Wednesday 4 November 2026

10.35 am

80.             The Chair: Good morning, and welcome to this meeting of the Constitution Committee. Today, we are continuing to take evidence for the committee’s inquiry into the UK constitutional safeguards. Later on, we will be joined by Daniel Greenberg, Parliamentary Commissioner for Standards. Before that, we are delighted to be joined by Sir Brian Langstaff, former chair of the Infected Blood Inquiry, and Sir John Saunders, former chair of the Manchester Arena Inquiry. We will be inviting you to reflect on your extensive experience of public inquiries and as senior members of the judiciary. You are both very welcome. I remind members to declare any interest relevant to this inquiry or today’s meeting the first time they speak; I have no relevant interests of my own to declare, so I will go into the first question.

Public inquiries are much in the news, on a whole range of areas. Although this is a bit of a wide question, it might allow you to make an initial statement if you wanted to. In your view, do public inquiries play a substantial constitutional role in the way we run ourselves as a democratically rooted country?

Sir Brian Langstaff: The clear answer for me to that is yes. It has to be recognised that the principal body which brings the Government—the Executive—to account is Parliament, but Parliament does its work necessarily through committees, debates and questions; it may not, and generally does not, have the time and resources or, for that matter, the specialist expertise to investigate particular questions in detail. Where there is a substantial matter of public concern which requires an answer, then some system is necessary to decide what the answer is and what light, if any, it shows on the way in which the Executive has worked and whether, on that occasion, the Executive should be held to account. It is fundamental, in many ways, to the trust which people can have in a mature democracy that it is willing, where the proper occasion arises, to investigate itself in public, to see whether it has failed, so that the public can be assured that it will not happen again.

The Chair: That is very good. Thank you very much.

Sir John Saunders: I agree. Can I just draw a distinction between my and Brian’s inquiries? Mine started off as an inquest, and the Government produced evidence to me as the coroner which they said was covered by public interest immunity and therefore could not come out in public; if we were going to hear this evidence, we would need to have a closed hearing. You probably all know all this; I am sorry. You cannot have a closed hearing in an inquest that is not closed from everyone; you can close it from the public, but you cannot close it from the families. Therefore, if there is information which simply cannot be shared with the families, you have to have a public inquiry.

It is up to the Home Secretary whether there is a public inquiry, and that can be significant. In my particular case, Theresa May, who was then the Home Secretary, when applying for public interest immunity, which clearly had to be granted in that case, said that she understood that, if you granted this application, there would need to be a public inquiry. You should contrast that with the Litvinenko Inquiry, where, in fact, the same Home Secretary refused to have a public inquiry; she said to the coroner—a very distinguished judge—“No, you cannot have a public inquiry”. He was saying that he could not do this inquest without having evidence which could not be given to the public. It went to the High Court, which did not say no to the Home Secretary, as I understand it; it said that she had not put forward a good reason yet and to go away and think again. She did, and there was then a public inquiry. But there is maybe some concern that that power is given to the Home Secretary and about the extent to which the courts could interfere with it.

The Chair: If that power was not with the Home Secretary, where would you want it to be?

Sir John Saunders: I would have thought it could have been with the coroner. Obviously, the coroner’s decision would be subject to judicial review. I know a bit about the case, but it may well be—you will know better than I do—that there was a political decision that we wanted to keep in with Russia at that particular time.

The Chair: Do you not think that it being with the Home Secretary is quite a useful protection, with her being a Member of Parliament and therefore accountable to Parliament, slightly unlike a coroner?

Sir John Saunders: If you do not have an effective inquiry into a death, then you are in breach of Article 2. Who will decide what is an effective inquiry? Should it be left to the Home Secretary when it is a fundamental right, or should it be left to someone else who can judge the merits in a slightly different way? The Home Secretary will always have a say in it, clearly, and put forward an argument, but should it be left to the Home Secretary on their own?

The Chair: That is a very helpful clarification.

81.             Lord Bichard: I should declare that I was chairman of an advisory board for the Infected Blood Inquiry. We are not here to reform inquiries but to look at the threats to our constitutional democracy. I have a couple of questions. Were you particularly surprised or disappointed by some of the things you found, and were there any that you thought were a threat to our constitutional democracy?

Sir Brian Langstaff: Yes. There were a lot of conclusions I was driven to by the facts that were uncovered which were uncomfortable. Not least was the way in which people had been misled—by the words used by parliamentarians and given to them to use by civil servants in particular, but also by the way in which documents went missing. I had, in the end, to draw the conclusion that some had been destroyed, knowing what they might contain and that they might be useful for those people who were then arguing for there to be a public inquiry and further investigation of what had happened.

All was to support a line to take. Lines to take may be, and are, useful in dealing with matters if they are properly founded. But if you take a line to take—such as was taken in the Infected Blood Inquiry by Parliament repeatedly, addressing some of the 3,000 people who had lost their lives as a result of infection through blood, that they had had the best available treatment—it begins to defy reason unless there is a proper foundation for it, and there never was. It was repeated so often that, as I put it in the report, it went from being a dogma to a mantra and was repeated repeatedly. I was surprised by that. I was surprised by the way in which constant public pressure for there to be answers, and found answers, was met with resistance from those in charge of the NHS at the time, from the civil servants and from many parliamentarians. There were some notable examples who differed, but often things were overpromised and underdelivered.

I was particularly surprised when, in England, Yvette Cooper, as Minister of Health at the time, asked to see what the documents showed and wanted a clear, straightforward description of that. A civil servant from outside her department was brought in to do it. He produced a report. That report was significantly altered over the next four years. She told the people who were interested in hearing what the situation was that they would be told of the report and shown it in due course.

Well, it took about four years to produce it, during which period it went through a number of iterations within the Civil Service. It ended up not being a document that was descriptive but a document that was argumentative in support of the preconceived position. 

Lord Bichard: Without putting words in your mouth, your conclusion is that these failings were so serious as to be a threat to our constitutional democracy because they undermined trust. Is that what you are saying?

Sir Brian Langstaff: Absolutely. One of the difficulties with public inquiries is that, if the public concern is justified—it may not be, but if it is—they may show that things have gone wrong because people have fallen short; they have not met the standards that they should have met or they have made mistakes and have not admitted to them.

If the inquiry identifies this and suggests what should be done to stop it happening again, the public will lose trust if nothing happens. It is one of the big problems that have been identified recently, over the last three or four years in particular. Inquiry after inquiry has produced recommendations. Quite a number of those have been accepted by the Government. In the case of my own inquiry, all 12 recommendations that I made, and the various sub-recommendations within them, have been accepted, but they have not all been implemented fully, and implementation is patchy.

That resulted in my having to recall the inquiry into session—it was still an ongoing inquiry—so as to hear evidence about what had happened in respect of compensation. As a result, changes were made; all credit to the Minister concerned who arranged that, but it was a pity that he was in that position in the first place. In part, that led from a decision earlier on to exclude the people who had suffered most—people who had been infected or were close to those who had been infected—from being involved in an expert group’s consideration for the benefit of the Government into what compensation would look like. 

This was despite my inquiry—or me—saying that any scheme designed for compensation ought of necessity to involve people who were affected in its design. Obviously, the Government was necessarily involved, but not the people who had suffered, who had the real interest and who could point out problems that those unaccustomed to that world would be unable to.

This was an eye opener to them and a disappointment to me the day after the report of the inquiry was published.

My first recommendation was compensation. I had recommended the detail of the compensation scheme in an interim report earlier, in the hope that, because the Government had said that they accepted the moral case for compensation, I would then be in a position to say that, if you accept the moral case for compensation, you need to start considering, and deciding, what it is going to look like. You need to set that out and be clear about it. If you accept that, this must follow. You are dealing with people here who may be in the last parts of their life; some are dying through illness. If they are going to get compensation, they should get it as soon as possible; you need to get on with it. 

Lord Bichard: Could I just ask Sir John: are there points from your inquiry that fall into this category of undermining trust in the state?

Sir John Saunders: It differs hugely. In Manchester, most of the people involved came along saying, “We got it wrong. This is how we got it wrong, and we’d really like to get it right. So we’d like to encourage you to make the right recommendations”.

That is very encouraging. I am not saying it was everybody, but the vast majority—the police, the fire service, the ambulance service—were keen to change things and get them right. Hopefully, they have done that.

The one possible exception relates to the closed hearings and the open hearing. My findings on the closed hearings differ considerably. Regarding what was said in the open hearing as to the position of the Security Service, I did not say, and I do not say, that we were being deliberately misled. They just got it wrong, as indeed I believe the ISC got it wrong in their inquiry, mainly because they were talking to the big chiefs and not to the people who were on the ground.

We said, “We want the people on the ground. We want to know what happened”. When we got to that, the answer differed, as far as we were concerned. But by and large, the atmosphere was constructive and I did not feel that people were trying to cover things up.

I have similar concerns as those Brian has expressed about recommendations and recommendations being implemented. 

82.             Baroness Laing of Elderslie: I want to ask Sir Brian a follow-up question. We are looking at the vulnerabilities of the constitution and what goes wrong. You have just given a very good account of what happened on the Infected Blood Inquiry, which you know intimately.

But something has gone wrong between you making recommendations, those recommendations being accepted, and the implementation, where there are large numbers of people who have never been compensated, or will never be because they have died. Can you make an assessment of what went wrong there? It is not really fair to ask you, but you have a unique position in observing this and I wonder if you could enlighten us. 

Sir Brian Langstaff: That is difficult, and I think that is because of two things. One is that there was a very slow start, and the slow start came because of what I was saying earlier. The second interim report that the inquiry made saying what a compensation scheme should look like echoed many aspects of the scheme that the Government themselves had called for. Penny Mordaunt was the Cabinet Minister responsible for the inquiry, and for telling the Government what compensation would look like if it was ordered; this was after a couple of years of the inquiry. She obviously had an idea that that might be an outcome of the inquiry.

The Government commissioned a report from Sir Robert Francis. That report was clear. The Government promised that, when the report was produced, it would be given to people and they would respond promptly to it. Well, they did not. They did not respond promptly and neither were they offered it, until we had a further hearing. Just before that further hearing, which involved the Prime Minister, the then Minister of Health and a couple of other Ministers, including Penny Mordaunt herself—immediately before that—things started to happen.

This was not an unfamiliar experience from the inquiry’s evidence: things that were right and proper to do, and recognised as such, did not necessarily happen immediately. But if some event such as an inquiry hearing was likely to happen, then shortly before that hearing, things did get done. Whether there is a link, I could not possibly say—but there might be. I think the cynic would say that this is a case of what Dr Johnson said: that a hanging to come in the morning concentrates the mind wonderfully. But that was the case.

To answer your first question, it started slowly. It is a huge undertaking to create the body that is awarding the compensation, and staff it. That takes time. I accept that. There are a lot of people who are likely to be compensated, hence the cost of it all. It is necessary therefore to prioritise, because you cannot pay everyone all at once straight away and you are dealing with public money. It is taking its time. It started off saying that some people might not be paid until 2030. That has now been brought down to the middle of next year; I hope that is right. These are people who are, if you like, the lowest in the order of priority, which has been set by the body itself.

Baroness Laing of Elderslie: Are you saying, therefore, that the reason why things have not moved forward, as you might have hoped they would, is practical rather than political? I am looking for where the vulnerabilities lie.

Sir Brian Langstaff: It is a mixture. It is more practical but there is certainly a political element in starting slow. If things had happened earlier, we would not be in the same position now.

83.             Baroness Hamwee: Perhaps I should start with Sir John; you might want to add to some of the things Sir Brian has been saying. We are looking at where there might be weaknesses in the process. I am wondering whether, as a routine, normal and standard part of the inquiry process, something should happen that does not often happen now: the Government giving reasons for accepting or rejecting recommendations. Should there be a standard way of following up recommendations—mechanisms to monitor and track whether they have been followed—and on whether the Chair’s involvement should continue? Perhaps you would like to riff on that.

Sir John Saunders: Perhaps I can deal with the recommendation side. There are certainly some things relating to how inquiries are conducted that could be done better. There is something in the criticisms that are made that they are too long, too expensive and do not achieve anything; they are not entirely justified. But we could do something about that: before the inquiry starts, we should be looking at the scope of the inquiry in much more detail. This comes about because, when an inquiry is set up, everybody says it will look in depth at absolutely everything. Then when you start, they complain about the length of time it is taking for you to look at the length and depth of everything. Scope is really important. We should not have too many lawyers involved because they ask lots of questions.

I also am a firm believer in the fact that the way in which inquiries are now conducted should be altered. We are very bad in having an interrogatory means of doing it. We are adversarial. Because I have been interested in inquiries, I have looked at some of the inquiries going on, and I think to myself, as Lord Judge would have said, “Could not you just ask why or what happened next?”, or something like that. Actually, the inquiry team have worked out in their own mind what the answer is and then, like every good adversarial barrister, they ask a question that intends to lead to the answer that they have already formulated it should be. It means that it sometimes becomes a bit of a public hanging. It also goes on for ever because the questions—I do not know whether you have ever seen them—are spread over pages and pages. In my inquiry, I had to say to the witness periodically, “I am sure there’s a question coming any minute now”, just to keep them concentrating. Then you stop and expect an answer.

Of course people who look at it in the sort of detail that inquiry teams do are going to have some preconceptions about it—but put them at the end when you have formed your conclusions. In my inquiry, the most revealing thing, which I cannot disclose, came out of a purely chance question that was not planned to get any answer at all. Suddenly, the whole picture changed. I should like to not be so adversarial.

Recommendations are the real problem. What I did worked for me. Brian has rightly said at other meetings that this does not work for everything, but it can work. I did it in different sections, so I had a hearing within about three months of the first report coming out. The idea was to say, “Have you got started?” As Brian says, starting it quickly is important. “Are there any problems with our recommendations? If so, we can change our recommendations to help you.” The principal witness from the Home Office who gave evidence said, “I’ve never seen so much activity around Whitehall within the couple of weeks before you were going to have your hearing.” Everybody realised they needed to get on with it rather than be publicly humiliated by saying, “We have not actually done anything yet.” That is important. I did not know, but the Home Office disapprove of this. It was quite a battle to be allowed to do it. Having been told by the Home Office, regarding the second part, that I could not proceed, I eventually said, “I am going to do it. If you do not want me to do it, get a lawyer to stand up in front of me and say I am not entitled to do it.” That did not actually happen.

Sir Brian Langstaff: May I come in on this, Chair? There is a difference between John and myself on the answer to your question. In our inquiry, certainly I regarded it as a collaborative effort from all who were parties to it, both those who might have been regarded by some as being on the defensive end and others who you might have regarded as being on the claimant end. That led to the counsel at the end of the case representing the hospital boards saying what a wonderful collaborative inquiry it had been. He was not doing that simply to gain respect for his argument; I think he meant it. We had similar expressions from the Scots barristers because we went across all four nations. Therefore, our context differed, and inquiries differ hugely.

The answer I give to the question you asked is that there are three areas of weakness. The first is before an inquiry is called, which is whether it should be called or not. I recommended in my recommendation 11, which was accepted by the Government, that there should be a system, under control of Parliament, of responding to a recognition of public concern that might justify an inquiry. It seemed important that there should be some such system, not least to ensure that an inquiry is called when it ought to be but not called when it should not be.

Baroness Hamwee: A parliamentary system.

Sir Brian Langstaff: A parliamentary system, absolutely. Parliament should be in control of the system. It should not necessarily be the responsibility of the Minister whose department it is. That may be appropriate if you have a Minister who is looking at an inquiry into some hospital, for instance, which does not affect the running of the department itself. But if the inquiry is coming closer to home, then you can well see why the Minister might not want to have an inquiry into the way in which his or her department has worked. That is a problem at the start.

John has just significantly dealt with the problem at the end. You make recommendations, but do they then go on the shelf marked “Accepted” but are never taken down, looked at and implemented? There is this implementation gap, which I have taken what steps I can to address in my inquiry but it needs to be formally addressed in a proper way. It is a weakness in the Act that there is no follow-up procedure.

The middle of the inquiry differs tremendously between inquiries. They will take time. That is necessary, because if you do not know the answer, and inquiries are called because you do not know the answer, you do not know how long it is going to take to find it. There are some inquiries which are quite simple and where you can put a time limit on it. If you can do so, then I understand why one would want to.

Lord Burnett of Maldon: You mentioned in one of your earlier answers that there is a danger that inquiries can become hunting grounds. A huge amount has been written on this, starting with investigating aviation accidents, particularly in the US. Do you think there is a danger that these can become hunting grounds and that that itself forces people to become defensive?

Sir John Saunders: Absolutely. You will know better than I do that, as lawyers, we are not good at being anything but adversarial.

One great aspect for me of being chairman of the inquiry was this: you hear some renowned advocate going through a very long question, the aim of which is that they are cutting off all the escape routes. That is standard practice; you have to come to the answer I want you to give, so I cut off all the escape routes. If you are there as a chairman—you could not do this as a judge—then, once you see where they are going, you just cut all that rubbish and go straight to the question they were going to ask at the end. They protest like mad: “I’m just coming to that question”, they say, but they were not—they had another 10 to go. That is the joy of being an inquiry chairman that we did not have as judges, because the Court of Appeal would say we were interfering too much.

Sir Brian Langstaff: I think it depends very much on the inquiry and the subject matter. Plainly, if the inquiry reveals wrongdoing and something that does not deserve trust, then to that extent trust is put in jeopardy, but I think it restores trust in people and in politics if there is a recognised system, one part of which is an inquiry process that will identify things if they go wrong and will take or at least recommend steps to put it right. It is that second area, the taking steps to put it right, that is critical in ensuring that there is trust for the future.

85.             Lord Waldegrave of North Hill: I should declare an interest as a former witness before Sir Brian. I have said in the Chamber of this House and repeat now that I thought that was an absolutely admirably conducted inquiry.

I have two questions, one to try to get a heads up a little bit. These inquiries take place, naturally, when there are different kinds of terrible catastrophe. First, I want your general, highly intelligent views on this: how do we try to ensure that accountability is working all the time, not when there has been some catastrophe when you and others, at great resource, are put to trying to find out why? What did you conclude from what you saw that might improve the day-to-day running of affairs and prevent these things happening?

Secondly, a particular interest of mine, perhaps relevant to both and to the BSE inquiry before which I appeared, is that the frontier between expertise and generalist civil servants and Ministers is very difficult. If a grand person in a white coat says something, it is much more difficult to challenge. I wondered whether you had come to any views about how we could improve the frontier between Ministers, who are by nature generalists, and civil servants, who are mostly generalists, and those specialists who are sometimes very difficult to confront.

Sir Brian Langstaff: On the first part of your question, my prescription for improvement would be to recognise that much of my inquiry was about risk and the approach to risk. With a couple of notable exceptions, throughout the time span of my inquiry, which was as long as the NHS had been in operation, there were a couple of occasions when risk was properly approached. They were straight after the Second World War with the risk of hepatitis carried by blood and when we had the possibility of vCJD being transmissible by blood when, broadly speaking, a proper approach to risk was taken then. It was accepted that nothing had happened; there had been no known case of vCJD being transmitted by blood, but it was recognised that there might be—so a risk—and, as a result, preventative steps were taken. It is quite possible that the jury is still out on that, but it might have saved a lot of lives and people suffering from vCJD.

With those two exceptions, we were just very bad at looking at risk. A lot of clinicians wanted certainty. They wanted to investigate further—a natural scientific reaction, perhaps. But, if you know there is a risk, you do not really need to know what is causing it, how exactly it is causing it, when it is causing it and then need to discuss it in 25 committees that have been set up and may produce differing advice to the Minister. Twenty-five is a slight exaggeration, but you get the point. I prescribe a better approach to risk and making sure that you put patient safety first.

That is more difficult than it sounds. A guide for managers in the health service was revised on 26 July, just a few months ago. One of the things which struck me about the report of Lady Justice Thirlwall into the Countess of Chester Hospital was when she said that this guide really should have started, as a matter of first principle, with saying that the safety of the patient should be the first concern. It did not and yet that was exactly what my inquiry was saying. This was a lesson that we should learn and it went all the way through it. It was fundamental.

The second prescription is to impose a duty, which has not been clearly imposed before, on managers and leaders to be accountable for the way in which those under their leadership respond to complaints and concerns. The Bristol inquiry 30-odd years ago made the point that there should be such a code. Professor Kennedy’s prescription there was to impose a protection for people who blew the whistle. But in a sense, that is almost recognising that people who blow the whistle would otherwise be at fault for telling tales. You want to have a system where everyone recognises that, if you do not tell the tales, there is a risk to public health and safety.

The airline industry, by and large, ensures accidents do not take place because everyone recognises that they all have responsibility for safety. If you notice somebody else has not done something, you say, “hey”, or you report him or her, and something gets done. As a whole, it results in a very safe industry. There are other examples of that such as offshore safety and chemical safety. We do not have a safety system operating within the NHS as yet. One of my recommendations is that it should be at least considered. Those are my prescriptions, and that is the first part of your question.

Lord Waldegrave of North Hill: What about dealing with scientists?

Sir Brian Langstaff: Obviously expertise has to be respected, but that does not mean that it cannot be questioned.

Lord Waldegrave of North Hill: Should there perhaps be more pluralism in the advice taken?

Sir Brian Langstaff: Yes, it is part of the advice. I think one would want to follow the science if one were sure about it. You would perhaps want to ask further questions of it and, in particular, be careful if the scientific advice were coming from just one white coat rather than from a panel.

86.             Lord Griffiths of Burry Port: A lot of the ground I imagined I might be questioning you on has been covered. The word “trust” has appeared rather a lot, and I am very impressed by the help you have given me to understand the processes by which you get alerted to a field of inquiry, how you handle yourselves in it and these different approaches. Educationally for me that has been splendid.

But there are inquiries and then there are inquiries. If I may quote you back about kicking things into the long grass, the pressure on a Government to set up an inquiry is frequently voiced by people who have a genuine concern and frequently from within a governing body that does not want to have to face the question now. For ordinary people, distinguishing between those two points of view can be difficult.

During the inquiries, some of which I can call to mind now, witnesses have been called or a part of the inquiry has been set up in such a way that someone who is well known in public is questioned or brings his views, and the press then go to town. That can quite easily disorient the goings-on by emphasising a view that that is particular to that person. You must have to pull in the reins quite cleverly to handle that because it could disrupt progress.

As in most of the work of this committee and others I have been on, the big question is how you portray the real dynamics of what you are doing to the public at large so that they are with you all the way. If it takes a long time or is done in a certain way, they can understand why. That business of communication with the public, and back again to trust, seems to me to be rather important. The work you do is fantastic. I am not quite so sure about the way or the speed at which things are implemented, poor old Grenfell and so on.

From your magisterial chair, as you are handling these processes, mingling, mixing, knitting together and doing all that, you have a job to help the public to understand something of what you are doing and the dynamics of it. Am I touching something real?

Sir John Saunders: Can I have a go? I have never sat in a magisterial chair, but thank you for that.

Lord Griffiths of Burry Port: You are doing it now.

Sir John Saunders: The press are hugely important. In my inquiry they reported very well and immediately in the Manchester area. It does not help when a reporter who clearly knows nothing says that all inquiries and all the rest of it are a complete waste of time. The press are important in a different way; they are important in making sure recommendations are followed. We are coming up to the 10th anniversary of the Manchester bombing, and people will be asking what has happened. What recommendations have been followed? The press will be saying that, so you get a lot of press pressure to do it and that is really good.