05 January 2018

The track record of public inquiries in delivering change is patchy. Parliament must have a bigger role in scrutinising the implementation of their recommendations by government, argues Marcus Shepheard.

The Government says that “preventing recurrence” is the primary purpose of public inquiries and the public purse has paid out more than £639m for them since 1990. Yet they their track record for delivering change is patchy. In order to deliver the change we need inquiries need better scrutiny by Parliament, particularly over the implementation of their recommendations.

The Government has invested heavily in public inquiries

The 68 public inquiries since 1990 have lead to more than 2,600 recommendations. Now the Government needs to invest in implementing those recommendations, and Parliament needs make scrutiny of this a core part of its work.

Inquiries usually aim to answer at least three questions: What happened? Who is to blame? And how can we learn from this to prevent future disasters?

All three questions are critically important. Victims deserve to know the facts and to understand the sources of blame. But inquiries must also be catalysts for change and it is here - on the third question - that our institutions and processes are at their weakest.   

Public inquiries cannot make changes by themselves

Inquiries rely on Government departments and public bodies to implement recommendations and bring about change. Following the Piper Alpha Inquiry regulators, government and industry changed the way offshore oil and gas operations were run and there has been no repeat accident. Similarly, the Dunblane Inquiry led Parliament to pass strong gun control legislation. The MacPherson Report into the death of Stephen Lawrence installed the concept of “institutional racism” into public life.

Yet far too many inquiries produce recommendations which go unheeded, leading to repeated failures, preventable deaths and a loss of trust in the UK’s institutions.

The inquest into the 7/7 bombing noted that recommendations for better radio communication between transport and emergency workers made by the 1988 inquiry into the Kings Cross Underground Fire had never been implemented.

Similarly, a failure to reform death certification procedures for doctors after the Shipman Inquiry saw the same recommendation repeated during the Mid Staffordshire NHS Foundation Trust Inquiry.

These failures to implement recommendations are only known because they were uncovered by a subsequent inquiry or inquest. For most inquiry recommendations, there is no good account of their implementation, or the lack thereof.

We need to a better system of scrutiny that begins the day an inquiry ends

Inquiries create a significant expectation of change, and the public grants them the moral authority to determine what that change should look like.

Only six inquiries since 1990 have received dedicated oversight by a parliamentary select committee. Of these cases, the scrutiny of Sir Robert Francis QC’s inquiry into the Mid Staffordshire NHS Foundation Trust stands out. In addition to a dedicated investigation by the Health Select Committee, the Department of Health published an interim implementation plan within a month, and then a detailed two-volume plan for reform nine months later.

Yet this is just one example out of 68 when it should be the norm. Inquiries are only convened in the most serious cases and their recommendations deserve similarly serious treatment by government. Parliament must play its part and take on the role of protecting public trust and ensuring that the millions spent on inquiries are not wasted by holding the Government to account.

Public inquiries have the potential to change government policy and practice — but they are often more conspicuous for their failure to do so. This must change.


This is an excellent piece of work. It raises fundamental and as yet unanswered questions about failure in public sector administration. Among them are these: can the present frequency of failure be reduced or is it inherent; and are there elements in the way governments typically deliver public services that contribute to such catastrophes?