My Lords, this is a probing amendment to enable debate on the concept of a new national oversight mechanism. The amendment proposes:
“The Secretary of State must launch a review into the merits of introducing an independent National Oversight Mechanism responsible for collating, analysing and addressing recommendations arising from the post death processes of investigations, inquests, public inquiries and official reviews following a major incident”.
With regard to public inquiries, there is no legal mechanism to require consideration, action or reasoned rejection of a recommendation made in the course of a statutory inquiry under the Inquiries Act 2005. In other words, recommendations made by a statutory public inquiry or a non-statutory inquiry have no legal force on the Government, public authorities, corporations or anyone else.
With regard to coroners’ prevention of future death reports, a large proportion of public bodies that receive recommendations fail to respond, and analysis using the Preventable Deaths Tracker developed by researchers at the University of Oxford found that only 33% of all PFDs issued by coroners had expected responses published, with 29% of responses overdue. Further, the researchers found that response rates to PFDs examined in 25 of their studies ranged only from approximately 10% to 60%, with no study resulting in a 100% response rate.
The Grenfell fire is a shocking example of this accountability gap. In 2009, the Lakanal House fire killed six people in a 14-storey tower block in Camberwell. Following the inquest into their deaths, the coroner, Frances Kirkham, made recommendations to the Secretary of State, the Mayor of London, the London Borough of Southwark and London Fire Brigade. These included making crucial improvements to building regulations, control room and incident command system training, awareness of the risk posed by cladding fire, and guidance on high-rise residential evacuation. In 2017, the Grenfell Tower fire killed 72 people in a 24-storey tower block in North Kensington. The Grenfell Tower inquiry exposed the fact that many of the Lakanal House recommendations were not implemented before the fire. Implementation was not considered to be urgent and was instead included in a medium to long-term programme of work.
During the inquiry, Dame Melanie Dawes, the former Permanent Secretary at the Department of Housing, Communities and Local Government, told the inquiry that
“there was no tracking recommendation put in place, something that I think was really important and there should have been”.
The lack of a mechanism was described as a gap in the Civil Service that
“could have happened in any department”.
The department itself stated that it missed the opportunity to look beyond recommendations and consider the widespread use of non-compliant materials on high-rise buildings and the associated risk of fire. That is just one example.
To address this accountability gap, the lobbying group Inquest, through me, is calling for the Government to establish a national oversight mechanism, which would be an independent public body responsible for collating, analysing and following up on recommendations arising from four post-death processes: investigations, such as those carried out by the Prisons and Probation Ombudsman, the Independent Office for Police Conduct or serious incident reviews; inquests; public inquiries; and official reviews into deaths, such as the Angiolini review into deaths and serious incidents in police custody. Inquest has put forward a mechanism by which this could be achieved, through the collation, analysis and follow-up of the data.
This amendment calls for a review into the processes and merits of creating such a mechanism. I look forward to hearing the Minister’s response and hope that he will commit to undertaking such a review. I beg to move.
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