Written evidence from INQUEST (IBI0006)

Public Administration and Constitutional Affairs Committee
Inquiry into the recommendations of the Infected Blood Inquiry (Stage 1)

1. INQUEST is the only charity providing expertise on state related deaths and their investigation. For four decades, INQUEST has provided expertise to bereaved people, lawyers, advice and support agencies, the media and parliamentarians. Our specialist casework includes deaths in prison and police custody, immigration detention, mental health settings and deaths involving multi-agency failings or where wider issues of state and corporate accountability are in question, such as the Hillsborough football disaster and Grenfell Tower fire.

2. The slow pace of change following public inquiries, stemming from a lack of central oversight of recommendations, is a serious concern for INQUEST and many of the bereaved families we work alongside. INQUEST’s extensive research[1] and campaigning on the issue has revealed inconsistent practice with respect to monitoring the progress following inquiries, indiscernible action to address failings, and a pattern of repeated deaths.

3. INQUEST’s 2025 report All or Nothing, based on a family listening day attended by victims of national miscarriages of justice such as the Hillsborough disaster and infected blood scandal, evidenced bereaved families’ unequivocal belief that someone needs to take responsibility to oversee and monitor any recommendations arising from inquests and inquiries, with one family quoted as saying “implementation is the one step that doesn’t happen, all the rules, regulations, findings and still nothing happens.”[2] As Sir Brian Langstaff, chair of the Infected Blood Inquiry, stated in regard to his own inquiry’s recommendations, “assurances have been given, and not kept.”[3] .

4. All of this serves to diminish public trust in investigations and add to bereaved families’ distress. Given the clear and well-documented problem of a lack of oversight of recommendations, increased parliamentary scrutiny of recommendations and conclusions arising from public inquiries is welcome. As set out in this submission, Parliament could increase oversight in several important ways. However, our response raises concerns about the limitations of parliamentary scrutiny, noting in particular the existing fragmented approach to oversight, and recommends a National Oversight Mechanism is established to aid parliamentarians in scrutiny of inquiries and other investigations.

What role should Parliament play in scrutinising the recommendations of public inquiries?

5. INQUEST is supportive of Parliament playing a role in scrutinising the recommendations that arise from public inquiries, noting that at present scrutiny is rare. Research from the Institute for Government shows that of the 68 public inquiries which took place between 1990 and 2017, only six were followed up by a parliamentary select committee to examine the implementation of recommendations.[4]

6. A recent example of positive practice in this regard is the Housing, Communities and Local Government Committee’s inquiry into Grenfell and Building Security which INQUEST provided evidence to. The Committee heard from victims and survivors on how far government had progressed in implementing changes following the Grenfell Tower fire. Concerns were raised about the lack of transparency on government action following the Inquiry’s final report. The Committee then held a session with the London Fire Commissioner, Kensington and Chelsea Council, ministers and senior officials where they incorporated family and campaigners’ ongoing concerns from the previous session into their questions. Following this inquiry, the Committee sent two letters calling on the government to go further in setting up an independent national oversight mechanism to deliver the government’s ambition to “deliver what people would want to see” from the inquiry.[5]

7. Notwithstanding the limitations of this approach, which we outline in paragraphs 14 – 17 of this submission, INQUEST believe Parliament should use its powers to call witnesses to give evidence to scrutinise the progress made following an inquiry. The ability to call witnesses from across government agencies and affected groups can, as the example above shows, put pressure on government to go further on key areas of concern or where progress is slow. Oral evidence sessions should occur frequently and routinely, however, rather than on a one-off basis which would limit the scope of examination and prevent long-term, sustained scrutiny.

8. As was the case with the Housing Committee’s session on Grenfell, it is vital that Parliament publishes reports to government with clear actions and timelines for delivery.

What inquiries should be in scope of any new processes for scrutinising the implementation of recommendations (for example, should non-statutory inquiries be included)?

9. As research has shown, there is a lack of follow-up to all types of recommendations following state failings. It is not only a feature of the handling of public inquiry conclusions. For example, in her interim comments on the ongoing national maternity and neonatal investigation, Lady Amos said there has been a “staggering” 748 recommendations since 2015 made to the NHS on the issue following independent investigations and reviews, such as the Kirkup or Ockenden Review.[6]

10. INQUEST also has serious concerns over the lack of oversight of inquest conclusions and coroners Prevention of Future Death (PFD) reports. Responses to PFDs are delayed, absent or formulaic[7] and treated as a paper-exercise, without specific detail or proper engagement in the issues to show learning from a death.[8] An analysis using the Preventable Deaths Tracker developed by researchers at the University of Oxford found that only 33% of all PFD reports issued by coroners had expected responses published, with 29% of responses overdue. Further, the researchers found that response rates to PFDs examined in 25 of their studies ranged only from approximately 10% - 60%, with no study resulting in an 100% response rate.[9] Coroners themselves have documented this trend and as one coroner put it to the BBC, “all too often the final PFD […] is ignored or downplayed by the agency to which it is addressed […] nothing changes.”[10] In her last annual report, the Chief Coroner raised the absence of a system to oversee or enforce responses to PFDs.[11]

11. Importantly, different investigation processes relate to one another and scrutiny of them cannot be done completely in isolation. A clear example of this is the Grenfell Tower Fire. The Grenfell Tower Inquiry found “some important recommendations affecting fire safety were ignored by the government” leading up to the Grenfell Tower fire, such as recommendations made by the coroner investigating deaths from a fire at Lakanal House in 2009. It was “obviously unsatisfactory”, the Inquiry said, that the relevant government department did not have a system for recording recommendations and keeping track of the action on them following the Lakanal House inquest.[12] The Inquiry found all 72 deaths in 2017 were entirely “avoidable” and recommended in its final report that,

“it be made a legal requirement for the government to maintain a publicly accessible record of recommendations made by select committees, coroners and public inquiries together with a description of the steps taken in response.” [emphasis added][13]

12. Another example is policing related deaths, where a single death can be investigated by the independent investigator, a coroner and/or a public inquiry. Chair of the Anthony Grainger Inquiry Judge Teague expressed concern regarding the lack of a proper system or national register for following up on inquiry, inquest and Independent Office of Police Conduct recommendations made following fatal police shootings, stating,

“[t]he danger that presently exists in the absence of the formality and discipline that such a register brings is that a patchwork quilt exists, in which knowledge of recommendations is variable and inconsistent.”[14]

13. Focussing only on inquiry recommendations without considering analogous inquest or investigation conclusions risks further embedding this fragmentary “patchwork quilt” scrutiny currently in place. Therefore, we think it is important that non-statutory inquiries, official reviews and inquests are also considered by Parliament in any future role they play in scrutinising state-related failures and deaths.

What role should the government play to effectively support a new scrutiny process?

14. Government should set up a dedicated and independent organisation that can work alongside Parliament to ensure scrutiny of recommendations that is comprehensive, thorough and sustained. An equivalent oversight mechanism set up by but independent from government is required to get around the limits of parliamentary scrutiny.

15. One key limit is the capacity and resourcing of existing parliamentary bodies. Reviewing progress following a public inquiry could involve the need to analyse information in response to hundreds of recommendations spanning different government bodies or public agencies. The Institute for Government found that 54 inquiries between 1990 and 2024 made 3,175 recommendations.[15] Select committees already have a high number of areas to investigate and it is questionable whether they would have the capacity to effectively follow-up on inquiry recommendations, or the resources to set up a new committee solely dedicated to this role. Further, while MPs and Peers will hold extremely relevant expertise on many of the issues covered by inquiries, many frequently move on and off committees and so there is a risk of losing institutional knowledge.

16. Relatedly, we do not think select committee’s inquiry-led way of working is conducive to proper oversight of recommendations. One-off sessions will limit the scope and time allowed to properly examine what progress has been made following an inquiry. Proper oversight to ensure transparency on action requires continued, routine research and analysis put in the public domain.

17. We are also concerned about the powers Parliament holds to ensure it is getting the right information to hold public bodies to account. While select committees have powers to compel witnesses and documentation, it is not clear what powers exist to sanction or enforce these powers and some evidence suggests that powers available to Parliament are rarely used.[16] This committee may want to further consider the Australian model of implementation monitors, which is a way of collecting on-the-ground evidence following an inquiry’s conclusions.[17] Such independent information is vital to test government assurances on the implementation of necessary changes. As Peter Apps told the Housing Committee,

“…one of my roles as a journalist is trying to keep track of whether the Government are implementing the recommendations that have come from the Grenfell Tower Inquiry and other processes. It is extraordinarily hard to do that if all you have to go on is the government’s own word. If you listen to Angela Rayner’s speech, you would probably come away with the impression that they were implementing the Phase 2 recommendations in full, but they are not. If you listen to the previous Government’s speeches on Phase 1, you would have come away with the impression that they were implementing their recommendations in full—largely because they said they were—but they were not.” [emphasis added][18]

Recommendation

18. INQUEST believes government should establish a National Oversight Mechanism. This would be a new, independent public body responsible for collating, analysing and following up on recommendations arising from inquests, inquiries, official reviews and investigations into state-related deaths.

19. A Mechanism could work with Parliament, bereaved people and victims, inspectorate and monitoring bodies to gather information on the action taken following investigations. A Mechanism could also work with bodies with prosecution powers, such as the Health and Safety Executive, Equality and Human Rights Commission, Care Quality Commission and the Crown Prosecution Service to escalate concerns around a lack of implementation on recommendations. A Mechanism should have powers to compel information from relevant bodies about their progress following investigations and impose sanctions on public bodies who do not disclose this information.

20. A National Oversight Mechanism would enable accountability by increasing transparency on the action, or inaction, of state and corporate bodies and work in tandem with Parliament to ensure complete oversight of recommendations by providing a holistic and comprehensive analysis of change across different branches of government in response to state failings.

February 2026