Page 70 - When Things Go Wrong

participant, described the consultation as “window-dressing which convinced
no one,” adding that “finalising terms of reference should be a lengthy process
to allow the Chair to research and understand properly the issues at play”.

4.22 We agree that sufficient time should be allowed for the setting of terms of
reference, to enable issues to be identified and proper consultation
(including with bereaved people and survivors) to take place. Given the
complexity of issues contributing to fatal events such as the Grenfell Tower
fire, or indeed the COVID-19 pandemic, we do not consider that the stipulation
of a standard minimum window of time is appropriate. However, the exercise
must allow for sufficiently wide consultation, followed by proper analysis of
responses. This would apply to the SPI as well as to public inquiries.

Venue

4.23 The physical environment of inquest and inquiry hearings is often unsuitable
for bereaved people and survivors. Insufficient resources can serve as a
contributing factor; the ‘INQUEST Handbook’ notes that “some inquest
venues have a designated room that the family can use as a waiting room … if
this is not available, the family often find themselves waiting in the same room
as other [interested persons], which can in itself be distressing”. 195 On occasion
however, distress is compounded by thoughtless layout. One bereaved parent
told us that at the inquest into the death of their child, the room was laid out so
that they had to share a bench with officials from the NHS Trust in whose care
the child had died. 196 One Senior Coroner described how, at the last minute, he
had personally moved chairs around the court to prevent members of the press
being seated directly opposite bereaved family members.

4.24 Participation in public inquiries has similarly been hampered by poor layout.
Both the choice of venue and the room geography of Phase I of the Grenfell

195 INQUEST (2016), supra note 157, p. 40. See also Owen Bowcott, ‘Bereaved woman asked to pay
£1,000 for private room at inquest’ (The Guardian, 10 September 2018).
196 The officials, we were told, “almost cheered when things went their way” through the course of the
inquest hearing.

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