Page 93 - When Things Go Wrong

VI. LEARNING, ACCOUNTABILITY AND SYSTEMIC
CHANGE

Forty-three years and one month before Hillsborough, 33 people died and over 500
were injured at an FA Cup tie between Bolton Wanderers and Stoke City…The Home
Office inquiry, chaired by Moelwyn Hughes, criticised the police and ground officials
for not realising the significance of the build-up outside the ground…Moelwyn
Hughes made many recommendations to prevent such a disaster happening again.
Professor Phil Scraton 258

6.1 A key feature that distinguishes inquiries from other parts of the justice system
is the expectation that recommendations will be made to prevent similar events
from recurring. Indeed, it has been argued that this is the primary function of
an inquiry: “to be forward-looking, to improve government and public
services, and to prevent the same mistakes from being made again – is the most
259
important contribution that an inquiry can make to the wider public interest”.

6.2 The report by the Institute for Government How public inquiries can lead to
change noted that many inquiries have delivered valuable legislative and
institutional change, citing the establishment of the Rail Accident Investigation
Branch, CRB checks and more effective gun control. 260 However, relative to
their expense, 261 the expertise they accumulate and the importance of the
subjects they address, the success of inquiries in precipitating meaningful
change remains questionable. In the Executive Summary of the Report of the
Mid Staffordshire NHS Foundation Trust Public Inquiry, Sir Robert Francis
observed that “the experience of many previous inquiries is that, following the
initial courtesy of a welcome and an indication that its recommendations will
be accepted or viewed favourably, progress in implementation becomes slow
or non-existent”. 262

258 Scraton, supra note 2, pp. 37-8.
259 Norris and Shepheard, supra note 21, p. 8.
260 Ibid.
261 Ibid, p. 4.
262 Francis QC, supra note 206, para 41.
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