When a catastrophic event or systemic failure results in death or injury, the justice system must provide a framework to understand what happened and to prevent recurrence.
This Working Party of JUSTICE, which publishes its report When Things Go Wrong: the response of the justice system, on 24th August 2020, seeks to address the erosion of public trust in the response of the justice system to deaths giving rise to public concern. These are major incidents causing multiple fatalities, or arising from a pattern of systemic failure. If it is to enjoy the confidence of the public, the justice system must provide a response that is consistent, open, timely, coherent and readily understandable.
Unfortunately, these systems are too often beset with delay and duplication, with insufficient concern for the needs of those affected by disasters. Instead of finding answers through the legal process, bereaved people and survivors are often left feeling confused, betrayed and re-traumatised. The lack of formal implementation and oversight following the end of an inquest or inquiry makes the likelihood of future prevention limited.
Having sat for a year, the report records 54 recommendations of the Working Party directed at remedying such shortcomings by building on the strengths of the present system of inquests and public inquiries:
- The framework – We propose new State and independent bodies to provide oversight and facilitate information-sharing – a Central Inquiries Unit within Government, a full-time Chief Coroner and a special procedure inquest for investigating mass fatalities as well as single deaths linked by systemic failure, able to consider closed material and make specific recommendations to prevent recurrence.
- Opening investigations – Greater collaboration between agencies, building a cross-process dossier, would reduce the multiple occasions that bereaved people and survivors have to recount traumatic events and ensure that they are fully informed throughout the process.
- Procedure – Processes for appointing inquiry chairs and panels, for establishing the terms of reference and for providing information and relevant documents to core participants need to be more structured and transparent. Drawing on previous JUSTICE working parties on accessibility, we recommend that bereaved people and survivors are placed at the heart of the process – in choice of hearing space; improved communication and questioning by professionals and signposting to support services. Aside from the legal formalities, we also call for widespread use of commemorative “pen portraits” and therapeutic spaces for bereaved and survivor testimony.
- A statutory duty of candour, including a rebuttable requirement for position statements, would help foster a “cards on the table” approach. Directing the inquiry to the most important matters early on could result in earlier findings and reduced costs.
- Accountability and systemic change – We conclude that an independent body should lead oversight and monitoring of the implementation of inquest and inquiry recommendations, whose review could aid scrutiny by parliamentary committees.
Chair of the working party, Sir Robert Owen, said:
A system cannot provide justice if its processes exacerbate the grief and trauma of its participants. Our recommendations seek to ensure that inquests and inquiries are responsive to the needs of bereaved people and survivors, while minimising the delay and duplication that impede effectiveness and erode public confidence. We think that this set of proposals, if implemented, will provide a cohesive and cost-effective system, with the prospect of a reduction in duplication and delay, and which in turn should serve to increase public trust.
JUSTICE’s director, Andrea Coomber said,
Our work began before the onset of the pandemic. But the current coronavirus crisis reinforces the relevance and timeliness of this project. Our recommendations, in particular our proposal for a special procedure inquest, aim to equip the justice system with a means of effective investigation less dependent on the mercy of successive governments. Further, they aim to ensure that the implementation of recommendations is monitored – a crucial objective if we are to understand how the virus has killed so many and how to avoid future recurrence.