries and the Inquiry Act 2005. Participants engaged in discussions on a variety of topics, such as the difficulties of ensuring the report’s recommendations are implemented and the important role of interim reports in maintaining public confidence[5].

Families bereaved by the Grenfell Tower fire, the infected blood scandal and Covid-19 are also calling on the new Prime Minister, Keir Starmer, to ensure that reports from public inquiries are followed up on.

Interim reports

The Inquiries Act 2005 permits interim reports to be published prior to the final report.  Inquiries operating in stages with the publication of interim reports is becoming more common.  For example, the Infected Blood Inquiry and the Post Office Horizon IT inquiry have both issued early interim reports to address issues of compensation to victims. It was also an approach used in the Grenfell and Manchester Arena inquiries and the Covid Inquiry is running on a module-by-module basis.

Interim reports are a welcome development and should be used where appropriate to help avoid delays.  Interim recommendations can address time critical changes already known about that are needed to prevent recurrence and allay concerns that repeat incidents could happen whilst the inquiry is ongoing.

This approach allows for the added benefit of the Chair being able to monitor whether the recommendations are implemented during the Inquiry. In the Manchester Arena Inquiry, interim recommendations were made, and hearings were held to monitor the implementation of interim recommendations throughout the Inquiry. This not only ensured accountability, but it also enabled public scrutiny where there had been delays in progress.


The Chair of an inquiry should be retained to monitor the implementation of final recommendations, upon completion of the Inquiry. This would also allow for public accountability as was highlighted by Sir John Saunders, Chair of the Manchester Arena Inquiry. He stated, “it is important for the public, and, in this case particularly the bereaved families, that reports on progress are made in a public forum. Whether that is to a select committee of Parliament as has been suggested or, in a report which is made public, there has to be public accountability”.[6]

Similarly, Sir Brian Langstaff, who chairs the Infected Blood Inquiry, will not close the Inquiry until the Government responds to the recommendations made in the Inquiry’s recently published report.[7]

Quicker progress

Inquiries should also consider whether different stages can run in parallel.  Bereaved families of those who died of Covid-19 in care homes have expressed disappointment in the Covid-19 Inquiry not conducting public hearings on the pandemic’s impact on social care until 2025.

Accountability within government

The Institute for Government suggested in 2017 that accountability could be improved by both an increased use of select committees and by a permanent ‘Inquiries’ unit being established within the Cabinet Office.

The use of select committees to oversee progress of recommendations from an inquiry remains low. In 2013 the Health Select Committee scrutinised the Mid Staffordshire NHS Foundation Trust Inquiry and in 2017 the Public Administration and Constitutional Affairs Committee reviewed the Government’s response to the recommendations made by the Chilcot Inquiry. However, following up on the implementation of inquiry recommendations could be administered by select committees. One or more select committees could regularly scrutinise the implementation of each inquiry’s findings. Where progress is unsatisfactory, committees could hold evidence sessions.  A permanent ‘Inquiries’ unit could help ensure lessons are learned from previous inquiries.

It seems clear that the number of public inquiries, the importance of the matters they consider, and the costs and time invested in them justifies and necessitates government monitoring of whether final recommendations are implemented.


Public inquiries play a crucial role in understanding the causes of tragic events and identifying lessons to prevent recurrence.

Yet, their effectiveness is currently undermined by inadequate follow-up on recommendations. Enhancing their impact requires urgent reforms, including the timely publication of interim reports, the establishment of a comprehensive monitoring framework, and the implementation of annual progress reviews by select committees. By adopting these reforms, public inquiries can truly fulfil their purpose, ensuring that the significant expenditure of public funds and resources translates into meaningful outcomes.

Addleshaw Goddard’s Safety, Inquests and Inquiries team is currently instructed on numerous public inquiries.  If you require support with a Public Inquiry, please contact Erin Shoesmith.


[1] Emma Norris and Marcus Shepheard, “How public inquiries can lead to change“, Institute for Government, 12 December 2017, pg. 3

[2] Emma Norris and Marcus Shepheard, “How public inquiries can lead to change“, Institute for Government, 12 December 2017, pg. 4

[3] The Thirlwall Inquiry, “Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues prepared by the Thirlwall Inquiry Legal Team”, 15th May 2024.

[4] Politicians and NHS criticised as they fail to carry out actions urged by Jimmy Savile inquiry after 10 years | The Independent

[5] UK Parliament Committees, “Statutory Inquiries- Oral Evidence“, 12th February 2024

[6] BBC News, “Manchester Arena bombing inquiry chairman raises progress concerns”, 4 July 2023.

[7] The Guardian, “Grenfell and other bereaved families demand next PM act on public inquiries”, 14th June 2024.

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Terry Callan
Terry Callan
8 days ago

I believe a very sucessful Public inquiry was the Piper Alpha inquiry. This ran from the 11th November 1988 to 15th February 1990, with 180 days of sitting. The recomendations were implemented and had a huge positive effect on Health and Safety in the UK oil and gas industry. I agree though that today some enquiries just go on and on. We have the ongoing UK Covid inquiry, even if it takes 3 or 4 years, it will reflect the devastating affect Covid had. Hopefully the recommendations will be implemented.