The truth is out there

Oct 23

Public inquiries are cathartic for grieving families but often fail to address the very failings they identify.

In recent years, public inquiries have become part of the fabric of our political life. Their recommendations are often the platform for major public policy changes.

When powerful organisations and government agencies appear to fail in carrying out their responsibilities, sometimes causing catastrophic human tragedy, there has to be a mechanism in place to effect change. Usually such inquiries follow a major disaster or matter of controversy, where there is suspicion on the part of the community involved – such as the parents whose babies died at Bristol Royal Infirmary and the families whose relatives were murdered by Harold Shipman. They are looking for the truth to be discovered in a wholly independent forum where lessons will be learned and recommendations will be made to make sure something similar cannot possibly happen again.

But most importantly they want complete transparency – for the search for the truth to be conducted in public with proper scrutiny open to all. And while inevitably part of that truth will be attributable to some human failing or misdemeanour, it is the exposure of evidence of systemic failure which is vital to identify where and how change must occur.

And there must be change if a similar tragedy is to be prevented. Believe it or not, before the Laming Inquiry into the death of Victoria Climbie, there had been a staggering 70 public inquiries into recent child abuse cases, producing thousands of recommendations. Yet scandalously children were still dying. often in horrific circumstances. How many of those deaths could have been avoided?

So how effective is our public inquiry system? Could it be more effective and, if so, how might it be improved?

As a clinical negligence lawyer, I acted for families involved in a number of inquiries, most notably Shipman. In that case the families even had to judicially review a government decision to hold the inquiry behind closed doors. And yet the subsequent inquiry, chaired by Dame Janet Smith, concluded that Shipman had killed more than 215 of his patients and identified extensive failings in the systems in which general practitioners operate – loopholes which Shipman had used to escape detection.

I am often asked what the point of a public inquiry is and whether the millions of pounds spent are justified. Recently, I interviewed a number of people who have worked on or ran inquiries to find out how they work, whether they really do work, and whether lessons are learned and changes implemented.

Lord Laming told me that a balance must be struck between thoroughness, fairness and efficiency. After all, while individuals will be open to criticism, an inquiry is a means of strengthening the accountability that we should expect of individuals and organisations that have power over the lives of others.

But after the government has considered the weighty reports and reflected on the evidence taken, what then? As former health secretary Frank Dobson told me, that’s all they are: recommendations.

In a Radio 4 documentary, I have explored not only the emotional dimension of dealing with major human tragedies, but also the search for truth. And while, for many, a public inquiry is undoubtedly cathartic, what still needs to be done?

Since the Shipman Inquiry, I know that the government has still not implemented many of Dame Janet Smith’s recommendations, even though it formally accepted them. And there isn’t even a timetable to do so. There are some reasons for this: ministers are reshuffled from department to department; inquiry chairmen have no continuing responsibility and will in any event have moved on in their lives. I ask whether a mechanism must be put in place to make sure that, after the media spotlight dims, something is done to ensure those institutional and systemic failings are a relic of the past.

  • Public Inquiries, researched, written and presented by Ann Alexander and produced by Jim Frank, will be broadcast as part of the Analysis series for Radio 4 on Thursday 30 October at 8.30pm, repeated on 2 November at 9.30pm. To comment, visit after the broadcast.

Ann Alexander, formerly senior partner of Alexander Harris, now runs a media and communications training consultancy (

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