5. Submissions on Behalf of Covid-19 Bereaved Families for Justice Cymru by Ms Heaven

Ms Heaven: Good afternoon, my Lady.

Lady Hallett: Good afternoon.

Ms Heaven: I represent the Covid-19 Bereaved Families for Justice Cymru, and as you know we’ve submitted detailed written submissions which we understand will be published on the Inquiry’s website today.

The Cymru group is dedicated solely to campaigning for truth, justice and accountability for those bereaved by Covid-19 in Wales. The Cymru group is led by Anna-Louise Marsh-Rees, Sam Smith-Higgins, and Liz Grant, and it’s guided by the concerns of its bereaved members across Wales. It is committed to giving a voice to all of those in Wales who are bereaved due to Covid-19, and to ensuring that there is proper scrutiny of all government decision-making relevant to Wales, including those decisions made in Westminster, and by the Welsh Government in Wales.

My Lady, as you know from the time that you spent visiting Wales prior to the commencement of these hearings, the people in Wales have experienced and continue to experience suffering and trauma due to the devastation caused by Covid-19. As you will also have been told, no doubt, on many occasions, many of those bereaved people feel that they were let down by their government. They feel let down because they have experienced first-hand the consequences of what they consider to be the catastrophic failure of the Welsh Government to adequately prepare for and respond to a pandemic in Wales.

I will touch on just a few of the stories relevant to Module 1, but of course there are many, many stories of loss which you will hear as part of Every Story Matters.

Like many parts of the United Kingdom, many people in Wales lost loved ones in care homes receiving patients from overwhelmed local NHS Wales hospitals where those care homes had inadequate isolation and inadequate personal protective equipment, PPE.

The numbers of those dying in Wales due to hospital-acquired Covid-19 was exceptionally high, and in many cases this was in the context of well known inadequate and poor infection control, and again a lack of PPE.

Many of those hospitals, as I said, were known to have inadequate ventilation.

Many members of the Cymru group have professional experience working in sectors heavily impacted by Covid-19, and they experienced shocking conditions as workers on the frontline. They saw first-hand the failures and deficiencies in the Welsh Government’s pandemic preparedness, risk management, and civil contingencies planning. The Cymru group have valuable first-hand experience to offer the Inquiry and they welcome the opportunity to participate and give oral evidence and they continue to offer you their full support, and it is hoped that the Inquiry continues to hear as many of the voices of the Welsh bereaved as possible.

Now, unlike Scotland, as you know, Wales has not been granted its own public inquiry by the Welsh Government. This Inquiry is therefore the only opportunity the people of Wales will have to ensure that there is proper scrutiny of the decisions of the Welsh Government and their advisers in the planning and response to the Covid-19 pandemic.

The people of Wales are looking for answers. They are also looking for accountability, and for failures to be acknowledged so that lessons can be learnt.

In the early days of this Inquiry, the Cymru group, the UK Government, the Senedd and indeed this Inquiry itself received repeated assurances from the First Minister for Wales, Mark Drakeford, and the Welsh Government that they were committed to fully engaging with this Inquiry. It is against this background that Mark Drakeford, as First Minister, maintained and continues to maintain that there is no need for Wales to hold its own public inquiry.

Mark Drakeford reminded the Right Honourable Boris Johnson MP, as he then was, as Prime Minister, that:

“… I would invite you to agree that all public bodies engaging with the Inquiry are expected to consider themselves under a duty of candour. That duty should drive their culture of engagement with the Inquiry and should lead to prompt and comprehensive disclosure of all relevant material to the Inquiry. A duty of candour should also guide the way public body witnesses should approach the Inquiry.”

The Cymru group do therefore formally wish to say today that they are very disappointed by what they consider to be the inadequate response and engagement by the Welsh Government with this Inquiry in Module 1. In earlier hearings core participants were told by your Counsel to the Inquiry, Mr Keith KC, about the fact that the Welsh Government had submitted first statements containing assertions which were not supported by documentary evidence.

Having received the final witness statements submitted by the Welsh Government and their advisers, the Cymru group remain, frankly, shocked by the brevity and lack of detail in some of those statements. It also appears very disappointing that in some quarters there appears to be a reluctance by certain ministers to take political responsibility for failures to prepare for a pandemic in Wales.

As you know, the Cymru group was so concerned with the brevity and gaps in the statements submitted to this Inquiry by First Minister for Wales Mark Drakeford that they raised those concerns directly with your Inquiry legal team.

It is important that I briefly touch on some of those concerns today so that the Welsh public, who we know are listening intently, are aware of what appears to be missing from this statement.

In outline, Mark Drakeford’s statement is exceptionally brief, and it only deals with the period of pandemic preparation for when Mark Drakeford was appointed as First Minister for Wales in 2018.

Crucially, it fails to cover in any detail the extended period from 2009 when Mark Drakeford was involved in health and local government policy, both as a special adviser to the First Minister and a Minister of the Welsh Government.

And crucially it fails to mention that as First Minister of Wales, from December 2018 to the current day, Mark Drakeford is head of and responsible for oversight over pandemic planning in Wales as the chair of the Wales Resilience Forum.

The statement provided by Carwyn Jones, who of course is a former First Minister of Wales, from 2009 to 2018, so that’s nine years, which are clearly within the remit of this Inquiry, contains just over four pages on pandemic planning.

My Lady, on any view these are fundamental and significant omissions, which leave this Inquiry and the bereaved in Wales at this stage with a significant gap in fully understanding the state of knowledge and decision-making and, ultimately, political accountability in relation to pandemic planning in Wales.

It is hoped, therefore, that moving forward there will be a full commitment from the Welsh Government to provide complete and timely disclosure and to providing as much detail as possible on the questions that you ask witnesses in your Rule 9 requests.

Now, the Cymru group consider that the critical questions that the Inquiry must closely scrutinise in relation to Wales are as follows: what did the Welsh Government know and not know in the period under consideration by the Inquiry? What should the Welsh Government have known and what different and better decisions could have been taken by the Welsh Government and their advisers? The Cymru group consider that the following propositions appear, even now, reflected in the evidence before this Inquiry, and we have addressed these in much more detail in our written opening submissions.

The Cymru group consider that pandemic planning in Wales was the responsibility of the Welsh Government and not the UK Government. For the avoidance of doubt, it seems to the Cymru group that the First Minister for Wales had ultimate responsibility and oversight for pandemic planning in Wales as chair of the Wales Resilience Forum.

The Cymru group consider that pandemic planning, preparedness and resilience in Wales was wholly inadequate, and that includes oversight and enforcement in relation to implementing pandemic recommendations.

The evidence before the Inquiry, even at this early stage, reveals that the Welsh Government and their advisers had sufficient notice, knowledge and warnings of the risks to the lives of people in Wales from a pandemic, including a SARS pandemic, but that they failed to take adequate steps to prepare and build resilience.

I’ll just touch upon a few examples. Whilst Wales held its own formal planning exercises, so that’s Taliesin 2009, Cygnus 2014, and Public Health Wales Dromedary 2015, these exercises appear bureaucratic and merely designed to satisfy administrative requirements rather than address the substance of pandemic planning.

In terms of the adequacy of that planning, Exercise Cygnus in 2014 tested the pan-Wales response plan in Wales. However, the outcome document is extremely brief and makes no mention of testing for NHS Wales surge capacity, for example, PPE or RPE demands and stockpiling. There is no mention of the impact of restrictions on free movement. There is no mention of workforce resilience. Just to pick out a few examples.

Wales did not formally plan for the impact of any lockdown measures, but tested them only after Covid-19 had arrived in the United Kingdom. Whereas England tested for surge capacity, it appears that Wales did not.

However, one of the most significant failures on the part of the Welsh Government was only planning for an influenza pandemic, to the exclusion of planning for other viruses with pandemic potential. This was a catastrophic and unjustifiable failure. Not only had the Welsh Government been warned about a very high death toll from a flu pandemic in the years prior to Covid-19, but there had also been two coronavirus pandemics in the 21st century, SARS and the Middle East Respiratory Syndrome.

The Inquiry is asked to pay close attention to the witness statement that has been provided to you from the COVID-19 airborne Transmission Alliance, which systemically dismantles the flaw in the UK and, by extension, the Welsh Government’s failure to engage in long-term planning for an aerosol-transmitted SARS virus. The Cymru group endorse and support the crucial work and analysis that has been carried out by the COVID-19 airborne Transmission Alliance.

So what about the implementation of lessons learnt from pandemic planning groups in Wales? There were a profusion of bodies apparently engaging in pandemic planning in Wales, similar to the other devolved nations and indeed to the United Kingdom.

For example, we’ve got the Wales Resilience Forum, we’ve got the local resilience forums, we’ve got the Health Emergency Planning Group, the Wales Risk Group, the Emergency Planning Advisory Group, the Mass Casualty Group, the Training And Exercise Group, and the Wales Pandemic Flu and Preparedness Group, and it goes on.

But what are these groups actually doing, the Welsh bereaved ask. For example, were they communicating with any administrations outside Wales? Whilst there were clearly updates and tweaks to pandemic plans in Wales over the years you are considering, the reality is that it was minimal and it was inadequate. There appears to be no evidence that all the groups that I have just mentioned, and indeed many more, or that the formal Welsh pandemic exercises, led to material changes to Wales’ level of preparedness and resilience.

Welsh hospitals continued with poor ventilation. There was no planning and preparation in Wales for responding to a sudden surge in demand in the social care system. There were inadequate measures taken to refresh or maintain sufficient levels of PPE and other protective equipment stockpiles.

In other words, there appears to have been inadequate implementation even for a serious and catastrophic flu pandemic, let alone a pandemic such as Covid-19.

The Welsh Government knew that they needed to improve infection control and the design and ventilation of Welsh hospitals and care homes to reduce infection. It appears in many of their very early documents that you have before you. The Welsh Government knew that they had to stockpile PPE/RPE but when the Covid-19 pandemic hit there was a shortage particularly of FFP3 respiratory masks and, of course, of PPE.

The Welsh Government knew they had to plan for excess deaths from a pandemic, including the worst case scenario, and the figures in the documents are 210 to 315,000 excess deaths nationally in 15 weeks. There is no evidence of a plan or a strategy to deal with excess deaths or the consequences.

To take one small example, there is no evidence for planning for sufficient body bags and storage. There appears to be no evidence of adequate planning in relation to post-death procedures, to protect dignity and to support the Welsh bereaved in the event of a pandemic, and this single failure caused untold suffering in Wales.

The Welsh Government knew many years before Covid-19 struck that there would be a significant burden on care homes and the care sector and on the vulnerable in the event of a pandemic, and again, my Lady, when you look closely at some of the very earliest Welsh planning documents, you will see those concerns raised. Yet there is no evidence that shows these areas were actually addressed in any real or substantive way.

In 2016, Exercise Cygnus revealed that “the UK’s current preparedness and response, in terms of its plans, policies and capability, is currently not sufficient to cope with the extreme demands of a severe pandemic that will have a nation-wide impact across all sectors”.

So the question or one of the questions that the Inquiry must consider is why there had been such a failure in preparedness and resilience prior to 2016, and in particular in Wales, from our clients’ perspective.

After the warning from Cygnus in 2016, the Cymru group want to know whether the Welsh Government then acted fast enough and seriously enough to prioritise pandemic planning in the way that it warranted. If Brexit or a lack of sufficient budget from the United Kingdom Government is to be used as an excuse by the Welsh Government for not protecting the people of Wales from a pandemic, the Inquiry is asked to ascertain how the Welsh Government sought to address such funding issues.

For example, did the Welsh Government consistently ask the UK Government for more money after devolution for pandemic planning? Did the Welsh Government tell the people of Wales and their Senedd that because of devolution they did not have the resources to adequately prepare for a pandemic and protect the people of Wales?

It is now accepted in the statement of Dr Frank Atherton, Wales’ Chief Medical Officer since 2016, that Wales did fail to plan for long-lasting pandemic and “the plans were inadequate for a two or three-year shock to the system”. The Cymru group consider that this concession simply does not go far enough. The truth is that the Welsh plans were wholly inadequate for any widespread and potentially fatal pandemic likely to result in high numbers of deaths, and requiring restrictions, wide-ranging use of protective equipment or wide-scale hospitalisation.

So the question is: why did this happen? My Lady, we and, indeed, you are now beginning to see an explanation emerging in the evidence before the Inquiry. If we look at implementation and oversight of pandemic-related recommendations in Wales, Reg Kilpatrick, the Director General for Covid Co-ordination and, from 2013, head of Welsh Government civil contingencies and emergency planning, which of course included pandemic planning, has now told this Inquiry that:

“Taking forward every recommendation has been challenging against other more immediate priorities, but we have endeavoured to turn learning into best practice where we can and change structures and processes where required for the better.”

Vaughan Gething, Minister responsible for healthcare in Wales, has admitted that he did not even check whether the learning from Exercise Cygnus 2016 had been implemented, but rather he states that he “assumed absent any advice to the contrary or questions in the Senedd that the lessons of Exercise Cygnus had been applied”.

Mark Drakeford gives a similar answer in his statement to this Inquiry, namely:

“I do not recall any advice from officials from there were any reservations about the state of Wales’ pandemic preparedness, nor did I recall any concerns in the Senedd being raised with me.”

It is deeply shocking to the Cymru group that those with political responsibility for protecting people in Wales from a pandemic did not consider it their job to understand and check the state of pandemic preparedness and resilience in Wales. Instead, there now seems to be a distinct attempt to shift responsibility for the oversight of pandemic planning implementation onto civil servants and the Senedd. The Cymru group consider that this gives the Inquiry an insight into the Welsh Government’s approach to pandemic planning in the years before Covid-19 and their willingness now to accept some responsibility for what went wrong.

In terms of risks arising in the event of a pandemic, the Welsh Government knew from before and during the period under consideration by this Inquiry that a pandemic was right at the top of the UK national security risk register. However, those responsible for pandemic planning in Wales do not appear to have taken sufficient steps to understand and plan for the risks of a pandemic as they would present in Wales. As now acknowledged by Reg Kilpatrick, the national security risk register contained assessments which “provide information at a UK level of analysis rather than one which would serve the Welsh Government”. Mr Kilpatrick now accepts that:

“Understanding threat and risk at a more disaggregated level is essential to effective preparedness.”

And as a result he now explains that Wales has its own Wales risk register.

However, risk in Wales ought to have been properly understood in detail by the Welsh Government at the time, and the Cymru group do ask the Inquiry to get to the bottom of whether or not there was, in fact, a Welsh risk register in place during the relevant period under consideration.

The simple fact is that Wales and the Welsh Government did not have an adequate understanding of the risks posed to the people of Wales from a pandemic before and during the relevant period, and this led to much more severe consequences from Covid-19 for vulnerable groups and communities in Wales.

For example, pandemic preparedness failed to take account of the acute health inequalities in Wales distinct from the rest of the United Kingdom, and that specifically includes levels of chronic ill health and disability in the older population.

Professors Bambra and Sir Michael Marmot in their report indicate that pre-existing health inequalities were considered in no more than in a minimal way in the devolved administrations and even in UK pandemic planning.

The Welsh Government should have sought to understand and incorporate considerations of health inequalities that existed in Wales into its pandemic planning as soon as they had the power to do so, which of course was after devolution in 1999.

My Lady, when you consider the explanations that will be offered to you by the Welsh Government as to why they could not fully and adequately build resilience and prepare for a pandemic in Wales, you just need to bear in mind that the Welsh Government have had 24 years since devolution to plan for such a pandemic in a way that best protected the most vulnerable and disadvantaged in our society.

There are many other vitally important topics that the Cymru group ask you to scrutinise which, for reasons of time, can’t be covered in detail in these submissions today. But, in brief, these include intergovernmental political relations between Wales and the United Kingdom Government; the co-ordination between the United Kingdom Government and the Welsh Government and their medical and scientific advisers; variation in standards in the approach to planning and preparation; the investment in resilience of – and the resilience of people and the systems in Wales, for example the adequacy of training, information technology and NHS Wales digitisation and data sharing; and finally, planning in relation to post-death procedures, as I’ve said, to protect the dignity and to support the Welsh bereaved in the event of a pandemic.

So, in conclusion, the Cymru group very strongly believe that there was a failure to adequately prepare and build resilience in Wales for a pandemic, and that this caused unnecessary pain, suffering and ultimately death.

Through their own experiences, the Cymru group know only too well that in Wales there were many preventable deaths from Covid-19. The Cymru group consider that the Welsh Government must now acknowledge what went wrong. This is vital to ensure that lessons are learnt from the experience of Covid-19 in Wales, so that when the next pandemic arrives Welsh lives are better protected. The Welsh Government must now make a genuine commitment to long-term pandemic planning.

Thank you.

Lady Hallett: Thank you very much indeed, Ms Heaven, very grateful.

Dr Mitchell KC.