Transcript of Module 3 Preliminary Hearing on 27 September 2023

(10.28 am)

Lady Hallett: Good morning, everyone. This is the second preliminary hearing into Module 3 of the Covid-19 UK Inquiry, the one that is focusing on the healthcare systems in Wales, Scotland, Northern Ireland and England. Without further ado, I shall hand over to Ms Jacqueline Carey King’s Counsel, who will tell us what progress has been made and whether we have faced any difficulties as we are making our way through investigating for the module hearings next autumn. Yes.

1. Statement by Counsel to the Inquiry

Ms Carey: My Lady, good morning. As you have just said, this is the second preliminary hearing held in relation to Module 3, in which I appear as lead counsel.

As you know, Module 3 will examine the impact of the Covid-19 pandemic on the healthcare systems, namely the NHS in England, Wales, Scotland and Northern Ireland. Since the last preliminary hearing, on 28 February earlier this year, a great deal of work has been undertaken by the Inquiry and by Module 3 in particular, and so much of my address today will be providing an update on that work and outlining some of the work to be undertaken in the coming months.

I should say at the outset that the Inquiry has confirmed, as your Ladyship just mentioned, that it expects Module 3 substantive hearings to begin in autumn 2024. Now, whilst to many observers that will doubtless sound a long way off, that timetable is set to ensure that those witnesses, whether they are corporate or otherwise, who are being asked to provide evidence have sufficient time to prepare their statements, an item to which I’m going to return on today’s agenda, and the timetable takes into account the Inquiry’s plan for other modules. That includes the Module 2 hearings examining UK core decision-making and political governance, which are due to start next week on 3 October, in early 2024 and throughout the spring you will be conducting public hearings in Scotland, Wales and Northern Ireland looking at the core decision-making in those countries, and in July 2024 there will be the public hearing in the vaccines and therapeutics module.

In addition to those public hearings, the Inquiry aims to publish its report setting out the findings and recommendations following the conclusion of the Module 1 hearings into the UK’s resilience and preparedness for the pandemic.

In addition, the Inquiry has also announced that Module 5, looking at government procurement, and Module 6, examining the impact of the pandemic on the care sector, are due to open before the end of this year.

Before I turn to the agenda, may I introduce the parties, whether in person or virtual. There are 30 core participants either present in the hearing room today or attending via the live link, and there are a number of them who wish to address you in oral submissions.

During the course of my address, I will respond to some but by no means all of the matters raised in the written submissions that you have received.

Dealing with the instructions in turn, Ms Munroe King’s Counsel appears for the Covid Bereaved Families for Justice; Ms McDermott for the Northern Ireland Covid-19 Bereaved Families for Justice.

Ms Mitchell King’s Counsel is remotely with us for the Scottish Bereaved; Ms Gowman for the Covid-19 Bereaved Families for Justice Cymru.

On behalf of the long Covid groups (Long Covid Kids, Long COVID Physio, Long Covid SOS and Long Covid Support), Mr Metzer King’s Counsel, who is remotely.

Mr Wagner is here for both the Clinically Vulnerable Families and the 13 Pregnancy, Baby and Parent Organisations; Mr Straw King’s Counsel for the John’s Campaign, Care Rights UK and the Patients Association.

Mind is represented by Ms Davies; the Trades Union Congress by Mr Jacobs; Ms Fenella Morris King’s Counsel for the Royal College of Nursing; Mr Stanton for the British Medical Association, the National Pharmacy Association and the Royal Pharmaceutical Society.

Mr Dayle is present for the Federation of Ethnic Minority Healthcare Organisations; Mr Simblet King’s Counsel for the COVID-19 airborne Transmission Alliance; the Frontline Migrant Health Workers Group is by Ms Sen Gupta King’s Counsel. Mr Jory is with us, I hope, remotely for the Independent Ambulance Association.

There are also a number of legal representatives who have indicated they do not wish to make oral submissions but are in attendance at the hearing: Ms Grey King’s Counsel for NHS England; Ms Peters and Ms Broad for the UK Health Security Agency; Ms Haghpanah for the Secretary of State for Health and Social Care; Mr Bowie King’s Counsel for Public Health Scotland; the Academy of Medical Royal Colleges, Mr Mattar and Mr Henderson are present; Ms Doherty King’s Counsel for NHS National Services Scotland; the Scottish Health Boards by Mr Pugh King’s Counsel; the Scottish Ministers by Ms Nicholson and Mr Way; the group of Welsh NHS bodies by Mr Hyam King’s Counsel; Mr Kinnier King’s Counsel for the Welsh Government; Mr Booth King’s Counsel for the Welsh Ambulance Services NHS Trust; and Ms Smith for His Majesty’s Treasury.

Notwithstanding that list, there are six core participants unable to attend today’s hearing. Each has written to the Inquiry explaining why they cannot attend and has indicated they mean no discourtesy to your Ladyship by their absence, and in fact some may be able to follow by the livestream.

As to that, these proceedings are of course being recorded and livestreamed. As is routine in public inquiries where there may be, from time to time, matters raised of a potentially sensitive nature, the broadcasting of the hearing will be conducted with a three-minute delay. That, my Lady, provides the opportunity for the feed to be paused if anything unexpected is aired which should not be. We do not expect such matters to arise over the course of today, but I mention it in case those who are following the proceedings from further afield understand the reasons for any short delay.

I know that your Ladyship will have seen the agenda for today’s preliminary hearing, and I’ll address each of the seven topics, if I may, in turn.

The first of those relates to the evidence requests and an update in relation to the Rule 9 statements that have been requested by Module 3.

My Lady, Module 3 has sent out 127 Rule 9 requests. The number and range of topics and issues referred to in those requests is quite frankly vast, and certainly it would not be a good use of today’s hearing time for me to rehearse each and every request made.

The core participants are aware of the broad topics covered in each request, as the monthly update notes provides that information. However, it is appropriate for me to provide a summary in public, outlining just some of the groups of recipients from whom requests have been made.

They include the government departments, including the departments of health in each nation, NHS England, His Majesty’s Treasury, the Cabinet Office, the UK Health Security Agency, or UKHSA as it’s known, and the public health bodies in each of the nations.

Requests have been made of each of the Chief Medical Officers, of a number of the Royal Colleges, trade unions and the Health and Safety Executive. The healthcare regulators and the Medicines and Healthcare products Regulatory Agency have been written to. A number of charities. All 14 ambulance trusts, more of which I will return to shortly. And almost all of the 36 core participants in Module 3 have received a Rule 9 request, and indeed many have already supplied draft statements for which the legal team is very grateful for their prompt response. Those who have not yet received a Rule 9 will be getting one in the next phase of Module 3’s work.

Out of the 127 requests, 66 statements are currently being reviewed and finalised, and in addition last week five statements were disclosed and there are a further 16 statements that have been signed and are being progressed for disclosure.

As will be appreciated from the update I have just given, some of the statements have been or are in the process of being finalised, and that’s particularly true for those recipients who received their Rule 9s early on in the process. So, my Lady, by way of example, and as an introduction to just some of the issues raised in those earlier responses, I’m just going to give a very brief overview of four areas of responses, to outline some of the issues that are being raised in those areas.

So in relation to ambulances, a review of the evidence on the ambulance trusts and associated Rule 9 recipients raises concern about the frequency of changes to guidance produced by Public Health England, now the UK Health Security Agency, and NHS England. They raise the fact that it was not, that guidance, specific to the ambulance sector. Their evidence also raises concerns about access to and the quality of personal protective equipment (PPE), and respiratory protective equipment (RPE) that ambulance staff required. A number of the ambulance trusts have stated that they were able to access Covid-19 testing for their staff before it became available as part of a government testing programme in the summer of 2020, but not all of them had the benefit of that, and where it did not exist they have stated that it impacted negatively on their trusts’ resources and capacity.

Evidence from Rule 9 recipients who were involved in pharmacies and pharmacists, such as the independent regulators and the professional membership bodies, have also identified some key themes, and they have told us about the impact of reduced access to GPs and the resultant surge in demand for community pharmacy services. The evidence attests to the impact of inconsistent or late designation of pharmacy staff as key workers or frontline healthcare workers. They raise issues related to the sustainable access to adequate PPE for pharmacy staff and the feasibility of implementing other IPC guidance in community pharmacy settings, the delivery of medicines to patients and the cost to pharmacies, the role of pharmacists in responding to shortages of specific medicines used to treat Covid-19. They speak of the delays to individual Covid-19 risk assessments for pharmacy staff, and state that this is of particular significance given the high proportion of pharmacy sector staff from black and minority ethnic backgrounds.

Another aspect of Module 3 is to look at and examine the quality of care and patient safety during the pandemic, and so the Inquiry has sought evidence from the Healthcare Safety Investigations Branch, HSIB for short. HSIB is an independent body funded by the Department of Health and Social Care, and it undertakes independent safety investigations into NHS funded care across England and they provide reports to the Department of Health and NHS England.

Now, HSIB has provided a witness statement to the Inquiry which is in the process of being reviewed and signed, but has also provided a number of other investigation reports to the Inquiry on topics that are within the scope of Module 3, including reports related to the NHS’s 111 response to callers with Covid-19-related symptoms, a report on the use of early warning scores to detect deterioration in the Covid-19 in-patients. There is a report in relation to prospective safety investigations concerning management of risk of Covid-19 transmission in hospitals. They have looked at surgical care of NHS patients in independent hospitals during the pandemic, oxygen issues during the pandemic, access to what they call critical patient information at the bedside, and that includes, my Lady, information relating to Do Not Attempt Cardiopulmonary Resuscitation notices, or DNACPRs as they are known, and they have prepared reports in relation to stillbirths and maternal death investigations during the pandemic.

Finally, just by way of overview, and really allied to that last report from HSIB, the Module 3 team has received a number of statements relating to maternity issues in the pandemic, and the evidence there already attests to the distressing impact of Covid-19 restrictions on pregnant women and their partners. There’s evidence in relation to limitations on choice during childbirth, affecting home births, birthing centres, water births, caesareans being denied.

The evidence received has covered issues relating to access to health visitors, which are considered to be particularly important to the physical health of the newborn, but also the physical and mental health of mothers, where some women have suffered increased postpartum maternal depression and anxiety during the pandemic, and that in turn may have exacerbated existing health inequalities.

The evidence received to date raises concerns about access to suitable and sufficient PPE for health visiting practitioners and mixed views about virtual health visits.

They also raise the identification and categorisation of pregnant women as clinically vulnerable at the start of the pandemic and a concern that that decision was made without consultation or prior warning, leading therefore to contradictory advice and guidance being given to colleagues and confusion amongst pregnant women.

As I say, those matters that I’ve just outlined are very much by way of example to give you and those following the hearing a flavour of some of the initial themes and concerns raised in the evidence received thus far.

It will be appreciated that the Rule 9 requests to date have primarily been addressed to organisations and institutions. One aspect of Module 3’s work this autumn will be to start issuing Rule 9 requests to the individuals relevant to Module 3, including the respective Secretaries of State and ministers for Health, the deputy chief medical officers, the chief nursing officers, along with a number of other individuals who played a key role in advising the governments.

In the written submissions that you have received, a number of the core participants have named individuals that they propose that we should Rule 9, and we will be considering those suggestions as we embark on this next phase of the module’s work.

There is one other matter that we would wish to raise in relation to Rule 9s. There are some recipients of Rule 9 requests that were sent in March, April and early May of this year where Module 3 is becoming concerned about slippage in deadline for responses and the impact that that will have not just on Module 3 but for other modules as well.

This includes the chief medical officers in England and Northern Ireland, the Department of Health and Social Care, the Department of Health in Northern Ireland, and the UK Health Security Agency.

My Lady should know, for example, that in relation to the Department of Health and Social Care, the department informed the Inquiry they wish to provide their statement in five sections. That is a request that has been made by other Rule 9 recipients and which has invariably been granted, but it is disappointing to note, however, the Inquiry has not received any section of statement from the Department of Health and Social Care, either in draft or otherwise, when the Rule 9 was sent to them in March of this year.

Now, Module 3, my Lady, is not unrealistic about the demands that other Inquiry modules have placed on recipients such as the Department of Health, the chief medical officers and the UKHSA, and nor are we blind to the demands that these organisations and individuals face in their day job, if I can put it like that. But we are concerned about these delays and the detrimental effect that these will inevitably have on Module 3.

My Lady, it cannot be the case that some recipients need over six months to respond to Rule 9 requests or acceptable that they miss agreed deadlines for statements to be provided in smaller, more discrete sections.

In relation to the chief medical officers, the CMO for Northern Ireland has indicated they will answer the Rule 9 by the end of October. The Office of the Chief Medical Officer informed the Inquiry yesterday that the office is on track to provide a statement before the end of the year. My Lady, we appreciate that the chief medical officers have smaller offices and legal teams than some of the other organisations I have named, and that they have been heavily involved in earlier modules, and have also commitments to Module 4, but these proposed dates are five and seven months respectively after the request was made, and so we look forward to receiving this important evidence at the earliest opportunity, and certainly by no later than the dates I’ve just outlined.

If it is not obvious, these statements are needed so that we can identify further lines of enquiry and areas that we will need to ask individual witnesses about. So delays now risk holding up the next phase of Module 3’s work, and that in turn may also impact on other modules’ ability to progress their investigations in a timely way.

I hope it won’t come to this, but in the event of further delays we may invite your Ladyship to consider whether it is necessary to issue a notice under section 21 of the Inquiries Act to the Department of Health, and/or any other bodies, requiring the evidence to be provided within a specified time.

Now I turn to disclosure as the next item on the agenda.

Last week, on 21 September, Module 3 made its first tranche of disclosure to core participants. In total, the 136 documents were disclosed, including some statements and exhibits from the disabilities charities consortium, St John’s Ambulance, West Midlands ambulance healthcare trust, Public Health and the Independent Healthcare Providers Network. Also disclosed were documents from the British Medical Association and the Department of Health and Social Care.

In addition, Module 3 has disclosed the expert reports of Professors Marmot and Bambra, and Professor Heymann, and the relevant parts of the evidence given in the Module 1 hearings, and Module 3 will be disclosing the expert report of Dr Claas Kirchhelle and the transcript of his evidence given in Module 1.

In addition to the disclosure already made, we are progressing the Rule 9 statements and exhibits for disclosure, and will continue to review the evidence provided to other modules and make disclosure of relevant material in the coming months.

There is one discrete matter in relation to disclosure requests that I wish to update the core participants and your Ladyship about. In my note on 29 August, the core participants were made aware of an issue relating to the retention of emails within the NHS Wales Microsoft 365 email service. In short, at the beginning of August this year, the Inquiry was informed that Digital Healthcare Wales, DHCW, had in February of 2023 discovered that email mailboxes and all the contents stored in those mailboxes, so not just the emails but calendars, contacts, notes and the like, for people who had left an NHS organisation or had left an NHS organisation to join another NHS organisation within Wales, were deleted.

The Inquiry has been informed that some accounts were not affected. Two health boards, Cardiff and Cym Taf, had separate back-up mail for staff who have left those organisations so they were not affected.

Now, upon learning of that issue, the Inquiry wrote to DHCW requesting an explanation as to why that issue was not brought to the Inquiry’s attention at an earlier date and to ascertain the scale and potential impact of that issue. In response, DHCW apologised for not informing the Inquiry sooner and explained that it did not consider the deletion of some accounts to be a material factor in relation to DHCW’s ability to respond to the Inquiry. That was because some key documentation was stored in document repositories and was not solely in mailboxes. However, DHCW told us that as the Covid Inquiry progressed and they were more involved in helping the health organisations to find copies of emails from affected mailboxes, they considered they should notify the Inquiry of the potential problem.

Now, my Lady, in relation to Module 3 in particular to date, no Welsh Rule 9 recipient has told the Inquiry the mailbox deletion issue has affected their ability to respond to Module 3’s Rule 9 requests.

Unconnected to the Microsoft mailbox deletion issue, Cardiff and Vale University Health Board have recently told us that the mailbox of Professor Stuart Walker, who was the executive medical director between July 2019 and September 2021 and then the interim chief executive until February 2022, cannot be accessed from the period from 5 December. Now, Cardiff and Vale University Health Board are still investigating the reasons for this, but it does not appear to be connected from the move to Microsoft 365.

I should say that that aside, no other recipient of Rule 9 requests outside of Wales has indicated that their mailboxes are affected, and we would expect of course them to bring this to their attention if they had suffered a similar fate.

Turning to the next item on the agenda, my Lady, behind your tab 7, will find what is called the provisional list of issues. Now, as was made clear when that list was circulated to core participants, the list is very much an initial draft of issues that are emerging from the material provided to the Inquiry to date.

It is not intended to be exhaustive or prescriptive or final, nor could it be, given that there is more evidence to come from the Rule 9 requests that are issued to date and the Rule 9 requests that are going to be issued in the coming months.

Inevitably, some issues may come into greater or lesser focus as the module progresses, and some may drop away and others may emerge.

Is my Lady struggling to find it?

Lady Hallett: No, no, it’s all right, I’ve found it. There is a curious system of filing today but, don’t worry, I’m there.

Ms Carey: A number of core participants have made submissions about additional matters and topics that should be included in that list. Some of those matters are already within Module 3’s contemplation, and so, where appropriate, they’ll be added into version 2 of the list.

For example, there is reference in the current list to clinical support staff. Now, that was intended to refer to non-clinicians working in clinical settings, and to include healthcare workers and non-healthcare staff, and that can be clarified in the later version.

Rule 9 questions have also asked about, for example, individual risk assessments and the use of the private sector by the NHS, and so again version 2 of the list can provide clarification where needed, and there’ll obviously be an expanded version of the issues as the evidence is received by the module.

There were some topics, however, that were proposed, such as more capacity, lack of bereavement support or counselling, comparisons of treatment between people who live in one country but received treatment in another, impact on adults detained under the Mental Health Act, they are all just examples of topics that we submit either are not within the scope of Module 3 or, in our submission, are topics that it is not proportionate or necessary to focus on within the course of this module, examining as it does the impact on the healthcare system.

There were joint submissions to your Ladyship from the Covid Bereaved Families for Justice and the Northern Ireland Covid Bereaved Families for Justice core participant groups, inviting the Inquiry to consider instructing an expert to look at how healthcare systems in other countries responded to the pandemic.

At present, Module 3 does not invite your Ladyship to instruct such an expert, given that you’ll already be looking at the responses within the four nations and that some of the draft statements may touch on an international response or on scientific knowledge as it developed around the world during the pandemic. I’ve no doubt you’ll want to keep that request under review, though.

The John’s Campaign core participant group submits that Module 3 is too focused on hospitals and GPs, and that the module should include healthcare provided in the home, or in residential care, or in supported living, or in mental health units. My Lady, in our submission, to cover all of those topics would broaden the already wide scope of Module 3 too far, and in any event it may be that an examination of the impact of the pandemic in some of those settings would sit better in later modules, particularly within M6 looking at the care sector.

Mind submits that Module 3 should include a greater examination of the impact of the pandemic on mental health services, and contend that focusing on in-patient children and adolescent mental health services, now referred to as children and young people’s mental health services, CAMHS or CYMPHS for short, is too narrow. Mind submits that the module should include consideration of CAMHS within the community.

Now, amongst other issues, Module 3 will examine the impact of the pandemic on referrals and admissions to in-patient CAMHS, including the reasons for those changes, and that will encompass the consequences of reduced access in the community for children and young people, and so, to that extent, CAMHS within the community will be considered within Module 3.

Mind also submits that Module 3 should look at mental health services more widely. My Lady, whilst undoubtedly important, we submit that this is one of those areas where a difficult decision has had to have been made not to look at broader issues of children’s mental health in the community or wider mental health services within the UK’s healthcare system. We submit that Module 3 should focus on a discrete section of acute mental health services for children in the four nations, which will enable a suitably detailed examination of this area of mental health, whilst ensuring a proportionate focus on non-Covid conditions is maintained. But, again, I know that you’ll want to consider any supplementary oral submissions about that topic.

I hope it follows from all that I have just said that where core participants have invited Module 3 to broaden its scope we have taken very great care to ensure that we do so in a way that is necessary and proportionate. Where evidence is being called on a topic, we submit that you do not need to receive each and every available piece of evidence on that issue, only that will which will enable you to come to fair conclusions and enable you to make meaningful recommendations.

Item 3 on the agenda deals with the topic of experts.

Module 3 has currently identified a number of areas within the scope of Module 3 where the Inquiry would benefit from expert evidence. Those areas are in relation to long Covid, intensive care and critical care for patients with Covid-19, infection prevention and control in healthcare settings, and the four non-Covid conditions.

By way of introduction and explanation, when instructing the experts, the Module 3 legal team has been greatly assisted by the Inquiry’s research team to identify those witnesses with the expertise, independence and capacity to assist the Inquiry. Some core participants I know will be disappointed they were not asked to assist in this task, but once the report is prepared in draft, the draft copy will be sent to core participants for their observations so that content that needs either amplifying or clarifying can be incorporated before the final version is disclosed.

So, in addition to the Rule 9s and the disclosure that’s been made to date, and dealing with each of the experts in turn, in relation to long Covid the Inquiry has instructed Professor Chris Brightling and Dr Rachael Evans, experts in long Covid, to prepare a report in relation to both Module 2 and Module 3. The report was divided into topics of general applicability, such as understanding the emergence of long Covid, and topics which are more specific to Module 3, such as the treatment of long Covid.

Given the imminent start of Module 2, the first part of the report has already been sent to the core participants in Module 2 and will be disclosed to Module 3 core participants. The Module 3 section is nearing completion, and will be sent to Module 3 core participants for their input, queries and comments to be considered.

The second expert report is in relation to critical care for patients with Covid-19, and in this regard the Inquiry has instructed Dr Ganesh Suntharalingam and Professor Charlotte Summers, both of whom are expert intensivists, with extensive practical experience of matters affecting patients and staff in intensive care units and high dependency units.

Their report will cover topics including how Covid-19 affects the body’s systems, a summary of the Covid-19 treatments given to critically ill patients, the numbers and roles of staff involved per patient in treating critically ill patients. They have been asked to report on details of any geographical variations in the treatments across the UK or difference in treatments by reference to patients’ age, sex, ethnicity or other characteristics of the patient, including those with pre-existing health conditions, disabilities or other inequalities.

They are giving a summary of the clinical guidance disseminated about how to treat Covid-19 patients, including how people who are less critically ill were treated in hospital or in the community, and they are going to report on the extent to which decisions about treatment, particularly escalation of care, or affected by the existence of a DNACPR order. They are looking at end of life care in intensive care, resourcing in intensive care, including staff, beds and equipment.

It is by no means a short report, but their report is expected in late autumn of this year, and I can confirm that both experts have been asked to address all four nations when drafting their report.

In relation to those experts, the joint submissions of the Covid Bereaved Families for Justice and the Northern Ireland Covid Bereaved Families for Justice have, notwithstanding what is accepted to be Dr Suntharalingam’s significant expertise and Dr Summers’ imminent qualifications, queried whether those doctors are sufficiently independent because of their involvement in developing clinical guidance.

My Lady, when instructing any expert, the Inquiry undertakes a comprehensive background check for any potential or actual conflicts of interest, and we were already aware of their roles in professional society guidelines, but we have concluded that this does not materially impact their independence and there will be a section in the report setting out any areas of potential conflict.

My Lady will have gleaned from the overview I gave in relation to the ambulances, pharmacists, maternity care and the HSIB reports that preventing the spread of Covid within healthcare settings is clearly a matter of significance within Module 3, and to that end and in order to assist matters relating to infection prevention and control measures, a multidisciplinary panel of experts has been identified to prepare an expert report into IPC.

That report will assist with matters including how Covid-19 is transmitted, whether IPC guidance followed the scientific community’s contemporaneous understanding of transmission, it’s going to include a chronological summary of that IPC guidance including where there were changes in guidance implemented in the devolved administrations and the reasons for any variations. It will consider the minimum standard of PPE required for healthcare workers and visitors as IPC measures. Matters relating to IPC within care settings though are not within the scope of Module 3 and so the experts have not been asked to address this.

My Lady, the IPC experts, who bring a diversity of experience and have been involved “on the ground” dealing with outbreaks of infections in hospitals are a panel of five experts.

Stephanie Dancer is a consultant medical microbiologist at NHS Lanarkshire and a professor of microbiology at Edinburgh Napier University. Assisting her will be Katie Jeffery, the director of IPC and a consultant microbiologist at Oxford University Hospitals NHS Trust. Director Jeffery is an associate professor at the Radcliffe Department of Medicine.

The third expert is Hajo Grundmann. Professor Grundmann will bring an international perspective to these issues as he is based in the University of Freiburg in the Institute for Infection Prevention and Hospital Epidemiology, and he is considered to be a world leading expert on hospital transmission, with experience in both nursing and in medicine in England as well as in Europe.

The fourth member of the panel is David Eyre. He is a professor of infectious diseases and an honorary consultant at the University of Oxford. He has particular expertise in testing and genomics, which is the study of genetic material, and how that information is applied in IPC.

The fifth expert is Clive Beggs. He is an emeritus professor of applied physiology at Leeds Beckett University and he has expertise in medical engineering and biology, which includes understanding and preventing the transmission of infectious diseases in hospitals, and the application of what are called biophysical or engineering interventions, such as UV disinfection, HEPA filtration, to mitigate the transmission of infection.

So we submit, my Lady, that across those five experts they are bringing a range of expertise and experience to the issue of IPC within Module 3.

The Inquiry will be, over the course of the autumn, continuing its work to instruct experts in relation to the four non-Covid conditions, namely colorectal cancer, ischaemic heart disease, hip replacements and the in-patients’ CAMHS. The monthly update notes to CPs will keep them informed as to the Inquiry’s progress on this, and any other topic where expert evidence would assist your Ladyship. We anticipate that those experts will consider matters such as delays in diagnosing and treating people with those conditions, and the impact of any such delays on patients’ health. It follows, therefore, that the experts will be asked to look at the available data and, where there is an absence of data or a gap in the data, to make reference to that in the report.

It is anticipated that the experts will be asked where possible to comment on broader systemic issues relating to the impact of the pandemic on healthcare provision for conditions other than Covid-19 rather than add further detailed examinations of the impact on specific health problems beyond those four non-Covid conditions.

In the written submissions, there were requests made for expert evidence in relation to the impact of the pandemic on maternity care and a statistical expert to look at deaths of healthcare workers and, my Lady, the Inquiry will consider those requests this autumn.

There is one other matter in relation to experts. In relation to those four areas, your Ladyship will be aware that Module 2 has instructed a number of experts to consider inequalities across a variety of areas. Now, those reports are being finalised but the drafts contain matters that are relevant to Module 3 and so those reports will be disclosed to Module 3 core participants in due course.

Given the centrality of inequalities to the Inquiry’s work as a whole as well as to Module 3 in particular, it may be appropriate at this stage and by way of example only, just to outline some of the areas that those draft reports have commented upon.

There is a report from Professor James Nazroo reporting on ageing that refers at the outset to the increased vulnerability of older people to a pandemic caused by a respiratory virus. Now, Professor Nazroo states that older people are at greater risk of flu-related complications and mortality as a consequence of a combination of factors, including the greater prevalence of chronic illness, reduced immunity and more generally frailty in older people.

The report notes that an analysis from Public Health England in 2020 showed that once infected, those aged 80 and over were seventy times more likely to die than those aged 40. The report also considers that older people who are social distancing are especially at risk of social isolation, and whilst they may benefit from being able to use digital technologies to carry out their daily lives, including remote consultations with healthcare, they are in fact the people least likely to be able to use remote digital technologies.

Professor Nazroo, along with his colleague, Professor Laia Bécares, have provided a report on ethnicity, and they noted, for example, that morbidity and mortality data demonstrates higher, though variable, levels of chronic diseases, including ischaemic heart disease, in ethnic groups. They argue that explanations for ethnic inequalities in health that focus on cultural or genetic health differences should be rejected, and they submit that genetic and cultural explanations for ethnic inequalities are a form of racism denial, as they lead to a minimising and sometimes a denial of the role of racism in shaping ethnic inequalities in health, social and economic outcomes.

Professors Nick Watson and Tom Shakespeare’s report on disability references the fact that disabled people in the UK could and should have been foreseen to be at higher risk from a Covid-19-type virus due to factors including the fact that some disabled people are at higher risk of Covid-19 due to intrinsic vulnerability to infection. They are higher risk as a result of societal, structural and institutional failings. And that disabled people in 2020 were in a weakened socio-economic situation compared to their non-disabled peers, particularly, they submit, due to changes experienced since 2010. And they, thirdly, say they are at higher risk because many disabled people are dependent on health and social care services which were themselves weakened as a result of the pandemic.

The report on gender by Dr Clare Wenham highlights the disproportionate impact of epidemics and pandemics on women that existed prior to Covid-19, and the report looks at the impact of austerity measures, which, it is argued, have exacerbated gender inequalities.

There are two other reports which Module 3 proposes to disclose: Professor Bécares’ report on LGBTQ+ notes that evidence suggests that LGBTQ+ inequalities are stark and long-standing, with worse health, healthcare and social outcomes for those groups when compared with heterosexual and cisgender populations. Cisgender meaning those whose gender corresponds with their sex assigned at birth.

The report on child health inequalities by Professor Taylor-Robinson includes an analysis of the causes of those inequalities, such as poverty, obesity and experiences during pregnancy and the early years, which are important for a child’s physical and mental health. The report also notes that there is growing concern in the UK over the rising prevalence of mental health problems in children and young people, which will no doubt resonate with that non-Covid condition that Module 3 will be examining.

We anticipate disclosing those reports to Module 3 core participants in the very near future. Given that the Rule 9 requests we have made to date have included questions relating to inequalities and there is this body of expert evidence, we submit that, contrary to the submissions of one of the core participants groups, it is not necessary to reinstruct and reissue letters of instruction to these experts.

May I turn to the non-Covid conditions to be examined.

Your Ladyship will be aware that there are some submissions that, in addition to the four non-Covid conditions that I’ve outlined, Mind submits that the Inquiry should consider the impacts of the pandemic on those with dementia. I have no doubt that your Ladyship will wish to consider the submissions made, but to date Module 3 has indicated it does not intend to examine dementia, not because it’s not important but because the size of this module is already such that the Inquiry needs to keep a tight focus on the matters to be examined, and in any event it may be that if your Ladyship wishes to look at that topic, you will consider that later modules are better placed to do so.

The Clinically Vulnerable Families core participant group raises a concern that the Inquiry is not looking at any underlying long-term conditions that would lead a patient to become immunosuppressed. However, shielding and the impact on the clinically vulnerable is explicitly referred to at paragraph 11 in the provisional outline of scope and so the experiences of immunosuppressed people will be covered within Module 3.

The next matter on the agenda relates to Every Story Matters, the Inquiry’s name for the Inquiry’s listening exercise.

In my note to the core participants for this hearing, I outlined that ESM, Every Story Matters, will be holding community events across the UK to enable people to tell the Inquiry about their experiences in person in their own communities. The Inquiry will be piloting the approach to events in late 2023 but prior to this the Inquiry’s secretariat are running events at interested organisations, pre-existing events, to encourage participation in ESM. They have already attended the TUC congress in Liverpool and a virtual Royal College of Midwives event earlier this month, and will shortly be attending the Northern Ireland Bereaved Families for Justice conference, and I know that the secretariat are very grateful for being invited along to explain more about ESM.

Within Module 3 in particular, accompanying my update note was a document setting out the key lines of enquiry relevant to Every Story Matters which will help inform a bespoke report to Module 3 on the human impact of the pandemic.

Now, those key lines of enquiry will be explored through what is called targeted qualitative research which aims to gather the experiences of individuals from underrepresented, seldom heard and/or vulnerable communities, and from those where there are significant barriers existing to engagement. It will also gather the experiences of individuals who experienced particular impacts related to matters within Module 3, including those directly affected by the pandemic, including bereaved individuals, their families, the patients who were hospitalised with Covid, and long Covid patients, those indirectly affected by the pandemic, such as people who used NHS 111, those who were advised to shield, and the healthcare workers and staff. The findings of that research will be brought together with findings from the analysis of people’s experiences which have been shared online through those accessible participation routes or through the events.

Taking all of those matters together, those insights will be turned into an anonymised thematic report which will be disclosed to core participants as evidence in good time for the hearing. It is anticipated that that report will be available to support the Inquiry legal team ahead of the hearings and will be a source of evidence for the final module report and its recommendations, and importantly, my Lady, it will form a part of the formal record of the Inquiry.

May I just turn to one matter that’s not on the agenda but didn’t fit into the agenda items, and whilst I’m doing so, I may have, I’m afraid, inadvertently said that we have disclosed a Public Health statement. It’s actually the Parliamentary and Health Service Ombudsman statement that we have been disclosed, and I’m sorry if I didn’t give the right information earlier this morning.

The one matter that doesn’t fit into any of those agenda items is in relation to a submission from the Covid Bereaved Families for Justice and Northern Ireland Covid Bereaved Families groups. They have asked how treatment of Covid-19, which is within the provisional scope of Module 3, is different to paragraph 2 of Module 4’s provisional scope.

Now, paragraph 2 of Module 4’s provisional outline of scope states that Module 4 will examine the development, trials and use of new therapeutics during the pandemic, in addition to the use of existing medications. Now, it may be that this query was answered in part during the Module 4 preliminary hearing which was heard earlier this month on 13 September, during which Mr Wald King’s Counsel, who is the lead counsel to Module 4, explained that Module 4 will consider the way in which new therapeutics were developed and existing medicines were repurposed to treat Covid-19, and he made clear that Module 3 will therefore examine the use of therapeutics in practice, by which we mean how therapeutics were used once effective treatments had been identified and improved.

My Lady, by way of example, the intensivist experts’ report have been asked to set out how treatments for Covid-19 developed and changed over the course of the pandemic.

It may be that your Ladyship will hear this morning submissions from the CVF core participant about the Inquiry’s investigation into therapeutics and the division of this topic across Module 3 and Module 4. The thrust of the submission is that whilst not precluding examination of therapeutics in Module 3, Module 4 should also consider the use of therapeutics, and it’s clearly not appropriate for me to trespass on or speak for the Module 4 legal team, and so that is a submission for them.

My Lady, I know that you have had an opportunity already to consider the written submissions and will be considering those submissions alongside any oral submissions made today, and you will publish any appropriate directions. Can we ask you to consider whether you wish to publish any written submissions on the Inquiry’s website. That’s a matter entirely for your discretion in due course.

So may I turn or return to where I first started by looking at the next steps for Module 3.

It is anticipated that the hearings will run for ten weeks with two short breaks and will be heard here at Dorland House. In their joint submissions, the Covid Bereaved Families for Justice and the Northern Ireland Covid Bereaved Families for Justice submit that the Inquiry will need up to 31 weeks of hearing time set aside for Module 3.

Putting aside the sheer impracticality of holding a six-month long public hearing given the Inquiry’s other modules and your Ladyship’s stated intention in your opening statement to run the Inquiry as thoroughly and as efficiently as possible, in our submission, Module 3 does not need to set aside that amount of hearing time. The multitude of ways in which evidence can be placed before you means it will not be necessary to call each and every witness who can provide evidence on any given topic.

Moreover, I anticipate that where a witness is called live, there will be a laser-like focus on the key issues, and I know that those with a speaking role will do their utmost to ensure that questions do not deviate from those essential issues.

In the written submissions, your Ladyship has also been asked to consider bringing Module 3 forward to start after Module 2C, which is being heard in Northern Ireland. Indeed, I think you received submissions on this topic during the Module 4 preliminary hearing.

Bringing Module 3 forward will not be possible, not least because it is likely that not all of the evidence Module 3 needs will be available by then. You have also been asked by the John’s Campaign core participant group to consider moving the care sector module, Module 6, to start straight after Module 3. Again, the logistics of timetabling an inquiry as large as this one means that is not possible either. And it goes without saying that the order of modules is not intended to reflect a hierarchy of importance. All the modules are important and the Inquiry has taken great care to devise a sensible order that allows the Inquiry to progress its work.

The Module 3 public hearing will include hearing evidence from the bereaved, patients and those working within the healthcare system. Identifying those witnesses who can shine a light on systemic issues, including issues of disparities and unequal impacts, is another aspect of this autumn’s work, and we are grateful for the offers of help from the core participants in selecting the individuals who we can approach to provide this evidence.

My Lady, there will be a further preliminary hearing in the spring of 2024, and unless I’m told otherwise, that brings to a close the submissions I wish to make on behalf of the Module 3 legal team. I know there are many core participants who wish to address you during the course of this hearing, but can I invite you first to hear from Ms Munroe King’s Counsel, and your Ladyship will find the order of speaking behind tab 3 in your bundle.

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

Ms Munroe, I think we can fit you in before the break.