Page 17 - When Things Go Wrong

for holding the Government to account for promises made in the aftermath
of inquiries, the implementation of recommendations is patchy, in some
cases repeat incidents have occurred and there is no system for allowing
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inquiries to build on the learning of their predecessors.

1.17 Our evidence gathering suggested that this is of great concern to bereaved
people and survivors. The hope that others will not have to endure near-death
experiences, or the deaths of loved ones in similar circumstances, is
consistently dashed when PFD reports and inquiry recommendations are not
implemented.

1.18 JUSTICE’s expertise as a law reform and human rights organisation dictated
that our principal focus would be the justice system’s response to catastrophic
death. However, thorough interrogation of this concern obliged us to consider
the outcome of the “legal” process, especially the framework for
implementation.

Methodology and scope

1.19 The Working Party set out to consider the three overarching issues outlined
above. We aimed to arrive at practical recommendations to ensure that
inquiries into fatal events are more efficient, more humane and more likely to
precipitate lasting change.

1.20 Following the scoping phase, the Working Party was convened in June 2019.
Its work was initially supported by three sub-groups, engaging collectively
with the first two issues explored above:

i. Conceptual framework and investigative coherence (chaired by Sir
John Goldring);
ii. Public engagement (chaired by Deborah Coles); and
iii. Practice reform (chaired by Martin Smith).

21 Emma Norris and Marcus Shepheard, How public inquiries can lead to change (Institute for
Government, 2017), pp. 3-4.
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