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intractable. Further, our consultation with bereaved people suggests that
lengthy investigations are on occasion welcomed where length is perceived to
correlate with thoroughness.
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1.9 However, unnecessary delay and further anguish is caused by wasteful
duplication. Multiple investigators may ask the same questions of the same
witnesses. Public inquiries may follow inquests established to investigate the
very same matters. Coroners may issue a series of Prevention of Future Death
(PFD) reports, each making identical findings aimed at preventing recurrence.
Inspired by the challenges facing the bereaved people and survivors of the
Grenfell Tower fire, this project was originally conceived as a means of
identifying how such duplication (and associated delay) might be avoided.

Issue two: barriers to effective participation

1.10 The erosion of public trust is not merely a product of multiple legal processes,
and the duplication and delay that may result. The legal processes may
themselves be retraumatising and alienating. Nominally inquisitorial processes
pitch bereaved people and survivors into an unequal battle against State and
corporate interested persons with vastly greater financial resources and
knowledge of the process: “an adversarial wolf in inquisitorial sheep’s
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clothing, to which the bereaved have to turn”.

• the investigation must be capable of imputing responsibility for the death; and (where appropriate)
the identification and punishment of those responsible; and the identification of any shortcomings
in the operation of the regulatory system.
11 See INQUEST, ‘Family reflections on Grenfell: No voice left unheard (INQUEST report if the
Grenfell Family Consultation Day)’, May 2019, p. 27 “[F]or all the frustrations the consensus from the
groups was that a thorough and meticulous inquiry would best serve the families and future generations
living in tower blocks”.
12 Adams, supra note 1. Adams writes of a tacit assumption amongst officials that “when very bad things
happen, those directly involved would sit somewhere like this, 18 months or two years down the line, in
front of a polite QC and a retired judge and a bank of lawyers with box files... That understanding – that
the horrific tragedy would lead inevitably, in the first instance, to a public inquiry – was not immediately
grasped by the survivors of the Grenfell fire, or by the bereaved, whose mothers and fathers and sons
and daughters and brothers and sisters were among the 72 who died”.

13 Scraton, supra note 2, p. 198.
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