Transcript of Module 2 Public Hearing on 3 October 2023

(10.30 am)

Opening Remarks by the Chair

Lady Hallett: Good morning to all those present in the hearing room, and to those following us online.

Today marks another important milestone for the Covid-19 Public Inquiry United Kingdom. We begin the public hearings into the response to the pandemic. The focus of Module 2 will be on governance and key decision-making at a high level in the United Kingdom, during the time when the pandemic was at its worst and when it caused so much suffering.

Some of those who suffered and who continue to suffer maintained a dignified presence outside the hearing centre this morning to remind us of why we are all here. We will be hearing from some of them during the course of this module.

We will be calling many witnesses, advisers, experts, scientists, politicians and civil servants, but I’ll also hear from about 15 witnesses who will describe the suffering and the problems faced by various groups during the pandemic.

First, I will hear from four representatives of bereaved families. They will be followed by experts on ethnicity, later life, children and young people, frontline and key workers, sex and gender, disabled people, LGBTQ+ and long Covid.

Their evidence will enable us to put the decision-making into context and to help us establish the extent to which decision-makers took into account the interests of such groups and the impact on them when making their decisions.

I know that some of the bereaved have campaigned for me to call more bereaved as witnesses during this Inquiry. I understand their concerns. However, we simply do not have the time to call more witnesses. The need for me to reach conclusions and make recommendations to reduce suffering in the future, when the next pandemic hits the UK, is pressing. I say “when the next pandemic hits the UK” because the evidence in Module 1 suggested it is not if another pandemic will hit us, but when.

The more witnesses we call in any module and the longer the hearing takes, the greater the delay in making recommendations and the greater the delay in hearing other important modules investigating, for example, care homes and children and young people.

I have therefore had to find other ways, with the Inquiry team, to make sure the voices of those who suffered during the pandemic are heard. The Inquiry is not ignoring the bereaved or any other group who suffered; far from it. They may be called as witnesses in later modules where there will be a greater focus on the impact of the pandemic or where they can assist me on the subject of systemic failings. They can contribute to the listening exercise, Every Story Matters, the reports from which I will consider very carefully and which will inform my conclusions and recommendations. Some of them may contribute to the impact films, one of which we are about to see.

14 people from across the United Kingdom have been recorded talking about the devastating impact the pandemic has had on their lives and the lives of their families. The film includes references to bereavement, to grief, to care homes, hospital wards, funerals, feelings of guilt, feelings of anger, loneliness and isolation, long Covid in adults, long Covid in children, mental health, physical disability, and to lockdown rule breaking. I am extremely grateful to all those who have agreed to participate. I know how difficult it must have been for them to recount their experiences on camera.

As with the impact film we showed at the beginning of Module 1, this film too is extremely moving, and there will be those who will find it too distressing to watch. I will pause in a moment to allow those who are in the hearing room who wish to do so to leave for a few minutes. They will be taken to a part of the building where the film will not be shown. The film lasts just over 20 minutes. Those who are following online should press mute or pause the streaming if they do not wish to watch it.

After the film has been played, we shall reassemble, and Mr Keith KC, Counsel to the Inquiry, will begin his opening submissions. He will explain in far more detail than I have done what we shall be examining in this module and what the issues are that I need to resolve, with the help of Counsel to the Inquiry and of course all the core participants.

So would those who would like to leave the hearing room or switch off the streaming online please do so now.


(Video played)

Lady Hallett: We shall now reassemble to hear Mr Keith’s opening submissions.


Lady Hallett: Mr Keith.

Statement by Lead Counsel to the Inquiry

Mr Keith: My Lady, we turn today to the Inquiry’s consideration of how the highest levels of government, senior ministers, civil servants, advisers and scientists, responded strategically to the crisis that enveloped the nation.

In Module 1, the Inquiry considered the state of the United Kingdom’s emergency preparedness, response and resilience structures at the time just before SARS-CoV-2 commenced its deadly work.

Module 1 asked in essence: were those structures and systems ready for what befell us? The prior question of whether the right groundwork had been laid and the extent to which the civil contingencies framework anticipated a pandemic of this nature was a necessary one, because it provided the vital context for the decisions that the government had to make as the pandemic began to unfold. And so the Inquiry now examines how well the government discharged those decisions, that decision-making process, the essential burden that is placed on all governments of safeguarding the life and health of its citizens.

In the momentous decisions that the government took concerning the control of the virus, the lockdowns, the social restrictions, the shutting of businesses and schools, did the government serve the people well, or did it fail them?

How is this to be measured? The virus left in its wake, of course, not just death but injury, incalculable hardship and misery, as those heartfelt and terrible recollections of a few moments ago remind us.

However, if the protection of life is the pre-eminent duty which every government owes to the people, the numbers of those who died is the marker against which the government’s response must be judged. This is the stark metric which matters most. Death, my Lady, was the inevitable consequence of a runaway high-consequence infectious disease, and the prevention of death should arguably have been the government’s primary obligation.

The number of deaths across the United Kingdom calculated by whether Covid-19 is mentioned on the death certificate is now over 230,000. By the measure of excess deaths or excess mortality, the figures are likely to be similar.

That is, by any measure, a shocking figure, and a terrible loss of life. It is almost one too large to comprehend, and the testimonies which you’ve heard remind us that each death represents the loss of an individual, often in circumstances which makes their death even harder to bear for their families and friends, and which multiplied their grief many times over.

So standing back and in the broadest possible terms, such loss of life demands the question: did it have to be that way? That question must be inquired into and answered by your Inquiry. The bereaved and those who otherwise suffered, of whom there are very many in number, are absolutely entitled to nothing less.

The consequences of the lockdowns were, of course, grievous too. In societal terms, there was an explosion of mental health disorder, an entire generation of educational prospects was harmed, pre-existing inequalities were seriously exacerbated. Non-Covid health conditions went untreated and undiagnosed. In economic terms, there was a 10% fall in GDP in 2020. Public finances were seriously damaged, and massive debts were incurred. Were those appalling consequences avoidable?

A related vital issue in this module is the position of the vulnerable and at-risk groups, and the extent to which the government assessed the likely impacts upon them of its contemplated non-pharmaceutical interventions, that is to say the interventions that the government imposed that were non-drug or vaccine related.

Given the importance of this issue, and because it runs throughout the module, I introduce it now. How was the danger to health posed by the virus weighed up against the risk of societal and economic damage to vulnerable and at-risk groups? To what extent was the possibility of serious long-term health consequences arising from the NPIs foreseen and addressed?

Tomorrow you’ll start to hear from representative witnesses from the bereaved groups. Later this week you will hear evidence relating to the impact of the pandemic on certain vulnerable and other demographic groups in society. That evidence will address the pre-existing structural inequalities that those groups faced before 2020 and the exacerbation of the inequalities caused by the pandemic and the measures taken to combat it, in particular the lockdowns.

So, in the course of this module, we’ll be exploring whether the interests of all those groups were properly considered. Later in the module, we’ll be hearing from Dame Priti Patel, the then Home Secretary, Kemi Badenoch MP, then Minister for Equalities, and Justin Tomlinson MP, then Minister for Disabled People.

Also amongst those who suffered, and indeed continue to suffer from Covid, are the victims of the post viral syndrome that is known as long Covid. In March this year, the Office for National Statistics, the ONS, estimated that 1.9 million people were suffering from self-reported long Covid. Long Covid gives rise to other questions, in particular whether developing understanding of the condition during the pandemic was taken on board and acted upon appropriately by decision-makers, questions we shall explore in the course of the hearings.

My Lady, I’ve referred to the government’s core highest level decision-making, and I must emphasise that the focus of Module 2 is on the most important strategic decisions that were taken.

Past public inquiries have attempted to give definitive accounts of relevant events, decisions, consequences, and of the entirety of the relevant technical or scientific hinterland. It is simply not possible to do so here. No Inquiry, however large, however long, could possibly enquire into all aspects of the government’s decision-making on Covid, because of course the pandemic and the government’s response impacted on virtually every area of public and private life. It would be an impossibly complex task.

You have instead determined that the module will focus on those aspects of the central government’s core response, in essence the Westminster decision-making, that had the potential for the widest effect, had the greatest impact, and which caused the most public concern.

Modules 2A, B and C will look at the analogous position in Scotland, Wales and Northern Ireland. So this Inquiry will enquire into, probe and challenge those core decisions to see if they were made on the best information, after proper consideration, as part of a well-ordered process and without undue delay or unnecessary prevarication.

There will also necessarily be a greater concentration on the events of January to March 2020, because to some extent the events of those extraordinary days and the government’s response charted the course of what was to come.

The virus became established, and this inalienable fact dictated all that followed. In responding to the virus by way of the imposition of the lockdown in late March, the government took the profound step of essentially shutting down society, and it set in motion a host of other consequences, the effects of which are still being felt today.

An essential part of the Inquiry’s work is therefore to understand whether the proper strategic objectives were identified. Why were the major strategic decisions taken as they were? Did the systems for reaching them work? How can we improve the crisis response machinery? It is absolutely essential to know before we have to face the next national crisis.

This module is therefore no less than a rigorous examination of how strategically the Prime Minister, Number 10, the Cabinet, senior ministers and their scientific and political advisers grappled with the crisis.

So, to this end, the module will be hearing from a range of scientists and academics both from within the many government committees that were constituted to give the government advice and from outside.

It will hear from many of the relevant secretaries of state and the then Chancellor of the Duchy of Lancaster, Michael Gove MP.

It will also be hearing from senior civil servants in Number 10, the Cabinet Office and the DHSC, past and current Cabinet secretaries, relevant permanent secretaries, and some of the former Prime Minister’s principal private secretaries.

We will hear from his chief of staff, his director of communications and certain of his special political and other advisers.

Lastly, we’ll be hearing from the then Prime Minister, Boris Johnson, himself, and the current Prime Minister, Rishi Sunak MP.

It is, of course, impossible to call every witness who can give evidence relating to the core high-level decision-making. Your Inquiry has neither the time nor the resource for this, and the general public would not wish it to be so.

I emphasise the focus on the core decision-making because it is that decision-making that affected the whole country. The more detailed scrutiny of the NHS response, the care sector, shielding, vaccines, PPE, procurement, test and trace, financial and business support, children and education, and many other areas, are for later modules, and you’ve referred to them already in your opening this morning.

So with that introduction, may I now introduce the stark reality of the pandemic.

Could we have, please, INQ000283367 on the screen.

This chart, entitled “Daily deaths with COVID-19 on the death certificate by date of death”, shows the number of deaths where Covid-19 was mentioned on the death certificate for the whole of the United Kingdom.

We can see from that chart that the peak of the first wave was 8 April, with 1,461 deaths occurring on that day. The peak of the second wave was 19 January, with 1,490 deaths. Similar waves occurred from late 2021 onwards, the highest peaking on 15 January 2022, with 260 deaths.

The following chart is a chart concerned with what is called “All-cause deaths in the [United Kingdom] - weekly”. This chart, taken in fact from public media – and we’re grateful to the organisation in question for its production – shows all the deaths that occurred in the United Kingdom, not just those caused by Covid, but all the deaths reported by all the official statistical agencies.

The expected number of deaths per week, based on an average from recent years, is denoted by the dashed black line. The red shaded area shows the actual number of deaths above, therefore, what was expected. The grey shading under the dashed line shows actual deaths at or below expected levels. Obviously, in those places and at those times where we can see the red shading, the deaths were above those grey expected levels.

The sharp dips are due to fewer deaths being reported on bank holidays rather than a real decline or, on one occasion, because there was a recalibration or calculation of the chart.

The peak of the deaths in the first wave, we can see, was considerably higher, reaching almost 25,000 in that week, double the usual number.

The peak was not as high in the second wave, but the second wave lasted over a longer period, the extent of the red shaded part, leading to a similar number of excess deaths in both waves.

The third chart shows hospitalisations across the United Kingdom. This chart shows the daily count of how many Covid patients were in hospital across the United Kingdom from 1 April 2020. The peak of the wave was, as we can see, around 12 April, with over 21,000 persons, patients in hospital. The peak of the second wave was around late January, with nearly 39,000 patients in hospital.

Up to September 2022, around 986,000 people had been admitted to hospital with Covid, and that figure is now well over 1 million. We can see a reference to the September 2022 figure in the bottom right-hand corner of that chart.

Could we now then move to chart 5, please, the reported cases of infections. This is entitled “Cases by specimen date”, but it actually shows the cases of infection in the United Kingdom following their reporting. It shows the number of infections per day over the whole of the United Kingdom.

The peak of the first wave was, as we know, of course, April 2020, but it doesn’t show on this chart, because it’s a chart that shows the reported cases, and there was, at that stage, very little by way of reporting. The under-reporting of cases was, as you know, particularly severe in the first wave.

The Alpha variant first emerged in Kent, around September 2020, and by the time of the peak of the second wave, 29 December, it was responsible for the vast majority of infections nationally. We can see – by way of reported cases, again I emphasise – the numbers going up in October 2020 and peaking in January 2021.

The next wave, primarily of the Delta variant, peaked on 15 July with around 62,000 confirmed cases. Then, and by this time of course the degree of reporting had become a great deal better, the huge Omicron wave, which peaked in January 2022 with over 275,000 confirmed cases.

The next chart, chart 6, is the ONS infection survey. It shows the results of a survey carried out by the Office of National Statistics for England, Wales, Scotland and Northern Ireland, and it gives a more accurate estimate of the true proportion of the population who were infected with the virus at any one time, because it works on the basis of a representative sample being taken across the United Kingdom and then extrapolated into these figures.

It also identifies patients or persons who had no symptoms, and they of course account for a very large minority of the persons, overall number of persons who were infected.

It didn’t in fact start reporting data until after the first wave was over, and that is why you will see very little by way of figures, estimated percentage, in the first few months up to September 2020.

But antibody surveillance, that is to say testing of the presence of antibodies in blood, shows that approximately 6% of the population had been infected by July 2020, ten-fold higher than the reported positive tests.

The arrows in the bottom left-hand corner of the chart show when results first became available, in blue for England, green in Wales – I think Wales in July, Northern Ireland in September, the red arrow, and Scotland in October, indicated by the yellow arrow.

Despite what we saw on the previous graph, at the peak of the second wave there were probably over 1 million people, therefore, infected across the United Kingdom, and at the peak of the Omicron wave, in 2022, there were perhaps as many as 5 million people infected, a very large percentage of the overall population.

The final chart, my Lady, chart 7, shows a comparison of official excess deaths statistics from a handful of other countries. We’ve selected them for illustrative purposes, and this isn’t intended to be a comprehensive ranking. There are obviously many more countries in the world than are demonstrated on this chart.

It shows, adjusted for population size, because of course each country has different sizes of population, the cumulative, the running total, excess of all-cause deaths that has built up over the pandemic, rather than taking a snapshot of the weekly figures.

It’s vital to understand that there are, of course, differences between these countries, and excess deaths, which is the genesis of this chart, are not solely affected by government decisions but depend on the proportion of elderly people, household composition, single or multigenerational, trust in government, travel connections, pre-pandemic resilience, and a host of other factors.

But a broad comparison is still useful. It shows, for example, here that the United Kingdom had a lower burden of excess mortality than indeed many countries. The example that we’ve chosen here is Italy, which had a greater degree of excess death than the United Kingdom. So we were by no means the hardest hit, but we did have a higher burden in terms of the calculation of excess deaths than many other countries, and we’ve put on this chart France, South Korea, Sweden and Denmark.

Some other figures, my Lady, are of no less importance. The direct impact of severe disease and death due to Covid did not fall equally. Older people were, as we all know, at particular risk. The median age at death in the United Kingdom at the beginning of the pandemic was 83. The median age of persons who died was 82.

In the first wave more than 80% of the approximately 50,000 deaths occurred in those over 70. Those over 70 had a 10,000 times greater risk of dying as those under 15.

Years of life lost is one way of estimating how long someone would have lived had they not died. On average, each person who died with Covid lost over ten years of life. Of course age is not the only factor that led to stark inequalities and deaths from Covid, although no other individual factor has a stronger effect. Mortality was 2.6 times higher in the most deprived than the least deprived tenth of areas. People from some ethnic minority groups had a significantly higher risk of being infected by Covid and dying from it. Covid-19 mortality during the pandemic has been highest in people from the Bangladeshi, Pakistani and black Caribbean communities. Mortality rates were higher amongst people with disabilities, in particular those with a learning disability.

While women can expect to live longer than men, so would lose, theoretically, more years of life if they died at the same age, men have been up to twice as likely to die from Covid as women of the same age.

Finally, my Lady, the issue of flu. Covid has been compared by some to seasonal flu in its effect. In a bad flu year, around 30,000 people in the United Kingdom die from flu and pneumonia, with a loss of around 250,000 life years, and that’s in a context, of course, in which there are few or no social restrictions or non-pharmaceutical interventions put into place to control transmission.

That figure is one sixth of the 1.5 million life years lost to Covid in the first year of the pandemic, despite the extensive non-pharmaceutical interventions which were, as we know, put into place.

Those figures expose the underlying reality. Once infected, death was, for that desperate minority, inevitable. But infection was not inevitable. The figures show a massive difference in mortality rates between the United Kingdom and, for example, South Korea. The overarching question for you in this module will be whether the massive casualties of the first and second waves were the direct result of a plain and obvious failure to put in place proper infection control across the country. Why was that so, if that is what you conclude?

The Covid-19 Bereaved Families for Justice and the Northern Ireland Covid-19 Bereaved Families for Justice point out in their submissions that the United Kingdom is a wealthy country, with mature scientific, academic and administrative frameworks and a very substantial health system, if struggling somewhat of late.

The government knew, just as well as other countries, that the virus was coming. In fact it had greater notice than some, by virtue of our island status and being on the western edges of Europe. So why did so many deaths occur?

To start answering that question, I need to turn to the early days of the pandemic and set out the history for your examination. Nothing, of course, that I say is evidence. You have reached no view on the evidence one way or the other. We haven’t even heard it. But I need to set it out simply to provide the context for the identification of the issues. You will, of course, be identifying the right and the correct events and the issues in your report.

January 2020.

Two of the most important issues for the Inquiry’s focus in Module 2 will be whether, putting it in the broadest terms, the government reacted with sufficient speed in the early months of 2020 on learning of the emergence of the virus in China, and whether it was provided with the right information to enable it to react with sufficient speed.

This is of central importance to your Inquiry, because some argue that had the government reacted with greater urgency and to greater effect in January and February, it might not have been forced into making the extraordinary far-reaching decisions that it later felt itself obliged to take.

So the chronology. On 9 January, the World Health Organisation issued a statement concerning a cluster of pneumonia cases in Wuhan, China. The first formal note went to ministers. The risk to the UK population was assessed by Public Health England to be very low at that point in time, but the risk on the UK basis, on the UK level, is a risk not of what might happen in due course or what events might inure, but what the risk is that is posed at that very point in time.

The risk was assessed to be very low, although officials and ministers correctly gauged that there were a number of countries with very high volume links to Wuhan which had themselves already introduced some form of port of entry screening.

Public Health England’s assessment was that port of entry screening was, however, neither efficient nor effective in the case of the United Kingdom. On 11 January Chinese media reported the first deaths from the novel coronavirus. On 13 January, the Ministry of Public Health in Thailand reported the first imported case of novel coronavirus from Wuhan.

On the same day, NERVTAG, the New and Emerging Respiratory Virus Threats Advisory Group, a UK scientific committee, met for the first time. It noted that the last official report from China had stated that there had been no significant human-to-human transmission, and that implied to NERVTAG that there may be some evidence of limited human-to-human transmission which had not yet been made available.

The issue of human-to-human transmission is vital, of course, because it means that humans and persons may become infected from other people, rather than directly from a carrier of the virus, a bat or some other form of wild animal.

As for port of entry screening, NERVTAG said:

“… the body of scientific evidence and previous experiences indicate that port of entry screening, whilst not having zero effect, has very low efficacy and the benefit is very unlikely to outweigh the substantial effort, cost and disruption.”

On 14 January the World Health Organisation announced that:

“Preliminary investigations conducted by the Chinese authorities have found no clear evidence of human-to-human transmission …”

On 16 and 20 January, cases were reported in Japan and the Republic of Korea.

On 16 January, the novel coronavirus was classified as a high-consequence infectious disease, requiring in the United Kingdom barrier care, steps to be taken to protect healthcare workers from infection from patients, and the use of specialist units.

Professor Neil Ferguson, an epidemiologist, and his colleagues at Imperial College calculate on that day that Wuhan was likely to have been harbouring more than a thousand cases by 6 January, so more than ten times the official figure, and they distribute their findings in their estimate to officials in the government, including the Chief Scientific Adviser, then Sir Patrick Vallance, the Chief Medical Officer, then and now Sir Chris Whitty, and the Deputy Chief Medical Officer, then Professor Sir Jonathan Van-Tam.

On 19 January, the World Health Organisation Western Pacific Regional Office tweeted that, according to its latest information, there was now evidence of some limited human-to-human transmission.

By 20 January, 282 confirmed cases had been reported from four countries including China. Officials, in particular the CMO (the Chief Medical Officer), the DCMO (the Deputy Chief Medical Officer), and the CSA (the Chief Scientific Adviser), become increasingly concerned about the risk. They speak to Public Health England, and Public Health England agree the risk assessment requires revisiting. The first meeting in the DHSC at Permanent Secretary level takes place, and it’s agreed that the situation is developing rapidly, but that entry screening was currently neither effective nor efficient.

On 21 January, the issue of Covid is raised with the Cabinet Secretary in London for the first time.

NERVTAG meets again, but agrees that, although there is clear evidence of person-to-person transmission, the degree of transmissibility was not clear.

On 22 January for the first time a group known as the Scientific Advisory Group for Emergencies, SAGE, met, activated in fact on a precautionary basis, that is to say in advance of formal activation. It is the primary body in the United Kingdom for the giving of scientific advice to government.

The minutes, my Lady, are lengthy, and each SAGE meeting, of which there were subsequently over 100, produces reams of records of the conclusions that it reaches. The minutes on this occasion record, therefore, only in very small part the following words:

“There is evidence of person-to-person transmission. It is unknown whether transmission is sustainable … There is no evidence yet on whether individuals are infectious prior to showing symptoms.”

The minutes record that the United Kingdom did have a good centralised diagnostic capacity, that is to say a testing capacity, and “is days away from a specific test, which is scalable across the [United Kingdom] in weeks”.

Public Health England raised the current threat level to the United Kingdom from very low to low, and a report from Imperial College estimates again about the numbers of figures in Wuhan. It concludes that there were probably around 4,000 infected persons in Wuhan, and it advises that self-sustaining human-to-human transmission should not be ruled out.

On 23 January, public transport is suspended in Wuhan. The World Health Organisation issues a statement announcing that its emergency committee had been unable to agree that a public health emergency of international concern was warranted.

A central alert system is sent round the United Kingdom, or rather at least in England, from the NHS England National Medical Director and the PHE, the Public Health England National Infection Service Director, and the Chief Medical Officer, asking for clinicians to identify possible cases.

Imperial College issue a third report, shared with the United Kingdom government, which estimates that the basic reproduction number was above 1 – I’ll come back to the meaning of that in a moment – and that it indicates self-sustaining human-to-human transmission.

If the virus was spreading in such a way that one infected person could infect more than one other uninfected person, it could only mean that there was human-to-human transmission.

Their conclusion, although it was difficult to say at that stage, was that the reproduction number could even be in the range of 2 to 3, that is to say one infected person could infect two to three other uninfected persons.

On 24 January, COBR (Cabinet Office Briefing Room) crisis committee, meets for the first time. It’s chaired, my Lady, by Mr Hancock, who was then the Secretary of State for the Department of Health and Social Care, which was, as we know from Module 1, the lead government department.

COBR agrees a series of actions to be put in place, but only when certain trigger points are reached, which – they have not yet been so reached.

The Chief Medical Officer publishes a statement which reads in part:

“We all agree that the risk to the [United Kingdom] public remains low, but there may well be cases in the UK at some stage. We have tried and tested measures in place to respond. The UK is well prepared for these types of incidents, with excellent readiness against infectious diseases.

“We have global experts monitoring the situation around the clock and have a strong track record of managing new forms of infectious disease. [The UK has] access to some of the best infectious disease and public health experts in the world …

“There are no confirmed cases in the [United Kingdom] to date.”

France, however, that day reports the first confirmed Covid case in the European region. In London, The Lancet, a well known medical journal, publishes an article entitled “A novel coronavirus outbreak of global health concern”, and it reports that the detection of infection in China shows at least one household cluster and multiple infections in healthcare workers caring for patients infected with Covid.

Professor Woolhouse, who is a professor of infectious disease epidemiology at the Usher Institute at the University of Edinburgh in Scotland writes to the Chief Medical Officer for Scotland.

Could we please perhaps have his email on the screen. INQ00047559, page 2.

He writes to the Chief Medical Officer of Scotland, Catherine Calderwood.

I apologise, yes, it’s all on this first page. If you could just scroll in, please, to the middle of the page and the start of the sentence:

“If you were to put those numbers into an epidemiological model for Scotland (and many other countries) you would likely predict that, over about a year, at least half the population will become infected, the gross mortality rate will triple (more at the epidemic peak) and the health system will become completely overwhelmed. We can formalise those predictions (and there are many caveats to them) but those are the ballpark numbers based on information from [the World Health Organisation]. Please note that this is NOT a worst case scenario, this is based on WHO’s central estimates and currently available evidence. The worst case scenario is considerably worse.

“There are very good reasons to suppose it might not be as bad as that, but we need additional evidence … to move the dial on those predictions.”

That email is dated 25 January. Two days later, the WHO reports 80 deaths in China.

On 28 January, SAGE meets again and it’s informed that 50% of new cases in China are now occurring outside Wuhan. It has given evidence that there is a specific test ready for the United Kingdom, that it should be ready by the end of that week, with a capacity to run 400 to 500 tests per day.

The Chief Medical Officer emails a health special adviser in Number 10, copying in the Chief Scientific Adviser and others, to inform him of the possible scenarios.

On 29 January there is a further article, this time in the New England Journal of Medicine. It publishes an article from a field epidemiology investigation team in China, but the heart of the article provides their estimate that, based on their research of the first 425 cases, the basic reproductive number is 2.2, and it states in clear terms that there is evidence that human-to-human transmission has occurred amongst close contacts since the middle of December.

On 30 January, the World Health Organisation declares a public health emergency of international concern, the declaration that it had declined to do a week or so before. A level 4 national incident is declared in England, and the UK current risk level is raised from low to moderate.

The paperwork that we’ve seen, however, my Lady, shows that at the time that the risk level is raised, the reasonable worst-case scenario, the genesis, the font of the planning that was done pre-pandemic, was still judged by officials in the Civil Contingencies Secretariat to have only a 10% probability of occurring.

On this day, 30 January, the first case in the United Kingdom was confirmed. It was a 23-year old Chinese student who had travelled back to York from their family home in the Hubei region in China.

On 31 January the novel coronavirus is discussed in Cabinet, and the briefing for the Prime Minister, which sets out in advance of the meeting information for his use, and also possible conclusions that may be drawn from it, advises that preparations should begin to prepare for that reasonable worst-case scenario.

Could we have, please, INQ00056142.

This is an extract from Cabinet minutes, hence the words “Official, Sensitive” at the top. Item 3 was the coronavirus item, and the summary – I said minutes, I apologise, this is an extract from a document prepared for the meeting. The document provides introductory points for the Prime Minister in relation to coronavirus, so that he can “update … Cabinet on the Government’s understanding of the outbreak and how it may progress”, and you can see there there’s a reference to the information that it’s a “new and rapidly evolving situation”.

COBR had been chaired. The reasonable worst-case scenario should be begun to be prepared for. The Chief Medical Officer agreed, with support from his colleagues, the risk assessment should be changed from low to moderate and that note is taken of the World Health Organisation declaration of a public health emergency of international concern. And the debate then changes to a debate over the repatriation of UK nationals from Hubei Province.

That same day, my Lady, the Chief Medical Officer publicly confirmed that two patients in the United Kingdom, members of the same family, had tested positive. It was also Brexit day.

There was, of course, an obvious need to understand and quantify the nature of the risk posed by the new virus. The range of the severity of the symptoms, the case fatality rates, that is to say the proportion of confirmed cases which would lead to death, let alone the infection fatality rates, the proportion of infected cases, infected persons, that would lead to death, were not at all clear.

It’s a matter for you, and it will be a matter for you at the conclusion of all the evidence, but it may seem that by the end of January it was clear that a fatal respiratory disease was inevitably spreading across the world, transmitted person-to-person, possibly asymptomatically. The clinical consequences of that virus included, without any doubt, organ failure and death. There was and there didn’t remain for some time any antiviral drug to alleviate the disease, and there was, of course, no vaccine.

The only possibility of escape for other countries was if China managed to contain the virus and the outbreak. But since it was estimated that over 4 million people had left Wuhan between January 11 and the start of the travel ban on Wuhan on 23 January, and because China had not closed its borders, although it did introduce screening procedures, such an outcome must have appeared, you may think, unlikely.

So a number of questions arise immediately: was the fact that the virus would spread to the United Kingdom and start its insidious work properly appreciated in government? Were the consequences of the likely lack of any control adequately understood? Was there perhaps an undue degree of caution?

As for testing, to what extent was it suspected that any new diagnostic testing process that was forthcoming would be inadequate to control an outbreak once it had spread beyond the initial 20 or 30 cases?

The United Kingdom led the world in the speed and scope of its genetic sequencing, and it continued to do so, as it did in a number of other scientific fields. But testing capacity is not simply the number of tests but the ability to process them at scale, in a quality-assured manner, and to inform people of the results.

Why were there no such arrangements in place, and if they were not in place, why were they not called for in January?

What was the impact of the World Health Organisation not declaring a public health emergency until 30 January? Did it lead to an unwarranted degree of optimism on the part of countries, including the United Kingdom, that things wouldn’t turn out quite as badly as might be suggested?

Should consideration have been given, even at this relatively early stage, not just to the gearing up of NHS preparedness, but to the introduction of widespread public health measures in the United Kingdom?


On 2 February, a public information campaign was launched by the DHSC advising the population to adopt respiratory and hand hygiene behaviours. The Prime Minister receives an update on the evacuation of UK nationals and at SAGE, two days later, the CMO, the DCMO and the Chief Scientific Adviser and a number of other scientists from universities, from research institutes such as Imperial and the London School of Hygiene & Tropical Medicine agreed that United Kingdom-only China-focused measures would likely only achieve minor delays in slowing United Kingdom transmission, but that transmission could be slowed if multiple countries took concerted action. But of course as is well known no such concerted action took place.

A “consensus statement” – I’ve referred already to the process by which the scientific committees produced a statement concluding and summarising their views – a “consensus statement” from the modelling scientific committee, SPI-M-O, dated 3 February concludes:

“The number of confirmed cases of [Covid] in China is estimated to be at least 10 times higher than the number currently confirmed … It is unclear whether outbreaks can be contained by isolation and contact tracing.”

And it said this:

“[Our] view was that the impact of any intervention would be highly dependent on the patterns of transmissibility … As this is poorly understood … the impact of interventions is hard to determine … the impact of any individual interventions would be expected to be relatively small, and none would be expected to delay a UK epidemic by a month.”

“Little direct evidence is available on the effects of cancelling large public events.”

And then elsewhere in the minutes:

“The wearing of facemasks by the general population is unlikely to meaningfully reduce transmission.”

On 3 February the Prime Minister receives a briefing from the Chief Medical Officer as part of a wider NHS briefing on the potential risks of Covid. Sir Chris Whitty expresses the view that if Covid-19 spreads internationally and becomes a pandemic, there was a reasonable chance there would be between 100,000 and 300,000 deaths in the United Kingdom. The minutes of the SAGE meeting on 4 February record:

“12. Lack of data sharing is seriously hampering understanding of [the new coronavirus] … Case ascertainment in China appears to be low: possibly [only] 1 in 15 [cases] being identified … Case ascertainment outside China potentially [only] 1 in 4 … Asymptomatic transmission [that is to say the transmission by a person of the virus where they display no symptoms] cannot be ruled out and transmission from mildly symptomatic individuals is likely …”

On 6 February it is announced that the first UK national had caught Covid in Asia, and had travelled back to UK via the Alps.

Public Health England announced the development of a new coronavirus diagnostic test. The Chief Scientific Adviser presses the Prime Minister’s chief adviser, Dominic Cummings, to arrange a meeting with the Prime Minister at which levels of concern could be impressed upon him. That meeting takes place on 10 February.

Also on 10 February, the team of epidemiologists at Imperial provide a first estimate of the severity of the virus. They give an overall estimate of a case fatality rate in all infections, symptomatic or asymptomatic, that is to say the proportion of death from amongst confirmed cases of Covid as around 1%.

SPI-M-O, the modelling committee, estimates on the same day the number of confirmed cases in China is likely to be ten times higher than the number of cases confirmed. The minutes say this:

“It is a realistic probability that outbreaks outside China cannot be contained by isolation and contact tracing. If a high proportion of asymptomatic cases are infectious, then containment is unlikely via these policies … It is a realistic probability that there is already sustained transmission in the UK, or that it will become established in the coming weeks.”

On 13 February, the seventh meeting of SAGE takes place. It debates, in the context of a discussion of how to delay the peak of the epidemic, as opposed to trying to suppress its spread entirely, the impact of mass school closures, restricting mass gatherings, and mask wearing. The minutes state:

“SAGE and wider [government] should continue to work on the assumption China will be unable to contain the epidemic … SAGE concluded that travel restrictions within the UK, unless draconian and fully adhered to, would not be effective in limiting transmission. They would also be ineffective if Covid-19 cases were already established in the UK … There is no current evidence to suggest prevention of mass gatherings is effective in limiting transmission. Public actions in the absence of a mass gathering could have comparable impacts (eg watching a football match in a pub instead of a stadium as [being equally] likely to spread the disease).”

Lady Hallett: Is that a convenient moment?

Mr Keith: My Lady, it is.

Lady Hallett: Just so everybody understands, because we have so much to get through today and tomorrow – well, throughout this module – the plan is to break now for 15 minutes, return at 12, and then go through to 1.15. I’m afraid just 45 minutes for lunch thereafter. Thank you.

(11.46 am)

(A short break)

(12.00 pm)

Lady Hallett: Yes, Mr Keith.

Mr Keith: My Lady, picking up the chronology on 21 February, news emerges that day of a cluster of locally transmitted cases in Lombardy in Italy. A lockdown begins there covering ten municipalities of the province of Lodi in Lombardy, and one in the province of Padua.

On 22 February, UK passengers from the cruise ship the Diamond Princess arrive back in the United Kingdom. Now, the Diamond Princess had been quarantined on 3 February by the Japanese Government after a passenger from Hong Kong, who had been on board, tested positive for Covid after having earlier left the ship on 25 January. Of the some 2,600 passengers and the 1,000 crew, over 500 people became infected, but the significance of the Diamond Princess for these purposes is that early reports showed that around 18% of the people who had become infected had showed no symptoms.

On 23 February, the DHSC reports 13 cases in the United Kingdom.

At the COBR meeting on the 26th, the Deputy Chief Medical Officer reports that official data from China showed that case numbers were continuing to increase internationally, case numbers outside China were going up, and that this highlighted clear person-to-person transmission, and particularly sustained human-to-human transmission in Italy, which received a high number of travellers to and from the United Kingdom.

On the 27th the Prime Minister calls for activity to be stepped up, the Civil Contingencies Secretariat of the Cabinet Office circulates a report on the most significant choices that the government might have to take, but it asserts that the global pandemic is not yet certain.

On the same day, the Deputy Chief Medical Officer and others advised the Secretary of State for the Department for Culture, Media and Sport, that the epidemiological data did not support the cancellation of the Six Nations England and Italy game in Rome.

COBR meets again on the 28th. The United Kingdom reports publicly its first case of confirmed community transmission.

A day later, the total number of confirmed cases has risen to 23, after over 10,500 people had by that stage been tested.

On Sunday 1 March Professor Whitty announces the total number of confirmed cases in England is 33.

Later estimates, taken not long afterwards, suggest that several hundred infections had probably already occurred by that date.

Most significantly of all, on 2 March the committee, the modelling committee to which I have made reference, SPI-M-O, reports it is highly likely that there is sustained transmission of Covid-19 in the United Kingdom. 2 March.

You will need to consider the extent to which the end of February was therefore a pivotal time, because it showed that community transmission might by then have been well established in the United Kingdom. If so, only the extent would have remained unclear, and that would have to remain unclear in the absence of a sufficiently clear surveillance system. Unless all contacts were traced and quarantined, if the virus had taken hold and there was sustained transmission human to human, then the risk of the epidemic becoming inevitable had gone up dramatically. If so, each person infected would inevitably infect two to three other people, and of the total number of people infected a proportion would die, as the very reasonable worst-case scenario planned for influenza pandemic envisaged they would.

But by that time, all that were in place were travel advisories or restrictions, that’s to say compulsory self-isolation (not state quarantine) for travellers. There was enhanced surveillance of travellers from identified high-risk regions and limited contact tracing around index cases. That’s where the majority of the limited available testing was focused.

So a major question for the Inquiry is whether it was then clear by 2 March that the epidemic could not now be controlled by test, trace and quarantine alone. If so, why were other stringent restrictions not being considered more seriously and considered early, especially as there was evidence that restrictions had been seen to work in Wuhan? Had the opportunity to reduce social mixing in a way that would keep some sort of brake on the virus already been lost?

Subsequently, extremely sensitive genetic tests showed that there were 1356 different strains of Covid in the approximately 16,000 people who had tested positive in the first half of 2020.

So over a thousand different strains amongst the 16,000 people or so who tested positive.

Those strains were compared genomically to sequences from Covid in Europe. More than a thousand of those 16 and a half thousand people had brought coronavirus in from Western Europe. In February they had mostly come from Italy, in March mostly from France and Spain. 70% of all cases from the first half of the year that were traced – and of course many couldn’t be traced – could be tracked back to those three countries.

My Lady, I’ve spoken a lot about SAGE and its subcommittees, given the importance of their role and the crucial contribution that they make. Before I turn to March 2020, it’s therefore necessary to look at them in a little more detail.

There were a number of committees and procedures in place for providing the government with scientific advice. The main body for our purposes, SAGE, was a standing committee – it wasn’t a standing committee, I apologise, but was convened from time to time when it was needed. And it does what it says on the tin: it provides scientific advice during emergencies. It’s the main conduit in the United Kingdom for scientific input in the event of a major emergency. It has no standing membership other than the Government Chief Scientific Adviser, Professor Sir Patrick Vallance at that time, and it’s constituted with relevant experts from within and outside government for any particular emergency that requires scientific advice.

It played a crucial role during the pandemic because it brought together scientific advice and summarised it, through its minutes and through the conduit that the CMO (the Chief Medical Officer) and the Chief Scientific Adviser themselves constituted to Number 10 and the Cabinet Office. They relayed the advice from SAGE to government.

Advice given in SAGE meetings was minuted and those minutes formed the official record of advice. All SAGE minutes are now published and made publicly available, but that process of publication didn’t in fact commence until May 2020, when SAGE published the first of its 34 meetings.

SAGE was, of course, asked to advise on extremely complex issues. Scientific advice is always uncertain, but one of the difficult matters that it confronted was – and the one of the matters that you will have to judge upon – the limits on its role.

SAGE is a scientific advisory committee, its members during the pandemic were scientists, and largely epidemiologists, modellers and behavioural scientists. Politicians and civil servants did not have their expertise, and of course they required SAGE’s assistance to provide them with information.

But SAGE was not designed to make policy recommendations, let alone operational decisions, and so a matter for you is whether there was a disconnect between SAGE, operating as it did under its quite limited advisory limits, and the government, which had no body or group of people, certainly at this early stage, who could draw together all the complex strands and present it with clear options.

The limitation on the role of SAGE provides the foundation for the argument, which we’re all familiar with, that it was perhaps inaccurate or wrong for the government to claim that it was “following the science”. Many witnesses stressed the need in a crisis for government to set clear strategies and objectives. By publicly stating it was “following the science”, to what extent if any did the government undermine its own role?

Professor Vallance, the Government’s Chief Scientific Adviser, wrote evening notes every night or most nights during the pandemic in which he set down his thoughts from those extremely difficult and troubling days. He’s provided a copy of those notes, his diary, quite properly to this Inquiry.

In his notes for 7 May 2020, he makes this observation:

“Ministers try to make the science give the answers rather than them making decisions.”

It’s an issue that you will need to look at.

In practice, there was also an issue as to how well the system worked, because government didn’t give SAGE any clear idea of its own objectives or directives, and so there may have been a vacuum that SAGE did not feel able to fill with its own suggestions. It’s a matter for you, but this may be why lockdowns were not even openly debated by SAGE until mid-March. Perhaps they had simply not been debated because they had not been put on the agenda by the government.

The body the Institute for Government reported on these matters and noted in its own report that in the initial months ministers put too much weight on SAGE, relying on it to fill the gap in government strategy and decision-making that was not its role to fill.

That didn’t mean, of course, that SAGE was immune from political attack from its own side, the government. A diary entry from 10 June 2020 from Professor Vallance records:

“I am [worried] that a ‘SAGE is trouble’ vibe is appearing in No 10.”

It may even be the government selected on occasion from SAGE what it wanted.

There is a:

“Paper from No 10/[Cabinet Office] for 1[metre]/2[metre] review. Some person has completely rewritten the science advice as though it is the definitive version. They have just cherry picked. Quite extraordinary …”

SAGE’s advice was routed through to decision-makers through the CMO and the CSA. The Inquiry will want to examine the efficacy of this. That was a relatively narrow conduit and one that was, more often than not, not recorded.

Did and were the CMO and the CSA able to reflect the extent to which there was any divergence of opinion within SAGE when they gave their advice to the government?

There was no opportunity for SAGE or the subgroup members to understand, moreover, how politicians were interpreting their advice or translating it into policy, and therefore there was never any meaningful engagement at which the politicians, the civil servants and the scientists could engage in discussions about the appropriateness of policies or areas where policies might be needed.

As for the composition of SAGE, this is something you’ll also want to consider. Was there a lack of diversity? Too great a focus on biomedical and mathematical expertise? Although PHE was always represented and senior officials of NHS always attended, was SAGE weighted too much towards academia rather than those with extensive experience of public health, pandemic management, experience of infection control and community mobilisation?

You will also be considering in due course no doubt the issue of the members themselves. SAGE was never designed to be run at such speed, with such heat or for so long. It sat for over 100 meetings. In past crises it’s met generally on no more than five occasions. Its members worked around the clock unceasingly in the public interest and pro bono. And as you know, they were placed under sustained and also unfair media scrutiny and, increasingly, attacked.

The diaries of Sir Professor Vallance speak of SAGE and the CMO and the CSA being positioned as human shields.

My Lady, these issues are of central importance. Not only is it vital to guarantee the supply of high quality external scientific advice, but the transparency and speedy communication of such advice, and an understanding of the worth of its source, is scarcely less important.

Then lastly there is the issue of SAGE’s scope. The national crisis required at its heart the bringing together and resolution of intensely complex public health, pandemic management, societal and economic issues. SAGE was a scientific advisory body. It produced the science. It couldn’t integrate the economic and societal considerations. So who did?

The government, of course.

But when did and how did the Cabinet Office and Number 10 bring together those different strands of scientific, economic and societal analyses into coherent advice for the Prime Minister and his Cabinet? There was no transparency or equivalent process as there was with SAGE.

So all this gives rise to the question of whether there should have been a permanent pandemic management body above SAGE that could draw together all these issues, but in particular the societal and economic issues, and produce operational suggestions for politicians, then, in the light of other considerations, to decide to take forward and to act upon, or not, as they best see fit.

My Lady, there were a number of other subcommittees, the most important one probably being SPI-M, the Scientific Pandemic Infections group on Modelling, which reported formally to SAGE on the dynamics of infectious disease transmission.

My Lady, little or no work had ever been done on the effectiveness of non-pharmaceutical interventions such as closing schools and lockdowns, not least because there hadn’t been a respiratory pandemic recently, and no such societal measures had been applied in the United Kingdom for over 100 years. But this field of mathematical and statistical models in public health is an extraordinarily complex one, and there was a basic difference between forecasting and the construction of model-based scenarios, both processes engaged in by this committee.

Forecasting essentially concerns asking the question: what do we think will happen? Model-based scenario construction basically asks the question: what might happen if we do X or Y? How effective will closing schools be on reducing the spread of the virus?

That difference between forecasting and model-based scenarios was crucial, because scenarios were often wrongly treated by many as forecasts, so that when a particular scenario didn’t come to pass, for example the number of deaths that were estimated in that scenario did not come, and, for example, the number of deaths did not go up to the particular levels estimated on the closing of schools, or one of the other social restrictions that was imposed or could be imposed, this was treated as a failure of modelling or as the deliberate propagation of a climate of fear. It wasn’t.

The models were extremely complex, because there were a significant number of measures that had to be considered, mask wearing, hand hygiene, social distancing, closing schools, stay at home orders and so on, and it was simply no possible to know how society might react to such measures.

So for you, my Lady, in this Inquiry a number of related questions arise: were the limitations of that modelling properly understood by decision-makers, particularly at the beginning, when many of the assumptions upon which the models were based were not yet supported by data?

Professors Whitty and Vallance, together with teams of scientists, produced a technical report following the pandemic. In chapter 5, which deals with, amongst other issues, behavioural modelling, they say:

“The craving for certainty of what is to come, particularly in the early stages of a pandemic, may mean that model outputs are seen as ‘the answer’, which they can never be …”

So was there an over-reliance on epidemiological modelling? Was too much time spent analysing even the differences between the various types of models? Could more attention have been paid to tracking the policy responses of other countries, as well as, as I’ve indicated, the likely economic and social impacts of the lockdowns?

A second committee was the Independent Scientific Pandemic Insights Group on Behaviours, SPI-B, chaired by Professor James Rubin and Professor Lucy Yardley. Again, it does what it says on the tin: it examines and reports on behavioural patterns.

A key question for you is: how effective was the advice that SPI-B gave to SAGE and, through SAGE, to the government? It is that committee which engaged in an argument with the CMO as to where the notion of behavioural fatigue first originated.

SPI-B has been criticised by some in the public for seeking to orchestrate a culture of fear, and SPI-B itself complained that the communication of its advice was not sufficiently open to scrutiny. Professor Rubin, its co-chair, noted that after advice had left SPI-B it often appeared to disappear into a black hole.

Another important team that worked alongside SPI-B, but from within the Cabinet Office, was the government’s Behavioural Insights Team. This was established in 2010 by the Cabinet Office to provide the government with a better understanding of human behaviour when dealing with policy challenges and issues.

The director of this team, the Behavioural Insights Team, became increasingly concerned regarding SAGE and the readiness of the United Kingdom government: SAGE at the absence of clear operational advice or suggestions, a role of course that it was not permitted to perform; and the government because of the apparent failure to take clear proactive steps.

At a meeting on 13 March, at a meeting of SAGE, in fact, at the offices of the Department for Business, Energy and Industrial Strategy, the director of BIT wrote in his notebook:


A Number 10 adviser, equally concerned, leaned over, crossed out “NOT READY” and wrote “Fucked!”.

The issue for you will be whether, using different terminology, that was a fair reflection of the government’s position.

There were, indeed, a number of extremely difficult issues facing the government, and it was upon its ability to resolve them that much of the decision-making turned thereafter.


An issue for you will be whether there was a lack of basic data concerning the virus’s characteristics. A proper understanding of those characteristics is vital to be able to determine, in terms of pandemic management, the speed at which the virus spreads, what is the risk of hospitalisation, what is the risk of death, who needs protection, what measures are required to be put in place.

We’re all familiar with the notion of the basic reproduction number. The basic reproduction number for Covid-19, how many people will a single person infect in an unimmunised population, was of crucial importance.

To control an epidemic, the reproduction number needs to be maintained at or below 1. But it’s not at all easy to calculate how many people are ill, how many people are infected, how many people are hospitalised, and you need those figures in order to be able to work out the basic reproduction number. You can add up the number of hospital cases and deaths, but it takes time to get those figures back from GPs and hospitals and the like.

Hospitalisation and death only becomes apparent, moreover, around a week or respectively two weeks following infection. So if you wait for those figures before deciding what to do, it’s already too late, the infection has gone on in the meantime to grow exponentially, with further hospitalisation and death inevitable. And not every infection leads to hospitalisation or death.

You can test those with symptoms, but not everyone who is infected will or can be tested, and there is, again, a time lag. You can test the index cases under the scheme known as the First Few 100, but at the beginning of the pandemic the limited PCR testing, which is all that there was, took time, and reports of tests wouldn’t, in any event, reflect the number of infections that day but perhaps days earlier.

You can finally test large numbers of the populace to see what proportion is infected, but only if there is a process for mass testing, which there wasn’t, or you can do surveys asking people if they’ve got the virus, but those surveys only really got going in March and April.

There are a number of other important issues. Will an infected person show symptoms before they become infectious to others, pre-symptomatic, or never show symptoms at all, asymptomatic. And it’s of vital importance, because if you’re pre-symptomatic or asymptomatic, you may infect hundreds of people without knowing and there is – in the absence of mass testing, which there wasn’t – there is no way of calculating the virus’ spread. If you don’t show symptoms, how do you know how to self-isolate? Contact isolation will only work if there’s little or no transmission before the virus causes symptoms. People can, in that situation, be isolated immediately once they show symptoms and before they infect others. But what if the virus transmits, as Covid did, before you show symptoms? What’s the incubation period? The latent period, the generation period?

So ready access to accurate data was crucial and, as the minutes from COBR, SAGE and SPI-M-O, to which I’ve already referred, arguably show, there was a critical lack of data.

So you’ll need to consider the state prior to early March 2020 of the surveillance system in place.

The first detailed data was provided from around about 6 March in what is known as the First Few 100 dataset. It consisted of a spreadsheet with relatively detailed information about each case. As at 6 March, it listed 116 cumulative cases, but 164 cases had already been reported in the United Kingdom, so there was a divergence between the information on the dataset and the information that came from an alternative system, the Covid-19 Hospitalisation in England (Surveillance) System, CHESS, and also cases which were publicly reported. Moreover, the dataset gave up at 416 cases around the middle of March.

The general lack of a sophisticated, effective and up-to-date data system was particularly noticeable in Downing Street, according to Mr Cummings. He complains in his witness statement of there still being an analogue system, no secure Cloud access. He says officials argued over whether Google Docs or Teams should be used.

The government, nevertheless, pulled together the data that it had and, of course, day by day, week by week the surveillance systems became ever more sophisticated, and they issued a digital dashboard released for the first time on 24 March. By 5 may it ran to 85 pages. Here’s one example from 3 May, on that day, comprising, I think, 88 pages.

If you would be good enough just to scroll the first seven or eight pages, we’ll get some idea of the sort of information which was provided, daily average deaths of people, expected supply of PPE, the number of UK tests carried out, the leading indicator of GDP, people in hospital with Covid by location and then, finally, beds, critical care beds with Covid-19 patients.

There were also large-scale randomised control trials carried out. The UK took a leading role in the establishment of a very large number of highly sophisticated, large-scale epidemiological studies, the SIREN cohort study in healthcare workers, the Vivaldi study in care home workers, the ONS Coronavirus Infection Survey, the REACT study, the Covid-19 Clinical Information Network and some others.

There were gaps, however, and you will need to consider from the evidence whether, for example, data from care homes was not clearly or regularly provided. Were there delays in the transfer of required data between the DHSC, which subsumed the Joint Biosecurity Centre, and NHS track and trace?

Mr Hancock told the Chief Scientific Adviser:

“… the pre-pandemic data flow between [the] NHS and the rest of government [was] the worst in all government.”

My Lady, the lack of a full surveillance system had severe consequences, because, as at 6 March, for example, whilst there were only eight non-travel related cases on the First Few 100 line list, that had risen to 43 by 11 March, but the NHS Covid sitrep, situation report, from around that time, showed 350 Covid patients in hospital.

By 21 March it showed 2,156 people. So the surveillance data was missing more than 90% of hospitalisation cases. That was equivalent to approximately two weeks of epidemic growth, so the decisions were being made on the basis of a position which had been passed two weeks before.

A massive data system was, in the event, created. A vital task for this Inquiry is to enquire whether those data systems have been maintained and recalibrated to meet any future exigency.

I now turn to strategy.

Along with proper data, the Government also needed to have a clear strategy or aim on how to deal with any virus that managed to infect our shores. As SAGE commented, it was essential to understand the objectives behind seeking to manage the epidemiological curve. Once there was clarity on those issues, SAGE could then review all the methods that might be needed to limit the spread. The Government strategy was based, as you heard in Module 1, on influenza pandemic – on an influenza pandemic, and it published a book, an article or a publication – an article on 3 March, in which that presumption was built in. This was the “Contain, Delay, Mitigate, Research” strategy, INQ000237322. This is the Coronavirus Action Plan of, we can see, 3 March.

The heart of it was contained at paragraph 3.9, page 10, please. I think that’s 16. Thank you very much. Page 10:

“The overall phases of our plan to respond … are:

“Contain: detect early cases, follow up close contacts, and prevent the disease taking hold in this country for as long is reasonably possible.

“Delay: slow the spread in this country, if it does take hold, lowering the peak impact and pushing it away from the winter season.”

But, my Lady, how strong was that conditional if, “if it does take hold?” By 3 March, you will recall SPI-M-O had already reported sustained community transmission in the United Kingdom, so a matter for you will be whether containment had already failed, and why is there no reference in that publication to trying to control the spread of the virus once it had escaped the detection/containment of early index cases?

We all recall the expressions “flattening the curve”, “reducing the peak”, “squashing the sombrero”, a phrase used by Mr Johnson on 12 March, but they all meant the same thing: trying to reduce the very worst ravages of the virus, as opposed to trying to retain or get back control. Was this publication a reflection of that attempt just to manage the virus, as opposed to trying to achieve a rapid reduction of the reproduction rate to suppressing the virus?

A second, related presumption in this document, you may think, appears to have been that if attempts were made to suppress completely and not just mitigate the virus, and then the wave were to be completely unsuppressed later, the virus would reemerge like an uncoiled spring upon an unimmunised and vulnerable population. Of course, in the event, because a lockdown was imposed in March to save the NHS from being overwhelmed and the virus was suppressed in March to June, it did reemerge like an uncoiled spring in October 2020.

So an issue for you to consider is what would have been the alternative impact if there had been an earlier suppression of the virus, rather than the suppression that took place in March, by stringent methods falling short of a lockdown? Would the virus have reemerged with less venom in the winter of 2020 or perhaps been kept under control without the need for a national lockdown at all?

A third linked issue is the highly emotionally charged matter of herd immunity. What is herd immunity? Herd immunity, also known as population immunity, is the indirect protection from an infectious disease that happens when a population is immune, either through vaccination or immunity developed through previous infection.

Herd immunity through vaccination, rather than by deliberately allowing a disease to spread through any segment of the population is seen, of course, as a good thing. Herd immunity of the latter type may be thought to be very different, because it may result in unnecessary cases and deaths, hence the emotionally charged nature of the issue.

However stringently a government intervenes, it is of course not possible to stop everyone getting infected. Some will inevitably be infected and thus be immune, but that is a long way from deliberately exposing them to a virus that might kill them. There are a number of extremely problematic issues surrounding this issue. What proportion of the population might be required to become infected and therefore immune to ensure the epidemic dies out? What if lots of people accidentally, coincidentally become sick and then die? What if not enough people get infected and immunised to mean the epidemic dies out alongside that appalling vista. What if so many people fall ill and die regardless, that the health system becomes overwhelmed, or if the immunity they acquire doesn’t last?

So the issue of partial management or mitigation of a virus is an extremely problematic one. My Lady, you will need to consider the issue of whether it was possible to identify and separate those who are vulnerable from those who are not. Can parts of society be hermetically sealed? Care homes have to have carers come in from outside; someone has to deliver food and medicine.

A number of politicians and scientists referred publicly to this issue in March. Mr Johnson referred to “taking it on the chin” and to “allowing the disease, as it were, to move through the population”. At a 12 March press conference, putting it significantly differently, the Government’s Scientific Chief Adviser, Sir Patrick Vallance, said:

“It’s not possible to stop everyone getting it and it’s also not desirable because you want some immunity in the population. We need to have immunity to protect ourselves …”

He wasn’t, of course, advocating the deliberate spread of a fatal virus throughout the population. But you will need to decide whether herd immunity was a goal. Was it an aim in itself or was it just the inevitable consequence of not suppressing the virus completely in the initial response?

Why does this matter? Mr Cummings will say, we understand, in his evidence that the Government had a deliberate strategy, a goal, of herd immunity.


On Sunday, 1 March the EFL Cup Final was played at Wembley and 82,000 people attended. On 2 March, the Prime Minister chaired a COBR meeting for the first time. The World Health Organisation raised its alert to “very high”. The total number of cases in England is 37.

Mr Cummings texts Lee Cain, the Director of Communications in Number 10. The text reads:

“The PM doesn’t think it’s a big deal; [he] doesn’t think anything can be done, and his focus is elsewhere; he thinks it will be like swine flu and thinks his main danger is taking the economy into a slump.”

My Lady, is that simply an egregious piece of opinion hearsay or was it, albeit through the distorted lens of a text, a fair reflection of the Government’s thinking at that time?

On 3 March, the report – the publication to which I’ve referred you – was published. An adviser in Number 10, Ben Warner, who was provided with a draft, asked:

“This is a comms plan, where is the real plan?”

A member of the DHSC press group sent a WhatsApp saying:

“What are we doing to contain, what are we doing to delay, what are we doing to research, what are we doing to mitigate?”

On 5 March, the first death of a patient with Covid in England is announced. 25 further cases in England are announced, bringing the total to 115. SAGE recommends measures, such as individual home isolation, whole family isolation. The issue of mass gatherings is debated, again, and SAGE concludes there was still no evidence that banning large gatherings would reduce transmission.

By 7 March cases in Italy had risen five fold to 5,800 and deaths had risen eight fold in six days to 233.

Further proposed measures to combat the spread of Covid are announced. In Italy, there is a quarantine. It’s extended to all of Lombardy and 14 other northern provinces and the next day, 9 March, to all of Italy. On 8 March, Scotland played France at Murrayfield.

On Monday, 9 March, the eighth meeting of COBR takes place. It’s chaired by the Prime Minister. A report is circulated that NHS demand would greatly exceed capacity by, in fact, 240,000 beds, if the Government were to implement the measures then only under consideration, social isolation, and so on.

Professor Steven Riley, a Professor of Infectious Disease Dynamics at Imperial, sends an email to the SPI-M mailbox with reasons for the United Kingdom not to delay closing schools, to move to working from home, to implement any other possible social distancing. He warns that the mitigation strategy to Covid-19 will lead to critical care facilities in the UK being overrun.

On 10 March, the Cheltenham Festival commences. Public Health England is informed of the first Covid outbreak in a care home. Public Health England data suggests the true number of cases is not 5,000 to 10,000 infections but may be around 30,000.

Professor Ferguson emails a set of graphs to a Number 10 adviser, that he expressly asks the Prime Minister to see and understand. The graph showed that bed capacity will be outstripped by demand in the absence of a lockdown, that under mitigation strategies then being considered, that is to say not a lockdown, daily deaths are still likely to peak at 4,000 to 6,000 per day. The reasonable worst-case scenario in the Government’s plans was now Imperial College’s best estimate of what would happen.

On 11 March, Liverpool played Atletico Madrid at Anfield, 52,000 supporters were in attendance. According to Mr Johnson, in his witness statement, the Secretary of State for the Department of Health and Social Care, Mr Hancock, briefed Cabinet that:

“… without symptoms [it was] highly unlikely someone was suffering from coronavirus.”

My Lady, you will need to consider what was known in Government at that stage about the figures derived from the Diamond Princess incident, to which I made reference earlier.

On 12 March the WHO declared a pandemic. In the United Kingdom stay-at-home guidance is published for people with symptoms of possible Covid-19 infection, telling them to stay at home for seven days. The Government announces it’s moving from that “contain” phase to the “delay” phase and the UK risk level changes from “moderate” to “high”.

Initial contact tracing processes in community testing are ended, as they simply couldn’t cope and such supplies as there were were needed for hospitals. From 25 January to 11 March, 27,000-odd tests had been carried out in the United Kingdom. South Korea had carried out over 20,000 tests a day since late February.

Downing Street was, according to Mr Cummings, distracted by reports in the press concerning Mr Johnson’s personal life.

At a tense and heated 13th meeting of SAGE on Friday, 13 March, National Health Service England representatives are asked whether there is any way the NHS could cope with the number of hospitalisations being envisaged under any of the mitigation scenarios falling short of a lockdown, previously reviewed by SAGE.

There’s division as to whether suppression is viable because, as soon as lockdown is lifted the virus will come back like the uncoiled spring. But the minutes record SAGE’s view that owing to a five to seven-day lag in data provision for modelling, it now believes there are more cases in the United Kingdom than it previously expected at this point and we may, therefore, be further forward on the epidemic curve.

A senior Cabinet official comes through to Number 10 from the Cabinet Office to tell officials:

“… I think this country’s [headed] for a disaster, I think we’re going to kill thousands of people.”

That evening a discussion takes place between a number of Number 10 officials and advisers. One of them, Ben Warner, argues that the strategy is required to be changed from one of mitigation to one of suppression, because the modelling shows that, unless the Government changes course urgently, the NHS will be overwhelmed. On a whiteboard, the Prime Minister’s Chief Adviser, Mr Cummings, writes:

“Must avoid NHS collapse. To stop NHS collapse, we will probably have to lock down.”

That meeting agrees that the Government has to be advised to introduce a national lockdown as a matter of urgency.

On the Saturday, a national lockdown is announced in Spain. In Downing Street, a meeting takes place in Number 10 at 9.00 am between the Prime Minister and his advisers. There is then a meeting between the Prime Minister and his Health Secretary, the Chancellor of the Duchy of Lancaster, the CMO, the CSA and other senior officials. The Chief Scientific Adviser tells the Prime Minister that scientists had previously thought the UK was three to four weeks behind Italy but now it’s only two to three weeks. The Prime Minister asks for a package of measures to be drawn up, but no decision is taken then. A further meeting takes place afterwards and the advisers press for firmer action. The Prime Minister asks for the CMO and the CSA, who are not present at that last discussion, to validate the agreement for further action.

Professor Ferguson is asked to provide a slide deck illustrating the potential healthcare demand resulting from mitigation versus suppression policy options.

On Sunday, 15 March the Prime Minister discusses the matter with the Chief Medical Officer, the Chief Scientific Adviser and there is another wider ministerial meeting. He agrees that stricter measures should be taken to COBR the following day, including individual isolation and voluntary social distancing.

On Monday, the DHSC announces 1,543 confirmed cases, up 181 in 24 hours. Estimates show the number of infections, the true number, was between 35,000 and 50,000.

Imperial College publishes its report 9, which models the potential impact of stringent conditions and concludes that epidemic suppression is the only viable strategy.

On Monday, as we all recall, the Prime Minister made an announcement asking people to work from home and to stop all non-essential contact and travel. The government advises mass gatherings should not take place and that those in the same household as a symptomatic case should isolate for 14 days.

The Cabinet Office emails Mr Cummings to the effect that the Cabinet Office and the Civil Contingencies Secretariat had still not seen any departmental plans for a pandemic, let alone evaluated them. There were no NHS plans and no real-time data, he believes.

On Tuesday, there were national lockdowns announced in France and the Netherlands. In London, the Government advises against international travel. On Wednesday, 18 March, SAGE 17 convenes and there is a discussion over the locking down of London. SAGE advises immediate school closure. The PM announces an indefinite closure straightaway. On Thursday, 19 March, the NHSE/I publishes guidance for discharging patients from hospital, that is the discharge service requirements order.

On Friday, the 20th, it is decided that pubs, restaurants and gyms will be ordered to close. The Number 10 Behavioural Insights Team recommends , however, London should be locked down immediately. On Saturday, Public Health England publishes guidance on shielding. But over the weekend, the weekend of 21 and 22 March, the Prime Minister and his advisers become concerned by reports of continued social mixing. SPI-B produces two urgent papers on the degree to which the UK population was adhering to restrictions.

On Monday, that evidence is produced, it shows that compliance is not exceeding 75%. Even more importantly, intensive care patient numbers show that they’re doubling every three to five days and the hospitals in London will be overrun in a week.

By 23 March, my Lady, the number of cases verified by test was 6,650. Estimates from the First Few 100 study and CHESS showed the true number to be in the region of 500,000, with over 100,000 of those infections occurring on the day the lockdown began.


What are they? The rates of contact between people can be suppressed through voluntary behaviour or mandatory social restrictions. A lockdown basically means a mandatory social restriction designed to suppress the spread of virus. Lockdowns are a blunt instrument, however, and, on account of the obvious and severe damage they cause, they may be said to be an act of last resort.

Another feature of lockdowns is that they are not a long-term solution: a country cannot lock down forever. They only buy time, alongside immediate reduction in the spread of the virus and, unless the virus is eradicated ready indicated completely, as I’ve suggested, or brought under firm and continuing control, it will reappear with devastating effect.

Once the virus is established, it may, however, be very hard to eradicate it. An issue for you is whether, even had a complete elimination or zero Covid policy been pursued in the United Kingdom, as it was in some other countries, would general elimination have been possible? New Zealand and Australia, in particular, achieved near Covid from time to time, because the virus was never allowed to become completely established. They took control before there was widespread community transmission and, of course, they applied harsh and early travel restrictions, but they also have relative geographical isolation, lower levels of international travel, less crowded cities and lower population density.

So there are a number of issues which you will need to enquire into. First, would the early imposition of more stringent social restrictions short of a lockdown, perhaps in late February/early March, have avoided the need for a lockdown subsequently? Would any of those arrangements, of the type that South Korea imposed, have been possible here? Would it have been viable?

Secondly, whether to impose a lockdown at all. The main lockdown debate is a reflection of the agonising judgement call that the Government itself had to make. Did it suppress less, thereby undoubtedly allowing a greater loss of life and risking the collapse of the NHS, in order to prevent the even greater, by other terms, societal and economic damage that would be wrought by the lockdown?

My Lady, that is an extremely difficult issue to resolve. There is the complexity of the picture that faced the Government, because the outcome would depend on a number of immutable and difficult to identify features – population age, comorbidities, the state of the Health System and resilience – and no society wide intervention, even one short of a lockdown, comes without terrible cost and it is impossible almost to say in advance what the cost and operational challenges of an intervention falling short of a lockdown would be.

Then there was the issue of the delay between changes of behaviour and cases emerging. Some parts of the population had already started to protect themselves in advance of 23 March.

Fourth, there was the absence of data to which I’ve already referred. How could the Government decide the benefits of lockdown against alternative NPIs?

Fifth, what was the Government strategy? If the main objective was to ensure that as few lives as possible would be lost, then, logically, the only route is a full lockdown. Did the Government consider and decide what level of loss of life was, however, acceptable? If it had been a loss of life at the level of SARS or MERS, which have infection fatality rates of 11 and 35%, there would have been no question that the Government would have to fully suppress. No government could tolerate such a loss of life. But no government, on the other hand, suppresses flu by imposing a lockdown, even though there may be as many as 30,000 deaths in a bad year. No government would ever contemplate imposing a 5-mile an hour speed limit to stop the 30,000 persons killed or injured every year from being killed or injured. So what was the government strategy?

There are intense moral and societal balances to be struck at the heart of this debate, which will not be easy for the Inquiry to resolve. But some, of course perhaps a significant amount, of consideration must be given to the fact that the primary decisions were taken by our elected representatives.

What may, however, be clear is that there is evidence from Imperial College in June 2020 that, had a lockdown not been imposed at all, ie had just the earlier measures of 13 March, 16 March, 18 March and 20 March been imposed, the virus would probably – probably – have continued to grow exponentially. The evidence may also show – and it’s a matter absolutely for you – that achieving suppression, short of lockdown, would still have required a reduction in contact rates similar to lockdown and, therefore, brought terrible cost to the country.

A final issue in relation to lockdown is whether it should have been imposed earlier. Evidence of the possible collapse in the NHS appears to have started becoming available from around 9 March, but lockdown wasn’t imposed until the 23rd, allowing for the necessary time to put appropriate arrangements into place. The issue for you is whether there was avoidable delay.

On 12 March a text from Mr Cummings read:

“We’ve got big problems coming. The [Cabinet Office] is terrifyingly shit. No plans. Totally behind the pace. We must announce today, not next week ‘if you feel ill with cold or flu, stay home’. Some around the system want to delay because they haven’t done the work. We must force the pace. We’re looking at 100 to 500,000 deaths between optimistic and pessimistic scenarios.”

The then Cabinet Secretary wondered on 12 March whether the Prime Minister should “go on [television] tomorrow and explain to people the herd immunity plan and that it’s like old chickenpox parties”. The then Prime Minister was heard to wonder whether the virus should just be allowed to “let rip”. This is a matter for you on the evidence and I emphasise we have heard no evidence yet.

Ultimately, the immediate goal or objective of preventing the collapse of the NHS drove the Government to impose the lockdown. But if the emergency that drove the lockdown, the need to avoid the NHS, was only appreciate in mid-March, had the Government acted with the speed that was required? To what degree should it have seen that potential collapse coming? Was there too great a focus also on the NHS? What about the no less vital need of stopping the spread of the virus through the care home sector?

Professor Hale, who is an expert in social restrictions, in non-pharmaceutical interventions, will give evidence that the country followed a rollercoaster pattern. As a new wave arose, restrictive measures were often introduced, only when it became apparent that the health system as a whole would be at risk, not earlier when there still might have been potential to prevent a wave from rising in the first place.

Moreover, because restrictions only came in once Covid was highly prevalent, it became necessary to keep them in place for a longer period of time to bring transmission back down, in turn, perhaps because the difficulty of enduring long periods of restrictions, measures were relaxed, but relaxed whilst Covid remained prevalent, thereby allowing the conditions for a new wave to arise.

I emphasise that that is just his evidence, whether you accept it is another matter. But the issue for this Inquiry will be: did countries that waited have overly complicated and layered decision-making processes and, which were late to react, have worse outcomes? It will be a matter for you.

I now turn to set out some of the evidence relating to the way in which the core decision-making of the Government but, more particularly, the Cabinet Office, Number 10 and the Prime Minister, operated.

Before I do so, I need to say something about the issue of the many WhatsApp groups and threads and also diaries and notebooks which have been disclosed to the Inquiry. This material provides, of course, a window, perhaps a somewhat distorted one, into the workings of government.

My Lady, we requested, or rather you requested through us, from decision-makers and advisers WhatsApps relevant to Government decision-making. We’ve received approximately 250 separate WhatsApp groups from over 24 custodians, in addition to thousands of pages of one-to-one WhatsApp threads. In light of the press reporting this morning, I should say that that material includes copies of WhatsApp groups to which Rishi Sunak MP was a participant. We also have multiple one-to-one threads of WhatsApps with him. We have the material extracted from an old phone belonging to Mr Johnson, so rather more than the press in other quarters has received from various other people.

It’s right to say we have not received everyone’s WhatsApps, texts or iMessages. A lot were not retained and were got rid of in accordance with what their owners believed was Government policy, long before the Inquiry came calling. Some were apparently deleted accidentally and we’ll be asking why that happened.

However, in light of the very large number of messages and diary entries that we have received, we have, we believe, a very good picture of what happened. Given the multitude of people who were party to or privy to the core decision-making, and who took decisions in the presence of other people, and the range of WhatsApp and diary material that we have – which of course necessarily engages more than one person, because they’re conversations – there are unlikely to be any hidden corners that have escaped the Inquiry’s examination.

You will, of course, exercise considerable caution when assessing the worth of the WhatsApps. They were often sent in speed, were largely informal and spontaneous, and were sometimes ill considered. They were always short, naturally, and could never be a reflection of any nuances of any particular debate. They often reflected irritation or even vitriol. Mr Cummings’ WhatsApps, in particular, contained a certain degree of brusqueness.

The diary entries must too be treated with some caution. Although highly relevant to the private thoughts and opinions of their authors and, by extension, retrospectively their opinions of the decision-making skills of others, they’re rather less relevant as a tool by which the core policy making and decisions can themselves be scrutinised. It’s also impossible to gauge the extent to which they accurately reflected the authors’ contemporaneous and actual views of the merits of any given decision, as opposed to being crafted for a later audience.

However, that material shows that many of the important decisions were taken by the Prime Minister and, to a significantly lesser degree, the Cabinet. Below them, as you will recall from Module 1, the complex and diffuse government structure was split between Number 10, the Cabinet Office, the lead government department, the DHSC and a host of other departments and bodies, including the NHS and PHE.

The disharmony between Number 10 and the Department of Health and Social Care is apparent from the WhatsApps and diary entries.

A core question for you is whether, regardless of the unceasing toil by individual politicians, civil servants and advisers, there were just too many disparate and moving parts and an insufficiently firm control at the centre. Mr Cummings suggests that the lead government department, the DHSC, just did not have the systems or authority to orchestrate all the things that needed to be done, which meant that it was too much for the Cabinet Office and Number 10 to do.

There was no minister responsible exclusively for civil contingencies overseeing a department with the job of ensuring that there was an effective and well-maintained civil contingencies structure in place. There was no standard manual for pandemics, no practical framework. You will want to enquire into how effectively in the early days the Government machinery worked.

There were also a number of other underlying structural issues that may have had a bearing on how efficient the machinery was. Witnesses speak of the perennial difficulties associated with the division of functions between the advisory role of the civil service and the executive power of, and I emphasise in crisis management terms only, the more amateur ministers.

There was an overload on existing personnel and perhaps a lack of a straightforward mechanism for the rapid scaling-up of administrators. Was there a lack of general experience in crisis, let alone pandemic management? Such institutional memory and experience as there had been may have been lost through the ever-present rotation of ministers and senior civil servants and, perhaps, a mismatch between ministers and the demanding requirements of their posts.

What about Cabinet? Mr Cummings – and his general level of objectivity will be a matter that you’ll have to determine – observed that it was not the place for serious discussion or decisions. It was a rubber-stamp, the main function of which was to function as political theatre. Perhaps more importantly, he says Cabinet committees were scripted. Ministers were given scripts to read out and conclusions were drafted in advance so problems were simply not grappled with.

Ironically, you may conclude that Mr Cummings was himself a source of instability and contributed to the undermining of that very same Cabinet. After he left, one regular attendee at Cabinet, though not a minister, observed:

“Cabinet is more effective post [Dominic Cummings].”

You will have to assess the truth of these claims.

You will want to assess the degree, in fact, to which Mr Johnson did take decisions alone, having no doubt received advice from his advisers but in the absence of fellow ministers.

My Lady, having seen the debate through WhatsApp messages and texts and the diary entries that took place in Cabinet, you may conclude, as they say in diplomatic circles, that it was more often than not frank and constructive. So it would seem that Cabinet itself undoubtedly believed it was contributing appropriately to the decision-making.

The psychology of central government and, in particular, Downing Street is also an issue. Was there an unwarranted degree of optimism on the part of Government advisers and officials that things wouldn’t turn out as badly as was being suggested by the scientists? There may have been a complacency that the UK’s plans were the best there were, along with a misplaced and arrogant belief that other countries’ experiences were of little assistance.

The primary authority, however, and responsibility for the major decisions with which this module is concerned appear to have remained throughout with the Prime Minister. He also had the overarching discretion of deciding the extent to which matters were debated within Cabinet. Number 10 doesn’t exercise exclusive executive power, however; it must ask in lock-step with the Cabinet Office. They are to a very large extent part of the same organisation.

Was there a lack of confidence in the Cabinet Office and with its head, the then Cabinet Secretary? Mr Cummings suggests in his written statement that the Cabinet Office was bloated at senior levels with poor lines of responsibility, huge numbers of comms and engagement staff but too few civil servants who could drive priorities.

The Cabinet Office, he says, was effectively replaced by the 8.15 am meeting between officials and Special Political Advisers in Number 10. At the same time, he says, the private office of Number 10 was too small to compensate for the shortcomings of the DHSC and the Cabinet Office. He says the Cabinet Office was a failure. But perhaps he would say that, as the Chief Adviser to the Prime Minister.

In any event, the WhatsApp messages between Messrs Johnson, Cummings and others portray a depressing picture of a toxic atmosphere, factional infighting and internecine attacks on colleagues.

A text from Simon Case, then a senior civil servant, yet to become Cabinet Secretary, to Matt Hancock on 29 April reads:

“The Cabinet Office is a totally dysfunctional mess at present, so not a great place to be!”

Mr Cummings’ emails on the 13 July:

“The current [Cabinet Office] doesn’t work for anyone – it’s high friction, low trust, and [obviously] many good parts but overall low performance … friction is [built] into the system including institutional friction between [Number 10] and the [Cabinet Office].”

Sir Patrick Vallance notes in his evening notes:

“[Number 10] chaos as usual.

“On Friday the [2-metre] rule meeting made it abundantly clear that no one in [Number 10] or [the Cabinet Office] had really read or taken time to understand the science advice on [2 metres]. Quite extraordinary.”

On 11 November, reporting in his diary something said by the then Cabinet Secretary, he says:

“… Number 10 is at war with itself – a Carrie faction (with Gove) & another with SPADs downstairs. PM is caught in the middle. He [the Cabinet Secretary] has spoken to all his predecessors as [Cabinet Secretary] and no one has seen anything like it.”

Debate, perhaps even ferocious argument between officials and advisers is to be expected, but the issue for you is whether the internal machinations hindered the good working of government. A significant number of WhatsApp and diary entries refer to Mr Hancock. It appears to be the case that the Prime Minister and a number of officials and advisers held him in low regard, in particular on account of an apparent tendency, to use their words, to get overexcited and then “make stuff up”. The WhatsApps and diary entries contained multiple references to Mr Johnson’s loss of confidence in Mr Hancock and to a general belief that he was less than candid when informing Number 10 and the Cabinet of progress that he and his department were apparently making.

You will have to assess the truth of the claim of this certain lack of candour on his part and, if you accept the claim, whether this trait was deleterious to good decision-making. Did it actually matter? That is a matter entirely for you.

What of the Department of Health and Social Care? It was the lead government department. Was it equipped for such a role in the far-reaching crisis that Covid presented? Was there adequate leadership? Did it try to hold onto too many responsibilities. Was the department, as Dominic Cummings has suggested publicly, a “smoking ruin” and in crisis itself?

The attitude within Government towards a public inquiry may also be of relevance. Sir Patrick Vallance’s diary records the Cabinet Secretary as saying that any:

“Inquiry should go on for a decade or more [he] wants someone like Saville to chair it and keep it going forever”, a reference obviously to the duration of the Bloody Sunday Inquiry.

You, of course, have already said that you will not allow this Inquiry to drag on and we’re already at Module 2 just 18 months after the end of Covid restrictions.

Was this apparently divisive and dysfunctional system the reality?

You will need to explore the role of the Chancellor of the Exchequer and the Treasury in relation to decision-making. Did it carry out and share sufficient economic analyses? Did it balance its approach with other trade-offs? How far, to what extent, did it push Downing Street beyond that which the analysis would support?

You will also need to consider the issue of leadership. The evidence of some witnesses may show that the character and operating style of Mr Johnson and his team created instability and exacerbated some of the pre-existing structural and cultural issues and tensions. Some of this may have been deliberate, perhaps even beneficial. But some of it, it’s a matter entirely for you, stemmed perhaps from Mr Johnson’s own character. Was his decision-making style antithetic to effective and speedy decision-making?

He has already in the press, notoriously, been described as a trolley, liable to career off in unexpected directions. Witnesses and texts and WhatsApps and diary entries speak repeatedly of flip-flopping, of him ignoring problems then U-turning, of poor and delayed decision making and of oscillation.

Some witnesses will say he had a tendency to say different things to different people, to reverse settled decisions and to be heavily influenced by pressure from parts of the media.

These are perhaps, my Lady, undesirable traits to have when dealing with the demands of a viral pandemic. They are matters for you.

Sir Patrick’s diary contains entries such as:

“This flip-flopping is impossible, one minute do more, next do nothing.

“He doesn’t seem to push actions or resolutions.

“Morning PM meeting, wants everything normal by September and only deal with things locally and regionally. He is now completely bullish about opening everything – as [another person] said it is so inconsistent. It is like ‘bipolar decision-making’.”

Then this, on 19 September, the crux or the time when the argument over circuit breakers was raging:

“He is all over the place and completely inconsistent. You can see why it was so difficult to get agreement to lock down first time.

His ability to manage those around him may also be an issue. Could he build – did he build a high performance team? Did he take the role in which he was placed seriously enough? Witnesses cite his ignoring of advice not to shake hands, his failure, due perhaps to his libertarian tendencies, to restrict mass gatherings and the obvious continuation of Government business in person. Was he in those terrible early days overly dismissive of the threat faced by the United Kingdom?

Public trust in government and its leaders is of vital importance, as it’s a key part of promoting resilience and ensuring compliance. Although he was not obliged to chair COBR, which was and was just as easily chaired by Matt Hancock MP as the Secretary of State to the lead government department, the Prime Minister did not chair the COBR meetings of 24 and 29 January and 4 and 12 and 18 February. Was an opportunity to demonstrate leadership lost? He first chaired COBR on Monday, 2 March, just three weeks before the national lockdown was imposed.

Moreover, there’s the difficult issue of whether, as one witness suggests, his attention in February, that most crucial of events, was diverted elsewhere. Brexit Day, the resignation of Sajid Javid MP and the reshuffle that followed, Storm Dennis, his personal issues concerning half-term holiday, the finalisation of his divorce, the announcement of Carrie Symonds’ pregnancy on 29 February, and the IOPC investigation into allegations made against him by another have all already been publicly ventilated. To what extent, if at all, is any of that relevant to his leadership of our country in those weeks?

Turning to, finally, some of the other important Government bodies, what of the Public Health England agency? It’s been described by witnesses as leaderless and totally dysfunctional. A 3 June entry by Sir Patrick records:

“Quad call [that’s a ministerial quad call] exposed the massive internal operational mess inside DHSC and PHE. Getting something done is almost impossible.”

My Lady, how is the Inquiry to approach such matters? The Inquiry is, of course, completely politically agnostic in its approach. It has no personal or political inclination or disinclination towards any of the primary actors in the appalling tale of this pandemic. There has been enough politicisation and polarisation of the public discourse in any event but, in any event, you may conclude that this is not an exercise in apportioning blame. It is and can only be an inquiry into what actually happened so that the vital lessons may be learned for the future. But these decisions were, at their heart, not political decisions, they were matters of public health, although the Prime Minister plainly came under intense pressure from certain elements in the press and his own backbenchers to open up whenever possible and not to reimpose the lockdowns, which had, of course, such terrible consequences. The Inquiry has no interest in the political position or views of the primary actors. It is interested only in how they discharged their functions.

So it’s not a personal attack. Those at the heart of the Government’s decision-making undoubtedly tried their best and they worked night and day, like many others, in the face of unprecedented crisis. But politicians, although members of a party, owe their governmental responsibilities to the country as a whole, and those civil servants who exercise this level of power and authority are accountable to those over whom they exercise it.

My Lady, is that a convenient moment?

Lady Hallett: It is. We shall return at 2 o’clock, please. I apologise to all of those who were distracted by the noise. I suspect probably people over that side of the room are most distracted. I certainly find it most distracting. It’s coming from next door. We will do what we can. Whether we have any power is another matter.

Thank you.

(1.15 pm)

(The short adjournment)

(2.00 pm)

Lady Hallett: Mr Keith.

Mr Keith: My Lady.

My Lady, the list of issues for Module 2 pose a number of questions in relation to how Westminster engaged with the devolved administrations, the regional and local authorities as well. There are some key questions relating to the degree of liaison and whether the key decisions taken by the United Kingdom government were taken after a proper process of advice or consultation with the devolved administrations and regional and local authorities.

The starting point is that the United Kingdom could not readily exercise direct control over pandemic management throughout the United Kingdom, because health is a devolved matter, and once the United Kingdom government used public health legislation and the Coronavirus Act to respond to the pandemic rather than the Civil Contingencies Act, the Rubicon had been crossed.

But as the pandemic progressed, the DAs, devolved administrations, started to go their own way in terms of the imposition of non-pharmaceutical interventions, starting with mass gatherings and, later, the Welsh circuit breaker. They obviously also took differing approaches to tier systems and local lockdowns.

Mr Johnson suggests in his statement that this divergence represented a regrettable failure to ensure consistency of approach, but the ministers of the devolved governments insist the divergence was the inevitable consequence of the way in which the virus spread across the various nations of the United Kingdom and that in implementing policies that diverged from Westminster, they were simply exercising their proper devolved powers.

There are a number of evidential conflicts for you to determine. Written evidence suggests that the devolved administrations were not updated on some UK decisions. They did attend COBR, but the material suggests that concerns about the briefing of the media afterwards led apparently to a general disinclination for the Westminster officials to want to thrash issues out in COBR, and meetings became more scripted and formulaic.

One attendee at COBR describes:

“COBR [was] not really a COBR at all but more of a talk to the DAs and then a series of ‘give us more money’ questions.”

The DAs were not invited to Covid-S, but they did attend Covid-O. They weren’t, of course, present at the 9.15 in the morning Prime Ministerial meetings, and although the Joint Ministerial Committee existed to provide a formal historical forum for meetings between UK ministers and the First Ministers, after May 2020 it doesn’t appear, following a submission to the Prime Minister, that the Joint Ministerial Committee ever met.

Four-nation COBR calls and meetings were held and chaired by Michael Gove, the Chancellor of the Duchy of Lancaster, but the DAs say in their written material that they had insufficient meaningful input into decision-making. There was, however, ample communication between the United Kingdom government and the devolved administrations at the health minister and chief medical officer level, and, of course, as I say, in the Covid-O meetings.

As for the local and regional government, the evidence appears to suggest that the United Kingdom government was characterised by an absence of engagement with regional and local leaders in decision-making, or at least there was plenty of engagement but, from the viewpoint of the regional authorities, there were repeated failures to inform and involve them sufficiently.

Turning to schools, which is another important area on our list of issues, the issue of school closures and the obvious impact on schools and educational prospects of the lockdowns will be addressed in detail in a later module, but it’s necessary to look briefly at how the decision on schools came to be considered and decided by Number 10.

This is because, from a relatively early stage, the possibility of closing schools was discussed by SAGE and civil servants. It was discussed repeatedly at SAGE and SPI-M-O meetings in February, and the possibility of shutting schools was contained in the “Contain, Delay, Mitigate” plan of 3 March. The Department of Education had been represented at the SAGE meetings and had had access to the papers. It’s a matter for you whether proper plans or impact assessments were drawn up.

Very late in the day, however, around 16 March, the Department of Education was asked to consider closure and to write an advice overnight for the Prime Minister. Gavin Williamson MP, in his written statement, describes that process as discombobulating. He did agree with closing schools but disagreed when the date for introducing attendance restrictions was brought forward to 23 March instead of from the end of the Easter holidays.

There is an issue for you as to the extent to which guidance was properly prepared and published. That, as I say, is for a later module. But why was there a sudden change in Downing Street around 16 March, and why was more advance thought not given to this possibility?

Schools were not closed during the second lockdown. The Department of Education was, it seems, very resistant in mid-December to letting schools close early for the holidays. Mr Williamson advised that schools should remain open, which increased testing, and the issue was vigorously debated, but in the very early days of January there was what was described by him as “a panic decision”. There was a very late decision, as you’ll recall, to close schools. Some pupils returned for the first day of term and were then sent home.

So in this module, what was the thinking in Number 10? The material shows that some officials sought to dress up the change of position between 29 December and 1 January as being the result of new evidence and data, despite the fact that the two decisions, diametrically opposed as they were, had been taken just two days apart.

The care sector is, again, for a later module, but it’s convenient to examine, in part, one of the major decisions affecting the care sector in this module, given the debate over the extent to which core decision-makers were aware of it and, of course, of the catastrophic consequences. It was, notoriously, the decision of 17 March 2020 to discharge hospital patients into social care.

There is an issue as to the extent to which Number 10 were advised or understood that clinical or scientific advice was to the effect that testing wouldn’t work. Was there a lack of capacity? Did a greater number of infections come from staff who worked for more than one care home? Was isolation the proper route?

The final resolution of those issues from the viewpoint of DHSC and those in the care sector must be for the later module, but evidence will be called in this module as to the extent to which Number 10 was aware of the decision and, of course, of the terrible consequences which arguably ensued.

Turning to the exit from lockdown 1 and back to the chronology and Eat Out to Help Out, restrictions were eased over late spring and the early summer of 2020, but there was a growing political and press pressure for a complete lifting of restriction, and the order and timing of the lifting of restrictions became ever more a political decision.

A divide opened up between the advice from SAGE and the preparedness of government to keep restrictions in place. On 21 March Sir Patrick’s diary recorded:

“SAGE position maintained and clear but [Chancellor of the Exchequer] really pushing for more … Simon Case [who was then still a very senior civil servant not yet Cabinet Secretary] commented it was like children pushing their parents to see how far they could go without being smacked. Totally inappropriate way for the politicians to go on and puts SAGE in a terrible position.”

The final package of restrictions was lifted on 4 July. Cases started to increase immediately afterwards, but this wasn’t immediately apparent as case numbers were low and there were significant variations in the reporting because of differences in testing and also because of differences on different days of the week. But the consistent trend was upwards.

Sir Patrick’s diaries reflect a growing level of concern at the government’s approach. 9 July:

“PM cancelled the big announcement and has gone more cautious … PM is simply not consistent. (as he wasn’t at the beginning).”

13 July:

“The ridiculous flip flopping is getting worse …”

28 July:

“[The Chief Medical Officer] and I are both worried about the extreme inconsistency from [the Prime Minister]. Lunching from open everything to panic.”

Then on 3 August the government introduced the Eat Out to Help Out scheme, designed and driven by the Chancellor of the Exchequer and Her Majesty’s Treasury. The scheme gave a 50% discount on meals up to £10 per person, but didn’t apply to takeaways.

The policy objectives were obvious: to support the economic recovery by stimulating consumption in the hospitality sector, but it didn’t appear to have been discussed with the Chief Medical Officer or the Chief Scientific Adviser, and it was not the subject of advice from SAGE, SPI-M-O or SPI-B. Professor Whitty and Professor Vallance’s written evidence is that had they been consulted they would have advised it was highly likely to increase transmission.

The Inquiry will be hearing from the then Chancellor of the Exchequer, Mr Sunak MP, on this. Treasury advance a number of arguments. Plainly the scheme was devised and implemented in the context that hospitality venues had already been opened safely and were operating Covid-secure guidelines. That was the premise upon which the scheme was introduced. It was also supported by the Prime Minister and recommended by industry and think tanks and a significant number of other countries has also used similar stimulus vouchers.

A second wave, they say, was always anticipated and it is unfair and wrong to attribute blame for that second wave from Eat Out to Help Out.

Most importantly, perhaps, the Treasury argues that the scheme and the re-opening of the hospitality sector did not have any noticeable impact on the rates of infection. The evidence on this is not clear. Some other evidence suggests there was an increase. But the conflict may not be easier to resolve and we don’t invite you to do so. The lack of clear evidence one way or the other means that you’d only ever have quite a weak foundation from which to draw any conclusions and recommendations. But there is a wider important point: did the scheme send out the wrong message to the public, with the consequence that other ongoing measures were indirectly weakened?

On 24 August Mr Hancock sent a WhatsApp message to Mr Case, still then the Second Permanent Secretary in the Cabinet Office:

“Just want to let you know directly that we have had lots of feedback that Eat Out to Help Out is causing problems in our intervention areas. I’ve kept it out of the news but it’s serious. So please please let’s not allow the economic success of the scheme to lead to its extension.”

So in relation to the aftermath of the first national lockdown, was the lockdown lifted in the most appropriate way? How effective were the local restrictions that were introduced in England? Were the local restrictions and differences between them the most effective way of managing the virus? What was the impact in terms of messaging of the Eat Out to Help Out scheme?

Then the second lockdown. At the beginning of September, on 1 September, a Cabinet briefing to the Prime Minister noted:

“Since reopening hospitality seven weeks ago, we haven’t seen a widespread resurgence in transmission. Clusters of high transmission have largely been driven by social interactions between households, not formerly closed sectors.”

At a Cabinet meeting on 8 September there was a robust debate over segmentation, that’s to say shielding for segments of the population and allowing the virus to move through the population otherwise, also the merits of the rule of group of six and red teaming and herd immunity. Some ministers stated that things should be opened up, in particular the Chancellor of the Exchequer.

The Chief Medical Officer noted that if the government waited for deaths to increase before it took action, that would inevitably result in a substantial number of deaths.

The Prime Minister’s view was that the government had known for a long time that a second peak was coming and was as well placed as it could be.

The rule of six was introduced on 9 September. It’s unclear to what extent SAGE was sighted on the merits of that proposal. Professor Vallance noted:

“What a week - feels like Feb/March…strikes me that the delay in introducing the new rules until Monday is exactly what they did in March. Why delay??”

There was then a debate in government over the introduction of a tiered system. A modelling team at the University of Warwick published a paper on 14 September which concluded that a well timed and strong lockdown for a two-week period could have a very notable impact.

By the 16th it was noted that infections were doubling and admissions to hospital had gone up by 100% since the beginning of September. The Prime Minister indicated he wanted to explore, however, a range of views from different scientists before final decisions were taken. A meeting was set up for the following Sunday, 20 September.

On 18 September, Mr Case told Mr Hancock “the firebreak idea is gaining traction” with the Prime Minister, but later in the day he advised:

“[The Prime Minister] wants to double down [instead] on present strategy … tougher local lockdown/enforcement, warning [measures] about what happens if people don’t follow the rules.”

On Sunday 20 September the meeting to which I’ve referred took place, chaired by Mr Case and attended by the Prime Minister, the CMO, the CSA, and Professors Edmunds, Gupta and Heneghan, Dr Anders Tegnell, from Sweden, and Professor Dame Angela McLean, the Deputy Government Chief Scientific Adviser, also attended.

The Chancellor also attended, but he says in his written statement he doesn’t have strong recollections of that precise discussion.

Professor Edmunds’ evidence is that he tried to point out that the epidemic was increasing exponentially and harsh measures would have to be introduced soon to stop the NHS from being overwhelmed. He says for him the decision was not not to lock down or not, but to lock down now or be forced into locking down later. His arguments were not accepted.

Mr Johnson says in his own written statement that whilst he greatly respected Professor Edmunds’ views, he had always put him at the gloomier end of the spectrum and he had wanted to give the Rule of Six a chance to work and to hear some alternative views.

At a presentation on 21 September, the CMO and CSA warned that at the current estimated rate of doubling, there could be 50,000 cases a day by mid-October.

The 58th SAGE meeting on that day considered a paper addressing the effectiveness and harms of different non-pharmaceutical interventions. It noted that the incidence of Covid was increasing across all the country and that the effect of opening schools had only just begun to affect that increase. A package of stringent interventions would be needed to be adopted. In his written statement, the Prime Minister suggests that the advice in that meeting was “not pushed on me very hard”.

In a statement to Parliament on 22 September, he instead set out new national restrictions, including working from home, table service extensions in pubs, bars and restaurants, a closure of hospitality venues at a maximum of 15 at wedding ceremonies and receptions. There is a debate about the extent to which SAGE would ever have recommended a 10 pm curfew, because it was of the view that it would be likely to have, in any event, only a marginal impact.

On 30 September SPI-M-O indicated that, according to medium-term projections from five models, the epidemic was likely to breach the agreed reasonable worst-case scenario of the next two weeks.

On 8 October, the Prime Minister gave a press conference at which the three tier system was announced, and one issue for this module is the practical wisdom of those measures. They were complex, politically divisive, and they led to considerable public confusion.

The existence of different control measures in

different places at different times also, you may

conclude, made it difficult to establish a clear

national message. A WhatsApp from Mr Cummings read:

“This is a shitshow. We should have gone a month

ago as we said.”

At a meeting on 25 October, an argument began before

the Prime Minister, to use the words of the proponents

of one side of the argument, “let it rip - they have had

a good innings”, and the contrary argument was put that pm, extended requirements on face coverings and 10 a democratically elected government’s primary obligation

was to save lives. The Prime Minister acknowledged that

it was “a complete shambles” but that he really didn’t

want to have to enter another national lockdown. He was

told that if he went down the route of not imposing

a lockdown, he would need to tell people that he was

going to allow them to die.

On 30 September, Sir Simon Stevens, head of the NHS,

reported that hospitals would be overrun in every part

of England. The decision to lock down was made but the

decision leaked and the announcement was brought

forward. There would be a lockdown from 5 November.

The third lockdown revolves largely around the

emergence of the Alpha variant, which first emerged in

Kent in late November and early December, which was up

to 70% more transmissible. The winter plan of 23 November set out a return from the second lockdown to a three tier system.

Unlike the earlier three tier system, there was no negotiation this time with local authorities. On 2 December, the last day of the lockdown, the Medicines and Healthcare products Regulatory Agency gave approval for the use of the first Covid-19 vaccines; the Pfizer-BioNTech vaccine. The miraculous availability of a vaccine turned the course of the pandemic, but it would naturally be some time before vaccines could be made widely available.

Debate again raged in government in late November and early December as to whether it would be possible for the majority of the country not even to be in tiers 2 and 3. Would testing enable control to be maintained? The figures showed that cases were going up faster and faster. And then the genomic testing revealed the new variant on the loose.

As a result of that new Alpha variant – laboratory studies in relation to which it was not likely to be more severe or pathogenic but that it was, as I’ve said, highly transmissible – was that the hospitalisations and deaths would result in even greater number, despite the current measures and the start of the immunisation programme.

At an extraordinary meeting of NERVTAG and SPI-M-O on 21 December, the debate began as to whether or not a lockdown was required.

A number of areas across England, including London and the south east, and then across Scotland, Wales and Northern Ireland went into blanket tier 4 effective lockdowns. On 30 December MHRA approval was given for AstraZeneca-Oxford.

In the first few days of January the Prime Minister announced that children should return to school after the Christmas break, but that restrictions in England would get tighter, but in the event a third national lockdown was announced on 4 January.

Hospitalisations peaked in mid-January, though by this time roughly 70% of all ICU beds available in the NHS were taken up by Covid patients. Deaths increased from 82,000 or so by 11 December to 152,000-odd by 1 April. Roughly 70,000 people died in the wave despite the start of the vaccination programme and the imposition of severe restrictions.

Was a third national lockdown necessary? To what extent were lessons learned from the first two? Should the decision to impose a lockdown have been taken before 4 January?

My Lady, there’s no need, I think, to address you on the detail of the roadmap, the emergence of the Omicron virus, because, of course, no fourth lockdown ensued from the emergence of that particularly prevalent variant. You’ve seen from the charts earlier, of course, today the incredible number of infections that ensued from the emergence of that virus in November 2021.

The growth rate was alarming: it doubled every three to four days, despite the UK’s high level of immunity. In late December there was a Cabinet meeting held to discuss whether to introduce further restrictions before the Christmas break. No further restrictions were put in place, and after Christmas the Prime Minister decided that the plan B restrictions which had been announced should be scrapped on the basis that things had indeed, on this occasion, turned out more favourably than had been feared.

There are two remaining issues before I conclude. They are public messaging, public confidence and legislation enforcement.

The Inquiry is enjoined by the list of issues to seek to ask how effective the public health communication steps were that were taken to control the spread of the virus. What did the move from “stay at home, save lives” to “stay alert” actually mean? Were the rules on group of six unwieldy and counterproductive?

The Inquiry will hear evidence from government officials as to the performance of the Government Communication Service and the Covid communications hub.

What also was the impact of alleged or proved breaches of rules and standards by ministers, officials and advisers?

The link between public trust and compliance is well known, and the evidence suggests that, over the three weeks after the breaking of the story that Mr Cummings had driven to Durham with his wife and child during the lockdown and had been seen and had then driven to Barnard Castle on Easter Sunday and then of course had held a press conference on 25 May, that willingness on the part of the public to comply with the regulations dropped sharply.

Confidence in the government was badly damaged. The impact of emerging stories in December 2021 of parties in breach of lockdowns, regulations and guidance was no less dramatic. So the Inquiry will need to explore the critical need in a crisis for government to maintain public confidence through leadership.

Legislation and enforcement.

The Inquiry will ask how proportionate were the health and coronavirus legislation regulations proposed and enforced. To what extent were equality impact assessments carried out? Were their conclusions taken into account when passing laws and regulations?

The lack of clarity, it may be thought, in the legislation and regulations may have made it difficult for the public to know what was criminalised. How was the balance struck between incentivising people to adhere to social restrictions and punishing them? Were the rules enforced fairly?

There is some evidence that the majority of fixed penalty notices were given to men. Three-quarters of them were issued to white people, but proportionately people from ethnic minorities were 2.3 times more likely than white people to receive one in England and 2.8 times more likely to receive one in Wales.

Fines were also issued more frequently to people living in disadvantaged communities. Fixed penalty notice recipients were 7.2 times more likely to be living in one of the most economically deprived areas of England and Wales than one of the least disadvantaged areas during the first lockdown. So an issue for you is: how fairly were the rules enforced?

My Lady, in light of that identification of the issues, I now make some concluding points about the way in which your Inquiry may wish to approach its task.

At the outset, the legal team which has prepared this material recognises that there were no easy decisions. The government, in common with other governments, was required to make extremely serious and far-reaching decisions about how it would respond. Its decisions were literally matters of life and death.

Equally, no government is expected to be or can be perfect in its response. No amount of skill, resource or judgement guarantees that mistakes will not be made. Was there a limit – it will be a matter for you – to what this government, any government, could do in the face of an organism, a virus, that exists only to infect, spread, maim and kill?

This was doubly so when one considers the evidence that you’ve heard in Module 1 as to the lack of preparedness. Different elected leaders may also have drawn different conclusions as to how to balance the extremely complex ethical, public health, social and economic challenges posed by a lethal pandemic.

Some countries comparable to the United Kingdom imposed lockdowns yet suffered lower levels of death. Other countries fared worse. So comparison may therefore only be drawn with caution. Some may say the United Kingdom was probably in the middle of the pack. But that brings no solace to the bereaved.

In any event, your task is surely to ensure that the government does better next time. The Inquiry also does not intend to enquire through the distorted lens of hindsight. As Anthony Hidden Queen’s Counsel, later Mr Justice Hidden, remarked in the Inquiry into the Clapham rail disaster inquiry:

“There is almost no human action or decision that cannot be made to look more flawed and less sensible in the misleading light of hindsight.”

So, of course, in the particular context of the lockdown decision-making, counterfactual scenarios must be treated with particular caution.

The evidence may show, but the degree will be a matter for you, that the odds may always have been stacked against the United Kingdom because of the deadly spread of the virus, that’s what viruses do, because it was exacerbated and made more difficult to deal with by the UK’s international integration, deep travel and trade links to the wider world. The impact of the virus may also have been exacerbated by the relatively poor health and age of the UK’s population, by its lifestyle, relatively congested cities and population density.

But the evidence may also show, we will have to see, that there was a failure of technical insight. Was the inevitable spread of the virus properly appreciated by government? Was there a failure to appreciate the early reports from China, of the Diamond Princess, of the medical journal reports? Were the consequences of the likely lack of any control adequately understood? Was there a failure to direct the putting into place on a crisis basis of mass testing and surveillance systems? Was there a general failure on the part of government to appreciate until 13 and 16 March the true nature of the likely explosion in cases and deaths and that this would lead to the collapse of the NHS? Was there a mistaken assumption that delaying and suppressing the peak would have the collateral benefit of bringing about herd immunity?

Was there, as a result, no early consideration given to how to suppress the virus and to try to keep or regain control? Was there a failure of process? Ministers claimed to be following the science, but did they probe and analyse it sufficiently? Did they allow themselves to believe that the pandemic could be withstood and contained without more urgent action? Was there a failure to obtain and consider specialist non-scientific advice along with the advice from SAGE? Was there a sufficiently effective and robust system for decision-making? Was a proactive strategy adopted and pursued?

Finally, was there a failure of leadership and decision-making? Was there an absence of leadership?

The Inquiry will enquire into whether the government demonstrated sufficient leadership when it came to the events of March 2020, the first lockdown, the reemergence of the virus in September to October, and the second lockdown in November 2020.

The question for you will be whether any of those lockdowns became necessary as a result of any earlier failures, if you find them to be established. And also you will need to examine the timings of those lockdowns. Were they the result of prevarication by government? If so, another issue will arise, which is whether the system by which our leaders prepare themselves for, are advised upon and respond to, events of such magnitude, requires itself radical reform.

Ultimately, the United Kingdom was spared worse. It was spared worse by: the individual efforts and heroism of civil servants and public servants, and health and social care workers who battled the pandemic; the scientists, medics and commercial companies who researched valiantly to come up with the miracle of life saving treatments and ultimately vaccines; the local authority workers and volunteers who shielded and delivered food and medicine to the elderly and vulnerable, and who vaccinated the population; the emergency services, transport workers, teachers, food and medicinal industry workers and other key workers who kept the country going.

But we must find out why so many died. Never again can a virus be allowed to lead to so many deaths and so much suffering. Unless we learn the lessons and implement change, all that effort and heroism will all have been in vain when it comes to the next national emergency. There must be, as we turn to the witnesses, accountability and ownership of what went wrong, if anything, and by whom.

Lady Hallett: Thank you very much indeed, Mr Keith, I’m extremely grateful. We’re now going to hear from core participants.

I think 18 core participants wish to make oral submissions, so we have a great deal to get through before we begin hearing evidence, we have therefore had to limit the amount of time available to the CMOs. I’m sorry about that, but it’s because of the tight table that we have imposed on us, by me. I will therefore have to be strict with people to ensure they stick to the allotted time. If I intervene, please accept my apology, but rest assured I will read carefully everything that is contained in the written submissions that people have very kindly already sent.

Mr Weatherby KC, I think you’re starting off.

Submissions on Behalf of Covid-19 Bereaved Families for Justice UK by Mr Weatherby KC

Mr Weatherby: Good afternoon, my Lady, and thank you for that.

Can I start by welcoming the opening comments by Mr Keith, which were comprehensive, and we will assist to the best that we can to assist in answering the questions that he’s posed. I take your encouragement to stick to the time limit, and I will endeavour to do so. I might just go slightly over, but I hope you’ll stay with me. In January 2020 Lord Bethell was the government health whip in the House of Lords, and in March 2020 he became a minister in the Department of Health and Social Care. This is what he said in a recent interview with the Institute for Government, which was widely reported: “By mid-January, we in the top floor of the DHSC had a pretty clear idea of what the train was looking like coming down the tracks.” He then said this: “No 10 didn’t want to prioritise the pandemic in early 2020, even though the evidence was mounting – there was a post-election, ostrich head-in-the-sand mentality … its priority, and what we were told many times, was Brexit and levelling-up. ‘We have to deliver Brexit, so could your pandemic quietly go and mind your own business, please’, we were told. After that, we got a lot of erratic dipping-in – in Yiddish, it’s called ‘kibbitzing’, erratic and ill-informed interference.”

What you made of the Module 1 evidence remains of course to be seen, but in our submission it showed a shocking lack of preparedness, little resilience with a chronically underfunded health sector, and the absence of a functioning social care system, compounded by a lack of any proper pandemic planning.

We pose the following questions: how many lives would have been saved if there had been a whole-system pandemic plan, proper resilience within the health and social care systems, a minister responsible for civil emergencies, a standing scientific committee on pandemics, a proper collaborative framework for working with the Scottish, Welsh and Northern Ireland devolved administrations, and also with local authorities? Many lives would have been saved, is the answer that we would provide.

So, most relevant to present purposes, the Module 1 evidence has highlighted that the United Kingdom had a standing start, in our submission, from January 2020, and it’s the role of any competent government or administration to react swiftly to whatever crises arise, with the resources that are available to catch up, and to protect the population so far as is possible.

What was needed, then, was a dynamic and proactive government response to lead and galvanise the country. But instead we got what Lord Bethell has starkly stated, in what amounts to a pretty devastating series of admissions from within the centre of government: ostrich syndrome, fixation on Brexit to the exclusion of anything else, and erratic ill-informed interference from Number 10.

His words, not mine.

It amounts to dither, delay, indecision, denial, bluster and, above all, a lack of leadership.

And the views of Lord Bethell will come as no surprise, given the views of others as set out by Mr Keith this morning and which I don’t need to repeat.

Mr Johnson himself appears set to paint a rose-tinted account to this Inquiry, and recently he asserted that the United Kingdom “defied most of the gloomier predictions and has ended the pandemic … well down the league tables for excess mortality”.

Is that really so? Well, according to an analysis by the John Moores University of Medicine cited in our written submissions, per head of population the United Kingdom was the number 20 worst of 173 countries in terms of the number of deaths.

Was the outcome really as good as Mr Johnson pretends? It will not surprise you that the 7,000 bereaved family members we represent will beg to differ.

The bereaved families want vital questions answered. They want candour from public representatives and public servants, not self-serving justifications, bluster and downright fiction. They present 230,000 reasons why Mr Johnson’s “we didn’t do too badly” opening gambit should be rejected. I’ll return to the bereaved families in a little while, because of their real life experience, some of which you heard this morning.

If it’s correct that the UK Government started with no plan and no real health or social care resilience, how quickly did the government mitigate those deficits? Well, it appears that the starting point was that Mr Johnson failed to take the emerging threat seriously. Initially he will tell us that he thought it was just a scare, and in his statement he says that the impact of the Creutzfeld Jakob disease was initially overstated. He refers to a “bird flu scare” when he was Mayor of London, and he remarks that the 30 January WHO declaration of Covid as a public health emergency of international concern was just one of a number since 2009.

His government approached the emerging crisis as a health issue to be dealt with by the DHSC rather than the real whole-system threat that it actually posed.

I’ve already mentioned Lord Bethell’s views by mid-January that it was clear to him and others at the DHSC what was coming down the track. But Deputy Chief Medical Officer Jonathan Van-Tam will tell us that as early as 16 January he was “certain that the UK would be struck by a severe pandemic”.

Mr Hancock will tell us that by 22 January he was warning Mr Johnson directly in a phone call that there was a 50% chance that the virus would escape China and, in his words, “go global”, and that a “very large number of people would likely die”.

Mr Johnson says he doesn’t recall this conversation, a somewhat surprising assertion, given its content. Mr Hancock will also tell us that Number 10 refused his request for COBR, the central government emergency committee, to be stood up until 24 January, calling him “alarmist”.

Although this evidence would suggest at least Mr Hancock was taking the crisis seriously at this time, other evidence indicates complacency on his part too. In a WhatsApp exchange on 25 January, Dominic Cummings asked him about the extent of preparedness for a pandemic. Mr Hancock replied, “We have full plans up to and including pandemic level regularly prepped and refreshed”. It will be interesting to see how he squares that assertion with his Module 1 assessment that the UK level of preparedness was “woefully inadequate”.

Of course, Mr Cummings was the PM’s Chief of Staff at this time. For reasons which are unclear to us, his statement and documents have yet to be disclosed, as indeed has the content of Mr Johnson’s phone from this period, so I’m unable to take this part of the story too much further, as to what was behind this request of Mr Hancock.

Whilst I am on the subject, Mr Johnson claims that although he’s downloaded the phone, the WhatsApp messaging from the crucial period of 31 January to 7 June 2020 are unrecoverable, a remarkable and unfortunate coincidence, we would say.

In line with your forthright warnings earlier in the process around the integrity of evidence, we would urge the Inquiry to commission experts to see why those messages can’t be retrieved, and whether they may have been deleted.

In considering whether, as Mr Keith says, Mr Cummings was part of the problem and Mr Hancock was less than competent, as some would have it, you’ll no doubt take account of the fact that they were in positions at the appointment of Mr Johnson himself.

Mr Keith has set out the chronology in some detail. The Inquiry will have to consider whether vital time to form a contingency plan and to act was squandered. Urgent continencies were certainly needed: to do what was possible to mitigate the lack of resources and resilience in hospitals and care homes, increase bed capacity, find ways of increasing staffing availability, provision of isolation and quarantine units, extra intensive care provision, ventilators, PPE, guidance and planning for infection control. Vital time was lost which should have been used to ramp up the manufacture of tests, which had been devised, we’re told, by mid-January. Facilities to roll them out, laboratory capacity, PPE procurement and distribution, facilities to vigorously pursue test and trace, similar to contact tracing successfully operated in other countries.

None of this would be done, because part of the government was in denial and others had a false view of its own preparedness.

None of these failings, in our submission, can be explained by scientific advice.

We’ll be told, of course, as Mr Keith has indicated, that some will say that they were following the science. Is that really the case?

Mr Keith has helpfully referred to an email from Professor Woolhouse on 25 January warning about the urgent threat of the pandemic, the risk of the NHS being overwhelmed. That email copied to all four UK Chief Medical Officers. It was one of a series of emails in fact sent between 21 and 31 January by Professor Woolhouse, and it’s important to note that this key one referred to by Mr Keith begins with an apology for when it was sent, on a Saturday.

That, we would say, is a clear measure of its urgency. And he was at pains to set out that the tripling of the excess death rate and overwhelming of the NHS was not a worst-case scenario and that he’d conferred with other leading lights in the scientific world, Jeremy Farrar and Professor Ferguson in particular.

If the government was following the science, what happened as a result of that dire warning from such eminent experts? And we would say we can identify precious little over the following two months that followed from those warnings. And in fact, of course, those warnings, Mr Keith has said, are not isolated. By 29 January COBR was being briefed that the UK faced a possible reasonable worst-case scenario similar to pandemic flu. The importance of that is, of course, that the reasonable worst-case scenario was 800,000 deaths.

We’ve heard Mr Johnson wasn’t at COBR to hear this, and he wasn’t at COBR for more than another month after, until March. He’ll tell us that he properly left things to others, but the reality is there was a leadership void.

As we set out in the written opening, as Mr Keith has graphically outlined this morning, during this period there was a daily trail of warnings and evidence of the pandemic going global.

In April, The Sunday Times ran an article headlined “38 days when Britain sleepwalked into disaster”. The thrust of the article was that the UK sleepwalked into widespread community infection, with little action to slow it or prepare for the worst that was to come.

It struck a chord at the DHSC, which, unusually, put out a detailed rebuttal, asserting in the strongest of language that “the article contains a series of falsehoods and errors and actively misrepresents”.

Now, I’m not here to defend The Sunday Times. I’ll leave that to the government’s Chief Scientific Adviser, Patrick Vallance. His contemporary notes say:

“The [Sunday Times] got it about right. We warned of pandemic flu level deaths in January. [Matt Hancock] kept too much in DHSC and didn’t move fast enough. [The Civil Contingencies Secretariat] was slow as well.”

He continued that The Sunday Times had “basically … got it right”. So, again, was the government following the science?

In a different entry, in April, Professor Vallance quotes Matt Hancock admonishing him:

“Science advice we can’t do because of supplies, is worse than useless.”

The clear inference is that certain ministers were not so much following the science as wanting cover from scientific advisers for shortcomings in provisions. Here it was masks.

The theme continued with the change of designation of Covid as being a high-consequence infectious disease; as we know it was designated as such on 16 January, given that it had the potential to spread widely and with large scale fatal consequences.

But on 19 March as the UK slid into the first devastating wave, the UK downgraded the designation of the virus, no longer categorising it as an HCID. As we understand it, without advice or consulting SAGE.

The effect of downgrading was to reduce the standards of PPE required by healthcare guidance. Or moving the goalposts to avoid criticism might be a way that we would put it.

We’ll hear from Mr Johnson that scientific advice is also responsible for poor decisions. He will suggest that there was no evidence of asymptomatic transmission, and that explains why the risks were underestimated in the early months.

We’ll hear from Mr Hancock that there was a global scientific consensus until April 2020 that the virus did not transmit asymptomatically. That is completely untrue. The High Court unpicked this issue in its judgment in the Gardner case. The 29 January COBR meeting already referred to was briefed that there were early indications of asymptomatic transmission. The Professor Woolhouse emails referred to earlier noted that by 31 January there was growing evidence of asymptomatic transmission. By mid-March Patrick Vallance was publicly saying on the Today programme that asymptomatic transmission was a probability.

It’s important to note that this very public acknowledgement by Professor Vallance came just four days before the decision on 17 March 2020 to discharge 30,000 patients from hospitals without testing, many to care homes. I’ll return to that a little later.

Mr Keith has already referred to the fact it was two months into the emergency before Mr Johnson attended his first COBR meeting, 2 March. The day before he engaged in what can only be described as cavalier and incredibly unhelpful public messaging when he visited the Royal Free Hospital, telling the media, “I think there were a few coronavirus patients and I shook hands with everybody, you will be pleased to know, and I continue to shake hands”.

We now know he received a briefing the night before his hospital visit expressly referring to transmission by touching an infected person. It’s difficult to see his actions and media comments as other than dismissive of a disaster which had been looming for two months and was now just around the corner.

By 2 March the pandemic had not only struck China, the Far East, South East Asia and Italy, but there was sustained community transmission in Germany and France. The contact tracing in the UK had failed.

Mr Keith has gone through what did and didn’t happen in March, and we’ve set it out in our written opening, but in overview, until 23 March the approach was largely messaging, advice rather than action. Pubs, clubs and restaurants remained open until 20 March. A particular issue, as we’ve heard, was mass assemblies.

By early March, Madrid had become a hot spot, yet thousands of fans would travel to the Champions League match in Liverpool on 11 March because the UK government not only did not have travel restrictions but did not curb mass assemblies and encouraged the match to go ahead. Other major events went ahead around the same time as we’ve heard: rugby internationals, incidentally attended by Mr Johnson himself; the Cheltenham Festival between 10 and 13 March, with international travellers. Only on 16 March was there even advice against gatherings.

Joan Lally picked up two close relatives from the Liverpool v Atletico Madrid match. They all contracted Covid, and Joan died. Her husband John believes her death would have been prevented had the government acted to stop mass sporting events at a time when it should have been obvious to them that they would become superspreading events, resulting in mass infection and death.

John comments that his wife’s death was not only his loss, because for decades she had run a girl guides group in a disadvantaged area which had to close as a result of her untimely death.

Likewise, Richard Mawson developed symptoms a few days after attending the same match. He died on 17 April, his son Jamie believes, again, the result of the failure to stop mass sporting events.

Inaction had consequences.

No doubt the government did receive differing advice, some against taking certain measures. It seized upon that to explain its indecision, its dithering and its delay. The families I represent count that decision, that incompetence, in the numbers of their loved ones who died, and their stories show how these failures really impacted.

Jo Goodman’s dad Stuart died on 2 April. You will hear from her tomorrow as the Covid Bereaved Families for Justice UK group witness. She believes that Stuart contracted Covid in a crowded hospital waiting room at an outpatient appointment on 18 March a week before lockdown. He was vulnerable as he was due to begin cancer treatment and had taken his own sensible precautions. But without lockdown, without apparent infection control in public spaces, without general mask wearing, restrictions on transport and mass assemblies, he was left extremely vulnerable when he had to travel and attend the hospital appointment.

The early decisions, the lack of action, are therefore of acute concern to Jo. Indeed, Jo was in India in early March, and she was present there when many of the events of the important religious festival of Holi on 10 March were cancelled. She comments, in contrast at that time the UK was allowing large sporting events to continue and, worse, thereby promoting mass international travel from hotspots such as Madrid.

Alison Saunders’ partner James Yates died on 8 April. He had an impaired immune system and Alison believes he contracted Covid at a factory in Livingston, in Scotland, where he worked, or possibly as a result of a trip to Glasgow prior to lockdown, where he visited a number of pubs which had been allowed to stay open.

Alison believes that the lateness of the lockdown, the failure to take other important decisions early enough, the lack of safeguards provided to vulnerable people such as James, increased the probability of him and others succumbing. She comments that many such deaths were preventable had there been earlier action by the UK and the Scottish governments. In this regard she particularly notes the apparent differences between the Scottish and UK governments about restrictions on mass assemblies at the time which she believes added to the delay.

In this regard the families are concerned that the Inquiry fully considers how the UK Government and devolved administrations co-operated and collaborated or the extent to which they did or didn’t.

Mr Johnson would have it that his government involved the devolved administrations, including in COBR and through the CMOs. We don’t doubt there was co-operation at some levels. What we urge the Inquiry to look at, however, is whether the UK Government was really interested in the compliance of the devolved administrations, persuading them to go along with UK policy such as it was, or whether they actually valued the devolved relationships and differing opinions, in particular in meeting different challenges.

Mr Johnson has commented that he put Mr Gove in charge of the relationship with the devolved administrations because he didn’t want there to be a “mini EU” of four nations. That will be an issue which will need some explaining and unpicking.

Ranjith Chandrapala was a London bus driver on the No 92 route, which started at Ealing Hospital, where subsequently he sadly died. His family believe he contracted Covid at work around 20 April. A number of his colleagues had Covid at the time. There was no testing for drivers. He had not been provided with PPE. There were no Covid safeguards on the buses and those being carried were not required to wear masks.

The family comment that Ranjith was a frontline worker left without proper protection, and his death illustrates not only the likely effects of delay and lack of early measures, but also the disproportionate impact of the pandemic on transport workers generally, and black and brown emergency and key workers in particular, given that a third of Transport for London employees are from minority ethnic communities.

Disproportionate effect was a factor particularly evidenced in sectors with high percentages of black and brown workers, including health and social care, transport and the gig economy. The Inquiry has instructed experts on structural discrimination issues and it will be vital that it looks at how such issues were considered – if at all – from the outset, and throughout the pandemic.

Structural racial discrimination, other forms of structural discrimination, in particular regarding disability and age, and with respect to gender and sexual orientation, had a real impact. It’s not suggested that an emergency response to any civil disaster can solve such issues, but it is emphasised that the reality of structural discrimination should have been a consideration of central importance to policymakers in mitigating that disproportionate impact. It’s simply not correct that the pandemic affected us all equally. So far as we can see, as with the preparedness evidence in Module 1, structural discrimination was an elephant in the emergency response room. There’s scant evidence that it was considered at all.

It’s important to acknowledge that disproportionate impacts persisted throughout the pandemic. Winston Jones, for example, was a 53-year old transport worker. He died on 6 January 2021. His wife Wendy and his three children believe that he and his fellow workers were impacted by mixed messaging after the first lockdown – which I’ll turn to in a moment – poor guidance, and a lack of supervision of those measures that were in place by the time of his death.

When the government ended the first lockdown, it appears that its decision-making got no less erratic. Mr Keith has mentioned the Eat Out to Help Out policy, which involved subsidising people who were coming out of a lockdown designed to minimise social gatherings to gather with others in enclosed spaces. Explained as an economic recovery measure, it appears that it was rolled out without any scientific advice. We anticipate that scientists will say their advice would have been strongly against such a hare-brained scheme.

The Inquiry will have to consider whether the government really was following the science, or whether Mr Sunak’s flagship policy hastened the next wave of infections.

Furthermore, did Mr Johnson, as in March, unduly delay the second lockdown leading to greater loss of life and longer economic and social disruption? What is clear, in our submission, is that lessons were not being learned as the government went along.

Christina Fulop died of Covid on 8 January 2021. She lived at home and was assisted by domiciliary care workers. Her daughter Naomi, herself a professor of health care organisation and management, notes that the care workers were provided with no masks during March and April 2020. At the beginning of May 2020 her mother was sent 21 masks for one week to give each carer when they visited her. She had three per day. At the end of that week, Christina received a letter from the care agency saying that the policy as set out by Public Health England had changed and that carers would have one mask per eight-hour shift.

Although Christina survived the first wave, she contracted Covid during the winter and died during the subsequent lockdown. Naomi believes that insufficient PPE for care workers, the late imposition of the second lockdown, and the ineffectiveness of NHS Test and Trace led to her mother’s death. She further notes that she had been unable to see her mother for some weeks because of the lockdown, was unable to visit her in hospital when she was dying, and could only have a very restricted funeral. This hugely distressing experience was greatly exacerbated as it coincided with some of the illegal drinks parties at Number 10.

The families have real concerns that the ongoing failures of policy and erratic response firstly led to mass discharges of mainly older patients from hospitals to care facilities without testing, causing greater transmission into the most vulnerable settings, and then led to the under-admission of older people who needed hospital treatment and the triaging of patients resulting in the restriction of critical care for older and vulnerable people and the inappropriate use of DNACPRs. The families raise issues about dignity too, the treatment of the deceased and of the bereaved in terms of cultural norms and funerals, as you saw powerfully in the impact films this morning.

Finally, the families raise the obvious points that Mr Keith mentioned about public figures, Mr Johnson, Mr Sunak, Mr Cummings and Mr Hancock amongst them, breaking their own regulations, reports of suitcases of drink being taken into Downing Street during lockdown, illegal partying. These are already established facts, they’re not for the Inquiry to determine, but the families urge the Inquiry not to ignore the undermining of public messaging that these crass and disgraceful events caused. Whilst the vast majority of the country buckled down, complied, and came together, some did not.

Thank you.

Lady Hallett: Thank you very much indeed, Mr Weatherby. And thank you too for the written submissions that you sent. I found them all extremely helpful. Thank you.

Mr Weatherby: Thank you.

Lady Hallett: I think the suggestion is that we should carry on. I’m not getting a nod from our lovely stenographer. I think we’ll take a break now.

We’ll have a ten-minute break now and then, if necessary, have another break later.

So Ms Campbell KC, after the break, please.

(3.05 pm)

(A short break)

(3.15 pm)

Lady Hallett: Yes, Ms Campbell.

Submissions on Behalf of Northern Ireland Covid-19 Bereaved Families for Justice by Ms Campbell KC

Ms Campbell: Thank you, my Lady.

My Lady, on behalf of the Northern Irish Covid Bereaved Families for Justice, together with Peter Wilcock King’s Counsel, our junior counsel including Mr McGowan, who’s here today, and our instructing solicitors, PA Duffy & Co, we welcome both the opening address from Mr Keith King’s Counsel and also this opportunity to address you further today on behalf of the devolved administrations and Northern Ireland in particular.

This module of course focuses on central government and later modules, we know, are to examine in greater detail the response of the devolved administrations, or DAs as I might call them.

In the case of Northern Ireland, that examination will come in Module 2C in April into May next year, but it’s important that I emphasise at this stage that this module is of critical importance to the Northern Ireland Covid Bereaved, because this is a starting point for examining and assessing the pandemic response in Northern Ireland, and there are a number of reasons for that.

The most obvious is that Westminster was taking decisions which were not or at least ought not to have been just for England but were of UK-wide significance.

At the early stages of the pandemic and at many stages throughout, all eyes, including those of the devolved representatives, were on Westminster. Initially eyes were strained waiting and willing the UK Government to act, and to act with purpose, the purpose being, we hoped, to protect lives. And thereafter, eyes were open in horror and distrust as stories of disarray at the heart of government and parties at the height of the pandemic gripped the headlines, rubbing salt into the wounds of the bereaved.

The action and inaction in Westminster had consequences far beyond its postcode.

Of course in this module at its core we examine the communication between the UK Government and the devolved administrations. Communication that we observe could have been conducted via well-established mechanisms, could and should have been based on consultation and transparent decision-making, could and should have recognised the need to make decisions based on the particular needs of the devolved nations, could and should have respected the insight to be gained from our local representatives, and should have been driven by a desire to protect our populations rather than to protect any perceived political hierarchy.

My Lady, from the material received and considered to date, the Northern Irish Covid Bereaved fear that at almost every level there were failings in that communication.

In order to properly assess where the failings may lie and the consequences of such failings, it will be important to closely scrutinise all sides of the story. Were the apparent fears of the Westminster government justified that the devolved administrations would diverge from Whitehall for “the sake of being different”, as the former Prime Minister suggests, or does that suggest a belittling of the decision-making of our elected representatives?

Is there evidence before this Inquiry from all quarters, from the DAs, and from regional mayors, that there are systemic problems with the governance emerging from Westminster in that it failed to recognise or even adequately attempt to recognise the need for a localised approach to this global pandemic?

You’re aware, my Lady, of our previously voiced concerns at the decision you took not to hear from devolved witnesses in this module, and those concerns persist. But in order to go some way to assuage them as this module progresses, we do ask that you keep under close scrutiny the approach of Westminster to how the pandemic gripped the devolved administrations in areas that include scientific analysis, political response, international relations, and financial constraints, because the decisions or indecisions by Westminster were of wider impact. They directly affected our lives in Northern Ireland.

By way of just two examples, both that we’ve heard of today, the Cheltenham Festival and the Liverpool football match attract significant support from across the island of Ireland. The Cheltenham Festival invited many thousands of Northern Ireland to travel, to mingle, and to spread the virus across three full days in mid-March 2020, and in the same week football fans flocked to watch Liverpool play Atletico Madrid, flying and sailing to the northwest of England, many returning home with the virus.

Our clients strongly believe that these decisions allowed the disease to flourish on the island of Ireland, and considered that it was obvious at the time that this would happen. Their belief appears to be supported by the evidence that you will receive in this module. Your expert witness, Professor Thomas Hale, identifies numerous studies that support that conclusion. He observes that the rapid banning of public events played a crucial role in explaining decreases in death rates across European countries during the first wave the pandemic. According to studies, a single day of delay in implementing a mass gathering ban or a school closure meant, respectively, a 6.97% and a 4.37% decrease in cumulative deaths. Every day mattered.

There is no doubt that people in Northern Ireland, including those in authority, looked to and relied on the UK to inform our own response. While many of those whom we represent would criticise our own Northern Irish responses, little more than the UK response with a two-week delay, it is important in the context of this module to consider the extent to which Northern Ireland was hindered in its ability to reach informed decisions either despite or because of the reliance on the United Kingdom response.

My Lady, I’ll touch briefly on science, because one aspect of concern was access to information and scientific advice.

Baroness Foster, from whom you heard in Module 1, will emphasise the importance to Northern Ireland of access to the wider pool of experts, including SAGE, greater access than would have ordinarily been available in Northern Ireland. And given this reliance, the make-up of SAGE, therefore, is a matter of importance to us. Despite this being a public health emergency, in fact the public health emergency of our time, and despite the large pool of experts available in the United Kingdom, evidence suggests that there was not a single public health expert or coronavirus expert on SAGE in the early stages of the pandemic.

Did that failure to ensure that appropriate experts were contributing from the outset result in early but significant errors in approach?

Our concerns don’t stop there. The devolved authorities may have been denied the opportunity to identify critical omissions given the lack of a devolved representation on SAGE, as you heard in Module 1. This absence was in fact most glaring in Northern Ireland. The earliest date of any Northern Ireland representative at a SAGE meeting was on 9 April. That was the 24th SAGE meeting, coming weeks after a nationwide lockdown had been imposed. Did this inequality of access inhibit the devolved nations’ ability to implement an informed response? It’s difficult to see, we submit, how it could be said to be otherwise.

The Inquiry will also see and hear evidence that more than half of the SAGE sub-groups had no representation at all from a devolved administration. According to Professor Henderson, from whom you will hear, a predominantly English frame of reference undoubtedly meant that advice to local populations at times did not meet local circumstances. So, in following the science, was the science just for England? And if that is correct, given the influence of SAGE recommendations on the political response, to what extent did that response make decisions in the best interests of the devolved regions and Northern Ireland in particular?

You know, my Lady, only too well that the Northern Ireland Executive did not function before 10 January 2020, and by that stage we know that there were already important developments in what was known about this new coronavirus and assessing what the potential risk was.

Key questions for the Inquiry in this period are: who was watching out for Northern Ireland in the absence of an Assembly? Was the situation in Northern Ireland, a part of UK without a functioning government, considered at all? It doesn’t appear to have been. And what was told to relevant officials in Northern Ireland at that very early stage? Questions that of course are all the more important now, given that our Assembly is once again in a state of collapse.

The Inquiry will hear evidence that, following the reinstatement of the Assembly in January 2020, the Northern Irish First Minister and deputy First Minister were not invited to attend a COBR meeting until 2 March 2020. Could this Assembly, in its infancy, properly begin to respond to the pandemic that was taking hold if it didn’t have full access to the science about what was to come and to the political decision-making in response to it?

Sir Jeremy Farrar, formerly of SAGE, writes that knowledge must be shared within hours and days and not weeks, and knowledge must lead to action. The world had all the information it needed by 24 January 2020: a potentially fatal novel respiratory disease that could spread between people without symptoms, with no vaccines or treatment, that had already ravaged a huge highly connected Chinese city. Early scientific papers were spelling out its grim clinical consequences in patients.

The world may have had all the information it needed, but did the UK Government consider it and share it appropriately with the devolved nations? And of course how did they, when they began to communicate, do so?

The evidence that you will hear suggests that mechanisms which should have been well placed to allow for a co-ordinated response and communication across these islands and amongst the devolved administrations had fallen into disuse and were not resurrected.

You will know of the observation of Professor Henderson that “pre-existing organisations to facilitate intergovernmental working were notably not pressed into service during the coronavirus pandemic”, and she references the use of the JMC and the British-Irish Council.

In April 2020 the former Prime Minister agreed to a proposal to “manage the devolved administrations”. That language is repeated and, we submit, it’s telling.

But his proposal to “manage the devolved administrations” was through the usual Joint Ministerial Committee mechanisms. But despite the JMC having a joint secretariat and being staffed by officials from the Cabinet Office and from devolved administrations, it didn’t materialise, and there were no meetings of the JMC in the relevant period.

Instead, as with other responses of central government to the pandemic, the approach to devolved administrations was to use ad hoc meetings without any meaningful defined role for devolved actors.

My Lady, the Inquiry may find it illuminating that the very same advice to Boris Johnson which suggested his daily 9.15s, his 9.15 meeting, to “allow for decisions to be taken at that meeting”, also expressly advised that the devolved administrations should not be invited. Rather, they were going to be updated on the response via a separate process established with the Chancellor of the Duchy of Lancaster.

Notably absent from this advice was the suggestion of any advance consultation or co-operation between Westminster and the devolved administrations. The logic underpinning it was that decisions would be taken without them in the room and meetings with devolved administrations became opportunities to convey those decisions and the details of decisions already taken.

It’s important to recognise that these decisions to exclude devolved actors from decision-making were deliberate. They were not as a result of urgency, or as a consequence of oversight. The approach appears to reflect the views of those in government at the time, such as those expressed by the then Secretary of State for Health, Mr Hancock, who recalls thinking that it was “madness that the devolved government will be taking their own lead on domestic health policy”.

This view, we suggest, led to flawed decision-making. It undermined co-operation across the islands. It reinforced the appearance of the response as England-centric. It failed to treat the people of Northern Ireland with the respect or afford them the protection to which they were entitled, and in due course we anticipate we will invite you to make such recommendations as to ensure that that does not happen again.

My Lady, a brief word on the Treasury. Significantly, the devolved response can’t properly be analysed and assessed without considering that Westminster was at all stages controlling the purse strings. It was not reasonably possible to implement effective public health measures without financial support, and we know that. As Professor Hale notes, and is common sense, economic support bolsters compliance. But did the Treasury provide economic support where and when individual jurisdictions needed it? Was there financial scope for Northern Ireland to diverge where necessary from the approach being taken in England? Or was it simply a matter of how soon the same measures were imposed and lifted in England dictated how soon they would apply in Ireland?

The First Minister of Wales, Mark Drakeford, describes the Treasury refusing his request for funds to allow Wales to implement a circuit breaker until such time as it was necessary to take those actions in England.

What of our nearest neighbour, the south or Republic of Ireland? Northern Ireland sits on a different island and epidemiological unit to Great Britain. What approach did Westminster take to address the unique geographical and epidemiological circumstances of Northern Ireland? Was there any consideration or adequate consideration of communication with the Irish Government in the best interests of the citizens of the north?

My Lady, one insight into the interface between the UK government response and the need to co-ordinate with the devolved administrations comes from the outcome of a meeting of 14 March 2020. You heard about it briefly this morning. It was between the Prime Minister, the Chancellor of the Duchy of Lancaster, the Secretary of State for Health, the CMO and the CSA. It was, by this stage, mid-March. As Mr Gove will put it, there was pressure on the Prime Minister to “shift gears and accelerate plans” at this time. No official from the devolved administrations was present or represented at this meeting, but the outcome bears some attention.

It says this:

“We require a cross-governmental package on shielding the vulnerable and elderly by Wednesday lunchtime …”

I add, that being 18 March 2020.

“… for review by the Prime Minister the following morning [ie 19 March 2020], to be in sufficient depth to be ready for implementation. The advice should include ‘how to handle the devolved administrations’.”

We were then in mid-March, and the government was calling for a package to shield the elderly and vulnerable against a background in which, on 21 January 2020, Professor Woolhouse and his colleagues, Professor Ferguson and Farrar, loudly sounded the alarm that they expected a pandemic fuelled by mild cases but with significant mortality in the vulnerable groups.

Seven weeks on, seven weeks of the Prime Minister expressing concern not to scare the financial markets, belittling the risks of contracting Covid, dithering and delay, he calls, for what appears to be the first time, for a package to protect the elderly and the vulnerable, and to “handle the devolved administrations”.

That package was too late for many. It was too late to provide any protection for Ruth Burke, the indomitable mother of Brenda Doherty from whom you heard powerful evidence at the end of Module 1. You will recall that Mrs Burke was amongst the first to die from Covid-19 in Northern Ireland, passing away on 24 March 2020.

That package provided no protection for Mary Magdalene Mitchell, nor any consolation to her five daughters who grieve her loss. Mrs Mitchell fell ill on 18 March 2020, the very day that cross-governmental package was to be ready for consideration. She had until then lived in her care home in Belfast, to which access was unrestricted.

On 19 March 2020 while the then Prime Minister was, we dare to hope, considering how he might protect the elderly and vulnerable, she tested positive for Covid-19 and was admitted to hospital.

When it quickly became clear that she was not going to recover, her five daughters had to choose which one of them would attend hospital to say their brief final farewell, and she passed away alone on 25 March 2020, her family then having to suffer the indignity and the trauma of being unable to fulfil their mother’s funeral wishes.

Of course, from then we know the situation escalated. Professor Medley warned starkly, just on month later, in April 2020, that his reading of the situation is that:

“We have widespread ongoing transmission in the health and social care systems. Hospital and community health and social care appear to be driving transmission and potentially at an increasing rate. In effect, this is the opposite of shielding, the vulnerable are being preferentially infected.”

Those chilling words resonate with so many of the bereaved in Northern Ireland, and if I may conclude with reference to some of them, including some who are here today.

They include the family of Ann McIvor who lost their very much loved mother. Mrs McIvor had been supported and protected by her family in her own home in the early stages of the pandemic, but when she required hospital treatment they entrusted her to the health and social care system. After weeks of moves and mixed messages and chaos in a system that was ill equipped and ill prepared to cope, Mrs McIvor contracted the virus and passed away alone on 20 May 2020. On that same date up to 200 people had been invited to a “bring your own booze” party in Downing Street, an event that was attended by the then Prime Minister.

Almost one year later, Nuala Scullion died on 24 April 2021. Her family are here today. She was taken in an ambulance to the hospital and never saw her family again. She was admitted to the ICU, placed on a ventilator for weeks, and the hospital imposed a DNR without contacting her family, and in circumstances where Mrs Scullion was not in a position to give informed consent. The indignity of her death and the denial of her funeral rights continue to cause her family anguish.

The family of Raymond McAleese, who was 52 years of age when he died. He was a much loved uncle and brother. He was also a man with Down’s Syndrome. In September 2021, 18 months into the pandemic, and at a time when, as we have heard this afternoon from Mr Keith, Westminster once again flip-flopped or prevaricated on how to respond to the resurgence of the pandemic, Raymond contracted Covid in his care home and died within a matter of days. The confusion and fear he will have felt and faced, largely alone, in the days between his diagnosis and death continues to torment his family.

Later that year, on 23 December 2021, much loved husband, father and grandfather Peter Clarke passed away. Peter’s wife and his daughter are here today. He was a retired fireman and a diagnosis of bronchitis had been a legacy of his service to the fire service. Even at that advanced stage of the pandemic, his family harboured grave concerns about the preparedness of the response. He was admitted to a Covid ward without a Covid test, placed on a ventilator without the consent of his family, a DNR was noted on his records without proper consultation, and concerns persist about the medication and the move on to end of life care.

Of course there are many thousands more, including the father of Catriona Myles, from whom you will hear on Thursday of this week as part of the impact evidence.

My Lady, there’s an important overriding point to make on behalf of those whom we represent. It’s well known that Northern Ireland is a society that is divided politically, but the bereaved whom we represent are drawn from all sides of that community, sharing loss, grief, anger and trauma. That they do so reflects a basic scientific reality: a pandemic is not only or even properly a political challenge; it’s a public health challenge. And as Sir Graham Medley observed, pandemics do not respect national or subnational boundaries, a global failure was not to have international co-operation and concerted strategies and to agree a common approach.

Those whom we represent consider that this global failure was replicated domestically by the Westminster government. Their response lacked the necessary consultation to ensure effective co-operation and lacked strategies to agree a concerted approach with the aim of protecting lives.

We anticipate that the evidence in this module will show that the people of Northern Ireland and the UK as a whole were failed as a result of that.

Thank you.

Lady Hallett: Thank you very much indeed, Ms Campbell.

Right, Ms Mitchell.

Submissions on Behalf of Scottish Covid Bereaved by Ms Mitchell KC

Ms Mitchell: My Lady.

My name is Claire Mitchell KC, and along with my colleagues Kevin McCaffery and Kevin Henry, advocates, we are instructed by Aamer Anwar & Company, solicitors, on behalf of the Scottish Covid Bereaved at both the UK and the Scottish public inquiries.

In Module 1 we learnt that, despite expert groups and pandemic planning exercises, we were in no way prepared for the pandemic when it struck the UK. Healthcare workers had, on so many occasions, sounded the alarm that the NHS was already beyond breaking point. Austerity had bitten so hard that the NHS was already mortally wounded.

SARS and MERS outbreaks had not been properly studied. Pandemic exercise groups made recommendations that were never implemented. Myriad groups were set up with abounding acronyms and overlapping duties and responsibilities, yet none seemed to have an overall grasp on pandemic planning.

Brexit put an end to preparations for the inevitable pandemic and no proper plans were put in place at all for health, economic and the social impact of a pandemic on the people and on the businesses in the United Kingdom.

In Module 2 the Scottish Covid Bereaved want to find out how the lack of preparation and resilience affected the decisions of our politicians and civil servants faced with the onslaught of a pandemic.

This module will need to explore the UK Government’s relationship, or lack thereof, with the Scottish Government. It will be equally important to have this investigated from the Scottish Government perspective in Module 2A.

We will, of course, hear first from the Prime Ministers, the then Prime Minister Boris Johnson, his then Chancellor Rishi Sunak, Dominic Cummings, and many more who had key roles to play in the decisions made by the UK Government.

We must also hear from those who made decisions in the Scottish Government to understand their role and what part they took in the decision-making process.

From what we have so far read, it is clear that constitutional strife, petty squabbles, territorial power struggles, dictated decision-making rather than the needs of people facing death on a devastating scale.

From that substantial disclosure received so far, including the controversial WhatsApps, there has managed to be prised open a Pandora’s box at the heart of government in the critically early days of the pandemic. It reveals a government in crisis, scared and slow to act on expert advice, devoid of the relevant data needed to make critical decisions and significantly crawling behind other countries in protecting its population. As we now know of the thousands who died, there may have been those who could have been saved.

Senior Counsel to the Inquiry has in great detail highlighted that it will be important to closely examine the early days of the pandemic, and he has taken care this morning to set out what will be examined. I would like just briefly to look at a snapshot of that time.

By 24 February the World Health Organisation published a report of its mission to Wuhan, advising countries to immediately activate the highest level of national response management protocols to ensure that the all of government and all of society approaches needed to contain Covid-19 with non-pharmaceutical public health measures were implemented. Yet it was not until one month later, on 23 March, that lockdown was declared.

On 26 May 2021, Dominic Cummings, once at the heart of Boris Johnson’s government, gave evidence about what had been described as a crucial time, that being between Thursday 12 March and Sunday 15 March. It has been disclosed that at 7.48 on 12 March Dominic Cummings sent a text to the Prime Minister saying:

“We’ve got big problems coming. The Cabinet Office is terrifyingly shit. No plans. Totally behind the pace. We must announce today, not next week, if you feel ill with cold or flu stay home. Some around the system want to delay because they haven’t done the work. We must force the pace. We are looking at between 100 to 500,000 deaths between optimistic and pessimistic scenarios. You’ve got to chair the daily meetings in the Cabinet Room, not COBR.”

Mr Cummings has gone on to explain that the COBR system could not work as they couldn’t get all the data in properly.

Now, my Lady, having looked at that data, it was clear that the tsunamic effect of the lack of preparation was about to hit the UK shores. By Friday 13 March 2020 it was clear that the data showed that, even on the best case scenario, the NHS was going to become completely overwhelmed.

On 14 March Dominic Cummings said to the Prime Minister, “You’re going to have to lock down but there is no lockdown plan, it does not exist, SAGE haven’t modelled it, the Department of Health and Social Care don’t have a plan”.

So, as we see in the many thousands of pages disclosed in evidence to us, that despite advice from the World Health Organisation on 24 February, despite knowing the experience of other countries where Covid had already taken a grip, despite 16 March being the date SAGE eventually advised the government to embark on a lockdown, it was not until 23 March 2020 that the government announced it.

Where case numbers were doubling every three days, every minute counted, never mind every day. What was happening between those days, those hours, those minutes? Those are the questions that, my Lady, you will have to answer.

There is a very difficult balancing act between listening to all those who were affected and finding out from those who were in charge exactly what happened. As noted by the Chair in her opening statement, given the inevitability of a future pandemic, we don’t have the opportunity to call every witness affected. However, on listening to the Scottish Covid Bereaved, and to some of those people who we heard this morning, three requests appear again and again to emerge. Those are for answers, for accountability and, where due and sincerely made, for apologies.

The Scottish Covid Bereaved want to know the truth of what took place in those early days, to know about the decisions which directly impacted the death of their loved ones. Without truth, lessons cannot be learned, and without truth there can be no justice.

For the Scottish Covid Bereaved the knowledge of what happened cannot take away their grief, but it may, when analysed by this Inquiry, save the lives of many in the next pandemic to come. This, at the very least, is the legacy that they are entitled to expect.

These are the submissions on behalf of the Scottish Covid Bereaved.

Lady Hallett: Very grateful indeed, thank you, Ms Mitchell.

Right, now, I think Ms Shepherd, you’re standing in for Ms Harris, who’s sadly got Covid, I gather. I hope she gets better soon.

Submissions on Behalf of Covid-19 Bereaved Families for Justice Cymru by Ms Shepherd

Ms Shepherd: I appear on behalf of Covid-19 Bereaved Families for Justice Cymru. I will refer to them as CBFJ Cymru.

The subject matter of this Inquiry continues to be as relevant and pressing today as it was in 2020. My Lady, as you have already alluded to, Covid-19 is still with us.

The bereaved families in Wales are still fighting for truth, justice and accountability. They seek answers to the following questions: why did the UK Government and devolved administrations – what did they know about the risk posed by Covid-19 at each stage of the pandemic? Were the known risks given sufficient consideration? Was there anything that these administrations should have known but did not? And most importantly, for those who I represent, had those governments had sufficient heed to the risks posed by Covid-19, might there have been fewer deaths?

My Lady, in Module 1, CBFJ Cymru focused on whether the UK Government and devolved administrations were adequately prepared for a pandemic. In this module, we will see what happened when those inadequate preparations were put to the test. In Module 2 and the related Module 2B, CBFJ Cymru want to know how the decisions taken by central government impacted on those in Wales.

While most of the decisions shaping the response in Wales were decisions for which the Welsh Government was responsible, there were many decisions taken by the UK Government which impacted on the people in Wales and shaped the response.

Notably, the financial levers remained with the UK Government. So decisions on extra financial support were made at central government level. The Welsh Government sat on COBR and followed the UK Government’s approach at the early stages of the pandemic. They signed up to the coronavirus action plan, which was drawn up and initiated by the UK Government. The Welsh Government shared SAGE as a source of scientific advice, and a four nations approach remained, at least in part, a stated aim of the UK and devolved administrations throughout. Therefore, in order to understand decisions shaping the response in Wales, among the key areas for inquiry in Module 2 are: whether the UK Government and devolved administrations collaborated and worked together; the initial response to the pandemic leading up to the decision to impose the first national lockdown, which was taken on 23 March 2020, a decision which was agreed to by all four nations; how SAGE, the main source of scientific advice during the pandemic for both the UK Government and devolved nations, operated; and how decision-makers engaged with SAGE and the important matter of how scientific and health information, advice and data were shared between the UK Government and devolved nations.

CBFJ Cymru also ask the Inquiry to critically compare the decisions taken by the Welsh Government and the other devolved administrations alongside those taken by the UK Government.

The Welsh Government has long resisted calls to grant people in Wales their own public inquiry. Their position is that a proper understanding of governmental decisions affecting each of the devolved governments can only be achieved by seeing them within the context of the wider UK legal and policy landscape. We therefore invite that critical comparison?

Having introduced CBFJ Cymru’s position, I shall now turn to my substantive remarks.

When the pandemic struck, it was foreseeable that its effects would be unequal and that existing inequalities would be exacerbated. The Inquiry will hear stark evidence of those inequalities, for example that people with disabilities experienced inequality in access to healthcare, that domestic violence was persuasive, that some ethnic groups had greater representation in sectors of work where they were more exposed to risk of infection and, from the report of Professor Clare Bambra and Sir Michael Marmot striking evidence of the relationship between socio-economic inequality and unequal health outcomes.

This evidence provides vital context for examining the impact of the pandemic and what was required of the response to it.

CBFJ Cymru is concerned that there should be thorough examination of the position of older people. Prior to the onset of the pandemic, it was recognised by the Welsh Government that Wales has a higher proportion of older people than the rest of the United Kingdom, and that this cohort are more likely to develop chronic conditions and become frail. In Wales, the population was older than in other nations in the UK, and 71% of those over 65 had at least one long-standing illness. Wales and the UK generally are set to continue this trend towards an ageing population.

The expert evidence of Professor James Nazroo will highlight how older people are at risk of being suggested to ageism and deprioritisation in access to resources and healthcare, that it was known before the pandemic hit that care homes with vulnerable residents provided a setting conducive to rapid spread of influenza and other respiratory pathogens, that infections may be introduced by staff, visitors or new or transferred residents, and that outbreaks of influenza could have devastating consequences.

With this picture in mind, it is crucially important that the Inquiry will identify whether the needs of older people were overlooked. Was there a subconscious or unconscious tendency to view this cohort as lesser, to view them as dispensable?

CBFJ Cymru say that the response of the UK and Welsh Governments was wholly inadequate to the task. The reason for those failings must be fully examined and understood so that they will not be repeated. Why was a better understanding of the virus not gained earlier by those who had responsibility to take decisions? CBFJ Cymru seek to understand the extent to which the initial response, which was a shared response by all four nations, lacked a coherent strategy. Did a contemplated end point of herd immunity – and by “herd immunity”, my Lady, I mean the second type of immunity referred to by Mr Keith earlier, one which was pursued by Government – was that allowed to shape decisions on the timing and nature of interventions? Was the policy of saving the NHS from becoming overwhelmed applied in a way which was inconsistent with the overall aim of preventing loss of life?

CBFJ Cymru asks that the Inquiry specifically investigates the extent to which decision-makers took into account the prevalence and risk of long Covid.

We ask the Inquiry to examine the evidence which was available at all stages of the pandemic in relation to asymptomatic transmission. Was the approach to scientific uncertainty in line with the precautionary principle?

It has been suggested in the written evidence that the difficulty with asymptomatic transmission was that there was a lack of evidence of it or a lack of understanding of it. However, the problem was not so much a lack of evidence or understanding but a failure to factor into decisions something that was uncertain, but which had the potential to have very serious consequences. In the absence or uncertainty of asymptomatic transmission but in the context of there being evidence of a risk, decision-makers should have erred on the side of caution. In light of what was known, the decision in both England and Wales to discharge people from hospital into care homes without testing was indefensible.

Given it was clear from early on that asymptomatic infection and transmission could have devastating consequences, this Inquiry must scrutinise the decisions on prioritisation of testing for those who were asymptomatic. The evidence before the Inquiry shows that decisions on testing demonstrated a lack of urgency. In Wales, the decision to extend testing to all staff and residents in care homes was not taken until 16 May 2020. This appears to have been slower than the other three nations.

We therefore ask the Inquiry to scrutinise the issue of airborne transmission and the state of knowledge concerning routes of transmission at each stage of the pandemic. The possibility of Covid-19 being airborne should have been recognised from an early stage. As early as 14 February 2020, several possible routes of transmission had been recognised by the UK’s Chief Medical Adviser and the Chief Scientific Adviser. These included the potential for transmission via droplets, aerosols, direct physical contact and indirect or fomite based physical transmission. If aerosol transmission was considered at least as likely as other routes of transmission, the question must be asked as to why the predominant messaging in early 2020 centred merely around the need to wash hands and avoid close contact.

The failure to properly acknowledge that Covid-19 is spread by aerosol transmission and to adapt public messaging, guidance and non-pharmaceutical interventions, or NPIs, has important implications for infection prevention and control guidance, including the requirement for healthcare workers to wear FFP3 masks for the routine treatment of Covid-19 patients, as well as wider implications for decisions about what NPIs were implemented.

Given what was known, measures should have been considered at an earlier stage to mitigate against the risk of airborne transmission. For example, there should have been a greater focus on indoor ventilation and air quality monitoring, alongside the recommendation to meet outside where possible. CBFJ Cymru ask the Inquiry to ascertain whether decision-making and public messaging as it unfolded accurately reflected the scientific understanding on the possible routes of transmission of Covid-19.

One of the decisions which led to a change in the NPIs which were implemented was the declassification of Covid-19 as a high-consequence infectious disease.

CBFJ Cymru asks the Inquiry to scrutinise the rationale for this decision. We say that such scrutiny is warranted, given the extent of transmissibility of Covid-19 and the number of fatalities that there had been worldwide. This includes asking whether the resource implications of classification were taken into account when deciding to declassify Covid-19 as an HCID.

CBFJ Cymru also want to explore how scientific advice was received by decision-makers and factored into policy. There is evidence to suggest that there was a blurring of policy decisions and expert advice, with UK ministers adopting a mantra that they were following scientific advice or following the science, rather than exercising their ministerial judgement.

UK ministers and Welsh ministers should have been informed by the science and not led by it. It has been suggested that decisions were held off until scientific advice was overwhelming, rather than using scientific inputs alongside other analysis. The Inquiry should seek to explore how decision-makers used the scientific advice alongside other factors to inform decision-making.

In a similar vein, there should be examination of whether decision-makers who received advice from SAGE knew how to effectively engage with it and to use it to work out a coherent plan, which was their responsibility.

Not only does the question arise of whether decision-makers knew how to engage with the expert advice, but whether the structure for seeking and receiving advice from SAGE provided sufficient opportunity to ask questions and to explore the issues further with experts.

There should be no confusion about the fact that it fell to ministers to evaluate the advice, to ensure that relevant information was called for, and to make the decisions.

Turning to intergovernmental relations, the way in which the UK Government and the devolved governments interacted with each other in a prolonged time of crisis is a vitally important area of examination. People across the UK are entitled to expect no less from their elected representatives than that they will conduct relations with each other in a way that is conducive to the most effective response possible. The Inquiry must examine whether COBR, which is in the initial stage was the main forum for intergovernmental relations, was an effective means of consultation with devolved nations. Were the devolved nations mere observers on COBR, not having the same information and advice as the UK Government? Was policy analysis shared late? COBR meetings were called on an ad hoc basis by central government. There is evidence from the Welsh Government that requests were made for a more structured, regular and predictable arrangement. While SAGE was available as a source of expert advice for all four nations, there was no reliable protocol for how the devolved administrations could engage more with SAGE.

SAGE provided its advice based on questions from the UK Government alone. Though more direct engagement was requested with SAGE by the devolved administrations, it does not appear that this was achieved. We wish to know why.

The Inquiry must ask whether enough was done to find a reasonable and structured means by which to conduct intergovernmental communication. Did these structures enable orderly co-ordination and discussion concerning divergences in policies? We believe the evidence will show that such structures that there were were ad hoc and unequal to the task. A good deal more work is needed in this important area, notwithstanding the recent intergovernmental review.

Internal border control is a particular area of interest and concern to CBFJ Cymru. This was an area where the decisions made by UK Government directly impacted on those living in Wales. One of the measures taken in Wales in the second wave of the pandemic was the “Stay local” message which sought to prevent people living in Wales from leaving their local area. The rule of thumb was said to be 5 miles. In England, there was no such restriction. As a result, people in England appeared largely unaware of the travel restriction and sought to come across the border. Then Prime Minister Boris Johnson ignored calls from the Welsh Government to assist in regulating travel between England and Wales. Travel restrictions from parts of England to Wales remained subject only to guidance as opposed to enforceable restrictions.

The Welsh Government amended regulations to make it clear that people living in areas with a high prevalence of Covid-19 in England, Scotland and Northern Ireland would not be able to travel to parts of Wales, but the UK Government did not legislate to assist in restricting cross-border travel.

CBFJ Cymru ask the Inquiry to scrutinise the decision-making and communication on this issue, and to ascertain whether there was evidence to suggest any outbreaks in Wales were directly caused by cross-border travel from England into Wales. There were many areas of divergence in NPIs between the Welsh Government and the UK Government. Given the shared border, there are some towns which span the border. This had the potential to cause confusion and disruption for those living in Wales.

Some of the changes were small, such as the number of people from different households who could meet. Given the need for consistent and clear communication with the public, there should have been a good reason for any areas of divergence in policy between the territories of the four nations.

The Inquiry must examine whether divergences between nations and their NPIs were based on sound reasons. The Inquiry should examine whether, bearing in mind the risk for confusion, the leaders of all four nations did all they could have done to deliver a clear message to the public about measures being applicable to one part of the UK but not another.

The evidence will show that there were repeated failures at UK Government level to make it clear where measures being announced applied to England only. This caused unnecessary confusion for people living in other parts of the UK. A report commissioned by this Inquiry sets out how UK Covid press briefings repeatedly failed to clarify the territorial scope of the rules, namely that many of the new rules announced were England specific. An analysis of the texts of prepared speeches throughout 2020 shows that those speaking on behalf of the UK Government did an incomplete job of outlining the territorial scope of their data, information and guidance.

The Inquiry must seek an explanation from the UK Government as to why there were such repeated and avoidable failures in its public messaging, which was ultimately to the detriment of the public.

To conclude, my Lady, it has been acknowledged by some witnesses that errors were made in the response to the pandemic. We say that acknowledgement does not go far enough, and that the errors which have been acknowledged are the tip of the iceberg in terms of what the evidence will uncover.

These errors caused unnecessary pain and suffering. This Inquiry must therefore reach findings which will lead to decision-makers making better decisions and the institutions of the government working more coherently and collaboratively with devolved administrations of the UK. Changes must be made speedily, in light of those findings so that when the next pandemic strikes, as it inevitably will, people across the UK will be better protected from harm and loss of life.

Diolch yn fawr, thank you very much.

Lady Hallett: Thank you very much indeed, Ms Shepherd.

Mr Metzer, there you are. I don’t have a map today, so I couldn’t find you.

Submissions on Behalf of Long Covid Kids, Long Covid SOS and Long Covid Support by Mr Metzer KC

Mr Metzer: Thank you.

Forgotten, unheard, disbelieved, isolated, unemployed, disabled, immobile. These are the words that characterise the life-altering and devastating experience that people with long Covid have continued to suffer in the pandemic.

My Lady, I appear with Sangeetha Iengar and Shanthi Sivarkumaran on behalf of the long Covid groups, instructed by Jane Ryan of Bhatt Murphy.

The long Covid groups are Long Covid Kids, Long Covid SOS, and Long Covid Support, grassroots patient advocacy organisations whose members were compelled to come together in the early months of the pandemic to give voice to and raise awareness of long Covid, the long-term illness caused by Covid-19.

At the outset, the long Covid groups wish to acknowledge the pain suffered by the bereaved families who lost loved ones to Covid-19 and offer their condolences to them.

As Hugo Keith King’s Counsel has previously noted, long Covid is an injury, a serious condition, even a serious morbidity, which is the result of having had Covid. People with long Covid are the surviving ongoing victims of the pandemic. We have seen on the impact film people with long Covid explaining movingly that they did not know if there will ever be light at the end of the tunnel. My Lady, the long Covid groups ask your Inquiry to shed light on whether their suffering was avoidable. They seek truth and accountability for the harms they have suffered and, crucially, reassurance that the suffering of 2 million people in the UK is not an inevitable fate bound to be repeated in future pandemics.

The Inquiry will hear from multiple sources that the possibility of long-term post-viral illness was well known before this pandemic. Sir Patrick Vallance states:

“From my perspective, I was conscious that long-term sequelae were a possible outcome of Covid-19 from early on in the pandemic.”

Professor Brightling and Dr Evans echo this view and point to lessons from previous corona pandemics, SARS and MERS, that should have been learned. Their expert opinion is that it was foreseeable that there was going to be long-term sequelae from Covid-19, extrapolated from previous coronavirus pandemics and previous knowledge of post viral syndromes.

My Lady, a running thread of concern for this Inquiry will be: long Covid was foreseeable, so why was it not foreseen?

The Inquiry will hear of a dissonance in Westminster between knowledge of long Covid, on the one hand, and political recognition of it, on the other, and an even greater dissonance between knowledge of long Covid and any reaction to its risks.

The first of six framework questions which the long Covid groups hope the Inquiry will investigate is: what did decision-makers know and understand of long-term sequelae and long Covid? To answer that, the Inquiry will hear evidence from scientific advisers. Members of NERVTAG on 6 March 2020, before the first lockdown, had already advised that identifying the end of symptoms may be very prolonged or very difficult to define.

On 28 April 2020, SAGE 29 went further, advising on the importance of cohort studies of Covid-19 survivors to understanding the longer term effects.

By 15 May 2020, NERVTAG discussed the need for ongoing clinical issues post-Covid and the potential need for a clinical forum. There was also early understanding that long-term sequelae could pose a risk to children. NERVTAG noted this risk in February 2020 and by April 2020 SAGE 29 agreed to action priority studies on Kawasaki-like syndrome in children.

The Department of Health and Social Care was equally alert to the long-term health impact of Covid-19, and in June 2020 recorded sequelae of the disease, potential long-term lung and organ disease, as one of four major implications for the health and care system that would have to be catered for.

By 17 July 2020, Matt Hancock chaired a roundtable mandated to discuss the long-term impacts of Covid-19 in order to better understand, prepare and prevent it.

The NHS similarly prepared a detailed briefing note in August 2020 estimating that 60,000 people in the UK were expected to experience persistent or permanent physical health problems similar to previous coronaviruses such as SARS and MERS.

Whilst the understanding of the long-term health impacts of Covid-19 in adults and children was growing behind the closed doors of scientific advisers and public health departments, the complete absence of public information and government advice created a vacuum which patients, parents and carers were forced to fill.

Long Covid is a patient-made term created by patients using social media to find solidarity and share their experiences of suffering the long-term health impacts after infection of Covid-19.

The first posts on social media about protracted symptoms of Covid-19 were published in March 2020, closely followed in the traditional media. There was no government recognition or published advice on long Covid at this time. It was left to the long Covid groups to mobilise and advocate decision-makers for recognition of long Covid.

It was only on 7 September 2020 that the first official government guidance on the long-term effects of Covid-19 were published by Public Health England. The Inquiry will surely wish to examine the unique and significant role that patient advocacy was forced to play in the recognition and response to long Covid, the second framework question, and in turn to explore why the government delayed publicly recognising long Covid.

The early recognition of long Covid amongst scientists, clinicians, public health bodies, patient advocates and even the Secretary of State for Health and Social Care is clear. Against this backdrop, the evidence paints an entirely incongruent picture from the corridors of power in Westminster.

In October 2020 while the DHSC was publishing guidance on long Covid and called for recognition and support for people with long Covid, then Prime Minister Boris Johnson scrawled in capitals that long Covid was “bollocks”. Mr Johnson has admitted in his witness statement that he didn’t believe long Covid truly existed, dismissing it as “Gulf War syndrome stuff”.

The Inquiry will be concerned to probe how the former Prime Minister could possibly hold this view in October 2020, when SAGE, NERVTAG, DHSC, NHS, the WHO, and patient advocates around the world had recognised and registered the risk that long Covid was already posing with its own unique global ICD classification of the disease.

The Inquiry will no doubt wish to carefully scrutinise whether the science was followed.

It is perhaps noticeable that the former Prime Minister now accepts that long Covid is a serious health condition, but does not say when he changed his mind.

I’m sure, my Lady, you will be fully cognisant that adults and children were and still are suffering from debilitating, painful and terrifying symptoms for months and now years after infection, as we saw in the film earlier this morning, and yet Mr Johnson denied the truth of their suffering.

The UK’s senior most decision-makers were dismissing, diminishing and disbelieving the very existence and risk of long Covid. This inevitably led to inaction and a failure to protect the UK public from long-term harm to their health. That failure was three-fold:

First, a failure to monitor and collect data on long Covid.

Second, a failure to integrate the risk of harm from long Covid into decision-making.

Third, a failure to communicate the risk of long Covid to the general public.

The surveillance and monitoring of long-term sequelae is foundational to understanding its nature, severity and prevalence, yet seems to have been overlooked. The Inquiry will hear evidence to answer the third framework question, whether there was data collection and modelling of long Covid.

From the very outset of the pandemic, even though there was a foreseeable risk of long-term sequelae, the government focused only on the twin metrics of deaths and hospitalisations.

Professor Chris Whitty admits that initial planning for Covid-19 took no account of long-term impacts of Covid-19. The long Covid groups are concerned to understand why the gap in data monitoring wasn’t remedied sooner. They ask why, on 7 May 2020, when SAGE 34 identified the existence of longer term health sequelae and the importance of monitoring these impacts, was data not immediately sought by government decision-makers.

It was left once again to patient advocates to draw decision-makers’ attention to this chasm in data monitoring. Patient advocates gave evidence on the need to collate data on long Covid in August 2020. However, it was only on 1 April 2021, one entire year after SAGE had noted the importance of monitoring long-term sequelae, that ONS began publishing the first statistics on the prevalence of long Covid. Delay and dissonance continued to define the government’s response.

The ONS published its last bulletin on the prevalence of self-reported long Covid in March 2023 and had stopped collecting and publishing data. This is despite currently rising numbers of Covid-19 infections and where long Covid continues to be a current major health problem. So the long Covid groups are gratified to learn that the ONS has just announced a winter study on Covid-19 infections, which will include the impact of respiratory infections including long Covid.

The fourth question we ask is whether the prevalence and risk of long Covid was taken into account in decision-making on NPIs.

The only way to avoid long Covid is to avoid contracting Covid-19. The possibility of long-term damage to health should have been and surely must be a relevant factor. It was not simply a case of considering metrics for deaths and hospital admissions or balancing, in a binary assessment, the risk of harm the virus posed to the elderly and vulnerable against a risk of harm measures posed to the younger population. There is a fundamental third metric that affects children and adults: that’s of long-term morbidity.

A government that was considering the long-term health impacts of the virus would have considered the harm that long Covid causes to individuals, the public health burden of people contracting long Covid including to parents and carers, messaging to warn the public against the debilitating health damage long Covid causes, the social and economic cost of workplace absenteeism long Covid causes, the cost of financial support for people with long Covid on sick leave, the extra demands on the social care sector to support people with this debilitating illness, policy implications such as categorising long Covid as a disability in line with the approach taken in the United States in July 2021.

Instead, the evidence before you, my Lady, will demonstrate that tools like the dashboards and CRIPS that decision-makers used didn’t include the risk to long-term health. Their analysis of risk was distorted, overlooking the very real impact of long-term and disabling health consequences. Professor Whitty acknowledges the shortcomings of not recognising the risk of long Covid, saying that when they did, “it made us more cautious of the effects of Covid-19 in young and otherwise healthy adults as the pandemic progressed”.

The failure to integrate the risk of long Covid into pandemic decision-making continued throughout all the lockdowns and into the government’s exit strategy in preparing for “Freedom Day”.

When we look at the evidence, it prompts the question: was long Covid overlooked or was it dismissed? Minutes from a Covid-O meeting on 5 July 2021 suggest a dismissive attitude to long Covid persisted when it was recorded, alarmingly, that long Covid should not be used loosely, as it described a number of syndromes at a time when personal independent payment claims had reached an all time high.

Twinned with an assessment of decision-making around NPIs is the issue of whether timely and clear public messages were issued so that the public were alert to the risk of long Covid to adults and children. The public cannot protect themselves from risks they don’t know about. During the relevant period there appears to have been only one public health video on long Covid released by the DHSC, in October 2020.

The evidence prompts our fifth framework question: how and to what extent did decision-makers warn the public about the risk of developing long Covid and take the disease into account in public health communications?

The distressing experiences of the long Covid groups is one to be heeded and learned from. We hope the Inquiry’s important work will ensure that never again will it take thousands of patients to fight for recognition, to strive to be believed for their physical suffering and to advocate for their own safety and protection.

The final and most central question weighing heavily on all those who have suffered from long Covid is whether the government could and should have done more. Was the long-term suffering of nearly 2 million adults and children from long Covid avoidable?

Thank you, my Lady.

Lady Hallett: Thank you very much indeed, Mr Metzer.

Mr Friedman, just two more to go, you’re the penultimate one.

I think I’m being encouraged …

Mr Friedman: Yes.

Mr Keith: A five-minute break, I think, by the look on the face of our wonderful stenographer.

Mr Friedman: Certainly.

Mr Keith: Right, and I will be back promptly just before half past.

(4.24 pm)

(A short break)

(4.29 pm)

Lady Hallett: Sorry about that, Mr Friedman.

Submissions on Behalf of Disabled People’s Organisations by Mr Friedman KC

Mr Friedman: Not at all.

My Lady, I act for the Disabled Peoples’ Organisations, or the DPO, run by and for disabled people. They are Disability Rights UK, Inclusion Scotland, Disability Wales and Disability Action Northern Ireland.

Disabled people died more of Covid-19 than anyone else. Disabled people suffered physical and mental harm during the lockdowns in ways that others did not. People who took years to set up and maintain systems of independent living lost those systems overnight. They lived with the fear of non-resuscitation, lesser prioritisation of treatment, or dying in their homes because no one knew they were ill.

The questions our clients bring to this Inquiry are: why did disabled people fare so badly during the pandemic, and what does it tell us about the society we have chosen to live in and could choose to change?

Disabled people are 20% of the UK population and six out of ten of the Covid dead. That should make their fate one of the most significant of public issues, but it is not. The DPO therefore suggests an essential starting point for the Inquiry, that the bulk of disabled people’s fatal and damaging outcomes during the pandemic were chosen. They were the product of the way our society is organised, and the dominant values and beliefs that guide it. Our clients use the terminology of disabled people because people are disabled by the fact that social spaces, services and provisions are modelled around certain kinds of bodies and minds to the disadvantage of others.

That does not deny the reality of individual impairments, but what disables people, because of their conditions, are barriers and attitudes that are not experienced by those without such conditions.

The predicament of disabled people overlaps with having lower income and rates of employment, inappropriate housing, and suffering food scarcity, isolation and hate crime. Disabled people are often treated worse because of their age, race, sex and gender. Inequality is now a core issue in this Inquiry, but during the pandemic these matters were initially not spoken of, or characterised with euphemisms such as “disparities” or “non-clinical vulnerability”; anything other than the made inequalities and inequities that they are.

One of the reasons for euphemism was to defend the indefensible. Austerity had particularly severe consequences for disabled people. It is perverse for its architects to suggest otherwise. There is an inescapable tension between, on the one hand, government’s withdrawing services in the ten-year period before Covid – a period when life expectancy ceased to improve for the first time since the beginning of the 20th century in this country – and, on the other hand, the central reliance on resilience within UK Government emergency doctrine.

The foundation of the choices that rendered disabled people particularly vulnerable during the height of the pandemic is a dominant ideal of personhood in our society. That person is autonomous, independent and self-sufficient.

Nothing signifies the notion of personhood more than the central place of the home in the government’s pandemic response. The person the government imagined when it told us all to stay at home was someone who could financially, physically and logistically afford to stay there. It did not imagine the person who had no spare room to isolate in, the person dependent on assistance from others, the person who could not stay at home or isolate within it because they need to care for someone else or because they could not survive without going out to work. Instead, it imagined a non-disabled, autonomous person who would regard their home as a place of safety and be capable of moving their life into it.

There is a different way to see all of this. It arises from the truth, that we are all vulnerable, we are all in a state of dependency at the beginning of our lives and are likely to be at the end of it. In between we will all, in some way, at some point, be affected by physical ailment, emotional suffering, or some kind of bodily limitation. In that respect, vulnerability is universal.

The opposite of vulnerability is not invulnerability, but resilience. Resilience is acquired over time by virtue of resources and relationships which the state is critical in either fostering or denying, depending on its policies. Laws against discrimination that secure a level playing field are good in themselves but not enough to produce a fair and resilient society, one that can offer protection to us all in a pandemic.

What is required is a more positive conception of rights and responsibilities that deals with differences of power and situation in a more responsive, imaginative and resourced fashion.

My Lady, the inequities suffered by disabled people should be understood as issues of public health, but they are also human rights violations. The UK has signed and ratified the United Nations Convention on the Rights of Persons with Disabilities. What that global convention confirms is that disaster planning, data collection and co-production and co-design on policy are not just good ideas, they are binding international law. These rights were endorsed by the WHO’s 2011 report on disability, and in the 2015 Sendai Framework for disaster risk reduction.

Also, as my Lady knows, in 2017 the UK was criticised for its non-compliance with the UN Convention, with identified shortcomings in emergency planning, data collection and failure of consultation.

Having considered tens of thousands of previously confidential documents now disclosed by the Inquiry, what is extraordinary is how little these rights reports and guidance documents featured in government approaches at the outset and during the pandemic. These are some of the most important documents in the history of disability rights. On present disclosure, they left no footprint in the UK Government decision-making during the pandemic at all.

Against this background, the DPO identify nine failures in the Covid emergency state.

First, there was no system of disaster management because the UK does not have one. That much is clear from the evidence in Module 1. What we have scattered across legislation, regulations, guidance and plans does not cater for the critical collaboration between state and society that the Covid response demanded. Crucial links between central and local government are missing. Reliance is placed on the voluntary sector and community to fill gaps but without mandating that they be involved in planning or be funded to respond. Before 2020, none of the DPO were invited to engage on planning for a pandemic. They still have not been invited.

Second, with no plan beforehand, disabled people’s situation was then made worse by no plan being created. We now know that there was no high-level ministerial meeting on the impact of Covid on disabled people until 21 May 2020. On that day, the general public sector ministerial implementation group dealt with an agenda item on disability for the first time. The effect of that meeting was a plan to get a plan.

During the autumn of 2020 the government focused on the disproportionate impact of Covid on ethnic minority communities. Our complaint is not about that. Focus on all disproportionately impacted groups should have been prioritised. However, the Covid taskforce noted a direction from Mr Johnson and Mr Gove as late as November 2020 that planning for disabled people was to go on a “slower time”. That was despite knowing by June 2020 that disabled people were dying in disproportionate numbers, and despite Michael Gove in October 2020 declaring that, “time is running out” for the risks to disabled people, amongst others, to be mitigated in the second wave.

As a result, there was no plan for disabled people throughout the first and second waves of the pandemic, and there is still no plan.

Third, when it comes to equality matters including with regard to disabled people, the machinery of government is minimal. Roles are dispersed across several departments and dual ministerial posts with no overall lead minister. The Cabinet Office Equality Hub is described as a creature of policy and not an operational department. Yet the Minister for Disabled People, Justin Tomlinson, will suggest that he deferred to its Disability Unit, or DU, on the most essential features of his role.

During the pandemic, aside from the abject failure to escalate disability issues to ministerial meetings for months, other shortcomings include Minister Badenoch, whose portfolio did not include disability, being commissioned in June 2020 to conduct a review of disparities in pandemic impacts that did not examine the impacts on disabled people.

Fourth, none of the key decision-making during the pandemic was informed by the expertise of disabled people. Of the many problems with the slogan “follow the science” was that SAGE was initially dominated by medical scientists. Those who gave or acted upon SAGE’s advice did not benefit from the expertise of service providers or end users, including disabled people, and for a very long time no one appears to have noticed the problem. When it was noticed, the corrective action focused on race, ethnicity and gender. The perspective of disabled people remained missing.

Fifth, one of the consequences of no expertise is that there was no proper recognition of how disabled people fitted into the pandemic response. Most significantly, the administrative and political decision-making moved only incrementally from a clinical shielding focus to a broader social focus. Even then, disabled people remained subsumed within the notion of vulnerability, locating their risk within them as individuals as opposed to acknowledging inequality as its source.

Sixth, despite obvious risks to disabled people from the outset, the government did not properly engage with them or their organisations during the pandemic response. The encounters between Minister Tomlinson, DPOs and other organisations were qualitatively too little, too late, and too one-sided to constitute compliance with the principles of co-production and co-design. The Inquiry has evidence from multiple DPO and other civil society groups whose insights and networks could have been harnessed in the crisis but were not.

Seventh, government needed to engage properly with disabled people because they began the pandemic bereft of sufficient data about them. The papers issued by the DU on 21 May and 30 October 2020 registered an increasing awareness of the problem.

As of 12 November 2020 the DU proposed a data commission to understand factors driving increased mortality risk, but that proposal was not acted upon.

On 30 March 2021 the DU still expressed concern about data deficiency and the need for a data improvement programme.

In July 2021 the DU published the national disability strategy that committed to “strengthen the data and evidence base to support policies that will transform outcomes for disabled people”, but did not say how it would do that and still has not done so.

Eighth, failing to engage early with disabled people and their organisations was a lost opportunity to afford some of the most significant protections. The DPO repeatedly emphasised that they could have assisted earlier to prevent disabled people confined to their homes being left without food. Other grave errors were made regarding care homes, the risk of Covid to people with learning disabilities, assumptions around digital and other information access, making services only available to those on official medical lists, sign language, and earlier identification of long Covid, all of which it is difficult to imagine would have been overlooked with better engagement.

Ninth, and finally, government policy did not involve any significant income distribution to disabled people. The financial provision for disabled people during the pandemic was extraordinarily limited. For those who did not work or could not work, furlough meant nothing. Those on carers’ allowance did not receive the extra £20 of Universal Credit, neither did those on legacy benefits. In its briefing to the Covid-O group on 30 October 2020, the Disability Unit acknowledged the disproportionate financial impact of Covid on disabled people but proposed no remedy, save a possible financial package which did not come.

My Lady, that is why we say what happened to disabled people during Covid was a choice. This country could make different choices. It could comply with international law and have us live under more responsive government, but to do that there needs to be a fundamental investment in collective resilience. What happens to disabled people during disasters provides an insight in what could happen to all of us.

The pandemic has made everyone more aware of the life cycle, the limitations of the body and value of relationships. It has dispelled the illusion that we are islands unto ourselves. It has made the ethics of mutual care far more pertinent in the way we might live. One task of this Inquiry should be to embed those ethics into its recommendations for the future.

Thank you, my Lady.

Lady Hallett: Thank you very much indeed, Mr Friedman.

Right, Mr Cohen, last but not least.

Submissions on Behalf of the UK Statistics Authority by Mr Cohen

Mr Cohen: My Lady, I have some brief opening submissions on behalf of the UK Statistics Authority.

The Authority is an independent statutory body encompassing a number of other entities. It’s a non-ministerial public body reporting to the UK Parliament and to the various devolved legislatures. It has responsibility for the more widely known Office of National Statistics, as well as for the regulation of statistics in the form of the Office for Statistics Regulation, and next week, my Lady, you’ll be hearing from the National Statistician, Sir Ian Diamond, who oversees the Authority. My Lady, the Office of National Statistics have of course been very closely involved in understanding the cost and toll of Covid. They are keen that any contribution from them to this Inquiry should begin with an expression of their profound and sincere condolences to the bereaved, and their very great sympathy to all those otherwise adversely affected. The Authority understand how devastating Covid has been in many sectors of society, and they recognise that in all that they can say and do now.

I’m also asked, my Lady, to thank the public for their willingness to co-operate with Office of National Statistics’ attempts to gain information during the pandemic, as well as to thank the staff of the Authority for their work on behalf of the National Statistician.

My Lady, the Authority sees that it can assist this Inquiry, both because of the leading role it took in the development of insights and statistics during the pandemic and also because the Authority is determined to learn what happened and what could have been done better.

The recognition of the likelihood of future pandemics and other emergencies is central to the Authority’s position. They are determined that in the event and when those matters come to a head, they are better placed than ever before to address them.

My Lady, it may be of value to trace out in broad brush terms some of the work that was done during the pandemic.

The role that the Office of National Statistics had remained constant, but it of course occurred in a difficult and unprecedented environment. There were particular challenges in producing official statistics in relation to the accuracy and quality of data. It is very difficult to undertake survey data collection when social distancing is understandably in place, and where it is no longer possible to knock on doors and ask questions. However, the ONS did put in place significant measures to try and minimise those limitations, including by re-weighting results and finding new and innovative ways of collecting data.

This all occurred, of course, my Lady, in circumstances where the appetite and demand for official statistics was perhaps greater than ever before. That was partly because of a governmental need for more information and evidence to inform policy development, and also because of an understandable thirst from the wider public to understand the statistical picture and what was going on in the country.

In the light of that increased demand, the Office of National Statistics adapted and increased the level of insight provided within its standard releases such as those concerning mortality. A decision was taken that the data on mortality should be linked to different characteristics such as ethnic group, disability and occupation, in the hope that this could provide a new perspective and new levels of insight.

There was also, of course, significant new work being undertaken, such as through the development of the Coronavirus Infection Survey, a world-leading survey set up in exceptionally rapid time to measure Covid-19 infection as well as antibody rate in the wider population. At its peak, 400,000 samples were being collected each month by the ONS, and that formed part of the evidence base for the government’s surveillance of the pandemic, as was occurring in the United Kingdom, with data broken down across the four nations and also by age, region and other characteristics.

The ONS also deployed statistical experts in other government departments, the devolved administrations and public bodies, including finding new ways of sharing their expertise, providing support to other departments on how best to use statistics and to understand what was needed from statistics professionals across government.

The lessons that the Authority has taken from that exercise, my Lady, are, first of all, that the need for immediate statistical assistance by government in the light of any new emergency is paramount. It is vital that statistical professionals and the ONS in particular are involved in future health emergencies from the first.

In addition, the understanding should be retained that some of the insights that the ONS was able to gather during the pandemic, such as its use of regular flexible surveying and providing value in tracking societal and economic issues, shouldn’t be lost. There has been an amount of knowledge built up which is of importance.

Finally, my Lady, the Authority’s regulatory function – which is spoken to in a witness statement that is available, or will be available in due course – shouldn’t be overlooked. That is an important and responsible aspect of the Authority’s work, seeking to ensure that official statistics are presented fairly, properly and in a manner which is not misleading.

My Lady, as I say, the Authority is determined that any lessons that can be learnt from this Inquiry are taken on board, and stands ready to assist in any way possible, most immediately through the evidence of Sir Ian Diamond next week, but on an ongoing basis of course.

Lady Hallett: Thank you very much indeed, Mr Cohen.

Right, that completes the submissions for today. I’m very grateful to everybody. Nearly everyone stuck to the allotted time; some, I think, were even slightly shorter. So I’m really grateful to you all, and I appreciate how difficult it is to try and get everything in, and also then not to be criticised for speaking too quickly.

So we’ve done jolly well today, we’ve had a great deal of information and a number of very interesting submissions that obviously at some stage I’ll be considering with all the care that people would expect of the Inquiry.

10 o’clock tomorrow morning, please.

Mr Keith: Thank you.

(4.55 pm)

(The hearing adjourned until 10 am on Wednesday, 4 October 2023)