Public inquiries: are we confusing investigation with accountability?

Anna-Louise Marsh-Rees

When my dad died from hospital-acquired Covid-19 in Wales in October 2020, I wanted answers. How had he acquired an infection in hospital? What had gone wrong? And would the decisions that contributed to his death ever be properly scrutinised?

When the UK Covid Inquiry was established, I believed it would help provide those answers. Having spent years examining evidence and participating in the inquiry, I have come to question not just what this particular inquiry has delivered, but something much bigger: what are public inquiries actually meant to achieve, and do they fulfil the expectations placed upon them?

Public inquiries are established after serious failures, tragedies or events that raise questions about institutions and those responsible for them. They are expected to establish what happened, explain why it happened, identify lessons and recommend changes to prevent similar failures in future.

But is that enough? And what happens when the hearings end, the reports are published and the inquiry team moves on?

When the scale changes everything

Public inquiries have investigated specific tragedies, including the Grenfell Tower fire, the Manchester Arena bombing and the contaminated blood scandal. Each involved complex questions about institutional failures, decision-making and responsibility.

The Covid Inquiry was different. It sought to examine the structures, systems and decisions underpinning the UK’s preparedness for, response to and experience of the pandemic, across four nations and almost every area of public life.

That scale matters. The inquiry had to navigate different governments, policies, institutions and responsibilities, while examining an enormous volume of evidence across a series of separate modules.

Was it realistic to expect one inquiry to examine such a vast subject and produce a coherent account of what went wrong, why it went wrong and what needed to change?

What were its overarching objectives? How would success be measured? And how could the inquiry ensure that evidence examined in separate modules contributed to an understanding of the pandemic as a whole?

These are questions about whether the structure and purpose of an inquiry are sufficiently clear from the outset, particularly when the subject is unprecedented in its breadth.

The UK Covid Inquiry has also raised questions about the relationship between formal participation and meaningful scrutiny. Those questions deserve closer examination, but they point to a broader issue: whether the way public inquiries are structured enables them to fulfil their purpose.

Evidence, findings and accountability

One of the most important functions of an inquiry is to establish the facts and examine the decisions made in the light of the evidence available at the time. But gathering evidence is not the same as reaching conclusions, and reaching conclusions is not the same as delivering accountability.

The inquiry has made me question how effectively these stages connect.

Consider the advice given to the public about how Covid spread, including the significance of airborne transmission. This was not a peripheral scientific question. It went to the heart of how an entire nation understood the risks and was advised to protect itself. The evidence behind that advice, whether it was appropriate and what the consequences were when advice was inadequate deserved rigorous examination.

The wider question is how an inquiry takes evidence of this significance and carries it through into its findings and recommendations. How are the connections between different areas of the investigation made? How does the final report establish not simply what happened, but what the evidence tells us about why it happened and what must change?

An inquiry can produce a detailed historical record without necessarily resolving every question that prompted it. It can identify weaknesses in systems and decision-making without establishing individual responsibility. And it can make recommendations without ensuring they are implemented.

That distinction matters because the public expectation is rarely just that an inquiry will tell us what happened. People want to know why failures occurred, whether those failures could have been prevented and whether anything will be different as a result.

What happens when the inquiry ends?

Perhaps the most fundamental question about public inquiries concerns what happens when they finish.

An inquiry is temporary. Its hearings end, its reports are published and its team disbands. Responsibility then passes to governments, institutions and other bodies to respond to its findings. The body that gathered the evidence and made the recommendations is no longer there to track whether those recommendations have been implemented or whether they have made a difference.

A government response does not guarantee implementation. A recommendation can be accepted without being delivered effectively, and a commitment to change does not demonstrate that change has happened.

If inquiries are intended to prevent future failures, this is a serious weakness in the model. Recommendations need to be specific, with clear responsibility for delivery, timescales and measurable outcomes. There must be independent oversight and transparent reporting on implementation, continuing long after the inquiry itself has closed.

Public inquiries should not have to remain in existence indefinitely. But there must be a clear mechanism for carrying their work forward, monitoring progress and holding the relevant institutions to account.

Otherwise, we risk treating the publication of a report as the conclusion of a process when it should be the beginning of another: ensuring that the lessons identified lead to action.

Four nations, different responsibilities

The UK Covid Inquiry covered four nations whose governments made different decisions at different times and had different responsibilities. The pandemic was shared, but the responses were not identical. In Wales, the timing of decisions was a significant issue, from the initial response to the pandemic to the introduction of restrictions as infections rose later in 2020. Findings and recommendations therefore need to recognise where responsibilities lay and address the specific failures identified in each nation.

Despite the scale of the UK Covid Inquiry, the Wales-specific hearings and evidence attracted relatively little public and media attention in Wales itself. This was frustrating, given the importance of the decisions being examined. Ensuring that Welsh experiences, decisions and evidence were brought into the inquiry was a considerable undertaking. Yet the extent to which that work captured public attention raises a wider question about how effectively public inquiries engage the people whose lives they are intended to examine.

Scotland’s separate Covid inquiry raises questions about how national inquiries can complement a UK-wide investigation rather than duplicate work already undertaken. Separate inquiries may be justified where they can examine distinct responsibilities and unanswered questions, but their purpose and added value need to be clear.

I spent years calling for a separate inquiry in Wales because I believed Welsh Government decisions and the actions of NHS Wales needed closer examination. I still believe Wales-specific questions deserve answers. But the UK inquiry has made me consider more carefully what another inquiry would need to achieve.

Before establishing another process, we should ask what remains unanswered, what the existing evidence has already established and what additional value a Wales-specific inquiry or review would bring. Could it examine questions that remain unresolved and produce recommendations tailored to Welsh responsibilities? How would it complement the work already done? And, crucially, what would ensure its recommendations were acted upon?

The distinction between a statutory inquiry and a review matters, particularly when it comes to powers to compel evidence. But my experience of the UK Covid Inquiry has also demonstrated the limits of those powers. Despite being a statutory inquiry, it did not secure full disclosure from Welsh ministers and public bodies: evidence was withheld and deleted, and accounts given were inconsistent.

Nor did statutory powers guarantee that those called to give oral evidence would appear. Two Welsh Government ministers, Kirsty Williams and Ken Skates, were scheduled to give evidence but did not appear. Statutory powers do not, in themselves, guarantee that evidence will be fully disclosed, accounts tested or those responsible questioned in public.

These limitations make it all the more important to understand how the proposed Wales Covid-19 Review will operate before judging whether it can answer the outstanding questions and deliver meaningful accountability.

The question is not whether Wales should have an inquiry simply for the sake of having one. It is whether the process chosen is capable of answering the questions that remain and delivering the outcomes required.

Rethinking the model

I began this journey believing an inquiry would provide answers about my dad’s death. My experience has not led me to dismiss the importance of public inquiries. It has made me question whether their design and the follow-up to their findings are sufficient to deliver everything we expect of them.

Public inquiries remain essential when serious failures demand independent scrutiny. But establishing an inquiry is only the beginning. Its objectives must be clear, its structure must enable rigorous examination, and its findings must lead to recommendations that address the failures identified. There must also be a credible mechanism for monitoring implementation and assessing whether the changes have made a difference.

The answer to every unresolved question cannot simply be another inquiry. Nor should the difficulties of conducting a large inquiry be taken as a reason not to investigate serious failures. Instead, we need to ensure that each inquiry has a clear purpose, is designed to fulfil it and is supported by a system that carries its work forward after it closes.

Ultimately, the success of a public inquiry should not be measured by the number of hearings held or the length of its reports. It should be measured by whether it answers the questions that matter, whether its recommendations lead to action and whether the failures it identifies are less likely to happen again.

If an inquiry exposes what went wrong but there is no effective way to ensure that anything changes, has it fulfilled its purpose, or have we confused investigation with accountability?

Anna-Louise Marsh Rees was co-lead for Wales Covid Bereaved Families for Justice from May 2021 to December 2025. This article represents her independent views following her involvement in the first eight modules of the UK Covid Inquiry.

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