Whether it’s responding to the systematic mistreatment of Post Office sub-postmasters or perceptions of institutional failure to protect children from group-based sexual exploitation, the government’s first instinct is familiar – to announce a public inquiry.
The move is simultaneously procedurally correct and politically convenient. It signals seriousness, but buys time to defer the hardest questions until after the intensity of the public eye has largely moved on.
The public inquiry has become the signature instrument of accountability in modern British governance. The numbers tell their own story. Between 2005 and 2025, 63 inquiries were launched across the UK, compared with 41 in the 20 years prior, according to the Institute for Government (IfG).
Between 2017 and 2025 alone, 19 inquiries were announced – the same number as had been announced between 1960 and 1990 combined. As of January 2026, there were 26 inquiries ongoing or announced – the most ever at one time.
In the age of social media, where victims' voices can reach a national audience within hours and political pressure can build overnight, governments have found it harder than ever to resist the call for a formal reckoning.
The inquiry has become the default setting at considerable expense. A report published by the House of Lords Statutory Inquiries Committee in November 2024, titled ‘Public inquiries: Enhancing public trust’, found the direct public cost of ongoing UK inquiries exceeded £130m.
Inquiries that had published their final report within the previous half decade had taken an average of nearly five years to complete their work, commanding huge staffing capacity as well as financial resources.
Perhaps the most startling statistic is another from the IfG showing that between 1990 and 2024, 54 inquiries made 3,175 recommendations.
With such a huge number of actions to wade through when the public organisations under the inquiry microscope are already stretched in delivering their statutory duties, a question emerges: what happens to the recommendations once the final report is published and the inquiry team disperses?
It’s one that has begun to dominate discussion in legal and policy circles, and the answer too often appears to be very little.
The implementation gap
The Lampard Inquiry, which is investigating mental health inpatient deaths in Essex, has commissioned a research paper by Dr Emma Ireton, Associate Professor at Nottingham Law School, that provides the most rigorous recent analysis of the implementation problem.
Its findings are sobering. Inquiry recommendations are not legally binding. Dr Ireton said this is deliberate to ensure responsibility for decision-making remains with democratically elected officials accountable to Parliament and the public. But the absence of legal compulsion makes it more challenging to track progress on implementation and it could be argued creates a culture of indifference.
The Inquiries Act 2005 does not require the government, public bodies or other organisations to respond to inquiry recommendations, explain why any are rejected, or even formally acknowledge an inquiry's findings – a position that has been widely criticised.
It is not uncommon for inquiry recommendations to be accepted in principle but implemented only partially, diluted, delayed or ultimately forgotten.
The human cost of this failure is crystallised by a single, damning example. The Statutory Inquiries Committee heard evidence that had the recommendations from the inquiry into deaths at the Bristol Royal Infirmary in 2001 been implemented, the patient deaths investigated by the Mid-Staffordshire Hospitals Inquiry in 2013 “may have been less likely to occur”. The same systemic failures were identified, the same kinds of recommendations were made, and yet history repeated itself at the cost of patient lives.
During a Shared Insights session run by Browne Jacobson, Eleanor Grey KC, of 39 Essex Chambers – one of the most experienced practitioners at the Bar in the field of public inquiries – highlighted the scale of the problem in practice.
At the launch of the Thirlwall Inquiry, an 850-page document was published listing recommendations in the healthcare sphere going as far back as 1967, together with a table of comments from the Department of Health and Social Care.
The absence of “green” entries – evidence of implemented recommendations – was striking. Even where core participants in that Inquiry argued that implementation was considerably better than the table showed, it nonetheless demonstrated the fundamental difficulty of tracking whether anything has actually changed.
A recurring theme of public inquiries over recent years is that people simply do not know how many recommendations have been made, or what they are.
This is not merely an administrative inconvenience. It goes to the heart of what public inquiries are supposed to achieve. The Statutory Inquiries Committee described the failure to implement accepted recommendations as “inexcusable”, warning that it “risks the recurrence of a disaster and undermines the whole purpose of holding an inquiry in the first place”.
The governance dimension
Framing this solely as a problem of government inaction, however, tells only part of the story. At our event, Moosa Patel, Director of the Office of Modern Governance, drew on his extensive experience reviewing NHS governance failures to illustrate how organisations themselves contribute to the problem.
Common reasons why organisations fail include lack of strategic focus, failure to follow process, not using the right data and information for reporting or forecasting, the dominance of personality and group-think, and failing to attend to the culture of the organisation.
Moosa cited a 2018 report into widespread failings surrounding a community health trust as instructive. Despite a seemingly robust governance structure, there was a single-minded board focus on achieving Foundation Trust status at the expense of everything else.
The district nursing workforce was cut by 50% without anyone on the board asking what the impact would be on services or staff. The board was inexperienced and very much led by an executive who ran the organisation at the expense of non-executive board members.
It provided an uncomfortable lesson in how the appearance of good governance – featuring initiatives such as committee structures, risk registers and staff surveys – provides no guarantee that an organisation is actually responding meaningfully to recommendations directed at it.
Safeguarding boards will often issue what they believe are good recommendations, receive assurance on implementation, but when they look more closely it is a completely different picture on the ground.
There is also a practical capacity problem. A 2024 report by the Health Services Safety Investigations Body highlighted that recommendations aimed at improving quality and safety in healthcare are issued by multiple stakeholders, both within and outside the system, often in high volume and without co-ordination.
Duplication in messaging, the report said, “creates ‘noise’ that makes it difficult for providers to prioritise and implement actions”. Public bodies can find themselves simultaneously subject to national inquiry recommendations, local coroners' reports, and a raft of independent reviews – some of which contradict one another.
The question of who determines the risk rating that applies to recommendations, and in what order they should be implemented, is a critical one that many organisations have not properly resolved.
Path to public inquiry reform
There are encouraging signs that the system is beginning to take seriously the implementation issue, even if the pace of reform has been frustratingly slow.
The Statutory Inquiries Committee's report proposed the creation of a dedicated parliamentary Public Inquiries Committee. Its remit would include publishing inquiry reports and government responses in a single place online, monitoring implementation of accepted recommendations through policy research, correspondence with government departments and evidence sessions with ministers and officials, maintaining a public online tracker showing the status of individual recommendations, and conducting thematic analyses across inquiries to identify systemic policy failures.
The government acknowledged in its February 2025 response that “too often” there had been “insufficient transparency and accountability” regarding the implementation of inquiry recommendations. However, the proposed committee has not yet been established.
The Lampard Inquiry's paper also points to a powerful model from Australia – the independent implementation monitor. In some cases, this approach has led to 100% implementation of accepted recommendations.
Rather than relying on self-reported assurances, implementation monitors take a “don't tell me, show me” approach, verifying progress on the ground through direct engagement and site visits, and reporting directly to Parliament at least annually. This model deserves serious consideration in the UK context.
In the meantime, those of us advising public bodies can’t wait for systemic reform to arrive. Public bodies need to ask what their governance arrangements are to ensure they implement the recommendations directed at them. They must also consider whether their governance model needs to change and adapt to embed implementation and assurance.
This means investing in genuinely robust corporate governance functions, establishing clear board-level ownership of recommendations, and maintaining honest – rather than performative – assurance processes.
Taking a systems approach in terms of something going wrong and looking at it from a board perspective can mean nothing to those with trauma if they do not feel as though justice has been delivered.
The victims of the Grenfell Tower fire, Hillsborough and countless other tragedies have given evidence to inquiries at immense personal cost, trusting that doing so would produce change. The least the system owes them is to ensure the recommendations made in their names are properly implemented – not retrofitted around what was already being done, or partially accepted and quietly shelved, but genuinely implemented and independently verified.
The UK has become very good at holding inquiries. It is time to become equally good at learning from them.
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