Page 9 - When Things Go Wrong

to consider closed material and make specific recommendations to prevent
recurrence.

Opening investigations
The opening of an investigation can be a disorienting experience for bereaved people
and survivors. There is a stark discrepancy between the rights afforded to victims in
the criminal justice system and bereaved people and survivors in inquests and
inquiries. Further, a lack of coordination between agencies can mean that they can
face multiple, repetitious interviews at the evidence-gathering stage. Greater
collaboration between agencies is needed to reduce as far as possible the extent to
which bereaved people and survivors have to recount traumatic events and to ensure
that they are informed throughout the process.

Pre-Hearing Procedure
There is currently insufficient attention paid to the needs of bereaved people and
survivors at the establishment of an inquiry. We consider that the processes for
appointing inquiry chairs and panels, for establishing the terms of reference and for
providing information and relevant documents to core participants need to be more
structured and transparent. We build upon other recent JUSTICE working parties in
recommending bereaved people and survivors are placed at the heart of the justice
system by considering the impact of the physical environment and process on
effective participation during the inquiry.

The duty of candour
Institutional defensiveness can impede the effectiveness of an inquiry or inquest, with
a detrimental impact on participation and public confidence. We consider that a
statutory duty of candour, which includes a rebuttable requirement for position
statements, would help to foster a “cards on the table” approach. Directing the inquiry
to the most important matters early on in the process could result in earlier findings
and reduced costs.

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