The inquiry that everyone forgot

“Have you heard of the Hyponatraemia Inquiry?”

Last week we received a call asking why our recent paper on public inquiries failed to make any reference to the Inquiry into Hyponatraemia-related Deaths (hyponatraemia is marked by abnormally low sodium levels in a person’s blood). The inquiry, running in Northern Ireland since 2004, had published its final report in January. This was news to us.

When we published our report back in December we were confident that we had assembled the definitive, comprehensive summary of all the public inquiries that had existed between 1990 and 2017. Yet somehow we’d missed one.

We weren’t alone. The House of Lords carried out a major examination of inquiry legislation in 2010 and missed this inquiry from its list. Its lone mention in the parliamentary records was made in February this year by Angela Smith, now Baroness Smith, who instigated the inquiry 13 years ago as a minister for Northern Ireland. In the few lists of inquiries that exist – in departmental memoranda and parliamentary reports, and notes in Hansard – the Hyponatraemia Inquiry is consistently absent.

Justice delayed is justice denied

This is the longest-running public inquiry since 1990. At 13 years and three months it took nearly a year longer than the Saville Inquiry into Bloody Sunday, which is infamous for its excessive length and cost. Inquiries should not take this long; doing so is not only a staggering drain on public resources, it also prolongs the uncertainty and suffering of those affected.

The reasons for the duration are ones that all inquiries can learn from. The most significant delays are those resulting from conflicts with police investigations. By law, inquiries cannot determine criminality, and so often give way to other investigations and court cases to avoid compromising efforts to deliver justice. In this case, however, the proceedings of the inquiry were deferred from 2005 until 2008 – a period during which no prosecutions were actually launched.

It is always a challenge to balance the work of an inquiry with the needs of the justice system. Lord Leveson tried to resolve this by splitting his inquiry into press ethics into two, intending the second half to focus on criminality following the conclusion of the police inquiries. However, Leveson part two never began – and probably never will now that Matt Hancock, the new Culture Secretary, has announced the Government’s intention to terminate the inquiry.

This should be a warning to the Grenfell Inquiry. Sir Martin Moore-Bick, its Chair, says that he intends to run his inquiry as much as possible alongside the inquests and police investigations. However, Grenfell is a complex situation, encompassing many more deaths than the Hyponatraemia Inquiry. The risk that court cases could halt, or delay, the inquiry’s work are very real.

Don’t tinker with the terms of reference

Another reason the Hyponatraemia Inquiry took so long was that its remit changed: this was modified in 2008, adding complexity to the process. Updating the terms of reference is often necessary, as discoveries are made, documents are unearthed and witnesses come forward. However, too much revision creates a drag on an inquiry – and they are slow-moving beasts at the best of times.

Because of the changes to the terms of reference, and the delays caused by the police investigation, the inquiry only managed a single full public session in its first seven years. With the exception of the notoriously tortuous Saville and Maxwell inquiries, this pace is slower than any inquiry since 1990.

A cause without a champion

The saddest consequence of all this is that the report will not have much impact. In its 13-year life it has gone from one period of direct rule from Westminster to another where there is no devolved government in Belfast.

We have argued that at a minimum every inquiry should get a formal ministerial response. This should offer due recognition of the time, effort and resources that go into any inquiry. Without a minister, there is nobody visibly and formally accountable for driving the change these inquiries recommend.

Even when there is a ministerial response recommendations often get overlooked, ignored and forgotten. There is a vital role for select committees and other bodies which scrutinise the work of Government to ensure that its recommendations are implemented, so that the mistakes that triggered an inquiry are never repeated.

None of this is set to happen with the Hyponatraemia Inquiry. While it has satisfied two of the three main purposes of an inquiry – establishing what happened and why – it has been fatally undercut in its ability to deliver on the third and most important purpose, making sure that mistakes do not happen again.

While the Hyponatraemia Inquiry is not responsible for the politics of Northern Ireland, its fate should serve as a warning to other inquiries currently underway. If inquiry chairs hope to prevent another Grenfell fire, or the abuses of the Metropolitan Police’s Special Demonstration Squad, then they need to engage with government and ensure that someone owns the challenge of changing things for the better.

Read our Explainer on public inquiries.