Transcript of Module 6 Preliminary Hearing, on 19 March 2024

(10.30 am)

1. Introductory Remarks by the Chair

Lady Hallett: Good morning, everyone.

This is the first preliminary hearing into Module 6, which will be focusing on the care sector.

Leading Counsel to the Inquiry team for Module 6, and indeed for Module 3, is Ms Jac Carey King’s Counsel. In a moment, she will tell us what the issues are that I have to consider today and as a result of this hearing. After Ms Carey has spoken, I will then hear from those core participants who wish to make opening submissions.

Just so everyone knows who is following online or here in the hearing room, I will also be receiving written submissions, they will all be published, so the aim of the oral submissions from core participants is to highlight the most significant issues that they wish highlighted. It’s not that they need to go through all the matters that they’ve set out in their oral submissions, and we have quite a few to get through today so I shall immediately call on Ms Carey. Statement by LEAD COUNSEL TO THE INQUIRY for MODULE 6

Ms Carey: Thank you, my Lady.

My Lady, the devastating impact of the Covid-19 pandemic on those living and working in the adult social care sector is going to need little introduction, and certainly little introduction to those in the hearing room today and those following online. But by way of context for this module, the ONS statistics for March 2020 to the week ending 21 January 2022 suggest there were 45,632 Covid-19-related deaths of residents in care homes in England and Wales, and in Scotland between March 2020 and June 2022 the Care Inspectorate received 3,592 notifications of deaths related to Covid-19 from care homes, and in Northern Ireland between March of 2020 and March of 2022, according to the Northern Ireland Statistics and Research Agency, there were 953 Covid-19 deaths in care homes.

My Lady, that’s over 50,000 deaths.

The decisions that may have contributed to those figures will doubtless be examined in Module 6, but it is not just a question of statistics and data. Each number represents the loss of a loved one, often, as we will hear, in circumstances where they were not accompanied by family and friends saying goodbye at bedsides, but they died surrounded by PPE and by the imposition of visiting restrictions which prevented or inhibited them dying in the company and presence of those who loved them.

So whilst those tragic statistics from care homes may have made the headlines, the impact of the pandemic was felt not just in residential and care homes, but also more widely across the adult social care sector.

In fact, most adult social care in the UK is not provided in care homes, but in what is sometimes called domiciliary care, ie services provided to support someone in their own home. It’s not just about old people, my Lady. Moreover, adults of a working age, ie those between 18 and 64, make up a significant proportion of those accessing and requiring social care. So Module 6 is considering the impact not only on the elderly and those in later life but also on those other adults that require that care.

Of course, in addition to those receiving care and the impact on their families, there is the impact on those providing care. And whilst the size of the workforce in each nation inevitably varies, the adult social care workforce in England alone is estimated to be in the region of 1.5 million people, with more women than men working in this sector, women provide more unpaid care than men, the sector has a high proportion of workers from black, Asian and ethnic minority groups, and in some parts of the UK, for example here in London, a high proportion of migrant workers.

Sadly, care workers and those providing care in the home were in the occupations at the highest risk of death from Covid-19.

Now, that brief and sobering introduction gives an indication of the breadth and scale of the adult social care sector and explains in part why Module 6 has had to focus on particular care settings and issues, and I’ll return to that, if I may, when we look at the provisional outline of scope.

These proceedings are, of course, being recorded and livestreamed to other locations and there are a number of core participants who are following online this morning. In live streaming these proceedings, your Ladyship is fulfilling the obligation set out in the Inquiries Act to take such steps as you consider reasonable to ensure that members of the public are able to attend or see and hear the simultaneous transmission of proceedings. It also allows, live streaming, the hearing to be followed by more people than can be present in the hearing room at Dorland House.

Although we don’t anticipate it to arise today, as is routine in public inquiries, where there may be matters mentioned that are potentially sensitive, the broadcasting of the hearing is subject to a three-minute delay, and that provides the opportunity for the feed to be paused if something sensitive arises and anything unexpected is aired which should not be.

As I say, I mention that feature not because we anticipate it arising today but so that those who are following from further afield understand the reasons if there is a break in proceedings.

My Lady will have an agenda for today’s hearing which has been circulated and indeed is displayed on the screens here at Dorland House, and the first item for consideration this morning is the designation of core participants.

Module 6 received over 50 applications, some of which were joint applications, for core participant status, of which 27 have been granted. Given that it is the first preliminary hearing in this module, it is appropriate for me to introduce them, and indeed there are 14 core participants in the hearing room this morning.

There are those representing the Covid Bereaved Families for Justice UK, and the Covid-19 Bereaved Families for Justice Cymru, the Northern Ireland Covid Bereaved Families for Justice and the Scottish Covid Bereaved are here, along with the core participant group John’s Campaign, Care Rights UK and the Patients Association. Disability Rights UK, Disability Action Northern Ireland, Disability Wales and Inclusion Scotland have been known or are known as the disabled people’s organisations, and they are to your right, my Lady.

We have the Frontline Migrant Health Workers Group, the British Association of Social Workers, the National Association of Care and Support Workers, the Royal College of Nursing, the Trades Union Congress.

Care England, National Care Forum and the Homecare Association are a core participant group. Scottish Care. A joint core participant group of the Association of Directors of Adult Social Services, the Local Government Association and the Welsh Local Government Association. The Care Quality Commission, the Regulation and Quality Improvement Authority and the Care Inspectorate.

The Department of Health and Social Care, Department for Health Northern Ireland, the Scottish Territorial and Special Health Boards, the Convention of Scottish Local Authorities (known colloquially as COSLA), the Scottish Ministers, the Welsh Government.

And we have the four public health authorities: Public Health Wales, UKHSA, Public Health Scotland, and the Public Health Agency, Northern Ireland.

A list of all of the core participants that you have designated for Module 6 is now published online on the website.

My Lady, for those who were not granted core participant status, or for those who did not apply to be designated as a core participant, can I reiterate that not being a core participant in Module 6 in no way precludes any person or group from: applying in a later module; bringing any matter to the attention of the Inquiry and, importantly, providing evidence and information to Module 6; if appropriate and relevant, giving evidence at the public hearing. And if an individual affected by the pandemic wishes to take part, they can do so in the Inquiry’s listening exercise, Every Story Matters.

Item 2 on the agenda is the provisional outline of scope for Module 6, and I’ve asked that it is put up on the screens in front of your Ladyship, and indeed around the room, because it’s an important document and it’s a document about which you will hear submissions throughout the day.

Module 6 will examine the impact of the pandemic on the publicly and privately funded adult social care sector, known as the care sector, in England, Scotland, Wales and Northern Ireland. As you can see, set out there it will consider the consequences of government decision-making on those living and working within the care sector. This includes adult care in residential homes, including care provided in the home, but not care provided within daycare centres or in supported housing. It includes the decisions to free up capacity in hospitals by discharging patients into adult care and residential homes. It will address the steps taken in adult care and residential homes to prevent the spread of Covid-19 and examine the capacity of the adult care sector to respond to the pandemic. And the module will consider the impact of the pandemic on the residents, their loved ones and the impact on staff working within the care sector.

Set out below are particular aspects that the module will examine. There are eight in total. They are not ordered in terms of any hierarchy, and I make that clear at the outset, but the matters that will feature include this: the impact of the pandemic on people’s experience of the care sector. This will focus on residents and their loved ones, and those working within the care sector, and will include consideration of the unequal impacts on them.

The structure of the care sector and the key bodies in the UK and the devolved administrations will be looked at, at the start of and during the pandemic. That will include staffing levels and bed capacity immediately prior to the pandemic.

It will look at the key decisions made by the UK Government and the devolved administrations in respect of the care sector, including the decisions relating to the discharge of people from hospitals into the adult care and residential homes in the early stages of the pandemic.

The module will examine the management of the pandemic in adult care and residential homes. This will include the measures preventing the spread of Covid-19, such as infection prevention and control measures (also known as IPC), look at testing for Covid-19, the availability and adequacy of personal protective equipment (PPE), restrictions on access by and to healthcare professionals, and visits from loved ones.

The module will consider the use of Do Not Attempt Cardiopulmonary Resuscitation orders, or DNACPRs, and the communications with residents and their loved ones about the resident’s condition and treatment, including discussions and decisions about DNACPRs.

The module will look at changes to the regulatory inspection regimes within the care sector, deaths related to the infection of Covid-19, including deaths of residents and staff, and infection prevention and control measures for those providing care in the home, including by unpaid carers.

Now, my Lady, that scope is necessarily provisional. Although it introduces a wide range of topics, it’s neither practical nor advisable to identify at this stage all the issues that the evidence and material obtained under the Rule 9 process will address. Once that material has been obtained, the module is designed to accommodate and obtain documentation and from which then issues can be further distilled.

In due course Module 6 will circulate a list of issues to help identify the key issues arising from evidence, and in this regard we are grateful for the many helpful and thoughtful suggestions set out in the written submissions.

At the outset, though, given the public concern about the discharge decisions, and the fact that this policy primarily affected adult patients, I should make clear that the Inquiry does not intend to examine children in care in this module, and indeed aspects of the impact of the pandemic on children and young people will in any event be considered in a later module. Moreover, Module 6 provisional scope encompasses all adults requiring social care and not, as has been suggested by one core participant, only the elderly.

The Inquiry considers that the provisional scope provides a proper framework of the key issues and matters that the Inquiry is likely to enquire into, and that it sufficiently indicates for people and organisations who have relevant information and evidence, as well as the core participants, to be able to commence their preparations.

These issues will, however, be further developed once the response to the majority of the Rule 9 requests for evidence have been received.

A number of core participants have made suggestions for other matters that should be included in the provisional outline of scope. It’s not practical for me to address you on all of those today. They all require careful consideration and it may be that some of those areas, for example the impact of the proposal to make vaccination a condition of deployment for healthcare workers in England, are intended to be covered by the scope and are already within our contemplation, albeit they’ve not been expressly referred to in that scope.

There are, however, some specific matters raised in the submissions received about the scope that I would like to address today. The Covid Bereaved Families for Justice Cymru submit that Module 6 should be subdivided so that, in addition to Module 6, there are Modules 6A, 6B and 6C, looking at the social care systems in Scotland, Wales and Northern Ireland respectively. It is said that this would not only reflect the constitutional position, given that social care is a devolved matter, but also reflect the fact that the way social care is structured is 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 social care system is set up, without the need for individual hearings.

Moreover, your Ladyship has made plain that this Inquiry must be conducted efficiently, and the addition of further hearings would be contrary to your clear intentions in that regard.

It is further suggested that the scope should be re-worded so that there are specific subparagraphs for each nation, essentially repeating each part of the scope three more times. My Lady, in our submission, that is an unnecessary amendment. The opening of the scope makes clear that the module will consider the impact of the pandemic on the publicly and privately funded adult social care sector systems in England, Scotland, Wales and Northern Ireland.

A number of core participants have submitted that the scope of Module 6 should be widened to include the impact of the pandemic on other care settings, such as sheltered accommodation, supported living, shared lives schemes, hospices, assisted living and respite care.

Now, some of those settings in effect provide care to an individual in their own home, with the amount of support being provided varying greatly. For example, care in the home encompasses a carer visiting an individual’s private residence for a short time to provide personal care, for example getting someone up in the morning or helping them to wash or dress, but it also includes much more intensive support. Other settings, such as supported living, involve care in a home where there are a small number of residents and individuals, or sheltered accommodation where there is a warden on site.

So although there are a number of different settings in which people are provided care, it will not be necessary or proportionate to examine all the settings. The Inquiry considers that by focusing on adult and residential care and care provided in the home, by which we mean care provided in one zone accommodation by carers who do not live or work in the home, and therefore which doesn’t fall under the umbrella of supported housing, the Inquiry will have a sufficiently broad base upon which to make meaningful recommendations with regard to the critical issues.

There will necessarily be a significant focus on residential care homes due to the risks the pandemic posed to residents and their inherently vulnerable status across all the age demographics and the challenges of implementing effective IPC in care and residential homes, as well as their role as potential vectors of transmission.

My Lady, that is not to diminish the importance of other settings, but instead it reflects the very real need to make meaningful recommendations in advance of any future pandemic, and to address the stark impact of Covid-19 on such residents, including the disproportionate number of deaths.

It follows from what I have said that – the emphasis on critical issues, that the Inquiry will be unable to examine all the potential issues arising within the adult social care sector. There will necessarily need to be a focus on issues of significance, of wide impact, and of relevance to recommendations in the event of future pandemics.

So, understandably, some core participants have urged the Inquiry to examine a multitude not only of settings but of other issues, such as the potential increased use of restraints or sedation for some individuals needing care. They are obviously important issues for some adults in social care, but it will be appreciated, I hope, that it is not possible to examine each and every area of concern, nor would it be proportionate to do so.

Doubtless, my Lady, you will wish to consider the submissions made about the other settings and other matters that should fall into scope, and indeed, as the evidence emerges, if it suggests that other settings or issues need to be considered, the Inquiry will keep that matter under review.

May I just make two other observations in relation to the scope. In relation to preparedness, Module 6 does not intend to repeat or rehearse the evidence given in Module 1, although in due course Module 6 will obviously disclose relevant material that’s been provided to Module 1 and indeed any of the other earlier modules. However, it is not part of the Inquiry’s terms of reference to consider the state of the adult social care systems in the UK prior to the pandemic, save unless it is necessary to do so to understand how the pandemic in fact affected adult social care during 2020 to 2022.

Finally, this observation: it may be that the pandemic threw a harsh and painful light on issues such as pre-pandemic underfunding and the undervaluing of the adult social care sector, but Module 6 is focused on the impact of the pandemic, not on those wide-reaching and historic concerns and problems, and so, in our submission, it is not, therefore, within Module 6’s remit or scope to seek to fix or address those long-standing issues, although, again, I know you will want to consider very carefully the submissions that are made on that topic.

Turning to the next item on the agenda, which is evidence gathering and the Rule 9 requests for information.

Module 6 has started the process of identifying and issuing Rule 9 requests from relevant organisations and individuals, and they will include, just to give the headlines, the relevant government departments and agencies and ministers responsible for adult social care, the regulators, trade unions and membership organisations, relevant care providers, charities and interest groups, and bodies and organisations and core participants that can provide impact evidence.

The Inquiry is grateful for all the suggestions made in the written submissions as to who should receive a Rule 9 request and the Inquiry legal team has already started to consider those proposals.

One aspect of the Rule 9 work being undertaken is to try to obtain evidence from the local authorities in England, Wales, Scotland – and there are different arrangements in Northern Ireland so I’ll just focus on England, Wales and Scotland for the moment – looking at the local authorities who are responsible for social care.

In this regard, in November 2023, Module 6 asked the Local Government Association to conduct an online survey of all its members. All 337 members in England and Wales responded. My Lady, the survey covered a wide range of topics, but I’d like to give you a flavour of some of the findings of the survey. There’s just seven I’d like to refer to this morning, the first of which is this:

Following the onset of the pandemic, councils responded saying they adapted rapidly, with a large majority of the councils reporting a change in the structural mechanisms of decision-making. So, for example, councils reported undertaking a wide range of activities to support care providers, with nine out of ten providing and purchasing and distributing PPE.

Local government respondees felt that social care was sometimes treated as an afterthought compared to the NHS. In those survey responses they said two fifths of English councils reported that their orders for PPE were deferred to the NHS very or fairly often during the first six months of the pandemic. And respondents noted differences in staff capacity and vaccination and testing guidelines between the NHS and the social care sector, putting the latter at a perceived disadvantage.

Respondees commented on visits by healthcare professionals and said they were frequently limited by the restrictions imposed during the pandemic, and it was reported that those limitations resulted in longer waits for treatment, inadequate treatment, necessary transfers to hospital not being undertaken, or, conversely, unnecessary transfers to hospital being undertaken.

Eight in ten English councils reported that the NHS discharged people from acute hospitals into care homes without routinely testing them first, and almost nine in ten respondents said that care homes in their area were sometimes unaware of patients’ Covid-19 status on receiving them from hospital.

The survey asked about delays in receiving Covid-19 tests, and indeed delays in receiving the results made it harder to control outbreaks of Covid-19. Nine out of ten councils reported that test result delays made it difficult to control outbreaks, and to some extent compounded the difficulties caused by obtaining the tests in the first place.

Respondents to the survey consistently emphasised the confusing nature of key guidance distributed by central government and some national agencies. In this regard, three-fifths of respondents in England reported that the national infection prevention and control policies worked either not very well or not at all well, although 95% of respondents said that care homes in their area were able to isolate residents who potentially had Covid-19 at least to some extent.

My Lady, finally, this: the Covid-19 pandemic was reported by respondents to have had a highly negative impact on unpaid carers, with councils stepping up to help provide them and those they cared for with support. Over nine out of ten respondents reported that unpaid carers in their area suffered from mental stress, increased physical demands and/or a lessening of available respite.

Now, that is just a snapshot of the findings of the survey, and the Inquiry anticipates being able to publish the findings in one of the early phases of disclosure.

In relation to Scotland, the Inquiry is grateful to COSLA, the Convention of Scottish Local Authorities, for their offer of assistance with providing a Scottish version of the survey, an offer which Module 6 will gladly accept.

The arrangements in Northern Ireland are somewhat different, because there the five health and social care trusts are responsible for social care, and so Module 6 is in the process of considering how best to obtain this evidence, if possible, in relation to Northern Ireland.

More generally across the Inquiry, Rule 9 requests for documentation and witness statements are being issued on an iterative basis, and additional requests may be made of some recipients focusing on particular issues in due course.

As the Rule 9 requests will be issued on a rolling basis to organisations and witnesses, some issues will come into greater focus, no doubt, during the course of the investigation.

In line with your determination made in Module 1, core participants will not be provided with copies of the Rule 9 requests made by the Inquiry, but disclosure to the core participants of the Rule 9 requests themselves, as opposed to the documents and the material generated by those requests, is neither required by the rules nor generally established by past practice and, furthermore, in our submission it would serve little practical purpose, given the wide scope and the detailed nature of Rule 9 requests that are being made.

Whilst dealing with that, in addition your Ladyship has already determined that position statements are not required or needed and we would invite you to confirm that this remains the position in Module 6.

To ensure, though, that core participants are properly informed, the Inquiry will ensure that Module 6 lead solicitor provides monthly updates to core participants on the progress of Rule 9 work, and those updates will include a summary of who’s received Rule 9 requests, the topics those requests cover, what categories of documents have been requested, when the request was made and, indeed, when the response is expected.

That brings me on to disclosure to core participants and item 4 on the agenda.

In common with the approach taken in the preceding modules, Module 6 will adopt the following approach to disclosure: all core participants will receive all documents disclosed in Module 6, not just those documents relevant to them. The disclosure will be subject to three things: a relevance review, a de-duplication exercise, and redactions in accordance with the Inquiry’s redactions protocol. There is a significant team of solicitors, barristers, paralegals already in place to review the relevance of material that has been received.

We will make disclosure in tranches on a rolling basis, and disclosure updates will also be provided in the monthly update by the Module 6 solicitors team, informing core participants of the progress that has been made in obtaining relevant documents.

Now, the Inquiry has already identified material potentially relevant to Module 6 that has been provided to other modules. This material will be reviewed for disclosure and we hope to start making disclosure in the summer of 2024. I know that some core participants have queried why disclosure cannot be made earlier, and if it can be, it will be. But in reality, drafting the Rule 9 requests, allowing the recipients sufficient time to respond, reviewing and providing feedback on draft statements and then redacting and then disclosing the final signed statement and exhibits takes many months, such that, in our submission, summer seems a realistic start date.

Allied to disclosure is the issue of expert material and the instruction of expert witnesses.

Module 6 has provisionally identified a number of areas where expert evidence is likely to assist in examining some of the matters set out in the provisional outline of scope, and there are three areas that have already provisionally been identified.

The first is an expert on what I have called the structure and capacity of the adult social care sector across the UK. It is envisaged that this expert or experts will include an outline of how the care sector is structured and funded, and any key differences across the UK. And there are in effect four different adult social care sector systems at play here.

It will look at the numbers and types of care homes and providers, workforce capacity at the start of and during the pandemic, and the expert report, I repeat, will consider the position in all four nations.

Module 6 also intends to instruct an infection prevention and control expert. This is likely to include matters such as the development of the scientific understanding of Covid-19, including routes of transmission, and in particular in relation to care settings at the start and then throughout the pandemic. It will also look at IPC guidance relevant to the care sector, and issues relating to PPE within the care sector.

Module 6 has also identified this area for potential expert evidence, and it’s to look at the impact of the pandemic on those with specific conditions which commonly underpin the need for social care.

Now, the Inquiry is already considering which specific condition or conditions should be covered by expert evidence into the impact. This part of the module’s work is focused not on the providers of care, but very much on the individual receiving care and how the pandemic affected them, and to include where possible what are called indirect harms.

For obvious reasons, the Inquiry will not be able to obtain expert evidence on all relevant conditions, but it is hoped that expert evidence will be complemented by other evidence obtained through the Rule 9 gathering process, and we are considering looking at the impact on those with learning difficulties, people with mental health difficulties, those with dementia, physical difficulties, and those with multiple or complex needs.

That’s not to say that some people don’t, I’m afraid, suffer from a number of those conditions, nor is it to pigeonhole people, but there has to be a sensible way to try to understand the way the pandemic impacted people with those kinds of difficulties.

In this regard, we note the disabled people’s organisations’ submission that expert evidence on impact should not be based solely on condition but on whether the eligibility criteria is met.

Now, the Inquiry legal team wants to consider that submission, but note that one part of the eligibility criteria is looking at the adult’s needs and whether they arise from or are related to a physical or mental impairment of illness, and so it may be that, practically speaking, these are two sides of the same coin. But, again, we are considering the submissions received in that regard.

In relation to those three areas, and indeed any other future area for expert evidence, the identity of the expert witnesses and the questions and issues they will be asked to address will be disclosed to the core participants before the expert reports are finalised. So the core participants will be able to provide observations on the draft expert report. We anticipate that where there are significant differences of view amongst expert opinion, these will be made clear on the face of the reports, and of course in due course can be tested during oral hearings.

The appointment of the experts to the Inquiry are, though, matters exclusively for the Inquiry, although we have received already a number of helpful suggestions from core participants as to who should be appointed. We will consider those experts, and indeed the additional areas of expert evidence, and I’ve no doubt that you will hear further submissions about that today. So, before deciding on any additional areas, no doubt you’ll wish to listen to those oral submissions.

My Lady, item 5 on the agenda considers the Inquiry’s listening exercise, Every Story Matters.

Every Story Matters has been established to gather, analyse and summarise the experiences of those affected by the pandemic and the UK’s response to it. Module 6 will have an Every Story Matters report covering people’s experiences of care. The report will be anonymised but disclosed to the core participants and used in evidence so they can form part of the Inquiry’s written record. The report will identify trends and themes and include illustrative case studies which may demonstrate systemic failures.

Every Story Matters aims to obtain information from anyone who wishes to contribute and has been designed so that anyone and everyone in the UK can contribute if they wish to do so. Specifically in relation to Module 6, the Inquiry is particularly interested to hear from people who have interacted with the care sector, including the residents living within the adult social care sector and those who are cared for at home and their loved ones, those managing public and privately funded care homes, people working in adult social care settings during the pandemic, including those providing care at home, whether they are paid or unpaid.

To date, nearly 5,500 people have shared their experiences of the care sector with Every Story Matters and there have been a number of listening events at care homes that have taken place, but can I reiterate the Inquiry encourages anyone else who would like to participate to go online and share their story.

In addition to that, Every Story Matters is going to commission targeted research about the impact of lockdowns and visiting restrictions, including on the physical and mental health of those who receive and provide care, and looking at end-of-life care, DNACPR decisions and bereavement, the information that was provided to and about patients being discharged from hospitals, access to emergency and routine healthcare for residents in care homes, and it will look at IPC measures.

There is a proposed what are called key lines of enquiry that have been shared with core participants, along with the categories of potential audience groups that it is proposed are included in the sampling for those qualitative interviews, and again we are grateful for all the submissions that have been made in respect of the key lines of enquiry. These will be revisited once your Ladyship has had a chance to consider all of the submissions and made any necessary final decisions about the scope of Module 6.

The final matter on the agenda is this, my Lady, in relation to future hearings. There will be a further preliminary hearing for Module 6 held in due course at Dorland House. We anticipate that the public hearing in Module 6 will take place in London in the summer of 2025. The disabled people’s organisations have asked the Inquiry to consider whether a British Sign Language interpreter could be used in Module 6 for some or all of the public hearing. The need, feasibility and cost of this suggestion is a matter that the Inquiry is looking into, and your decision about this can be communicated to core participants in due course.

Your Ladyship has already indicated that you will publish the written submissions that you received. In addition to those written submissions there are 12 core participants present today who wish to make oral submissions, and the first to address you is Ms Morris King’s Counsel on behalf of the Covid Bereaved Families for Justice UK.

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

Ms Morris.