Page 18 - When Things Go Wrong

In order to address the issue of how inquiries can lead to change, a final sub-
group was convened in April 2020:
iv. Learning, accountability and systemic change (chaired by Ken
Sutton).

1.21 We were committed by our terms of reference to consider institutional
processes in other jurisdictions. We are grateful to our corporate partner
Morrison & Foerster LLP, whose lawyers prepared a comparison of the inquiry
structures and processes in 21 countries across five continents. This research
helped to contextualise and set the agenda for the Working Party’s discussions.

1.22 The Working Party was faced with the initial, and taxing, task of addressing a
fundamental question: what class of case fell within its scope? Some 30,000
22
inquests are established each year. The issues explored above do not affect
the great majority of these. Equally, we were conscious of the breadth of the
subject matter of public inquiries, capable of investigating a range of concerns
“from the actions of Harold Shipman in murdering his patients, to the
management of foot and mouth outbreaks in agriculture”.
23

1.23 Conscious of our initial commitment to explore duplication between inquests
and inquiries, we limited our consideration to the justice system’s response
to multiple fatalities and to single deaths arising from a systemic pattern
of failure. This is reflected in the ambit of our proposed special procedure
inquest (see paras 2.40-2.85 and Annexe).

1.24 However, we are conscious that many of the barriers to participation identified
above apply to inquiries into serious non-fatal harms such as near-death; sexual
abuse , human trafficking and most recently harmful side effects from
24

22 Ministry of Justice, ‘Coroners Statistics Annual 2019 England and Wales’ (14 May 2020).
23 Dr Karl Mackie CBE, ‘Public Inquiries: Proposals for a design rethink’ (Centre for Effective Dispute
Resolution, 2012).
24 A number of our members are involved in the Independent Inquiry into Child Sexual Abuse (IICSA).
With hearings ongoing, this large-scale inquiry provided us with a useful point of comparison and is
referenced throughout this report.

11