Parliament is considering what to do about public bodies ignoring recommendations from Inquiries. Every Inquiry and Coroner recommendation should appear in the annual report of the Department responsible, every year, until it is done.
When public funds are spent on an Inquiry, the annual report of the Lead Government Department should discuss the Inquiry’s recommendations and how implementation is going, every year, until the report says they are all complete and the National Audit Office has verified that. A “dashboard” is not meaningful scrutiny, particularly now that the Department of Health in England has stopped saying whether it accepts recommendations: a dashboard of accepted recommendations shows nothing if acceptance is never stated.
Why does nothing change even after failings are clear? Those whose past decisions created a scandal often refuse to believe that the continuing mess is their fault, so actively undermine improvements, and inertia lets them get away with it.
As Grenfell resident Gill Kernick describes in her book, every decision makes sense from some perspective, even if objectively catastrophic: “The point is not to see where people went wrong, but [to see] why what they did made sense… Without this perspective, we cannot learn.” If permitted, institutions will not learn as the people who insist they did nothing wrong are still there to continue unchanged, irrespective of the consequences. Every scandal demonstrates the capacity for institutional denial.
Recommendation 17 of the Thirlwall Inquiry into events at the Countess of Chester Hospital reads: “A new responsibility for auditing the implementation of the recommendations of statutory inquiries into NHS bodies should be given to the National Audit Office. Funding for appropriate additional staffing should be made available so that it may begin its work by September 2027.”
The NAO should be involved – but the recommendation appears influenced so as to close off and disempower effective scrutiny. (That NHS England didn’t object to it strongly is clearly a bad sign for its effectiveness.) The implementation should instead require the bodies responsible to outline progress in their Annual Reports, which the NAO already considers in their audit. This already happens for spending commitments, and the same explicit response should be applied to recommendations from Inquiries, and for prevention of future death reports. Because unless money is involved, organisations do not want to change – to be effective, bodies should expect to have to justify their failure to the Public Accounts Committee.
- Inquiries are Public Spending: Follow Up on Delivery of Recommendations
- A look at Departmental annual reports
- Health Investigations
- Someone Has To Be Watching
- What Parliament Can Do now
Inquiries Are Public Spending: Follow Up on Delivery of Recommendations
The public interest doesn’t end when a report is public, but all too often external interest does. Departmental annual reports are usually scrutinised by the PAC and the NAO, who can see whether the platitudes of last year have been repeated yet again, or if progress has been demonstrated. PAC takes written evidence for outside expert input when the Official Truth stated in a report may not be entirely accurate or consistent with reality on the ground, and one Select Committee can borrow expertise from the members of another.
One of the strengths of the Lead Government Department model is that there’s always a government Department responsible, and it always has Parliamentary scrutiny. The times when a statutory inquiry would report and the recommendations would actually happen are long gone. Parliament has to catch up – it has all the necessary levers, and simply needs the will to act.
When an Inquiry or Review exists, the decision has already been made that this was a worthwhile use of public funds to investigate, uncover, and prevent from recurrence – so it’s entirely within the remit of PAC and NAO to check whether the recommendations to prevent a recurrence are being delivered. It always comes back to money. The status quo that lost the argument against an Inquiry plays a long game, and can prevent recommendations being implemented – nullifying the point of the review, and the political intent that created it.
The Hillsborough Law was paused because of entrenched interests; the first Spycops inquiry has been dragged out for a decade and now the Home Office is “consulting” on closing it before it finishes. (Though when inevitably reopened it will be under Hillsborough Law obligations, which might show discrepancies in past official statements.)
Reports and recommendations that go nowhere are useless when they’re just sitting on a shelf. When officials decide to put a recommendation on the ‘too hard’ shelf, they have to know that it’ll get lifted off again and re-examined.
A look at Departmental annual reports
The Department for Transport annual report did mention the “two independent reports” it commissioned after the Stonehaven derailment – but it only mentioned them in one year, subsequently talking of recommendations being made (without discussion or description). The only mention after that is the financial penalty in the accounts from the health and safety prosecution.
Each Department for Education annual report studiously lists all of the PAC sessions they gave evidence at, and repeatedly mentions both the Independent Inquiry into Child Sexual Abuse and the Covid Inquiry – with no mention of recommendations from them, or follow-ups. Listing PAC appearances while saying nothing about outcomes shows that Departments record scrutiny events, not actual results.
Tasking the NAO to look at the implementation of recommendations cannot work unless there is material in the annual reports to read and scrutinise – whether by the NAO, PAC, or other committees.
One reason Inquiries are of current Parliamentary interest is the lack of follow-ups to the IICSA in practice, with Baroness Casey being “unimpressed” with changes across the public sector even when they are obviously the right thing to do; an inertia that means abuses of the records of three dead girls in Southport or a live boy has resulted in words not actions.
Health Investigations
In response to the Thirlwall Inquiry, DHSC said they’d have a dashboard for the implementation of the Inquiry recommendations they had accepted. This was claimed as a large improvement. Yet, in DHSC’s subsequent response to Module 3 of the Covid-19 Inquiry and again in Module 4, DHSC simply omitted to state whether they accepted each recommendation or not, sidestepping their previous commitment. A recommendation can’t be shown as failing or undelivered on a dashboard if the responsible body never said whether it had accepted it. Very civil service.
If you read the DHSC annual report, there are pages of descriptions of Inquiries, Reviews and Investigations, and basically nothing about the actual implementation of recommendations – except when it suits the Department to mention it. What is said should be scrutinised by the NAO when they go through the annual reports, and what is missing should be reported by the NAO and scrutinised by Parliament.
For example, the Inquiry into Ian Paterson (para 825) states that a response to the Inquiry was published, with a promise of a “year on” update to come. That “year on update” says “there are many actions and programmes that are still ongoing”, then it’s never mentioned again. DHSC hoped NAO wouldn’t notice the future omission and that no-one in Parliament would ask – and maybe they got away with it.
The Health Services Safety Investigations Body was set up by Parliament to make ‘no-blame’ recommendations about improvements to NHS care. Its recent report on the harms caused by NHS England’s method of rationing places on waiting lists (known as “advice and guidance”) is just brutal.
NHS leadership simply doesn’t want to know about failures, and the politicians have again helped the cover-up. This behaviour is long standing – NHSE was set up when DH didn’t care and didn’t want to know. And much of it still doesn’t. NHS England’s Chair has insisted HSSIB be abolished (alongside abolishing NHS England) because NHSE knows the new Department of Health in England would rather remain in the dark about avoidable harms. HSSIB is being abolished precisely because it was created to speak honestly to power.
Abolition comes after it emerged that DH/E tightly restricts other investigations by limiting how much they can say – refusing to allow them to make specific recommendations, and banning experts from answering questions about their reports. The usual practices of denial.
The deaths and harms will continue. The only difference is HSSIB will no longer be around to learn from them. It is unclear who, besides the families of new victims, will pick up that baton.
Someone Has To Be Watching
There are always reasons that an accepted recommendation gets dropped – possibly even good reasons, such as the wider environment changing beyond what was called for in the report. But all too often it’s politics moving on as a controversy falls out of the public’s attention, and meaningful change gets kicked into the long grass. Exhibit A: Grenfell, because when the dust settles it always plays out that the poor had no lawyers.
At many of the Post Office Inquiry hearings, or the Spycops Inquiry hearings, the only people not being paid to be there were the victims. Victims who have had to cover costs out of their own pockets while still waiting for compensation; compensation long delayed by people who did not have to wait for their bills to be paid. This shapes priorities and incentives: every official in every room is paid to defend their Department’s decisions, even where those decisions undermine an Inquiry’s recommendations.
The political cycle generates churn, and the civil service moves staff around. It is civil society and academia who remain engaged long enough to measure the effects of any promised change and whether it happens. Victims should be able to get on with their lives – they should not have to keep coming back to their experience because the government has failed them yet again.
Those interested in particular topic areas – whether asthma, mental health, or even you and your local hospital – can use DeathLessons.org and the Preventable Deaths Tracker to see what Coroners notified on topics of interest, and shine a light on the procession of failures repeated and unaddressed. DH/E and NHS England or your local hospital will generally do nothing unless someone is asking why they haven’t.
HSSIB’s Advice and Guidance report is only the latest in a long line of reports that show what is going wrong, with no power to stop it happening again. Coroners know that despair: promises made at one inquest are found to be undelivered at the next. With the abolition of HSSIB – abolished as punishment for speaking truth to the Department of Health in England – that will fall to someone else.
What Parliament can do now
Since Grenfell and the Infected Blood Inquiries reported, Parliament has been considering what to do about following up on Inquiry Reports.
The Public Administration Committee should expect that every Inquiry recommendation gets a page in the Lead Government Department’s annual report equivalent to the page that each accountability report item gets. It should say what the recommendation text was, what has happened, what is happening, and what is left to do – and that item should appear every year until the annual report confirms that the recommendation is complete.
As the Public Administration and Constitutional Affairs Committee are currently curating their Inquiry recommendations, in the second session of any Parliament, PACAC can (and should) ask the House Library to summarise the previous Parliament’s Inquiries, reports, and what disappeared. NAO/PAC scrutinise individual reports, with PACAC having the remit to take a broader public administration interest whenever appropriate, and select committees can engage on their particular topics in the normal way.
In the context of the current Health Bill, and the Hillsborough Law questions, and recent evidence of NHS England interfering in inquiries, one or more Parliamentary committees (probably PACAC and Health Select jointly) should write to every lead of health investigations asking them to submit anything they feel they were limited from considering or commenting on previously. Do Inquiry leads feel that the evidence they were given by public bodies would satisfy the Hillsborough Law, or do they feel that what the Inquiry was told was not, to reuse a phrase, “the truth”? Similarly, do coroners feel they’re being fobbed off in their work?
Prevention of Future Deaths reports can be read and are tracked to find major themes; minor themes remain hidden because Inquest findings generally aren’t published – although they easily could be where the coroner wished. Local health organisations can read the reports that relate to them locally, and condition-focused organisations can do the same when Parliamentary opportunities arise (a cheap use of an APPG’s limited time and resources).
Other political structures can do what Jennifer Pahlka calls an Outcomes Review to ask the question: did the intended change happen? Outcomes Reviews are a great idea, but require political power to start, carry out, and act on – and political power is the thing that change often lacks. Those selling new tech/AI will keep selling the tech, and HSSIB being fed into a woodchipper demonstrates what the tech people think of Outcomes Reviews.
None of this process needs new Parliamentary actions or committees – it would simply be using the system the way it can work today. No government ever failed to have a justification for their actions or inactions. It is up to informed outsiders to assess those claims, and Parliament is where those get challenged.
The victims and their survivors deserve nothing less than lessons being learned. Currently, the victims are being repeatedly failed.
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