Page 95 - When Things Go Wrong

suicide management and inadequate healthcare”, in addition to “other
contributory factors [including] lack of staff training, poor communication and
poor record keeping”. 268 This is despite 15 PFD reports relating to the deaths
having been issued over the same period.

6.7 The reasons why institutions fail to change – behavioural, cultural, political as
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well as legal – are complex, and stretch beyond the scope of this review.
However, the Working Party felt that it was critical to consider how the justice
system might be reformed to promote meaningful implementation following
the inquiry process. We appreciate that this is of central importance to those
principally affected by catastrophic events, who see recommendations
formulated at the conclusion of the legal process, then hear about deaths in
similar circumstances months or years later.

Inquiry design

Limited tenure of judicial chairs

6.8 Where judicial chairs are appointed, there is an inherent limitation in their
ability to initiate a process of systemic change:

By nature of their training and experience, judges tend to see the end of
an inquiry as a hard point of separation, after which their involvement
ceases…their oaths preclude them from getting involved in politics...
However, such a wall between an inquiry and its aftermath entails the loss
of the chair’s unique standing and moral authority, which often make
them one of the most effective advocates for their recommendations. 270

268 INQUEST, ‘Still Dying on the Inside’, May 2018, p. 16.
269 See Bennett Institute for Public Policy, ‘Workshop Report: Policy Lessons from Catastrophic
Events’, May 2020, Introduction. Various root causes include a “focus on regulatory requirements rather
than doing what is right for people”; a lack of diversity (including cognitive diversity) in decision-
making roles; a failure to take opportunities to learn from “near-misses”; a reliance on simple fixes and
resistance to acknowledging complexity; in addition to organisational systems, processes and cultures.
270 Norris and Shepheard, supra note 21, p. 17.
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