When something goes seriously wrong in healthcare, whether it’s widespread patient harm, institutional failures, or persistent safety concerns, the public rightly demands answers. One of the most powerful tools available to uncover truth, assign accountability, and drive reform is the public inquiry.

As a solicitor working at the intersection of clinical negligence and public inquiries, I’ve seen first-hand how these legal processes don’t just examine what went wrong, they can shape the future of healthcare.

In June 2025, newly appointed Health Secretary Wes Streeting announced a rapid national investigation into NHS maternity and neonatal services, in direct response to the mounting evidence of repeated failings across multiple NHS Trusts. The announcement marks a pivotal shift in approach, signalling that the government recognises the urgency of tackling systemic issues, not just isolated incidents.

What is a Public Inquiry?

A public inquiry is a formal investigation ordered by the government, typically led by a judge or senior legal figure, into events that have caused public concern. Unlike internal reviews or inquests, public inquiries are independent, transparent, and designed to restore public trust. Importantly, they don’t apportion blame, but they can criticise and more importantly for those affected create accountability and change.

Exposing Systemic Failures

One of the primary functions of a public inquiry is to identify patterns and systemic failings that go beyond individual error. Whether it’s the failings of Mid Staffordshire NHS Foundation Trust or the more recent Thirlwall Inquiry, these inquiries have revealed deep-rooted problems in healthcare systems, from chronic understaffing and poor leadership to toxic workplace cultures.

In my role, supporting clients affected by such failings, I’ve seen how the public inquiry process gives voice to people whose experiences might otherwise be dismissed or overlooked. Their testimonies often form the backbone of the inquiry’s findings, ensuring the human cost of failure is never forgotten.

In the Thirlwall Inquiry into the crimes committed by former nurse Lucy Letby, I had the privilege of representing families whose babies were tragically affected. The voices of the parents were central to the inquiry’s work, shaping the direction of evidence, highlighting failings in clinical practice and governance, and pushing forward the accountability that families so desperately deserve.

The latest rapid national investigation into NHS maternity and neonatal services, which builds on the foundations laid by the Ockenden and Kirkup reports, will have a broader national remit and aims to deliver initial findings by 2026. It’s a powerful acknowledgment that the problems in maternity care are persistent, widespread, and deeply rooted. For the families affected and the professionals trying to deliver safe care in broken systems, it offers a long-overdue commitment to action and accountability.

Catalysts for Reform

Inquiries do not operate in a vacuum. Their recommendations, often extensive and hard-hitting, frequently lead to real-world policy changes.

Examples include:

• The introduction of the Duty of Candour following the Francis Inquiry.

• National reviews and overhauls in maternity services after the Ockenden and Kirkup inquiries.

• New safeguarding frameworks after the Independent Inquiry into Child Sexual Abuse (IICSA), which also highlighted health sector shortcomings.

Although the process isn’t perfect, the transparency helps to restore public trust.

Healthcare regulators, professional bodies, and NHS Trusts are compelled to respond, often through revised protocols, new training standards, and tighter governance structures. While implementation can vary, the momentum created by an inquiry is difficult to ignore.

It is my sincere hope that, following the Thirlwall Inquiry, a clear system of tracking those recommendations which have been implemented is put in place: there is no doubt that doing so would be an important step in tracing the effectiveness of Inquiries as a whole.

Supporting Those Involved

For those called to participate, whether as witnesses, core participants, or families of those affected, the inquiry process can be daunting. Legal support is critical, not only to navigate complex procedural rules but to ensure that their voices are heard with dignity and clarity. Part of my role as a solicitor is helping clients engage fully and meaningfully, while protecting their rights and wellbeing throughout what is often an emotionally charged experience.

Holding Systems to Account

Public inquiries are not about assigning individual blame, they are about learning, improving, and ultimately preventing future harm. However, I believe accountability is important to those affected, and a mechanism to hold those responsible must follow.

In healthcare, where the stakes are literally life and death, this is particularly important. As legal professionals, we have an essential role in ensuring that these processes deliver on their promise, and that meaningful change follows.