Public Inquiry Report | October 2021

First and foremost, however, the UK Government must ensure the independence and impartiality of the public inquiry. The APPG recommends that the terms of reference of the inquiry should be determined by public consultation, with the public being continually informed on the progress of the inquiry. Both elements are essential to ensure public trust in the process. 

The APPG acknowledges that the management of the pandemic has not been solely the competence of the UK Government. It is therefore essential that consideration and coordination with different inquiries, namely the public inquiries of devolved nations, is given. In addition, the APPG finds that the inquiry must be structured in a way that ensures the aforementioned timely reporting. As such, the APPG recommends that the inquiry is divided into different ‘workstreams’ overseen by sub-panels of experts with knowledge of the fields being scrutinised would enable concurrent working on different aspects of the pandemic. 

Above all, the purpose of the public inquiry is to ensure that mistakes made are prevented from happening again. As such, the inquiry must ensure that its recommendations are practical and can be readily implemented. All interim and sub-panel reports should be made publicly available.

1. The UK Government must reaffirm its commitment to establishing an independent statutory  public inquiry into the UK Government’s response to the COVID-19 pandemic under the Inquiries  Act 2005. In the light of the recent announcement by the Scottish administration to hold an  inquiry this Autumn, and given that any inquiry of the pandemic is likely to involve both  devolved and reserved matters, the APPG recommends that the UK Government must also  commit to a public inquiry at the earliest opportunity, and within the same time frame as the  devolved administrations, to ensure consistency in approaching common issues.  

2. To ensure confidence in the independence and impartiality of the public inquiry, the UK  Government must adopt a transparent process for the setting up of the public inquiry and  consult widely on its terms of reference and appointment of the inquiry panel. 

3. The UK Government must set a timetable for the public inquiry to report its findings within a  reasonable timeframe and ensure that the public inquiry is adequately resourced. A timetable  for the public inquiry must be agreed in which Interim findings are published within two years,  and before the next UK general election. 

4. The UK Government must establish a duty of candour as part of the public inquiry, to ensure  that witnesses asked to provide evidence do so in as open and as transparent a manner as  possible. 

5. To ensure the public inquiry is able to reach conclusions and make recommendations in a timely  manner, the APPG on Coronavirus recommends that the inquiry be structured into sub-panels  of experts overseeing concurrent work streams and producing their own specific reports, all  feeding into the top-level panel, chaired by the inquiry chairperson. 

6. The public inquiry should scrutinise the UK Government’s decision-making process including the  quality of information available, advice given and weighting at the time a decision was being taken, as well as any lessons the UK Government learned during the pandemic. Furthermore,  the APPG on Coronavirus recommends that the inquiry terms of reference include scrutiny of  UK and its institutions and public services’ resilience and preparedness going into the pandemic,  and how UK Government decisions compared to those being taken by other countries in  comparable circumstances. 

7. The public inquiry must not simply produce a single final report at the end of the inquiry.  Instead, sub-panels and the top-level panel should produce interim reports and  recommendations to ensure conclusions and lessons learnt are implemented without undue  delay, even if other aspects of the public inquiry are ongoing. All interim and sub-panel reports  should be made publicly available. 

8. To ensure that recommendations are practical and can be readily implemented, the public  inquiry should consider using seminars that engage with the affected stakeholders, as was done  during the Mid Staffordshire NHS Foundation Trust Public Inquiry. 

9. Parliament and the relevant Select Committees must be granted the opportunity to scrutinise  and debate the inquiry’s recommendations. The decision not to implement any recommendation of the public inquiry must be scrutinised by Parliament.

10. To ensure continued oversight and implementation of the recommendations of the public inquiry, and to ensure that the lessons of the COVID-19 pandemic are learnt now and in the future, the APPG recommends the creation of a new independent statutory body called the Covid Inquiry Commission. In the short term, the implementation of lessons learned and recommendations made by the Public Inquiry should be overseen by the Covid Inquiry Commission. Once all these have been successfully implemented, the Covid Inquiry Commission should become the statutory body responsible for probing pandemic preparedness in  the UK.

11. Memorialisation of the COVID-19 pandemic will be a key part of any public inquiry. The APPG  on Coronavirus recommends that in parallel to the public inquiry the UK Government should  announce and progress the construction of a permanent memorial monument on Whitehall and an annual Covid Memorial Day on March 23rd, as recommended by the APPG on Coronavirus on  23 March 2020.

1. The function of a public inquiry into the UK Government’s handling of the COVID-19  pandemic is to address the three following questions: 

  • What happened? 
  • Why did it happen? 
  • What can be done to prevent this from happening again? 

The UK has suffered one of the worst health1 and wealth2 outcomes of comparable countries  due to the COVID-19 pandemic. It is imperative that the UK public, institutions, the Houses  of Parliament, devolved administrations and the UK Government understand how this  happened in the UK. 

Unlike other forms of inquiry, audit or inquest, the public inquiry into the UK’s handling of  the pandemic must be a statutory one, commissioned under the Inquiries Act 2005, with  the powers to compel witnesses to give evidence under oath and to produce documents, as promised by the Prime Minister on 12 May 2021. While a statutory public inquiry will not  be able to determine criminal or civil liability, it will be able to highlight where failings have  occurred and lessons need to be learned and implemented. 

Public inquiries can take years and cost vast amounts of public money. During this time,  institutions may change and key people involved in the decision making may leave office.  The public inquiry’s findings and relevant recommendations can be diluted by the length of  time that it takes to deliver the inquiry’s conclusions. 

For this reason, and because a significant amount of evidence is already available or in the  public domain, there is a compelling argument for starting the inquiry as soon as possible.


2. The commissioning of a public inquiry is set out in the Inquiries Act 20053, which requires  the Minister to appoint the chair, to determine the terms of reference, the start date and  budget allocation.  

If the findings of a public inquiry are to enjoy public trust, the process needs to be  completely impartial. This will require transparency and good communication throughout.  The Government must ensure that there is no political or Governmental interference in the  setting up and management of the inquiry, including the appointment of the Chair and panel  members. 


3. The terms of reference of the statutory public inquiry into the UK Government’s handling of the COVID-19 pandemic should be determined by public consultation. 

The terms of reference define the scope of the public inquiry. There is no statutory duty to  consult, but in practice wide public consultation on the terms of reference will be  instrumental in building public trust into the public inquiry and its findings.  

In the case of the pandemic, where every sector of society has been affected, consideration  must be given to making sure that consultation is wide, but also manageable, such that it  does not result in undue delay to the public inquiry.  

To manage the question of wide public consultation, consideration should be given to the  proposal that Parliamentarians consult their constituencies on the terms of reference. 

In order to maintain trust throughout the inquiry, the public should be continually informed  on the progress of the inquiry. This will require a communications team and a plan for  regular public engagement.  


4. Witnesses and organisations giving evidence to the statutory public inquiry should be bound  by a duty of candour to ensure that they cooperate with the inquiry in an open, honest and  transparent way.  


5. The structure of the statutory public inquiry will have a significant and direct impact on the  time taken for the inquiry to reach and publish findings and conclusions.  

Structuring the inquiry into different ‘workstreams’ overseen by sub-panels of experts with  knowledge of the fields being scrutinised would enable concurrent working on different  aspects of the pandemic and avoid the inquiry taking too long to reach and publish findings  and conclusions. The interconnected nature of decision making will require cooperation and  coordination between each of the sub-panels. All sub-panels should bring findings and  conclusions to the top-level panel, accountable to the Chair of the statutory public inquiry.  

Management of the pandemic has not been solely the competence of the UK Government.  Certain competences, including health and education, are devolved matters. As such, many  decisions relating to pandemic management were made by devolved administrations and  would be outside the scope of a UK wide inquiry. As already announced by the Scottish  Government, each devolved administration should hold its own public inquiry relating to  matters within their competence. Consideration should be given as to the coordination of  the different inquiries. 

Maximum use must be made of the work that has already been done, for example by the  National Audit Office, on NHS capacity, the state of adult social care and about health and  inequalities.  


6. The Public Inquiry’s unique competence will be the ability to scrutinise the UK Government’s  decision-making process during the COVID-19 pandemic in the UK. It should identify what  was known at the time, which organisations, committees and individuals were listened to  and how advice was weighted in order to establish the timeliness, quality and consequence  of key decisions. For any recommendation made by the inquiry to be practical and  meaningful, the inquiry should include consideration of the UK’s resilience and  preparedness ahead of the pandemic. 

The institutional capacity for learning during the crisis should also be considered. The same  mistakes appear to have been repeated on matters such as decisions on when to lock down.  The inquiry needs to look at why learning appears not to have been applied to UK  Government policy. 

The experience of, and measures taken by, other countries are key considerations which  should have influenced the UK Government’s response to the COVID-19 pandemic in the UK.  The inquiry should therefore scrutinise the UK Government’s response compared to other  countries, and establish what the UK Government did or should have learned from the  pandemic response of other countries.  


7. Interim findings, conclusions and recommendations made by the public inquiry should be  published throughout the course of the inquiry, setting out immediate lessons learned and  actions that should be taken. Their implementation should be tracked by the chair and panel  overseeing the inquiry.


8. Recommendations must be practical and workable. To this end, it may be valuable, as has  happened in the Mid Staffordshire NHS Foundation Trust Public Inquiry, to hold a series of  seminars before reporting, in order to develop the recommendations and make them as  implementable as possible.


9. There is no legal obligation to implement any recommendations made by a public inquiry.  Parliament and the relevant Select Committees should have continued oversight of any  implemented recommendations after the public inquiry has concluded. 


10. Memorialisation of the COVID-19 pandemic will be a key part of the Public Inquiry.  Commemoration will allow the UK to remember those whose lives were lost or changed  during the pandemic and enable the UK to bear witness to the events, to acknowledge  failures, and ensure that lessons learnt and recommendations made by the public inquiry  are implemented.