Page 11 - When Things Go Wrong

I. INTRODUCTION

Because we had never been involved in something like this, the inquiry was all a bit
of the unknown. I suppose I had a sense that the aim of it was to get to how things
happen and why things happen – but for us there was the fact that more than 70
people died that night, in our view essentially murdered. We were all about people
being arrested and we didn’t want any inquiry to hinder that. Natasha Elcock (Chair,
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Grenfell United).

1.1 An array of legal processes may flow from a single fatal event. The
Hillsborough Stadium disaster of 15 April 1989 triggered two sets of inquests;
a public inquiry; a non-statutory judicial “scrutiny”; and an independent panel,
2
alongside a number of civil, criminal and regulatory actions. At the time of
writing, the public inquiry into the Grenfell Tower fire of 14 June 2017 is in
its second phase, with inquests suspended, civil proceedings commenced
3
overseas and pre-charge criminal investigations ongoing.

1.2 It is not only mass fatality events that demand a multi-faceted response from
the justice system. The death of a new-born baby at HMP Bronzefield in
September 2019 gave rise to eleven separate investigations, including an NHS
clinical review, an inquest, and two police investigations in addition to an
4
independent review by the Prisons and Probation Ombudsman (PPO).

1.3 For those who survive or who are bereaved by fatal events, the encounter with
the justice system in all its multiplicity may be overwhelming. They are likely
to be faced with a situation wholly outside their experience, and may be
bewildered or intimidated by the processes in which they find themselves.

1 Cited in Tim Adams, ‘“It’s a room of lawyers”: what have we learnt from the Grenfell Tower inquiry?’
(The Guardian, 9 December 2018).
2 For a comprehensive account, see Phil Scraton, Hillsborough: The Truth (updated edn, Mainstream
Publishing 2016).
3 See the Grenfell Tower Inquiry website.

4 Hannah Devlin and Diane Taylor, ‘Multiple inquiries ordered into death of baby in UK prison’ (The
Guardian, 8 October 2019).
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