Turning Findings into Action: The Challenge of Implementing Public Inquiry Recommendations

Understanding Public Inquiries

Public inquiries in England and Wales serve a crucial role in uncovering the truth about events or conduct that have caused significant suffering and public concern. Their primary purposes are to create a publicly available record of what went wrong, provide accountability, and recommend practical and workable measures that, if implemented by Government, will prevent recurrence and improve systems, standards, and governance.

There are two types of public inquiry: non-statutory and statutory.

Statutory inquiries are governed by the Inquiries Act 2005 and Inquiry Rules 2006. The statutory inquiry Chair is empowered to compel witnesses to give evidence and to do so on oath, and to compel individuals and organisations to produce documents. Public inquiries are announced by Government ministers with the media often covering the announcement and ongoing inquiry. Examples of recent statutory public inquiries include the Southport Inquiry, the Nottingham Inquiry, the Thirlwall Inquiry, the Independent Inquiry into Afghanistan, the Post Office Horizon IT Inquiry, the Manchester Arena Bombing Inquiry and the Grenfell Tower Inquiry.

Non-statutory inquiries, for example the Manston Inquiry, Angiolini Inquiry, Cranston Inquiry and the Hillsborough Independent Panel, are not governed by legislation and that has pros and cons. They are more flexible and nimble, often taking less time to set up and being swifter to report. However, they lack the power to compel witnesses to give evidence or produce documents, though that may change if the proposals in the Public Office (Accountability) Bill (see our article here) are enacted.

Regardless of whether the inquiry is statutory or non-statutory, the Chair has no power to implement their recommendations, and the Chair’s role and powers end when their final report is submitted. The Government is expected to give careful consideration to the Chair’s proposals and respond to them formally with a publicly available statement of which are accepted and, in respect of any not taken forward, the reasons for this.

Some Chairs have taken novel approaches with the aim of exercising some measure of control over recommendation implementation. The Chair of the Infected Blood Inquiry indicated that the inquiry’s Terms of Reference would remain unfulfilled until there was a comprehensive adoption of the recommendations. The Chair of the non-statutory Independent Inquiry into Telford Child Sexual Exploitation provided for a two year review in the Terms of Reference enabling him to consider the local authority’s response to his recommendations.

Implementation of Inquiry Recommendations

All public inquiries are funded by the tax payer. Their potency (and value for money) is closely aligned with the number of recommendations accepted by Government and the precise way in which each is implemented. What, after all, is the point of Government commissioning these specialist, in depth investigations that are specifically tasked with advising on how to effect change and prevent future disasters, if the advice given is not accepted?

In 2024, the House of Lords Statutory Inquiries Committee called for a major overhaul of the public inquiry system to enhance efficiency and effectiveness. In its September 2024 Report “Public Inquiries: Enhancing Public Trust” the Committee stated that implementation of the following recommendations (see page 6) would make public inquiries more effective, cost-efficient, and increase public trust in the inquiry process:

• Establishment of a Parliamentary Public Inquiries Committee to: monitor the (non) implementation of inquiry recommendations, report on the same, and aim to drive through meaningful changes.
• Timescales for Inquiries to: promote transparency and understanding by means of a clear timetable and avoid unnecessary delays and excessive costs.
• Require inquiry Terms of Reference: to contain an obligation on Chairs and Secretaries to produce (at a minimum) a lessons-learnt paper on legal and policy challenges, and a working paper on logistics, providing an account of what went well for the inquiry and what could be improved in the future.

In February 2025, the Government responded to the House of Lords’ report re-iterating the importance of inquiry recommendations and agreeing to the establishment of a new monitoring committee.

The legal team advising the Thirlwall Inquiry (set up to investigate events leading to the conviction of neonatal nurse Lucy Letby) conducted a comprehensive review of recommendations made by 30 previous healthcare-related inquiries over three decades. The team’s findings revealed a concerning pattern whereby Government repeatedly implements inquiry recommendations in part only or not at all. To take three examples, the Royal Liverpool Children's Hospital Inquiry saw only 4 out of 67 recommendations implemented effectively, with 22 lacking clear evidence of any action. The Shipman Inquiry, which examined the actions of serial killer Harold Shipman, resulted in only 4 of its 33 recommendations being put into practice. Two years after the Independent Inquiry into Child Sexual Abuse reported, despite containing a module on Child Sexual Exploitation which might be thought to be a priority for the public, none of the recommendations had been implemented. This lack of progress on implementing recommendations had real world consequences, and some may argue that is one of the reasons that a further inquiry, considering CSE and grooming gangs, has been announced. The scale of the implementation gap is evidence of the systemic challenges that obstruct translation of inquiry findings into actionable and actioned reform.

When implemented, inquiry recommendations result in substantial positive change to policy and procedure. The four Shipman Inquiry recommendations adopted gave rise to tighter regulation of medical practitioners, the introduction of revalidation for doctors, and improvements in the monitoring of controlled drugs. The recommendation that medical certificates of cause of death should be subject to independent medical scrutiny resulted in the creation of the Medical Examiners service across England and Wales. The Mid Staffordshire Public Inquiry produced 290 recommendations aimed at transforming culture, transparency and strengthening patient safety across the NHS. This led to major reforms including legislative and regulatory change, such as the implementation of a statutory duty of candour and “Freedom to Speak Up” guardians. Further, as mentioned above, the Independent Inquiry into Telford Child Sexual Exploitation conducted a two year review to consider whether its recommendations had been implemented. It concluded that all organisations had implemented the recommendations to the Chair’s satisfaction and in some cases went beyond what he expected. 

Other notable examples of implementation success include:

• The Nimrod Inquiry, which investigated the loss of an RAF aircraft in Afghanistan in 2006 and focused on safety and maintenance failures, made 30 recommendations, 21 of which were accepted.
• The Hillsborough Independent Panel’s findings led to new inquest proceedings, catalysed significant change in how police handle major incidents, and resulted in the establishment of the Independent Office for Police Conduct (“IOPC”) and the Public Office (Accountability) Bill.
• The Grenfell Tower Inquiry Phase 2 report made 58 recommendations, including proposals for improvements in the construction, fire and rescue services and response and recovery industries. The Government committed to taking action on all 61 recommendations with a four year implementation plan, and a commitment to publishing progress reports. At the date of the last progress report in February 2026, eight of the Phase 2 recommendations had been fully implemented and 43 were still in progress and four out of six Phase 1 recommendations were also complete.
• The Infected Blood Inquiry made 12 core recommendations with 58 sub-recommendations. 16 of the sub-recommendations have been accepted, 20 have been accepted in principle and 22 have received a ‘mixed response’ with different levels of engagement across the administrations. The Infected Blood Inquiry has a published recommendations dashboard so that members of the public can track progress.
• The Cabinet Office also created a Grenfell Tower Phase 2 recommendation implementation dashboard suggesting that this innovation may become the norm.

Conclusion

Public inquiries, however constituted, are vital instruments for addressing significant societal problems, crises and disasters, providing much needed transparency, accountability, and justice. But the truest measure of the lasting success of each of them lies in the effective implementation of their recommendations.

Turning inquiry report findings into actionable change remains a complex challenge. Enhancing the ability of inquiries to foster systemic change requires a post-report multifaceted approach from Government and from all of the stakeholders involved. An expectation that Government will accept inquiry recommendations, transparent and workable timelines for implementation appropriate to the scale and seriousness of the problem being addressed, robust monitoring of implementation mechanisms to ensure that they are fit for purpose, follow up where implementation is delayed or ineffective, and a genuine muscular culture of accountability within institutions are all essential and are currently lacking.

To date, inquiry Chairs have had little power to ensure that their reports translate into a legacy of real world improvement in safety, health, protection, and governance. Some, however, have found ways to retain oversight of implementation after publication of their final reports. In 2025 the Government accepted that it had further work to do in relation to delivering effective implementation of inquiry recommendations and further updates, including in relation to a statutory duty of candour, can be expected.

This article was co-authored by Katie Gollop, KC of Serjeant’s Inn