Transcript of Module 3 Preliminary Hearing on 28 February 2023

(10.20 am)

Lady Hallett: Welcome everyone, including those attending remotely, to the first preliminary hearing into Module 3: heath systems across the United Kingdom.

May I begin with an apology for the fact that some Core Participants were sent to the wrong venue. I am genuinely sorry. It was a human error. People attempted to correct it as soon as possible but, obviously, the message didn’t get through in time. There will be representatives of the Inquiry team available during the breaks to make sure that nobody is out of pocket so please let them know if you have been incurred additional expense. I hope that everyone’s had a chance to get their breath from having rushed from one venue to the next.

I am also grateful to everybody from the Core Participants who has taken the time and trouble to submit written submissions. They have been extremely helpful and I look forward to hearing from those Core Participants who wish to speak today, highlighting the main aspects of those submissions.

In a moment, lead counsel to the Inquiry for this module, Ms Jacqueline Carey, King’s Counsel, will explain in more detail the areas that Module 3 will be covering. May I just say this at the outset.

Module 3, healthcare, is obviously at the heart of an inquiry into the Covid-19 pandemic. It is a huge topic and, as I’ve said before, my aim in conducting this Inquiry is to provide reports, interim reports, throughout the Inquiry and to make timely recommendations where possible in the hope of reducing the suffering that we witnessed during the pandemic.

That means that we’ve had to break down the vast array of issues that healthcare systems in the UK could cover into manageable chunks. So what you might at first have thought would be covered in Module 3 may well be covered in other modules. So, for example, there will be other modules dedicated to examining health inequalities and the impact of Covid-19 on mental health and particular groups such as the elderly, the disabled, the poor and minorities. Some aspects of the impact will be covered in this module and, obviously, the sooner we can make it clear to all the Core Participants what module will be covering what issues, the better.

There’s bound to be some overlap so there will be a module, as people know, dedicated to the care sector, and one obvious example of an overlap is the discharge of hospital patients into care homes.

So I know how frustrating it is and all I can do is undertake to ensure that as soon as we are able to provide you with more detail, so, for example, Ms Carey may speak about providing the Core Participants with a list of issues for this module as soon as possible, then we will give that detail.

But as everybody again, I hope, knows by now, the Inquiry team is working extraordinarily hard and at such a pace that these things are not proving easy. We’re doing our very best, I can assure you.

I hope that some of what Ms Carey will have to say today may allay some of the concerns, because I fear there may still be some misunderstanding amongst some members of the public and possibly some Core Participants.

Finally, may I say this in relation to the Listening Exercise, Every Story Matters. The aim of the listening exercise is to ensure that we reach as many people as possible across the United Kingdom, from the seldom heard and from those who are more often heard, to find out from them directly what their experience of the pandemic was.

That is our aim, so that that material can be fed into the Inquiry and can inform all the findings and recommendations that I make.

Some Core Participants, but not all, and some members of the public, have complained that they do not yet have enough detail of the exercise. Again, may I say it is a huge project, probably one of the biggest of its kind to date, and the Inquiry team with the task of designing and developing it have also been working extremely hard and doing their best to consult and explain as they go along.

But having heard some of the complaints, I have asked them to redouble their efforts to explain what they are doing to all those who wish to know.

To that end, the latest Inquiry newsletter, which will be published this week, sets out in clear terms what has been happening, and the team will be holding a webinar shortly for interested organisations at which they will attempt to answer any further questions. Could I invite all those who have concerns about the listening exercise to read the newsletter and/or to ensure that they find out from a representative organisation what happens at the webinar. It may help them to understand, and that, in turn, may encourage people across the United Kingdom to participate in the Listening Exercise because that is what the Inquiry needs: it needs to hear from people, and we can only do that if the millions of people across the United Kingdom, enough of them, decide to contribute to the exercise.

I will now just conclude my remarks by saying that during the break we are going to display a short series of images from the early days of the pandemic. The reasons are twofold. One, so that we recognise the work done by the healthcare sector in response to the pandemic, and some of the images show that in a moving way, and the other, of course, is that we don’t forget the impact of the pandemic on so many people.

So, with those comments, I will turn to Ms Carey, please, to outline more about Module 3.

1. Opening Statement by Ms Carey, KC

Ms Carey: Thank you, my Lady.

Module 3 is primarily concerned with the impact of the Covid-19 pandemic on healthcare systems in England, Wales, Scotland and Ireland. As I know my Lady knows, the majority of healthcare in the UK is provided by the National Health Service, a Health Service that was established over 70 years ago to meet the needs of everyone. It was free at the point of use and would provide care based on need rather than ability to pay. It is a matter, therefore, that affects us all, and so the scale of this module, and indeed the Inquiry as a whole, should not be underestimated.

By way of example, as at December 2019 the National Health Service employed over 1.43 million full-time equivalent staff and it is the biggest employer in the UK. There were approximately 35,000 full-time GPs, an average of nearly 158,000 in-patient beds, and by March 2020, when the UK went into lockdown, there were just under 5.3 million people on waiting lists for routine elective care.

My Lady, these proceedings are, of course, being recorded and live streamed to other locations. In doing so, your Ladyship is fulfilling the obligation pursuant to section 18 of the Inquiries Act 2005 to take such steps as you consider reasonable to ensure that members of the public are able to attend or see and hear a simultaneous transmission of these proceedings.

Live streaming this hearing also allows the hearing to be followed by a greater number of people than would otherwise be accommodated even within this large hearing room or people that can be accommodated in the overspill rooms.

In addition to the Inquiry’s counsel and solicitors teams today there are 27 Core Participants in the hearing room with a further four Core Participants in remote attendance, and five Core Participants are unable to attend today, each of those has written to the Inquiry explaining why they cannot attend and has indicated they mean no discourtesy to your Ladyship by their absence.

As is routine in public inquiries where there may from time to time be matters mentioned of a potentially sensitive nature, although they are unlikely to arise today, the broadcasting of the hearing will be conducted with a three-minute delay. This provides the opportunity for the feed to be paused if anything unexpected is aired which should not be. As I said, we do not expect any such matters to arise over the course of today but I mention this feature so that those who are following from further afield understand the reasons for the short delay.

My Lady, may I turn firstly to the designation of Core Participants. Pursuant to Rule 5 of the Inquiries Rules, 36 applicants, some involving joint applications, were designated as Core Participants in Module 3. They are the Covid-19 Bereaved Families for Justice, the Northern Ireland Covid-19 Bereaved Families for Justice, Scottish Covid Bereaved, Covid-19 Bereaved Families for Justice Cymru, the Secretary of State for Health and Social Care, Department of Health in Northern Ireland, the Welsh Government, the Scottish Ministers, Office of the Chief Medical Officer, NHS England, NICE (the National Institute for Health and Care Excellence). There are those representing the Scottish Health Boards, the group of Welsh NHS bodies, the Welsh Ambulance Services NHS Trust, the National Health Services Scotland, the Public Health Agency (Northern Ireland), Public Health Scotland, the British Medical Association, the Academy of Medical Royal Colleges, the Royal College of Nursing.

There are those representing the Royal College of Anaesthetists, the Faculty of Intensive Care Medicine and the Association of Anaesthetists, the Royal Pharmaceutical Society, [National Pharmacy Association], Core Participant group representing Long Covid Kids, Long COVID Physio, Long Covid SOS and Long Covid Support.

The Disability Charities Consortium, the Trades Union Congress (known as the TUC), the Covid-19 airborne Transmission Alliance, the Federation of Ethnic Minority Healthcare Organisations, John’s Campaign and the Relatives & Residents Association, and the Patients Association, those representing clinically vulnerable families, the 13 pregnancy, parenting and baby charities, the Frontline Migrant Health Workers Group, the UK Health Security Agency, Independent Ambulance Association, His Majesty’s Treasury, and Mind.

A list of the Core Participants that you have designated for Module 3 has now been published on the Inquiry website.

My Lady, for those who were either not granted Core Participant status or for those who did not apply to be a designated Core Participant, I wish to reiterate that not being a Core Participant in Module 3 in no way precludes any person or entity or group from applying for CP status in a later module, from bringing any matter to the attention of the Inquiry, from providing evidence and information and, where appropriate and relevant, giving evidence at a hearing.

As my Lady has just referred to, if an individual affected by the pandemic is nonetheless not granted Core Participant status, they are welcome to take part in the Inquiry’s Listening Exercise.

Having made the introductions to all of you today, can I turn now to the agenda for today’s hearing, which has been published on the website, and firstly dealing with the scope of Module 3.

I should say at the outset that the relevant period being examined during Module 3 is 1 March 2020 to 28 June 2022. That end date is set out in the Terms of Reference and so, although one Core Participant group asked you to consider the impact of ongoing restrictions, in our submission you have no legal power to do so. Section 5(5) of the Inquiries Act makes plain that your functions are exercisable only within those terms of reference.

I should also say that we are aware that the names of some of the organisations and bodies have changed since the start, indeed, of this Inquiry and, indeed, changed during the course of the pandemic. We will endeavour to use the terminology that was in use during the relevant period.

I know, my Lady, that everyone will have seen the document setting that provisional outline of scope for Module 3. That provisional outline states that this module will consider the impact of the Covid-19 pandemic on healthcare systems in England, Wales, Scotland and Northern Ireland. This will include consideration of the healthcare consequences of how the governments and the public responded to the pandemic. It will examine the capacity of healthcare systems to respond to a pandemic and how that evolved during the Covid-19 pandemic.

It will consider the primary, secondary and tertiary healthcare sectors and services and people’s experience of healthcare during a pandemic. That includes through illustrative accounts.

It will also examine healthcare-related inequalities such as in relation to death rates, PPE and oximeters, and there will be further detailed consideration given to a separate designated module.

But in particular this module will examine the impact of Covid-19 on people’s experience of healthcare, the core decision-making and leadership within healthcare systems during the pandemic, staffing levels and critical care capacity, the establishment and the use of Nightingale hospitals and the use of private hospitals.

The module will look at 111 and 999 and ambulance services, GP surgeries and hospitals, and cross-sectional co-operation between services.

The healthcare provision and treatment for patients with Covid-19, the healthcare system’s response to clinical trials and research during the pandemic is within the scope of Module 3.

The allocation of staff and resources, the impact on those requiring care for reasons other than Covid-19, and the quality and treatment of both those with Covid-19 and indeed non-Covid-19 patients.

The delays in treatment, waiting lists and the reasons for people not seeking or receiving treatment are within Module 3, is as palliative care and the discharge of patients from hospital.

The decision-making about the nature of healthcare to be provided for patients with Covid-19, its escalation, and the provision of cardiopulmonary resuscitation, including the use of do not attempt cardiopulmonary resuscitation instructions, is within the scope, and we will refer to that in future, my Lady, as DNACPRs.

The impact of the pandemic on doctors, nurses and other healthcare staff, including those in training and specific groups of healthcare workers, for example by reference to their ethnic background, is within Module 3. The availability of healthcare staff, the NHS surcharge for non-UK healthcare staff and the decision to remove the surcharge is also within the scope.

Preventing the spread of Covid-19 within healthcare settings, including infection control, the adequacy of PPE, and rules about those in hospital will be examined.

Communication with patients with Covid-19 and their loved ones about the patient’s condition and treatment, including discussions about DNACPRs, is a matter that will be looked at.

The deaths caused by Covid-19 pandemic, in terms of the numbers, classification and recording of deaths, including the impact on specific groups of healthcare workers, for example by reference to their ethnic background and/or their geographical location, will be in the scope.

Pausing there, my Lady, official statistics indicate that there were over 850 Covid-related deaths of healthcare workers throughout the UK over the time with which this Inquiry is concerned.

Module 3 will examine shielding and the impact on the clinically vulnerable, including those referred to as clinically extremely vulnerable, and the module will consider the characterisation and identification of post Covid conditions, including the condition referred to as “Long Covid” and its diagnosis and treatment.

My Lady, the Inquiry team are already actively working to identify key topics and themes which are likely to be the focus of requests for evidence, and which may in due course provide a structure for the hearing. Given the breadth of care provided under the umbrella of primary care, for the purposes of Module 3 the Inquiry considers it appropriate to focus on GPs and community pharmacy. However, areas in particular that Module 3 will consider within the scope include the impact of Government decision-making on healthcare systems across the United Kingdom, how the treatments available to those suffering from Covid-19 developed and changed over the course of the pandemic. As I said earlier, the quality of care provided to both Covid-19 patients and non-Covid-19 patients.

Module 3 will consider the protocols and policies relating to the discharge of patients as they affected hospitals and those being treated and working in the hospitals, and the care sector module will deal with the availability of care and/or the processes about setting up care packages and the impact of patient discharge on the care sector.

Module 3 will consider the effect of national guidance on infection control within healthcare settings. It includes the redeployment of healthcare staff from one area to another, the use of technology to conduct appointments and meetings, cancellation of surgery and the creation of surgical hubs in which the risk of Covid-19 infection was minimised, and the emergence of what is known as Long Covid and the treatments for that condition.

My Lady, further detail about this will be provided in the monthly updates provided by the Module 3 solicitors to the Inquiry.

By way of background, may I say this: as part of the scoping for Module 3, an initial request for information questionnaire was sent out to over 550 recipients across the UK. It comprised over 200 non-NHS organisations and over 300 NHS organisations. The purpose of those questionnaires was to assist the Inquiry to gather information and to identify areas for investigation in advance of sending Rule 9 requests.

Rule 9 requests are made pursuant to the Inquiry Rules 2006 and are formal requests for written statements.

The recipients of the questionnaires were asked to provide information about what they considered to be the key issues relevant to the provisional outline of scope, and they were asked questions, including in relation to responses to the pandemic, what went well and what did not go so well. They were asked to provide examples of how the particular healthcare system’s organisation operated and worked effectively and efficiently, and they were also asked how their organisation delivered and/or ranged examples of healthcare services that were adversely affected.

They were asked how particular groups of the individual organisations, local population, patients, staff or members were adversely affected.

The responses received to date have enabled the Inquiry to identify themes and issues arising and other matters that will be considered for inclusion in the Rule 9 requests, and they have assisted the Inquiry to identify who should receive the Rule 9 requests.

The decision whether to respond to the pre-Rule 9 questionnaires has been entirely voluntary. I know that submissions are made on behalf of the TUC for disclosure of the initial questionnaire and a list of the recipients. As I hope I outlined a moment ago, the general nature of the questions asked in those questionnaires covered the responses and examples of what worked well and what didn’t and how people were affected.

On behalf of the counsel to the Inquiry team, we do not consider that the provision of a list of recipients would, in reality, be of any assistance to the Core Participants, particularly given the voluntary nature of the questionnaire.

As at the middle of this month, the Inquiry had received 269 responses, and an initial analysis of those responses has identified a number of common themes and topics, which include but are not limited to: the authority and capacity of healthcare leaders to make decisions and deal with crisis management; the consequences of cancelling or pausing routine and non-urgent care on patients, and any inequalities, cross-conditions or indeed groups of people; the responses raised mutual co-operation between trusts and co-ordination across local organisations, including the accelerated implementation of what is known as integrated care systems.

My Lady, they are partnerships bringing together NHS organisations, local authorities and others to plan and deliver joined-up health and care services and to improve the lives of people who live and work in their area.

The responses identified issues relating to the measures used to manage the healthcare system capacity, including co-ordination with the private sector and staffing, mental health and well-being of healthcare staff and patients was raised, the adoption of new ways of working in the healthcare system such as the shift to technological delivery and online working featured and, my Lady, whilst a later module will consider Government procurement of PPE, Module 3 will consider the impact within the healthcare systems of access to and the suitability of PPE and the infection prevention and control measures put in place to manage patient and staff safety.

These matters are just some of the issues likely to feature in Module 3. Some Core Participants have requested they be provided with a list of issues. The Module 3 team considers this is an entirely sensible request and we unhesitatingly undertake to provide a list, which will no doubt be refined and updated as the module progresses.

A number of Core Participants have made suggestions for other matters that should be included in the provisional outline of scope. It is not practical for me to address all of those today. They all require careful consideration and it may be that some of those areas, for example the impact of the pandemic on some aspects of the mental healthcare system and indeed the impact on the mental health of nurses, doctors and healthcare staff, are intended to be covered by the scope and are already within our contemplation, albeit they have not been expressly referred to within the provisional outline.

There are, however, some specific matters relating to scope I would like to address today. The Covid Bereaved Families for Justice Cymru submit that Module 3 should be subdivided so that in addition to Module 3 there are Modules 3A, 3B, 3C, looking at the healthcare systems in Scotland, Wales and Northern Ireland respectively. This, it is said, would not only reflect the constitutional situation, given that the health is a devolved matter, but also reflect the fact the healthcare systems are different in each country and that different decisions were taken in the countries at different times.

In our submission, no such division is necessary. The themes and topics identified in the provisional outline of scope enable the Inquiry to take account of any structural differences in the way each country’s healthcare system is set up without the need for individual hearings.

At the same time, the hearing of a health-related matters in an overarching module such as Module 3 allows comparisons between all four nations to be more easily evidenced and drawn.

Moreover, your Ladyship has made plain that this Inquiry must be conducted efficiently and the addition of further hearings, in our submission, would be contrary to your clear intentions in this regard. It is further suggested that the scope should be reworded so that there are specific sub-paragraphs for each nation, essentially repeating each part of the scope three more times. My Lady, in our submission, this is an unnecessary amendment. As the opening line of the scope makes clear, and I make no apology for repeating, this module will consider the impact of the pandemic on healthcare systems in England, Wales, Scotland and Northern Ireland.

As part of their submissions on scope, the Royal College of Nursing submits that Module 3 should examine recruitment, retention, pay and conditions of nurses throughout the pandemic and beyond its lockdown stages, and the impact on nurses and patient care and the provision of death in service benefits.

Whilst the impact of the pandemic on nurses and other healthcare staff is very firmly within the scope of this module, in our submission, consideration of financial matters relating to pay, recruitment and retention are matters that are not specific to the pandemic but are areas of more general concern, and it is not, in my submission, for this Inquiry to seek to examine or resolve those more wide-ranging concerns.

My Lady has received submissions on behalf of the Core Participant group John’s Campaign, the Patients Association and the Relatives & Residents Association. They ask that Module 3 considers the experience of people at home and living in care settings who had healthcare needs. I have already referred to the fact that the Inquiry’s care sector module is the appropriate module for looking at the impact on those who live in and work in care settings. The Inquiry’s aware that many people are cared for at home but, in our submission, the capacity of the healthcare systems to respond to the pandemic is most appropriately and proportionately viewed through the lens of the National Health Service.

It may be helpful for those listening to know where Module 3 sits in the overall framework of the Covid-19 Inquiry. By way of background, on 12 May 2021 the then Prime Minister made a statement in the House of Commons in which he announced that there would be a public inquiry under the Inquiries Act 2005. He stated it would examine the UK preparedness for and response to Covid-19 panic and learn lessons for the future. That is this Inquiry.

Following your appointment as chair in December 2021, the draft terms of reference were consulted upon and were published on 10 March 2022. It also included – sorry, that consultation period included consulting with the devolved administrations and it included your Ladyship’s recommendation to the Prime Minister that you would be able to publish interim reports so as to ensure that any urgent recommendations could be published and considered in a timely manner.

I mention this because, as my Lady will be aware, the Clinically Vulnerable Families Core Participant group urges you to consider producing an interim report and make recommendations to improve the safety of those who are at higher risk of severe disease from Covid-19.

Whilst the topics and areas for inclusion in any interim report or reports are a matter for you to consider, I am sure this is precisely what you had in mind when you made this recommendation to the Prime Minister.

In addition, during your consultation, your Ladyship expressed the view that the Inquiry would gain greater public confidence if it was open to the accounts that many people, including those who were bereaved, would wish to give. Therefore, you suggested an explicit acknowledgement of the need to hear about people’s experience and that the Inquiry’s remit should consider any disparities in the impact of the pandemic.

A public consultation process on the Inquiry’s draft terms of reference was launched and your Ladyship consulted widely across all four nations and spoke in particular to a number of bereaved families. In parallel, the team met with – the Inquiry team met with representatives of more than 150 organisations, covering themes such as equality and diversity, healthcare, business and education and young people, amongst others.

In total, the Inquiry received over 20,000 responses to the consultation and an independent research consultancy was commissioned to analyse the responses and produce a comprehensive independent report on respondents’ views. It was following that, on 12 May 2022, that your Ladyship recommended a number of significant changes to the draft terms of reference, which was subsequently accepted by the Prime Minister in full.

The set-up date of the Inquiry was confirmed to be 28 June 2022, and on 21 July the Inquiry was formally opened. A fuller exposition of the background to the Inquiry has been provided to the Core Participants in a note by counsel to the Inquiry and, for those following today’s proceedings, that information is available in the video recording and the transcript of the Module 1 preliminary hearing which was held on 4 October.

Your Ladyship announced the decision to conduct the Inquiry in modules which would be announced and opened in sequence, and those wishing to take a formal role in the Inquiry were invited to apply to become Core Participants for each module rather than for the Inquiry as a whole.

Module 1 is primarily concerned with whether the UK was properly prepared for the pandemic, and will consider the high-level systems that were in place for the pandemic resilience, preparedness and planning across all four nations.

Module 2 will consider the core political and administrative governance and decision-making in the UK, concerning again the high-level response to the pandemic in March 2020 and thereafter.

Module 2 will pay particular scrutiny to the decisions taken by the Prime Minister and the Cabinet, as advised by the Civil Service, senior political scientific and medical advisers and relevant Cabinet subcommittees and, having considered the picture from a UK-wide and also English perspective in Module 2, Modules 2A, 2B and 2C will address the same overarching and strategic issues from the perspectives of Scotland, Wales and Northern Ireland.

As my Lady has already alluded to, other modules will consider vaccines, therapeutics and antiviral treatment, the care sector, Government procurement and PPE, testing and tracing, the Government’s business and financial responses, health inequalities and the impact of Covid-19, education, children and young persons, and other public services including frontline delivery by key workers.

NHS England have asked the Inquiry identify not just the later modules but also set the provisional scope for each of those modules and explain how cross-cutting themes will be addressed. Whilst the Inquiry understands why Core Participants and interested parties are keen to know more about the details about future modules, the Inquiry needs to retain flexibility about the precise timetable and adjust its plans in light of the evidence being gathered. I can, however, inform everyone that the Inquiry aims to announce the next phase of the Inquiry in early summer this year.

My Lady, may I turn to deal with evidence requests and provide everyone with a Rule 9 update as relates to Module 3.

The Inquiry has already issued or is about to issue formal requests for evidence to the following Government organisations which appear to the Inquiry to have played a central or significant role in Module 3. As one would expect, the requests for the Department of Health and Social Care, the Welsh Government Health and Social Services Group and the Department of Health in Northern Ireland are wide ranging.

The requests include questions relating to the structure of the healthcare system in each country, including roles and responsibilities and funding arrangements at the start of the relevant period and indeed throughout the pandemic. They include questions about the capacity of healthcare systems in terms of staffing levels and the numbers, for example, of GP appointments, of ambulances, of critical care beds, ventilators. There are questions relating to infection prevention and control and the availability and suitability of PPE. There are questions in relation to guidance about shielding, about DNACPR policies, about the creation, funding and use of Nightingale hospitals, or temporary field hospitals and surge facilities as they were known in Wales.

My Lady, in drafting those Rule 9 requests, the Module 3 team has reviewed Rule 9 requests made by earlier modules, and where a Rule 9 response has already been received, that has also been reviewed. In adopting that approach, we have been careful to try to avoid, where possible, duplicating requests previously made.

In relation to the Rule 9 request for Health and Social Care in Scotland, this request will be sent slightly after the Rule 9s to the other three nations for this reason. My Lady is aware both this Inquiry and the Scottish Covid-19 Inquiry are keen to avoid duplication, so the Module 3 team is checking not only requests made by Module 2A but also requests made by the Scottish Inquiry. That process means inevitably that this takes a little more time to issue the Rule 9 but it is hoped that in the long run that approach will be of assistance in minimising unnecessary repetition.

In that regard I should add that last week, on 23 February, the Inquiry published a memorandum of understanding setting out how this Inquiry and the Scottish Covid-19 Inquiry intend to work together. I am also aware that your Ladyship recently met with the chair of the Scottish Inquiry, Lord Brailsford, to discuss the constructive ways the inquiries can collaborate and co-operate.

In addition, where appropriate, joint requests for documents that may be relevant across a number of modules are being sent. For example, Audit Scotland will be sent a Rule 9 request on behalf of Module 2A but which also includes requests for material that may be relevant to Module 3.

Rule 9 requests are also being made of the 13 ambulance trusts in the UK, focused on 999 and 111 calls, emergency ambulance provision and patient transport services, and those requests include questions about funding, capacity and response times. There were also requests for information about how the patients were prioritised for a 999 emergency ambulance response, and questions relating to policies about which patients were conveyed to hospital or who should be left at home.

The Inquiry has already made requests to those involved in palliative care, including requests for information about how palliative care changed throughout the pandemic, the key policies and/or guidance relating to palliative care, and for evidence as to whether there was any distinction or differences in the way Covid-19 and non-Covid-19 patients received palliative care.

Rule 9 requests have also been made to the Commissioner for Older People in Northern Ireland and the Older People’s Commissioner for Wales and to Age UK, asking about a number of matters contained within the provisional outline of scope.

My Lady, questions in relation to healthcare inequalities in respect of both patients and those working in the NHS have featured in our Rule 9 requests made to date and will continue to do so.

The joint submissions of the Covid Bereaved Families for Justice and the Northern Ireland Covid-19 Bereaved Families for Justice, and submissions on behalf of the Federation of Ethnic Minority Healthcare Organisations, invite you to consider including an investigation into structural racism and discrimination in Module 3, whether through expert evidence or otherwise.

My Lady, those are obviously important matters within society today but they are also matters with a far broader reach than this module or indeed the terms of reference of this Inquiry.

Inequalities are very much at the forefront of our minds in Module 3 and, in our submission, including these matters is neither necessary nor proportionate, although I have no doubt that it may be a matter you will wish to keep under review as the Inquiry progresses.

Finally in relation to Rule 9 requests, Rule 9 requests relating to maternity care and services will include requests for information and evidence about antenatal and postnatal care. Over the coming weeks and months the Inquiry intends to issue further Rule 9 requests to organisations including but not limited to the Chief Medical Officers, NHS bodies across the four nations, the Academy of Medical Royal Colleges and some specific Royal Colleges, the professional bodies representing those working within healthcare systems, and to those Core Participant groups representing specific areas of interest within the scope of Module 3.

My Lady, in line with the determination made in Module 1, the Inquiry’s submission is the Core Participants will not be provided with copies of Rule 9 requests made by the Inquiry. Disclosure to the Core Participants of the Rule 9 requests themselves, as opposed to the relevant documents and material generated by them, is neither required by the rules nor generally established by past practice.

Furthermore, in our submission, it would serve little practical purpose given the wide scope and detailed nature of the Rule 9 requests that are being made.

Turning to disclosure, in common with the approach taken in the preceding modules, Module 3 will adopt the following approach:

All CPs will receive all documents disclosed in Module 3, not just those documents relevant to them. Disclosure will be subject to three things: a relevance review, so that only relevant documents are disclosed; a de-duplication exercise; and redactions in accordance the Inquiry’s redactions protocol. There is a significant team of solicitors and barristers and paralegals already in place to review for relevance once material is received.

Module 3 will make disclosure in tranches on a rolling basis. Disclosure will be made by the electronic data management and disclosure system Relativity, and there will be disclosure updates provided by the Module 3 solicitors’ team informing Core Participants of the progress which has been made in obtaining relevant documents and we will, of course, also do so at the next preliminary hearing or hearings.

The Inquiry will be asking document providers to provide a signed statement explaining how they have secured the preservation of documents, how they have conducted their searches and how they’ve satisfied themselves that they have complied in full with their duties. Each provider has been asked or will be asked to provide an account setting out in detail how the documents were originally stored, search terms used, or other processes used to locate documents and the nature of any review carried out by the document provider.

Where the Inquiry has concerns or queries about a provider’s processes for locating relevant documents, it will raise them and pursue them and, of course, as documents are reviewed and gaps identified, further documents will be sought.

I should also add that the Inquiry has already taken steps to ensure the preservation of documents. In January 2022, the director of the UK Covid-19 Inquiry set-up team wrote to the Director General of Propriety and Ethics at the Cabinet Office to request retention of records across Government, and the following month, in February 2022, the Director General replied indicating that steps were being taken to ensure records relevant to the Inquiry were retained across Government.

Should it be necessary, my Lady, you have the power to compel the production of documents under section 21 of the Inquiries Act. There are also provisions in section 35 of the Inquiries Act which make it an offence if, during the course of an inquiry, a person does anything to alter or distort a relevant document or to prevent any relevant document being produced to the inquiry or intentionally destroys, suppresses or conceals a document.

May I turn to the issue of experts. Module 3 has, already identified two areas where expert evidence is likely to be of assistance. The first area of expert evidence relates to the treatment given to Covid-19 patients in intensive care, including an overview of how treatment changed during the various waves of the pandemic, and the quality of care provided.

Secondly, Module 3 has also identified an expert in relation to the diagnosis of and treatment for Long Covid. It is an emerging area, my Lady, but it is something that we consider will be of assistance to you.

The identities of these two experts and, indeed, any other expert will be contained in the solicitor to the Inquiry’s update notes, and these notes will also provide the topics on which experts are instructed, thereby updating the Core Participants and enabling the Core Participants to comment on those matters.

My Lady, in the course of the written submissions a number of Core Participants have included suggestions for areas of expert evidence, for example, the Covid-19 airborne Transmission Alliance has suggested that the effectiveness of PPE might be a potential area.

I have no doubt that you will wish to consider that and, indeed, all of those suggestions after the conclusion of today’s hearing.

My Lady, in relation to pen portraits, in rulings made in earlier modules you stated that you were not persuaded that pen portrait evidence should be admitted a general rule in this Inquiry. However, you indicated and ruled that the terms of reference make clear that the Inquiry will not consider in detail individual cases of harm or death but will consider evidence of the circumstances of individual deaths where it is illustrative and probative of systemic failure.

The Covid, Bereaved Families for Justice Cymru have asked you to consider hearing some evidence about the particular circumstances of some deaths.

Module 3 wishes to explore the ways of hearing evidence about the devastating impact of the pandemic in a way that highlights or exposes systemic issues within the healthcare systems. Careful thought is needed about how best to present this evidence but this is already a matter under active consideration and we anticipate the number of the Module 3 Core Participants representing the bereaved families and those working within healthcare systems and other interest groups will be in a position to help us with that matter.

My Lady, in your opening remarks you already referred to the Listening Exercise, Every Story Matters. The terms of reference make clear that although the Inquiry will not investigate individual cases of harm or death in detail, listening to the accounts and experiences of the bereaved families and others who suffered hardship or loss will inform the Inquiry’s understanding of the impact of the pandemic and the response and of the lessons to be learnt.

Every Story Matters is the process by which the public can contribute to the Inquiry, so that the Inquiry will be able not just to hear the voices of the people and to reflect upon their experiences but to also incorporate their accounts into its work.

It is anticipated that the Inquiry’s ability to consider those accounts will be particularly important when it comes to Module 3 and indeed those modules which will consider the impact of Covid-19 and the decisions made about it. It will give individuals the opportunity to contribute to the Inquiry in a way which requires no formality nor any need to attend the hearing. It is open to all whose lives have been affected, whether by bereavement, illness, poor mental health or because their prospects, their education or their work has been affected, and to people whose family lives or relationships suffered.

No one person’s experience or loss will be the same as another’s. The listening anything exercise enables this Inquiry to capture the full breadth of human experience across the UK, including from those who might not otherwise come forward or otherwise have a forum to say what happened to them.

Every Story Matters will support the Inquiry’s legal process but it is not a legal process in and of itself. The experiences which people share will not be filed in the hearings by way of direct evidence or as individual testimony, and accounts will be anonymised, but there will be a set of comprehensive reports prepared that will be disclosed to Core Participants and may be admitted into evidence.

In November 2022 an initial pilot was launched by way of an online platform which enabled some people to share their experiences. As far as Module 3 is concerned, work has now commenced on gathering accounts from patients and relatives directly and indirectly affected by Covid-19, and from healthcare workers and support staff. The Inquiry is keen to hear from individuals who are seldom heard and so we are grateful for the submissions by Mind and the John’s Campaign Core Participant groups on the issues of capacity and the participation of individuals who are non-verbal. I know that the listening exercise will want to consider those submissions.

More information about Every Story Matters will be provided in the coming weeks, including by way of the webinar to which you referred, and there will be further updates of this part of the Inquiry’s work provided in the solicitor team note update in due course.

May I deal with commemoration. My Lady, you have made clear your wish to recognise the human suffering arising from the pandemic, including the loss of loved ones. It is important that is reflected throughout entirety of the Inquiry’s work, and the Inquiry, I know, is exploring ways in which this can be done, including by way of a commemorative memorial in the future hearing centre, through the Inquiry’s public hearings and indeed on the Inquiry’s website.

Finally, my Lady, some Core Participants have invited you to consider the way in which applications for funding are made and determined prior to the first preliminary hearing in a module. For practical reasons it is not possible to consider these applications in advance of that preliminary hearing. However, the Inquiry is taking steps through the pre-authorisation process to make sure that Core Participants who successfully applied for section 40 funding when invited to do so after the preliminary hearing can retrospectively cover their reasonable legal costs associated with preparing for and attending that hearing.

My Lady, I know that once you have had an opportunity to consider the written submissions, and indeed those that are already being made today, you will publish any appropriate directions. One matter that counsel to the Inquiry asks you to consider is whether you wish to publish any written submissions on the Inquiry’s website. That is a matter entirely for your creche.

There will be a further preliminary hearing for Module 3 held later in 2023 in London on a date and a venue to be confirmed, and it is anticipated that the hearing in Module 3 will commence on a date to be confirmed in 2023.

My Lady, that concludes all the submissions I wish to make to you on behalf of counsel to the Inquiry.

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

If we could turn, please, to – is it Ms Munroe, King’s Counsel? Careful as you make your way to the lectern. It is a bit of an obstacle course, I am afraid.