When Things Go Wrong

The Challenge 


Inquests and inquiries serve as society’s formal responses to the most traumatic events it endures. They are prominent and ubiquitous, rarely far from the media and the public consciousness. The Grenfell Tower Inquiry, the Infected Blood Inquiry and the Independent Inquiry into Child Sex Abuse (IICSA) provide compelling, ongoing examples.

However, other parts of the justice system are inevitably engaged in the aftermath of a major disaster. Criminal investigations and civil claims may be initiated that share identical subject matter with an inquiry, inquest or both. While criminal processes typically precede fact-finding procedures, politicians tasked with reacting to a major incident or disaster will call for an “independent, judge-led” inquiry with ever-increasing alacrity.

Concurrent processes across these different areas of the justice system lead to duplication and delay. From the perspective of those caught up in the aftermath of the disaster – including victims, witnesses and alleged wrongdoers – the process can be agonisingly lengthy. Inquiries themselves are notoriously time-consuming: the Bloody Sunday inquiry took over 12 years to publish its conclusions; IICSA is onto its fourth Chair. The 1989 Hillsborough stadium disaster has been the subject of an inquiry, an inquest, an independent non-statutory review and an independent panel.

Further, victims and their families often speak of alienation, mistreatment and whitewashing by the very bodies set up to identify the wrongs they have suffered. Their accounts suggest that inquest and inquiry processes are often highly adversarial and potentially re-traumatising.

The Working Party 


Chaired by Sir Robert Owen, this Working Party of JUSTICE will aim to make informed recommendations to reform institutional responses to deaths or other serious incidents where a “systemic pattern of failure” is evident. The needs and experiences of the bereaved and survivors will be central to this work and its intended outcome will be to suggest reforms that will promote public trust in the justice system.

The Working Party will consider:

  • timely justice: how elements of current fact-finding processes and investigation might be integrated to reduce duplication and delay;
  • transparency and responsibility: how investigations, inquiries and inquests can be better coordinated to embed best practice, promote certainty and ensure inclusion of bereaved people and survivors; and
  • fairer outcomes: how inquiry hearings can be improved with regard to procedures, evidence and effective participation.

To inform its review the Working Party will research institutional processes in other jurisdictions.

The Working Party expects to report by September 2020. When Things Go Wrong is generously supported by Morrison & Foerster LLP.

Members of the Working Party

  • Chair: Sir Robert Owen
  • Jodie Blackstock (JUSTICE)
  • Paul Bowen QC (Brick Court Chambers)
  • Deborah Coles (INQUEST)
  • Sir John Goldring
  • Professor Carol Harlow QC (London School of Economics)
  • Charlotte Haworth Hird (Bindmans LLP)
  • Emma Ireton (Nottingham Trent University)
  • Thalia Maragh (Garden Court Chambers)
  • Una Morris (Garden Court Chambers)
  • Andrew O’Connor QC (Temple Garden Chambers)
  • Dr Sara Ryan (University of Oxford)
  • Professor Phil Scraton (Queen’s University Belfast)
  • Martin Smith (Fieldfisher)
  • Leslie Thomas QC (Garden Court Chambers)
  • Sir Peter Thornton QC
  • Corporate Partner: Sonya L. Van de Graaff (Morrison & Foerster LLP)
  • Rapporteur: Robbie Stern (JUSTICE)

Members of the Working Party’s sub-groups:

  • Michaela Bolton (Infected Blood Inquiry)
  • Nicholas Griffin QC (QEB Hollis Whiteman)
  • Matthew Hill (1 Crown Office Row)
  • Lubka Mieresova (formerly IICSA)