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What could we expect from the UK Covid-19 Public Inquiry? – Part 1

  • United Kingdom
  • Inquiries and investigations
  • Central government


Since the Prime Minister’s announcement on 12 May 2021 that there will be an independent statutory public inquiry into the Covid-19 pandemic (“Covid-19 Public Inquiry”), stakeholders have awaited further details with bated breath. Baroness Hallett was appointed to Chair the Covid-19 Public Inquiry and the draft Terms of Reference (“ToR”) have now been published, ahead of a four week public consultation period. When the final ToR are confirmed it is hoped that the Inquiry’s work will start in earnest with the commencement of public hearings anticipated for 2023.

However, in the meantime, whilst awaiting the commencement of the Covid-19 Public Inquiry,  on 8 October 2020, two House of Lords Parliamentary Select Committees, the Health and Social Care Committee (“HSCC”) and the Science and Technology Committee (“STC”) (together, “the Committees”), announced they would undertake a joint inquiry into lessons to be learned from the pandemic so far (“Joint Inquiry”). The Joint Inquiry was not a statutory inquiry established under the Inquiries Act 2005, rather its power was derived from the Committees establishment under the Standing Orders (Parliamentary Rules).

In this series of articles we consider some of the areas of investigation suggested in the draft ToR for the Covid-19 Public Inquiry, through an analysis of the evidence already heard by the Joint Inquiry. We suggest the evidence given to the Joint Inquiry is a good indication of what may be heard during the Covid-19 Public Inquiry. The Joint Inquiry has already published its report “Coronavirus: lessons learned to date” (“the Report”) based on the evidence it has heard, making recommendations to assist in future pandemics, and immediately during the Covid-19 pandemic.[1]

In this series of articles we focus on the following four topics, which were all considered by the Joint Inquiry and included as areas to examine within the draft ToR of the Covid-19 Public Inquiry: 

i)            The UK’s prior preparedness for a pandemic;

ii)           The deployment of non-pharmaceutical interventions and the consequences of those measures;

iii)          Testing and contact tracing; and

iv)          The development of treatment and vaccines.

We have selected these as they are some of the central issues to the handling of the pandemic which were considered by the Joint Inquiry. These are also topics which have been suggested by Interested Persons, such as the Covid-19 Bereaved Families for Justice group, as those which should be considered by the Covid-19 Public Inquiry[2].  

The draft Terms of Reference of the Covid-19 Public Inquiry

The draft ToR have now been published. Whilst it is not a statutory requirement under the Inquiries Act 2005 to consult on the ToR of a statutory public inquiry, the Chair has confirmed that she will consult on the ToR, including with bereaved families and other affected groups.

Indeed, Baroness Hallett may choose to use the evidence published by the Joint Inquiry and other reports published before the commencement of the Covid-19 Public Inquiry, where they are relevant also to the Covid-19 Public Inquiry’s ToR, to give it a ‘head start’ on evidence gathering. The APPG recommended in its ‘Public Inquiry’ report dated October 2021 (“October 2021 Report”) that “maximum use must be made of the work that has already been done, for example by the National Audit Office, on NHS capacity, the state of adult social care, and about health and equalities.”[3] In the Report, the Joint Inquiry has also confirmed that “our findings, and all of the evidence we have gathered, will be available to the public inquiry.”[4] The draft ToR themselves say it “will seek to minimise duplication of investigation, evidence gathering and reporting with any other public inquiry established by the devolved administrations”, but it is not clear whether Baroness Hallett intends to extend this to other investigations which have already gathered evidence.

As a result, it will be useful for any individual or organisation likely to give evidence to the Covid-19 Public Inquiry to consider the evidence the Joint Inquiry heard, its Report and recommendations, and to assess its relevance to them, including whether any improvements to protocols / processes could be made now, ahead of the Covid-19 Public Inquiry commencing its work in earnest.

Background to the Joint Inquiry

The Joint Inquiry was chaired by Rt Hon Jeremy Hunt (HSCC) and Rt Hon Greg Clark MP (STC), and they hoped this would be a ‘rapid inquiry’[5]. They aimed to produce a report, including recommendations for the Government, by Spring 2021. However, the Joint Inquiry only concluded hearing oral evidence on 10 June 2021. The Joint Inquiry published the Report on 12 October 2021, confirming that “all learning needs to happen rapidly because of the likelihood of future pandemics which is why we are producing this Report now.”[6]

The Joint Inquiry invited written evidence and heard oral evidence from a range of witnesses, in panel-style oral hearings. The Chairs were joined by other members of the Committees, who also asked questions and sought witnesses’ views on whether anything could have been done differently or whether more could have been done during the pandemic. The Joint Inquiry heard evidence from individuals directly impacted by the pandemic, those currently or previously working in relevant government departments or the NHS, and experts in their fields.

It became clear during the hearings that the Joint Inquiry would hear, and receive, contradictory evidence, for example the oral evidence of Mr Cummings (former Chief Adviser to the Prime Minister) and the Rt Hon Matt Hancock MP (Former Secretary of State for Health and Social Care). It is likely that similar issues will arise in the Covid-19 Public Inquiry, and Baroness Hallett will need to weigh up the evidence, both oral and written, in the same way as the Joint Inquiry, in order to reach her final conclusions and to make recommendations for the future. 

Throughout the Joint Inquiry’s hearings, we noted that the questioning from the Chairs, and members of the Committees, was strictly focussed on learning lessons, given this was a lessons learnt review; according to the Report, this style of questioning was intentional[7]. The Joint Inquiry did not apportion blame. The draft ToR confirm the Covid-19 Public Inquiry will “identify the lessons to be learned from the above [areas to be examined], thereby to inform the UK’s preparations for future pandemics.”

The UK’s prior preparedness for a pandemic

The Joint Inquiry received a significant amount of evidence in relation to this topic, for example, from former and current Government ministers during the pandemic (to include, Mr Hancock and Mr Cummings), medical and scientific professionals. We would argue this topic was one of the cornerstones of the Joint Inquiry and one which will undoubtedly feature in the Covid-19 Public Inquiry. It is also an area which the APPG has recommended the Covid-19 Public Inquiry considers. In their October 2021 Report, the APPG has suggested the ToR “include scrutiny of UK and its institutions and public services’ resilience and preparedness going into the pandemic, and how UK Government decisions compared to those being taken by other countries in comparable circumstances.”[8]

Key areas within this topic considered by the Joint Inquiry include: preparedness for a pandemic, planning for the NHS to have sufficient critical care beds; and ensuring the NHS had sufficient staff numbers and skills for a pandemic.

i)            Preparedness for a pandemic

The Joint Inquiry gathered a wealth of evidence in respect of the Government’s preparedness to manage a pandemic and the development of the Government’s “pandemic plan” prior to the Covid-19 pandemic. The Report concluded that “the UK’s preparedness for responding to covid-19 had important deficiencies.”[9]

For example, the Joint Inquiry received written evidence from Mr Matthias Schmid (Chair of NHSE Clinical Reference Group Infectious Diseases[10]) in relation to the Government’s plan, preparedness and Personal Protective Equipment (“PPE”). He confirmed that “whilst the NHS has a fantastic EPRR response team, the preparedness had been eroded over the preceding years and investments into certain areas had not taken place including lacking investments in levels of PPE for both hospital and community.” The APPG’s ‘Interim Report’ dated December 2020 (“December 2020 Report”) concurred, and stated: “the UK government did not adequately prepare in terms of stockpiling sufficient and adequate Personal Protection Equipment (PPE).”[11]

Mr Cummings criticised the Government’s pandemic plan during his evidence, stating: “I thought that many of the plans seemed to me to fall very far short of what is actually needed. A lot of things are just kind of PowerPoints and they lack detail, but, most importantly, I think the process around them, as with the pandemic plan, is not open. There is not a culture of talking to outside experts.”[12]

Alex Thomas (Programme Director, Institute for Government) discussed planning during his evidence, when considering the strengths and weaknesses in the Government’s planning that the pandemic has highlighted. In particular he commented that “risk planning was in a box marked “Civil Contingencies” in the centre of Government and did not reach into other Government Departments strongly or clearly enough. For example, that meant that the Department for Education was underprepared for even a flu pandemic and what might happen in schools, because foresight, anticipation and contingency planning capability was too low.”[13]

In particular, a number of witnesses commented on the Government’s decision to focus on preparing for a flu pandemic. For example, Professor Devi Sridhar (Chair of Global Public Health, University of Edinburgh) confirmed that the Government was prepared for a flu pandemic, but not for a type of coronavirus like Covid-19. Mr Thomas described that the reference to a novel coronavirus on the national risk register was too dismissive, and despite having commenced emergency planning for SARS in 2007, the latest version of the risk register that predated the pandemic (the 2017 version) focussed on a flu pandemic.[14] The Report concurs: “it is clear from the covid-19 pandemic that the 2017 version of the National Risk Register underestimated the impact of a non influenza infectious disease.”[15]

The Joint Inquiry heard evidence that there was an underestimation of the risk of novel diseases and zoonotic disease. Professor Davies confirmed that the Government planned specifically for flu (as did Europe and the US, she notes), adding that “a number of problems come out that planning did not address because it was not planning for the specific issue.”[16] The focus on flu, she continued, which is not routinely tested, meant the UK did not have a test and trace system readily prepared and available in advance, and so this had to be developed whilst the Covid-19 pandemic was ongoing. We will consider the test and trace system in more detail in the third article in this series.

The Government’s DHSC, and ultimately the Secretary of State, is responsible for health pandemic planning and Mr Hancock did acknowledge in his evidence that the plans were made specifically for a flu pandemic, albeit he believes the plans were still useful.[17] Lord Sedwill (the former Cabinet Secretary) confirmed the pandemic flu plan was adapted for Covid-19.[18] Had a pandemic similar to SARS been planned for, Professor Davies notes the DHSC would have had to plan differently than for flu. Mr Thomas also stated lessons to be learned from this pandemic included improving the Government’s risk management and contingency planning strategies. The Joint Inquiry has heeded these suggestions, and recommended “plans for the future should include a substantial and systematic method of learning from international practice during the course of an emergency.”[19]

The Report concluded that the most important deficiency of the Government’s preparedness for the pandemic “was that much of our preparation was for an influenza-like pandemic—notably one that was not characterised by asymptomatic transmission (and for which testing was therefore not so important).”[20]

Importantly, Professor Davies also suggested that it was the resilience to a pandemic which the Government also underestimated. Prior to the pandemic, the Government had undertaken ‘Exercise Cygnus’ in October 2016, which was a cross-government scenario based planning exercise led by Public Health England; a flu based scenario was given which would have resulted in severe pressure on the NHS and modelling undertaken on that basis. Prior to Exercise Cygnus, in 2007, another exercise was carried out, called ‘Winter Willow’. This was broader than Exercise Cygnus, and also identified four broad areas of improvement and lessons to be learned.

It is not clear whether all the lessons arising from Exercises Winter Willow and then Cygnus were learned and put into practice, although some were, such as the drafting of legislation. The Report concluded: “despite carrying out simulation exercises, we heard that the UK did not adequately learn the lessons of previous pandemics. In particular, the SARS and MERS outbreaks contained lessons that the UK could have learnt at an earlier stage.”[21] Further, the Report found “previous exercises to test the national response capability, namely Exercises Cygnus and Winter Willow, did not squarely address a disease with the characteristics of covid-19.”[22]

The Campaign organisation “Keep our NHS Public” has called its own inquiry named the People’s Covid Inquiry (“People’s Inquiry”), which also considered Exercises Winter Willow and Cygnus. The People’s Inquiry heard testimony from over 40 witnesses, and was supported by a panel chaired by Michael Mansfield QC. On 7 July, the People’s Inquiry published its urgent findings and recommendations (“Urgent Findings Report”), based on evidence gathered at that point. The final report of the People’s Inquiry was published on 1 December 2021. In terms of Exercise Cygnus, the People’s Inquiry concurs with the findings of the Joint Inquiry: “recommendations from previous pandemic planning exercises were ignored”[23] and “ignoring pandemic planning exercise findings meant that stocks of PPE, testing capacity, border controls and contract tracing were not in place when coronavirus appeared. These measures would have saved lives.”[24] The People’s Inquiry also found “the Government failed to address the seriousness of the pandemic for several vital weeks from 23 January 2020 (Wuhan lockdown and Lancet articles published) to first lockdown on 26 March despite very clear indications this was urgent.”[25]

The recommendations made by the Joint Committee in the Report in respect of the preparedness for a pandemic will naturally be of interest to Government departments and if implemented could also impact NHS Trusts, local authorities and those other organisations involved in social care. It would be prudent for those planning for future pandemics to involve and consult those stakeholders when preparing plans.

ii)           Critical care capacity

Particularly during the early part of the pandemic, there was public criticism regarding the perceived lack of critical care beds[26] available to treat the number of patients requiring enhanced care in hospital. Over recent years, this had already been raised as an issue which could cause future deaths by Coroners, for example, in 2017, the Assistant Coroner for Nottinghamshire sent a Prevention of Future Deaths report (“PFD Report”) under Paragraph 7 Schedule 5 of the Coroners and Justice Act 2009 to two local NHS Trusts, and NHS England, in respect of the lack of critical care beds (in this case, the ICU at Nottingham was full), and the need to conduct “bed juggling” to ensure patients that required a bed could be treated by the ICU team[27]. The Senior Coroner for Milton Keynes has also previously sent two PFD reports in respect of provision of ITU beds in Milton Keynes University Hospital.  

Interestingly, during the pandemic, NHS England paused the collection and publication of some of the data relating to critical care bed capacity, which until February 2020 was published monthly. This is purportedly “due to the coronavirus illness (Covid-19) and the need to release capacity across the NHS to support the response, NHS England and NHS Improvement paused the collection and publication of some of our official statistics.” This release was last updated on 7 September 2021, and the collection of data relating to critical care bed capacity remains paused.[28] However, despite this official communication, some statistics relating to critical care beds have been released by NHS England, for example, the Guardian[29] reported on 4 February 2021 that by 31 January 2021, NHS England figures showed that 5,171 adult critical care beds were occupied in England, over 1,500 more than at any point in the past five winters. The same article reported that during the week of 31 January 2021, 18 of the 140 acute NHS Trusts that had critical care departments were running at 99% capacity or more, with 15 NHS Trusts running at full capacity.

In March 2021, the Chief Executive of NHS Providers, Chris Hopson, said in a statement that “Trusts’ experience of Covid-19 has strongly confirmed what we already knew – that the NHS has insufficient critical care capacity. We now need a formal review of what critical care capacity is required going forward… It’s neither safe nor sensible to rely on NHS hospital trusts being able to double or triple their capacity at the drop of a hat, as they’ve had to over the last two months.” Perhaps, it could be argued, that the lack of critical care bed capacity was known prior to the pandemic, and should have been addressed. This is one of the topics expected to be examined by the Covid-19 Public Inquiry, as set out in the draft ToR.

The Joint Inquiry heard evidence in relation to the availability of critical care beds in the NHS for the pandemic. Sir Simon Stevens (Chief Executive, NHS England and NHS Improvement) gave evidence to the HSCC on 17 March 2020, in respect of their separate inquiry on “Management of the Coronavirus Outbreak”, and described how the NHS intended to take steps to increase critical care bed capacity, even at that relatively early part of the pandemic.[30]

In her evidence to the Joint Inquiry, Professor Dame Sally Davies (Chief Medical Officer for England 2010-2019) stated: “we have not been good at learning from others in this outbreak, as far as I can see. You need preparedness. You then need a resilient system. We can talk about our comparators, but those Asian countries had more doctors, beds and ITU facilities[31] and “in the data at the beginning of Covid, if you look at Europe, we are in the bottom half dozen for number of doctors per head of population, number of hospital beds per head of population and number of ITU beds per head of population. We clearly had a less resilient system, and very little manufacturing.”[32] Taiwo Owatemi, a member of the HSCC, questioned Mr Hancock on ICU bed capacity on 10 June 2021.[33] Mr Hancock confirmed that during the pandemic, the NHS has always been able to provide the necessary treatment to patients due to the expansion of ICU capacity, but “there is no doubt that one of the lessons is that we needed more ICU capacity, and we have expanded it over the last 18 months.” Mr Hancock was not clear during his evidence how many of the ‘new’ critical care beds created for the pandemic would become permanent.

The National Audit Office has also prepared a report on “readying the NHS and adult social care in England for COVID-19” dated 10 June 2020, which looked specifically at the period at the beginning of the pandemic from March to April 2020. That report agrees that “between mid-March and mid-April, the NHS increased bed capacity for COVID-19 patients in NHS trusts in England, meaning that the number of patients never exceeded the number of available beds” and confirmed that in April 2020, 50% of critical care beds were occupied.[34] This suggests at the beginning of the pandemic critical care bed capacity was sufficient to manage the increase in Covid-19 patients.

In the Report, the Joint Inquiry confirmed it was “a remarkable achievement for the NHS to expand ventilator and intensive care capacity, including through the establishment of Nightingale hospitals… overall, the majority of covid-19 patients with clinical need for hospital care received it. However, the price paid to deliver this was significant interruption to NHS core services”[35] and “the NHS’s ability to respond in this manner demonstrated some aspects of effective preparation.”[36] The Report continues: “the NHS responded quickly and strongly to the demands of the pandemic, but compared to other health systems it “runs hot”—with little spare capacity built in to cope with sudden and unexpected surges of demand such as in a pandemic.”[37]

As the cases of Covid-19 rose again during Winter 2021 due to the Omicron variant, there was concern again regarding the number of critical care beds. For example, on 8 December 2021, one intensive care specialist confirmed "about one-in-five to one-in-four ICU beds are currently occupied by patients with Covid, meaning they're not available for delivering the work that we used them for before the pandemic… Every day intensive care units and hospitals are making decisions about the kind of activity they can manage to support, particularly around elective surgical cases."[38]

From the wording of the draft ToR, we consider it is likely that the availability of critical care beds will be considered by the Covid-19 Public Inquiry and also the impact the diversion of resources had on general NHS care and routine treatment. In preparing for the Covid-19 Public Inquiry NHS Trusts could begin to gather some of this information and prepare for the possibility of providing this evidence to the Inquiry.

iii)          NHS staffing

In respect of NHS staff, the Joint Inquiry questioned Sir Simon Stevens about the redeployment of NHS staff, and any lessons which could be learned from this. He was clear that NHS staff have responded flexibly to the pandemic: “we have medical students helping out. We have nursing students helping out. We have consultants from other disciplines helping out on the acute medicine ward. We have therapists and nurses flexibly supporting their colleagues in critical care. The silver lining, if one can even allow oneself that phrase, is that it has shown that under these circumstances health service staff will always go the extra mile, but that is not a sustainable basis on which to think either about the future of the pandemic or indeed the future of the health service.”[39] Sir Simon Stevens’ experience of speaking with healthcare workers has been positive, due to a feeling “it has been a professionally important thing to have an adjunct discipline.”

The General Medical Council (“GMC”) also endorsed more flexible training for doctors, having submitted written evidence, which included some recommendations for the Joint Inquiry to consider. Their suggestion was “for the Committees to support training that supports doctors to be responsive to changes, such as those that emerged during the pandemic. This requires flexible training structures which continue to concentrate on generic skills, as well as specialisation throughout doctors’ careers.”[40] The Report agreed with this suggestion. Should it be implemented, this added flexibility in terms of doctors’ clinical specialities, will affect NHS staff and NHS Trusts. This will also be of interest to organisations such as the GMC, the Nursing and Midwifery Council (“NMC”) and other organisations with a vested interest in healthcare workers, such as the British Medical Association (“BMA”).

There have also been concerns regarding the number of NHS staff available to manage the pandemic, which was also identified during Exercise Cygnus referred to above. Short staffing is another issue which has been considered by Coroners as an issue which would need to be addressed to prevent future deaths from occurring in similar circumstances, for example, the Coroner for London Inner South sent a PFD report to Kings College London, the Care Quality Commission and Chief Inspector of Hospitals in 2013 in relation to hospital staffing levels, and the Manchester West Coroner sent a similar PFD in relation to night staffing to 5 Boroughs Partnership NHS Foundation Trust the same year[41]. Further, the Coroner for Milton Keynes sent a PFD report to Milton Keynes University Hospital in the year 2019/2020 in relation to concerns of short staffing in the emergency department.[42] Perhaps, it could be suggested that any warnings regarding short staffing prior to the pandemic were not heeded.

As a result of the need for further staff, medical students, nursing students and retired healthcare workers were called in to assist the NHS during the pandemic. Nevertheless, the pandemic has placed NHS staff under unprecedented pressure, and there is concern that staff are suffering from burnout and fatigue, to which short staffing may have contributed. This has already been identified by the HSCC separately in its report on “Delivering core NHS and care services during the pandemic and beyond” dated 24 September 2020, which stated “we are, however, aware that this additional pressure has led to workforce fatigue and “burnout” with a significant cost being imposed on staff members’ mental and physical wellbeing. We have also heard that pre-existing issues relating to staff recruitment, training and retention have been exacerbated by the pandemic.”[43] The HSCC also raised that “given the pressures on recruitment and retention of staff, we are concerned that the People Plan does not set out future workforce recruitment objectives, therefore failing to address one of the biggest concerns that many staff have, namely whether there will be enough of them to give high quality care to patients.”[44] The HSCC has since produced a report specifically focussing on “workforce burnout and resilience in the NHS and social care” dated 18 May 2021, which found that: “at the heart of the solution to workforce burnout and resilience is one simple change, without which the situation is unlikely to improve except at the margins - namely the need for better workforce planning. There was a high degree of consensus in the submissions to our inquiry that both the NHS and social care workforce were overstretched and had been for some time.”[45] The HSCC’s recommendation was that “Health Education England publish objective, transparent and independently-audited annual reports on workforce projections that cover the next five, ten and twenty years including an assessment of whether sufficient numbers are being trained. We further recommend that such workforce projections cover social care as well as the NHS given the close links between the two systems.”[46] The Government  responded to this report on 17 February 2022, a response having been expected by 8 August 2021. In respect of this recommendation by the HSCC, the Government has responded to confirm there is a new duty in the recently introduced Health and Care Bill which will require the Secretary of State to publish a report setting out how workforce planning and supply is organised in England. This Bill is currently progressing through Parliament[47].

The APPG’s December 2020 Report also found that “there are significant staff shortages in both the NHS and social care sector. Covid-19 has had a considerable impact on the health, safety and well-being of the workforce”[48] and “even without the demands of the pandemic, there was (and remains) an urgent need to expand the health and social care workforce.”[49] During the APPG’s sixth oral hearing, APPG heard evidence from the Royal College of Nursing, GMB Union, Medical Protection Society, and Doctors’ Association UK on the impact of Covid-19 on frontline workers. It’s findings were similar to those of the HSCC in the aforementioned reports; the pandemic is having a clear impact on mental health of frontline staff, who are experiencing stress, depression and burnout[50]. More recently, concerns have been raised in relation to the number of frontline staff currently absent from work due to the spread of the Omicron variant of Covid-19, and the impact of those absences.

The People’s Inquiry also referred to the NHS’ resilience in the findings in its report: “the NHS had insufficient capacity for resilience during a pandemic and was forced to become a Covid service during the first and second pandemic waves. The severe weaknesses in the NHS included 100,000 staff vacancies, ITU, bed and equipment shortages, and the running down of laboratories.”[51]  They recommended that “the dangerous level of low staff morale, stress and burnout is apparent. This results from exhaustion, moral injury, burnout and PTSD. After nearly two years of intense pressure and contradictory responses from Government and some members of the public, any sense of wellbeing has been steadily eroded.”[52] It does not appear the Government has yet acknowledged or responded to the report of the People’s Inquiry.

Given the potential significance and long term implications for the NHS,  NHS staffing and training are likely to be considered and investigated in more detail by the Covid-19 Public Inquiry, which may be welcomed by NHS Trusts and NHS staff.

Preparing for the Covid-19 Public Inquiry

In its final conclusion, the Report notes that “it serves as an initial assessment of the handling of the covid-19 pandemic. A public inquiry has been promised to examine the response in fuller detail and needs to be launched as soon as possible.”[53]  From the draft ToR, it appears similar evidence and themes will be heard during the Covid-19 Public Inquiry this year.  

We have already published an article designed to assist those likely to be involved in the Covid-19 Public Inquiry with their preparations. Preparing for a public inquiry – Practical steps that you can take now.

It is important to consider what action can be taken now to help prepare for involvement with the Covid-19 Public Inquiry, having considered the above evidence and the recommendations in the Report, which will be of interest to those directly affected by Covid-19, from bereaved families, survivors of Covid-19, NHS Trusts and Bodies to suppliers of PPE and Governmental departments.   Interested parties should consider whether they agree with the information already gathered, the conclusions of the Report, and its recommendations. They should be considered a good basis for any internal reflections on actions or inactions and whether matters could and should have been handled differently, however, it is anticipated that the Covid-19 Public Inquiry will need to inquire into matters far wider than those considered by the Report.

We await the response from the Government to the Report, and confirmation of whether it intends to implement any of these recommendations at this stage. The Government’s response is now overdue, it having been expected by 12 December 2021. In the next article in our series, we will consider the deployment of non-pharmaceutical interventions and the consequences of those measures. Should you have any queries in the meantime in respect of preparedness for the Covid-19 Public Inquiry please do not hesitate to contact one of the authors of this article.

[1]               Coronavirus: lessons learnt (

[2]               UK COVID-19 public inquiry needed to learn lessons and save lives - The Lancet

[3]               The APPG’s ‘Public Inquiry’ Report dated October 2021, page 9.

[4]               Coronavirus: lessons learnt (, page 16.

[5]               Former ministers to hold 'rapid' inquiry into government's Covid-19 response | Politics | The Guardian

[6]               Coronavirus: lessons learnt (, page 8.

[7]               Coronavirus: lessons learnt (, page 8: “Its purpose is not to point fingers of blame but ensure an accurate understanding of both successes and failures to date so that crucial lessons can be learned for the future” and page 15: “The purpose of this Report is not to apportion blame, but we do seek to provide an early assessment of the key decisions, structures and underlying factors which contributed to the extent of the pandemic’s impact in the UK.”

[8]               The APPG’s Public Inquiry Report dated October 2021, page 4.

[9]               Coronavirus: lessons learnt (, page 17.

[10]              See document CLL0088.

[11]              The APPG’s Interim Report dated December 2020, page 34, available at Public Inquiry Report | October 2021 (

[12]              Transcript of oral evidence, 26 May 2021, page 36.

[13]              Transcript of oral evidence, 24 November 2020, page 9.

[14]              Transcript of oral evidence, 24 November 2020, page 11.

[15]              Coronavirus: lessons learnt (, page 18.

[16]              Transcript of oral evidence, 2 December 2020, page 2.

[17]              Transcript of oral evidence, 10 June 2021, page 13.

[18]              Transcript of oral evidence, 2 December 2020, page 23.

[19]              Coronavirus: lessons learnt (, page 32.

[20]              Coronavirus: lessons learnt (, page 17.

[21]              Coronavirus: lessons learnt (, page 20.

[22]              Coronavirus: lessons learnt (, page 31.

[23]              The People’s Covid Inquiry’s “Misconduct in Public Office (Full Report)” available on Home | PeoplesCovidInquiry, page 38.

[24]              The People’s Covid Inquiry’s “Misconduct in Public Office (Full Report)”, page 44.

[25]              The People’s Covid Inquiry’s “Misconduct in Public Office (Full Report)”, page 39.

[26]              “Critical care” has been interchangeably with Intensive Care Unit (“ICU”), or Intensive Therapy Unit (“ITU”) within hearings of the Joint Inquiry, and within documents.

[27]              Coroners Office-20170118151244 (


[29]              No free critical care beds at 15 NHS England trusts last week | NHS | The Guardian

[30]    , page 20.

[31]              Transcript of oral evidence, 2 December 2020, page 9.

[32]              Transcript of oral evidence, 2 December 2020, page 19.

[33]              Transcript of oral evidence, 10 June 2021, page 73.

[34]              Readying the NHS and adult social care in England for COVID-19 (, pages 11 and 34.

[35]              Coronavirus: lessons learnt (, page 10.

[36]              Coronavirus: lessons learnt (, page 29.

[37]              Coronavirus: lessons learnt (, page 32.


[39]              Transcript of oral evidence, 26 January 2021, page 16.

[40]              See document CLL0119.

[41]              Summary of Reports and Responses under Rule 43 of the Coroners Rules. Ninth Report for period 1 October 2012 to 31 March 2013 (, page 34.

[42]              Mr Tom Osborne, HM Senior Coroner For Milton Keynes, Annual Report 2019/20, page 7.

[43]              Delivering Core NHS and Care Services during the Pandemic and Beyond (, page 45.

[44]              Delivering Core NHS and Care Services during the Pandemic and Beyond (, page 48.

[45]              Workforce burnout and resilience in the NHS and social care (, page 41.

[46]              Workforce burnout and resilience in the NHS and social care (, page 54.

[47]              The Government Response to the Health and Social Care Committee Report on Workforce Burnout and Resilience in the NHS and Social Care (, page 27.

[48]              The APPG’s Interim Report dated December 2020, page 34.

[49]              The APPG’s Interim Report dated December 2020, page 36.

[50]              The APPG’s Interim Report dated December 2020, page 77.

[51]              The People’s Covid Inquiry’s “Misconduct in Public Office (Full Report)”, page 40.

[52]              The People’s Covid Inquiry’s “Misconduct in Public Office (Full Report)”, page 47.

[53]              Coronavirus: lessons learnt (, page 125.