INQUESTS & PUBLIC INQUIRIES: An Introduction

What does 2025 hold for the conduct of inquests and inquiries? For some years now, statutory public inquiries have been the go-to answer for matters of far-reaching public concern, seemingly the only type of investigation that will satisfy members of the public and press as to its independence from government and yet also be palatable to the those who order them. 2024 has seen no fewer than 18 public inquiries continuing in action, including the COVID-19, Dawn Sturgess, Undercover Policing, Post Office Horizon IT and Afghanistan Inquiries. Calls continue for further public inquiries to be set up, including in respect of matters as diverse as alleged abuse suffered by Harrods staff, the conduct of the West Midlands Fire Authority, transgender ideology in the NHS and schools, and the James Bulger murder.

However, while an inquiry into public inquiries might seem a bridge too far, the House of Lords Statutory Inquiries Committee attempted to undertake that heady task with their report, “Public Inquiries: Enhancing Public Trust”, published in September 2024. The cross-party committee’s wide-ranging report urges improvements to be made to the public inquiry process in terms of efficiency, cost and effectiveness. As they note: “We frequently hear calls from the press, politicians and the public for new inquiries to be established; yet, just as regularly, there is serious criticism of their cost, duration, remit and effectiveness”.

Among its criticisms, the report notes that millions of pounds are spent on public inquiries – sums that show no sign of reducing. In respect of inquiry process, the proposals include a recommendation that inquiry chairs be more widely chosen, that non-statutory inquiries be more readily considered, and that limited time or “indicative deadlines” be included for the completion of work.

However, perhaps the report’s chief criticism is that too little is done to ensure that the recommendations of inquiries are implemented. In a remarkable demonstration of the difficulties faced by those seeking action, the report recites the outcome of a previous select committee’s work, which in 2014 evaluated and prepared a similar report into the Inquiries Act 2005. At the conclusion of that 2014 report, some 33 recommendations were made to the government. Of those 33, 19 were accepted. Of those 19 accepted, it was found ten years later that not one had been implemented.

So, what might the report mean in practice? In respect of proposed efficiencies, all those inquiries up and running will not see any change to their Terms of Reference – and, in our experience, all those chairing inquiries seem well aware of the criticisms that the process may face. One person’s streamlined inquiry is another person’s cursory investigation, and the balance to be held between breadth, depth and efficiency can never be met to all parties’ satisfaction.

In respect of cost to the public purse, it will not have escaped any practitioner’s notice that the role (and cost) of lawyers forms a large part of the criticisms levelled at inquiries’ work. However, we would suggest that – as attractive as a reduction in legal involvement may sound – the difficulty faced in reducing the expense of larger inquiries will not be met by reducing legal input. Despite accepting apparent bias on our part, an inquiry will be efficient if those working on it are efficient and possess skill and experience in the field. Further, while successive governments continue to order such expansive canvases to be covered, there can be no sensible prospect that the large legal bills will reduce. Perhaps the primary focus for reducing cost needs to be on identifying the real issues and setting the terms of reference at the start.

As for implementing recommendations, those who practise in the field of inquests will see a similar theme here to recent calls for more oversight of Coroner’s Prevention of Future Deaths (PFD) reports. It is notable that at longer inquests, particularly those engaging Article 2, the publication or otherwise of such a letter has taken on a significance not initially intended by legislation and much energy, evidence and submissions can end up focused on this ancillary question. Indeed, when the outgoing Chief Coroner HHJ Teague KC published his final report in April 2024, he commented on the 550 PFD reports issued in 2023 – a 25% increase on the previous year – and noted that these should not be an inquest’s primary focus.

The Chief Coroner did, however, draw attention to the ongoing work of the Oxford University Preventable Deaths project, which runs web-scraping techniques to aggregate and analyse data from PFD reports. Although he emphasised that the Coroner’s role becomes functus officio at the point of having issued the report, it seems likely that efforts will continue to improve practices in monitoring outcomes. In respect of public inquiries, the Statutory Inquiries Committee’s report proposes the establishment of a new joint select committee, the “Public Inquiries Committee”. This would take on the role of monitoring and tracking the implementation of inquiries’ recommendations – and also, the report suggests, those recommendations from major inquests.

If implemented, one can foresee a forum in which executives and decision-makers are more readily asked to account for their actions, throwing into yet greater focus both inquiry recommendations and also PFD reports. However, an inquiry into inquiries making a recommendation that a recommendation-monitoring committee be formed not only requires some mental gymnastics but also may represent a real test of whether or not progress on this front is achievable.