Demanding inheritance: Finding families ‘at the heart’ of the public inquiry

1. Introduction

We often read that families are ‘at the heart’ of public inquiries.^[1] This phrase is shorthand for inquiries’ commitment to adapt their processes so that families bereaved or otherwise affected by state violence can participate effectively. There is ample evidence of relevant procedural reform and experimentation within public inquiries; much of it driven by family-led campaigns and grassroots organisations such as INQUEST. Emerging issues include involving families in developing inquiries’ terms of reference^[2] and in approving inquiry leadership,^[3] cultivating open working relationships with inquiry chairs,^[4] and support for families’ direct participation in inquiries’ forensic processes.^[5] However, inquiries cannot always guarantee the kinds of justice many families demand. Critical legal scholars understand that mere inclusion in state processes cannot guarantee justice.^[6] Recent efforts to modify public inquiry procedures to enable families’ participation have made a difference, but we must also interrogate inquiries’ underpinning legal methodologies. This means examining the habits of reasoning and unchallenged assumptions which underpin inquiries’ analysis and recommendations. This work enables us to better understand why family campaigns may be marginalised by established methodological approaches, even as inquiries work hard for their inclusion. In this article, I pursue this task using a critical account of justice as inheritance. Public inquiries deal with past state acts or omissions, whether that past is recent or, as is usual, more distant. ‘Inheritance’ traditionally describes how a property, trait, tradition or a claim is transmitted over time. Inheritance describes how aspects of the past maintain agency in the present and the future. Critical accounts of inheritance as justice insist that inheritance is political. Justice requires that we inherit responsibly. We must actively assess what has been handed down to us, nurture what is worth keeping and transform unjust exclusions by undoing violent patterns of repetition.^[7]

An inheritance focus makes three contributions to our understanding of public inquiries. First, inheritance resonates with the traumatic experiences – at once intimate and inescapably political – which drive families in campaigning for or co-operating with public inquiries. An inheritance framing foregrounds families’ legal agency. This matters because families do not participate in inquiries as bystanders or mere witnesses to others’ suffering.^[8] Rather, inquiries regularly consider harms going to the core of family life. A partial list includes bereavement; interference with mourning and care for the sick and dying;^[9] inadequate welfare support following catastrophic state failures;^[10] ill-treatment of families whose loved ones died or were abused in carceral or residential institutions;^[11] reproductive harm and child loss;^[12] and historical forced family separation.^[13] Inquiries recognise these losses as familial. However, they do so in a political context in which family loss and grief are privatised and individualised, so that hostility to politicisation of family experience is common. Even as they are praised for ‘fortitude, persistence and determination’,^[14] family campaigners must contend with victim blaming,^[15] or resource guarding.^[16] Their political activity may be pathologised within a quasi-therapeutic framing; as evidence of interrupted grief^[17] or troubling vulnerability.^[18] Even within a liberal framing, we find ambivalence around families’ participation in public inquiries, expressed as concern to balance families’ inclusion with the pursuit of impartiality^[19] and efficient reform.^[20] Critical accounts of inheritance reframe these concerns: rather than separating political agency from the intimate consequences of loss, they dignify both.

Second, on critical accounts, inheritance is political as much as personal. So, it can illuminate inquiries’ – and by extension the state’s – relationship to state violence. Consider the motives typically attributed to families participating in public inquiries. Families want others to understand that they cannot put their loss behind them because it has not been properly addressed: they live subject to an ongoing, unresolved and violent inheritance.^[21] Families want ‘answers’ which will enable them to understand how this inheritance came to them:^[22] the inquiry must expose the power structures which have visited terrible violence or neglect upon them. Families want their violent inheritance to leave a continuing legacy for others: the inquiry must enable changes which ensure that no other family suffers as they have done.^[23] Each of these elements of inheritance begins with families, but in pursuing inheritance through a public inquiry, families make corresponding demands of the state. They ask the state to recognise their continuing unresolved loss. They ask inquiries to explain how that loss arose, even if the explanation must unsettle prevailing orders of power. They ask inquiries to recommend changes which will leave a meaningful legacy by dismantling the conditions which caused their loss in the first place.^[24] The state, in turn, is expected to act on these recommendations, even if they are disruptive. So, public inquiries are both spaces where affected families perform some of the labour of inheriting the aftermath of state violence, and spaces where state agents and implicated others must engage in inheritance of their own. By identifying tensions and frictions between potentially competing projects and practices of inheritance we can come closer to explaining why public inquiries can frustrate families’ demands.

In this respect, an inheritance framing makes a third contribution. A critical approach to inheritance emphasises transformative, rather than possessive or preservationist, approaches to reckoning with the past. Taking transformation seriously crystallises a central problem with family participation in public inquiries.^[25] Each element of critical inheritance identified so far encompasses a demand for transformation. The demand for legacy, of course, is a demand for material change in the world. However, demands for recognition of continuing unresolved loss, and for answers, are also transformative in orientation. Families may ask for recognition of losses which might otherwise be normalised or ignored.^[26] The point is not only that their losses must be recognised as grievable,^[27] but that they must be recognised as deserving specific kinds of attention from the state. Families may also ask for answers which challenge hegemonic ways of knowing state violence. These demands challenge the state. They focus attention on violent experiences which the state would rather see forgotten.^[28] They unsettle state agencies’ authority to govern, and to deploy violence in future,^[29] by exposing contradictions between official actions and professed values.^[30] Even when decades have passed since the ‘original’ harm, they highlight the ‘slow violence’^[31] of justice obstructed and delayed.^[32] Moreover, family demands are compelling because they invoke a universal sense of grief, humanising and politicising demands made on behalf of otherwise marginalised communities.^[33] Elizabeth Stanley wrote that public inquiries can operate as ‘pressure valves’; empowering the state to evaluate its wrongdoing in terms which shore up its own authority and depoliticise family interventions.^[34] In this vein, I argue that prevailing public inquiry methodologies, rather than facilitating transformation, may favour possessive or preservationist approaches to inheriting state violence which favour the status quo.^[35] Another way to frame this point is to say that public inquiries recruit families into processes of social reproduction, by attempting to control how they inherit state violence.^[36] My point is not that public inquiries can entirely extinguish families’ transformative inheritance;^[37] families may, in the spirit of inheritance, remake inquiries’ findings, and inquiries’ refusals, in other spaces.^[38] Rather I argue that we must always be alert to inquiries’ projects of discipline and exclusion.

The article is in four sections. First, I outline a critical account of inheritance encompassing the three elements identified above: continuing unresolved loss, a search for answers and a desire for legacy. Rather than outline them in the abstract, I illustrate each using a single vignette drawn from the Bloody Sunday Inquiry (1998–2010). The next three sections apply the account of inheritance developed in the first section to case studies drawn from three different inquiries which promised to place families ‘at their hearts’. I discuss ‘continuing unresolved loss’ by reference to the Grenfell Tower Inquiry’s (2017–2025) commemoration hearings. Then, I examine the ‘search for answers’ using the Cumberlege Review’s (2018–2020) analysis of the Primodos pregnancy testing scandal. Finally, I focus on the desire for ‘legacy’ from the perspective of the Kirkup Review’s (2020–2022) inquiry into abuses in maternity care in East Kent. In each section, I focus on inheritance as a demand, not for participation in established public inquiry practices but for transformative inheritance. In turn, in each section, I examine the possessive and preservationist dimensions of the inquiry’s own efforts at inheritance and count their costs.

Before proceeding, I deal with some issues of definition and scope. First, given limitations of space, I can only discuss a few inquiries in detail. Where possible, my footnotes point to comparable issues arising in other inquiries. I am not arguing that the inquiries discussed are perfectly representative of, for instance, family-centred inquiries over the last decade. Rather, they exemplify aspects of demands rooted in transformative approaches to inheritance and demonstrate how these are affected by possessive inquiry responses. Second, for my purposes, public inquiries are ad hoc investigations of past scandals, commissioned by cabinet members but working independent of government.^[39] This article considers both statutory and non-statutory inquiries. The important legal differences between these types of inquiry are not my focus here. My interest is in self-declared ‘family-centred’ inquiries; a label increasingly adopted by inquiries of both kinds. Third, I recognise that families participating in public inquiries are not a homogenous group.^[40] My aim is not to impose a unitary idea of the ‘public inquiry family’, or to prescribe how individual families should engage with inquiries.^[41] Finally, I acknowledge that the harms inflicted on families affected by Bloody Sunday, the Grenfell Tower fire, the Primodos scandal, and child loss in East Kent differ from one another. I discuss these quite different inquiries in the same article because the state itself deals with diverse experiences using the same legal mechanism: the public inquiry. Alongside direct acts of sovereign physical violence such as deliberate killings by the military or police, public inquiries regularly consider the impacts of systemic neglect by healthcare and child protection authorities, corporate regulators, the police, military and other state agencies. I frame these diverse acts and omissions as ‘state violence’; a phrase which locates violence not only in exceptional or spectacular harms but in the everyday structural exclusions – social, political and legal – which normalise or even valorise those harms.^[42] A state violence framing also echoes solidarity and shared organising by families across the boundaries of very different investigative mechanisms.^[43]

2. Saville: inheriting a brown cord jacket

There is a brown cord jacket in a display case in the Museum of Free Derry.^[44] It once belonged to Jim Wray. He was wearing it when a British soldier shot him dead in Glenfada Park, Derry on Bloody Sunday 1972. The authorities kept the jacket for forensic testing. The Widgery Tribunal used those tests, among other materials, to suggest that Jim Wray was handling a weapon on the day he died. Widgery effectively exonerated the soldiers who killed Wray and other unarmed civilians on Bloody Sunday.^[45] At some point, the Wrays reclaimed the jacket and carefully preserved it for decades. Jim Wray’s father, also James, rejected Widgery’s conclusions. He kept the jacket believing that one day it could be used to prove his son’s innocence.^[46] He was proved right in 2010. Examining Jim Wray’s death over 83 pages, the Saville Inquiry concluded that he was unarmed on the day he died, was shot once in the back, and was probably shot again as he lay on the ground.^[47] I want to use this jacket to set out the key elements of a transformative approach to inheritance – continuing unresolved loss, a search for answers and a desire for legacy – as they manifested in one family’s engagement with one public inquiry.

The brown cord jacket reminds us that even intimate inheritances may also have public dimensions. Binding one generation to the next, inheritance connects families to collective pasts and imagined futures, including the nation-state’s.^[48] This public aspect of inheritance is difficult because it engages questions of power. As Elizabeth Povinelli says, inheritance shapes how we are ‘absorbed into the infrastructures of power’;^[49] how we are given a place ‘in a world structured to care for the existence of some and not others’.^[50] The Wrays confronted this problem. They risked engaging with a state-sanctioned tribunal, even though they had been badly wounded by Widgery and had their own doubts about Saville.^[51] They remade their own relationship to the state and its laws.^[52] In the process they opened themselves up to the possibility that the inquiry might further damage their brother’s memory.^[53] This was no unilateral inheritance. They were asking the Saville Inquiry, in many ways, to confront its own violent inheritance by revisiting the Widgery Tribunal.^[54]

The jacket’s very survival for later use in the Saville Inquiry testifies to the demand for recognition of continuing unresolved loss. It exemplifies a family’s inability to let go of past state violence. For families affected by Bloody Sunday, the present was suffused with memories of those killed,^[55] and with grief for foreclosed futures, and lives that could not come into being.^[56] These families demanded what became the Saville Inquiry even though the state required their loss to be forgotten,^[57] or considered it already resolved by the earlier Widgery Tribunal. Family inheritance of loss has its own temporality which may jar with the state’s timeline. Where inquiries perceive time-limited scandals, with definite beginnings and endings, families incorporate inherited state violence into narratives of lifetimes^[58] and generations.^[59] For instance, in his opening statement to the inquiry, the Wray family’s barrister incorporated Bloody Sunday into the story of Jim Wray’s young life, and that of his father, who died shortly before the inquiry began.^[60] The issue here is not that families ‘move on’ more slowly than the state but that they do not completely ‘move on’ at all. Many critical accounts of inheritance begin with Jacques Derrida, who wrote that we are always ‘violently elected’ by inheritance.^[61] Inheritance is an inescapable duty or a compulsion.^[62] Since families cannot simply refuse to inherit, they inhabit what Berber Bevernage calls ‘irrevocable time’.^[63] In securing the Saville Inquiry, the Bloody Sunday families drew the state into irrevocable time. This is a time not of brokenness or ‘stuckness in the past’ but of deliberately dwelling with the ‘pastpresence’^[64] of what has been lost.^[65] It may be that this kind of temporality is characteristic of many intimate losses. However, where a loss is inflicted by state violence, the inability to ‘move on’ is, partly, the product of unresolved injustice. Avery Gordon’s work on ‘haunting’ is apposite here;^[66] certain kinds of loss have a persistent hold on the present because they demand that something must be done.^[67] The brown cord jacket speaks to a mode of inheritance which resists the state’s desire for premature closure. It embodies a demand for transformative recognition; recognition of the wrongfulness of a loss which would otherwise be normalised. Certainly, the Saville Inquiry met this demand. However, critical inheritance requires more than an adjusted timeline. Critical inheritance, as I understand it here, has three interconnected dimension. We must also consider Saville’s encounter with familial demands for ‘answers’ and ‘legacy’.

The Saville Inquiry’s analytic treatment of the brown cord jacket – its three unrepaired bullet holes always posing the question of how and why its wearer died – recalls the second element of inheritance: the demand ‘for answers’. An inquiry may provide answers which reject the transformative work of inheritance; instead producing forms of knowledge which reassert the state’s authority over the family’s loss.^[68] Sara Ahmed remarks that inheritance may often look like passive reception, which hides the conditions under which the inheritance was received.^[69] Critical inheritance, however, requires us to inherit in ways which expose those conditions of reception. Vikki Bell, similarly, suggests that critical inheritance of state violence requires drawing connections between remembered events and the difficult political conditions which made them possible, to understand how they continue to influence the present.^[70] In the same vein Derrida wrote that inheritance ‘is never a given, it is always a task. It remains before us.’^[71] The Wrays, having carefully preserved their brother’s jacket for years, wanted to confront the political conditions under which it came down to them. Here, the Saville Inquiry’s methodology shows up the limits of critical inheritance within public inquiries. Saville corrected Widgery’s conclusions by accurately narrating the circumstances of Jim Wray’s death,^[72] but left core epistemic structures intact. The Wrays’ efforts at inheritance were readily integrated with familiar processes of legal and scientific meaning-making. Following Jim Wray’s jacket through the inquiry report, we find a resolutely legalist analysis; concerned with defined episodes of violence against named individuals. The report favours scientific evidence, tested through traditional contestation between experts and extensive, relatively adversarial cross-examination. The report deploys these methods to establish how bullets pass through lining or fabric, through slack, taut or crumpled fabric, through material in contact with the ground or not.^[73] The report interrogates oral testimony given from memory^[74] by traumatised witnesses,^[75] recalling how the jacket ‘jumped’ or ‘rose’ when the wearer was shot.^[76] It adapts this testimony to an individualised, supposedly depoliticised and objective model of causation. Inquiries favour these methods of sense-making because they appear to promise certainty; they satisfy the desire for control which marks possessive approaches to inheritance. This possession comes at a cost for families. The Saville report includes a startling image of a young short-haired man, lying on a carpet, raised up slightly on his arms. This is Jim Wray’s nephew, James, demonstrating, for the benefit of the inquiry’s expert witnesses,^[77] how his uncle may have lain on the ground shortly before he died. The inquiry transcripts show that the family was actively involved in producing this image;^[78] there is agency and resistance here, particularly when we recall that families did not speak before the inquiry except as witnesses.^[79] As I read this photograph, to satisfy the inquiry’s evidentiary demands, a young man role-played the uncle’s death he may have imagined many times but did not witness or remember.^[80] The inquiry provided ‘answers’, but to receive them, the family had to adapt themselves to its preferred methods of sense-making. A transformative approach to inheritance is inconsistent with rote application of traditional legal approaches to evidence. For instance, Karen Barad argues that rather than engage with the past in order to ‘entertain or reconstruct some narrative of the way it was’ the goal should be ‘to respond, to be responsible and to take responsibility for that which we inherit’.^[81] This means accounting for the relationships of power which motivate inquiries’ selection and preservation of preferred methods.

Finally, Saville shows that public inquiries may offer little in the way of the structural transformation required by demands for legacy. Critical inheritance, Barad writes, accepts that perfect repair of past injustice is impossible.^[82] For instance, because Saville focused in detail on attributing individual deaths to the ‘uncontrolled’ actions of individual low-level soldiers, it left broader assumptions of the legitimacy of military occupation intact.^[83] After Saville, Prime Minister David Cameron was still able to reassure the public that the nation’s military was the finest in the world.^[84] There is, arguably, some continuity between Saville’s limitations and renewed attacks on affected families’ rights in Northern Ireland today.^[85] Today, Jim Wray’s jacket is exhibited at the community-led Museum of Free Derry, as a relic of ‘irreconciliation’;^[86] of determined refusal to ‘move on’^[87] long after the inquiry wound up. The Museum puts the legacy secured by the inquiry in question, presenting it as a hard-won corrective to Widgery’s ‘whitewash’, while emphasising continuing injustices left unresolved.^[88]

The Saville Inquiry may be a poor starting point for thinking through inheritance within later ‘family-centred’ inquiries. Although Saville is remembered for taking measures to secure family participation,^[89] the inquiry process was hardly innovative.^[90] Indeed, Saville is often presented as a high watermark of public inquiry legalism which would not be repeated. Recall David Cameron’s assessment: ‘[I]t is right to pursue the truth with vigour and thoroughness, but let me reassure the House there will be no more open-ended and costly inquiries into the past.’^[91] In the sections which follow, I explore the three elements of critical inheritance through discussions of three more recent, ‘family-centred’ inquiries, to test whether Saville-like features of possessive or preservationist inheritance persist in more recent inquiry practice.

3. Grenfell: recognising continuing unresolved loss

The Grenfell Tower Inquiry opened with nine days of commemoration hearings. Families of those killed in the fire were encouraged^[92] to deliver ‘pen portraits’ of loved ones. Pen portraits are part of a developing ritual tradition within inquiries. Chairs often formally acknowledge families’ grief; for instance, observing a moment’s silence in memory of the dead,^[93] or offering condolences.^[94] While pen portraits had been used before Grenfell,^[95] it was unusual for an inquiry to allow so much time for so many family members^[96] to present them in the manner of their choosing. Some later inquiries have adopted similar practices.^[97] Families value pen portraits as a way of providing a ‘voice’ for lost loved ones.^[98] With photographs, music and poetry, they allow families to insist on the singularity of their beloveds’ lives,^[99] and reclaim them from the awful stories of their deaths.^[100] Pen portraits are not a taken-for-granted practice of the ‘family-centred’ inquiry. The Grenfell commemoration hearings were products of a resistant inheritance. INQUEST and family legal representatives persuaded the inquiry chair to hold them, despite his initial reluctance.^[101] The inquiry was compelled to respond to the first dimension of inheritance: the demand for recognition of families’ continuing unresolved loss. Families could not be expected to ‘move on’ immediately as a condition of their participation in the inquiry.^[102]

The pen portraits almost allowed the dead to haunt the inquiry, interrupting its expected rhythms.^[103] In opening these sessions, the chair seemed to recognise the pastpresence of the dead, making space for them in the inquiry’s proceedings:

When we die, we live on in the memories of those who knew and loved us. It is fitting, therefore, that the opening hearings of the inquiry, at which evidence will be taken, should be dedicated to the memory of those who died.^[104]

The pen portraits confronted the inquiry team with the reality of continuing unresolved loss. They were compelled to attend to their own emotional responses and those of others.^[105] Speakers sometimes struggled for composure. The hearing transcripts mark counsel’s efforts to assist. ‘There’s absolutely no rush’.^[106] ‘Nearly there. Big deep breath’.^[107] ‘Dry your eyes’.^[108] Others in the room were encouraged to applaud or cry if they needed.^[109] Proceedings sometimes stopped when those attending became distressed. There was a moment when counsel apologised for beginning to ‘lose it’ himself, when required to read the names of the deceased aloud.^[110] When Nabil Chouchair, who lost six family members in the fire, was struggling to present the last day’s final pen portrait others in the room called out to him ‘We love you Nabil! We’re here for you! One love!’.^[111] Some pen portraits were delivered as question-and-answer exchanges, in a style since repeated by other inquiries. Counsel for the inquiry led family members through their statements step by step,^[112] sometimes sharing in reflections on family photographs.^[113] The inquiry’s transcripts are punctuated with expressions of recognition, insisting on the inquiry team’s desire to listen.^[114] When a presentation finished, counsel and the chair often remarked on how ‘moving’^[115] or ‘beautiful’^[116] a pen portrait had been.^[117] However, the demand to inherit is not a demand to witness another’s mourning in ordinary ways.^[118] Displays of empathy, which can be offered without changing the hierarchies of power between inquiry personnel and family members, are no guarantee of transformative inheritance.^[119]

Transformative inheritance may begin by setting aside the desire to ‘move on’ from a loss suffered or inflicted. However, it also requires willingness to transform the orders of power which made that loss possible in the first place. Some family members’ pen portraits clearly invoked other dimensions of critical inheritance; particularly the demand for ‘answers’. The clearest example was Karim Mussilhy, who near the end of his tribute to his uncle, said:

I’d like you to remember not only my uncle, Hesham Rahman, I’d also like you to remember the 71 other souls we lost, their families and their friends. You have a duty to them and to yourselves, to the truth and not procedures. But I promise you, we will not let you forget.^[120]

Another was Damel Carayol, who presented the chair with a print of his painting of the burnt-out shell of Grenfell Tower, titled ‘Eyesore: The Final Straw!’, made in the days after the fire.^[121] On the print was a message signed by his family members: ‘To Sir Martin Moore-Bick, work until the truth is laid bare’.^[122] Another, Claudia Davis, demanded the chair ‘do right by her children’, in terms that suggested she was all too aware that she was powerless to make him do anything.^[123] Later, family members’ lawyers took up the pen portraits, notably to try in vain to persuade the chair to investigate the role of institutional racism and classism in the Grenfell fire, recognising that those who suffered and died in the tower were from an overwhelmingly working-class Black and minority ethnic community.^[124]

The commemoration hearings were not a restorative justice forum.^[125] Government ministers, and lawyers for implicated companies, were generally absent.^[126] So, the pen portraits were primarily addressed to the inquiry chair and his team. During the hearings, inquiry personnel appeared to recognise that the commemoration hearings were more than an archive of testimonies to familial pain. Indeed, they suggested that these hearings would influence the inquiry’s later work by focusing it on the families and their needs.^[127] However, pen portraits’ evidentiary status, if any, is unclear.^[128] Commemoration hearings are non-adversarial, in that they do not put the truth of the pen portraits in question. Families offering pen portraits at public inquiries may make statements establishing the circumstances of an individual’s violent death.^[129] They may also offer evidence of the harm caused by state violence. Inquiries may take such evidence into account in drawing systemic conclusions, even where that evidence has not been subject to cross-examination.^[130] It is not clear that the Grenfell inquiry treated the pen portraits as evidence or allowed them to influence its methods. The Inquiry Phase I report summarised the pen portraits in Part IV, Chapter 32, quite separately from the discussion of its other forensic work. It described them as a ‘permanent public record’^[131] and ‘celebration of … lives’,^[132] designed to offer ‘comfort’ to relatives.^[133] Crucially, the summarised pen portraits omit the transformative demands some speakers made of the inquiry. The report even tells us that the Carayol print hung on the wall of the main inquiry hearing room ‘as a permanent reminder to all present of the horrors of the night [of the fire] and its aftermath’,^[134] while omitting the message printed round the frame.

By attending to this question of evidentiary status, we see how the inquiry refused transformative inheritance while appearing to recognise loss and mourning. During commemoration hearings, the inquiry allowed speakers significant autonomy over pen portraits’ content. Strictly speaking, pen portraits should not express an opinion on the issues to be decided by the inquiry, particularly by attempting to apportion blame.^[135] However, several people who spoke at the Grenfell hearings resisted this constraint. They attributed their losses to ‘incompetence’,^[136] ‘gross criminal negligence’,^[137] ‘arrogance, who knows best, out-of-date laws, regulations and legislation’.^[138] During the hearings, counsel to the inquiry only intervened where speakers strayed into technical matters considered to be within the competence of expert witnesses. On one reading, the inquiry’s reluctance to police pen portraits, at least in public, suggested an initial embrace of the demands of critical inheritance. On another, however, it likely reflected the inquiry’s understanding that the pen portraits carried no real evidentiary value. There is a danger that inquiries’ ritual engagement with commemorative testimony is essentially non-performative. Sara Ahmed writes, the ‘non-performative’ describes how ‘naming can be a way of not [my emphasis] bringing something into effect’.^[139] The commemoration hearings were ‘non-performative’ in attributing to the pen portraits a transformative influence they could never have in practice.

Camillia Kong and colleagues write about an emergent ‘humanising imperative’ in participatory legal processes. In policy discussions of public inquiries, affected families are imagined as harmed or alienated by traditional legal processes.^[140] It is commonly suggested that commemoration hearings are humanising interventions, which offer a quasi-therapeutic legal space,^[141] where personal ‘catharsis’^[142] may be secured.^[143] Now, for Kong, either the humanising imperative is intrinsic to the law, or it merely compensates for the alienating characteristics of legal process.^[144] I suggest that a compensatory reading of the Grenfell Inquiry makes most sense; pen portraits soften the inquiry but are otherwise separate from its core work. Viewed from the perspective of critical inheritance, the inquiry used pen portraits as a compensatory device, without modifying how it exercised its core forensic and decision-making powers. These remained firmly within its possession. Kong and colleagues suggest that the humanising imperative stalls against because it challenges legalist expectations of impartiality.^[145] Similarly, demands for critical inheritance communicated through pen portraits come up against possessive modes of inheritance, which reassert inquiries’ traditional forensic methods. This issue also appears in post-Grenfell inquiries. For instance, during the Sheku Bayoh Inquiry, the chair’s reception of the family’s pen portrait was presented as evidence of his apparent bias.^[146] Arguments in the chair’s defence reduced his responses to mere kindness or civility;^[147] to compensatory efforts to smooth the rough edges of mainstream legal process. The suggestion is that a genuinely transformative response to a pen portrait would unsettle the inherited inquiry model, in ways that cannot be tolerated.

4. Cumberlege: searching for answers

Marie Lyon testified before the Cumberlege Review several times. Cumberlege was a non-statutory inquiry examining official responses to certain gendered medical harms.^[148] In 1970, Lyon used Primodos, a new hormonal pregnancy test, on her doctor’s advice. Like other women, she was not informed of potential risks.^[149] Her daughter Sarah was born with a visible limb difference. Marie Lyon chairs an association of affected families who argue that Primodos induced miscarriages^[150] and caused varied serious impairments in affected children.^[151] Some families are now bereaved. Others mourn lives they believe could have been otherwise.^[152] Denying that their losses were ‘all in the past’, Marie Lyon testified to a sense of irrevocable time marked by mothers’ ongoing worry and guilt; affected people’s lifelong ill-health and families’ struggles to adapt with minimal state assistance.^[153] In this section, I frame their engagement with the Cumberlege Review in terms of the second dimension of critical inheritance: the demand for answers.

Inquiries are often presented as revealing what is secret or hidden. Recent debates about public inquiry fact-finding have focused intensively on candour and open disclosure.^[154] Certainly access to institutional knowledge often matters deeply.^[155] In the case of Primodos, archival evidence accessed by families in recent years^[156] demonstrates that the German manufacturer Schering and British regulators suspected the drug’s dangers as early as 1967, but resisted its withdrawal from use in pregnancy testing until 1978,^[157] suppressing relevant evidence^[158] in order to protect Schering’s oral contraceptive pill, which contained similar ingredients.^[159] For families, Primodos’ history exemplifies how easily bad actors can conceal wrongdoing. In addition to addressing institutionalised concealment and forgetting, however, inheritance must also shape how we interpret near and distant pasts.^[160] Here, Cumberlege raises classic interpretative problems of legalism, which mark even ‘family-centred’^[161] inquiry processes. Ultimately, Cumberlege used the archival evidence discovered by families to argue that the accepted standards of practice in force at the time^[162] required state regulators to act on Primodos’ suspected, serious and avoidable risks in 1967.^[163] In consequence, Cumberlege argued that the government should apologise to affected families and offer limited discretionary redress to recognise the ‘avoidable psychological harm’ inflicted on women who took Primodos.^[164] This argument, which articulates a form of moral rather than strictly legal responsibility, may be read as unsettling a legalist inheritance.^[165] However, another reading demonstrates that Cumberlege preserved that inheritance, in essence, in ways which reinforced existing legal advantages for pharmaceutical manufacturers and the state and restricted families’ opportunities to exercise inheriting agency to reconstruct their own relationships to law as they would wish to do.

Legalistic and quasi-scientific understandings of causation are constitutive of families’ experience of state violence.^[166] Families first attempted to sue Primodos’ manufacturers in negligence in 1977. As often happens with so-called ‘toxic torts’, they fell at the legal hurdle of causation. Briefly, affected families must prove general causation (that, on the balance of probabilities, the quantity of Primodos taken, at the relevant time in pregnancy, could cause relevant impairments) and specific causation (that, on the balance of probabilities, Primodos actually caused these claimants’ impairments).^[167] As yet, families have been unable to demonstrate a ‘biologically plausible mechanism’ by which Primodos affects foetal development.^[168] Available epidemiological research cannot show a strong enough association between women’s use of Primodos and their children’s subsequent impairments.^[169] Without law reform, or a significant scientific advance, families are in limbo.

Now, Cumberlege’s terms of reference prevented it from directly contributing to families’ struggle to prove causation; for instance, by commissioning additional research.^[170] To borrow from Başak Ertür, these terms of reference effected a kind of ‘denial by deferral’. The inquiry could rehearse key scientific issues but not resolve them.^[171] In leaving the issue of causation unresolved, it allowed subsequent governments to refuse any redress payments.^[172] An inquiry facilitating transformative inheritance would have confronted the concept of causation which generated so many of Primodos’ inherited injustices. However, critical inheritance obliges us to confront structural violences, even in the face of such uncertainty. A transformative inheritance must concern itself not only with whether Primodos’ dangers are knowable in scientific terms but with how they became so difficult to acknowledge and address in the first place, with such painful consequences for affected families.^[173] This would mean grappling with how a legalistic concept of causation places structural harms beyond contestation. To underscore the point, I want to outline the consequences of failed inheritance here.

First, causation prioritises the biological, preventing families from making their inheritance fully known. Families often situate questions of biology within the wider relational realities of family life. Legalism subordinates those realities to the question of scientific proof.^[174] Claimants bear the burden of producing and defending that proof. Further, the law allows the defendants to benefit from^[175] the uncertainty and ignorance produced by ‘undone science’.^[176] The point here is not that anyone hoarded, destroyed or concealed evidence of Primodos’ risks.^[177] Rather, the defendants, their predecessors and the state failed to engage in the communicative projects that could generate more relevant knowledge.^[178] Primodos was not tested before it was released onto the market and no product licence was required.^[179] When women first raised concerns about its effects, they were ignored.^[180] As Hannah Jones argues, ignorance, understood less as a consequence of concealment than as an active turning away from uncomfortable knowledge, can enable or produce violence.^[181] Cumberlege comes close to recognising this violence in arguing that healthcare authorities of various kinds do not ‘listen’ to women,^[182] though without suggesting that any listening mechanism should alter prevailing approaches to causation in Primodos litigation.^[183] The danger is that failure to ‘listen’, on the inquiry’s limited feminist understanding,^[184] is understood as a failure to incorporate certain kinds of evidence of Primodos’ biological effects within what the inquiry assumes are objective systems for scientific meaning-making.^[185] In Tanya Serisier’s terms, Cumberlege requires ‘listening in’, within already familiar legalist structures.^[186] An inquiry committed to transformative inheritance would also listen ‘out’, for the consequences of repeated exclusions of women’s knowledge. Inheriting them otherwise means seeking to overcome unjustly gendered approaches^[187] rather than pluralising the kinds of evidence that can be considered within established legalist schemas.

Second, the law on causation individualises harm, contributing to ongoing responsibilisation of pregnant women under law. Cumberlege reinforces that individualism, recognising that mothers who took Primodos could not give effective ‘informed consent’ within the paternalistic medical culture of the time.^[188] This is certainly true. However, an exclusive emphasis on consent can legitimate the illusion of a neutral, science-led regulatory system which empowers individual responsible citizens to evaluate and even master bodily risk.^[189] In the late 1960s and early 1970s, women were increasingly promised meaningful reproductive autonomy; through pregnancy testing, enhanced access to contraception and legalised access to abortion. Families’ experience of Primodos reminds us that this period of capitalist progress in the name of reproductive freedom also made some bodies, as Jasbir Puar writes, ‘available for injury’.^[190] Following the thalidomide scandal, regulators understood that new drugs could affect foetuses in uninvited ways which far exceeded the mundane purposes for which women took them.^[191] Women, not regulators, were made to bear attendant risks. We can also set women’s exposed responsibilisation in the wider context of state violence against disabled people and their families. Pregnant women are expected to make choices which will preserve their children from impairment, constructed as avoidable bodily harm, naturalised as inherent to bodily impairment.^[192] What matters to law is how the impairment came about. Causation is central to a body of negligence law which prioritises corrective over distributive justice, normalising state denial of substantial financial support to disabled people whose impairments are attributed to nature, or to maternal failure, rather than to exceptional external malfeasance.^[193] Cumberlege’s redress proposal does not disrupt these structures. It proposes no redress to recognise, for instance, the financial and care needs of affected families.^[194] Families are obviously aware of what Rob Nixon calls ‘the ground rules of being counted and discounted’;^[195] the need to distinguish themselves from ordinary welfare claimants is apparent, for instance, in their insistence that any redress must be justified as an acknowledgement of wrongdoing, and not a ‘handout’.^[196] My point is that Cumberlege fails in the task of transformative inheritance because it reinforces these limited ideas of justice even as their violent limitations make themselves known.

The Cumberlege Review repeatedly promised to place affected families ‘at its heart’.^[197] However, its preservationist, possessive approach to inheritance parallels failures in the Grenfell commemoration hearings. Families were permitted to speak to pain and suffering: Cumberlege describes their ‘harrowing stories’.^[198] Yet, they could not inform how that pain was interpreted in legal, scientific or other terms, and they could not politicise it. They were entitled to receive scientific and medical knowledge, but not to shape how that knowledge was produced. Veena Das argues that when victims are asked to speak to their suffering while also being deprived of the means of showing how that harm has been caused, their suffering becomes merely ‘ornamental’.^[199] It is striking that this is how a public inquiry deals with families who are, in many ways, ‘embodied health’ activists.^[200] Through her advocacy, Marie Lyon transformed a collective inheritance, working over decades to develop expertise in the science and history of Primodos.^[201] She conducted crucial archival research herself.^[202] She collaborated with expert researchers^[203] and advocated for her collective’s preferred interpretation of available scientific evidence in multiple forums.^[204] Before Cumberlege, she produced a persuasive account of how Primodos came to be given to women like her, and of why it was not withdrawn. Within this narrative, women who had felt profound guilt that they had taken a drug which harmed their children^[205] came to understand themselves instead as systematically neglected by those they depended on for their families’ safety.^[206] Cumberlege certainly provided answers to affected families. However, through a combination of the inquiry’s own legalism and the constraints imposed on it by government, it refused the challenge of transformative inheritance. The inquiry only permitted affected families a disjointed inheritance; one which emphasised scientific proof in ways which prevented them from effectively politicising their own violent experiences.

5. Kirkup and the demand for legacy

Bill Kirkup began the report of his non-statutory inquiry into failures in maternity and neonatal care in East Kent with an open letter to the Secretary of State for Health and Social Care and the Chief Executive of the NHS.^[207] This was a letter, in many ways, about legacy. In his letter, Kirkup insisted that deaths of babies in maternity hospitals within the East Kent Hospitals University NHS Foundation Trust were not exceptional or one-off. Instead, they were attributable to patterns of failure present in East Kent but repeated across public inquiries into maternity services elsewhere. Here, Kirkup named the investigation he chaired into events at Morecambe Bay, and Donna Ockenden’s independent investigations into Telford and Shrewsbury and Nottingham (ongoing at the time of writing). Each completed inquiry elicited official promises that similar failures ‘[would] never happen again’. As Kirkup observed, the repetition that comes of non-implementation (even where government accepts a recommendation) undermines inquiries’ efforts at reform. Other inquiry chairs have raised the same problems in different contexts.^[208] At East Kent, this repetition of failures had real consequences for bereaved parents. Kirkup wrote that he had heard the ‘harrowing’ stories comprising parents’ memories of their babies’ short lives and reflected:

How much more difficult must [the experience of losing a child] be if the death need not have happened? If similar deaths had occurred previously but had been ignored? If the circumstances of your baby’s death were not examined openly and honestly, leaving the inevitability of future recurrence hanging in the air?^[209]

The temporality of failed or stalled reform is an affront to demands for transformative inheritance and, in particular, to the demand for a meaningful legacy. Kirkup is concerned not only with families who lost a child because recommendations made by a previous inquiry were not implemented, but with families whose hope for a legacy has been frustrated. Repetition and return are a symptom of unresolved loss.^[210] When inquiries attempt to make change but fail, state inaction holds affected families in time;^[211] as Kirkup observes, the possibility of repeated violence ‘hangs in the air’. Non-implementation of recommendations extends an arduous process of ‘waiting out the state’,^[212] or awaiting a promised good change that never arrives.^[213] My point here is not that inquiry recommendations can always leave effective legacies for families. Legacy, within a critical account of inheritance, is itself subject to later inheritance, later reinterpretation and remaking. Recommendations, in this sense, are always provisional and double-edged.^[214] They cannot promise finality.^[215] However, harm is undoubtedly done when the same recommendations are repeated but never acted upon.^[216] Sara Ryan,^[217] writing about the disproportionately high rates of preventable deaths of people with learning difficulties, argues that ‘social murder’ is the best term for this damage. Social murder is what happens when the ‘foreseeable and avoidable conditions that precipitate these deaths remain untroubled, reported and repeatedly ignored’.^[218] ‘Social murder’ is the cost of the state refusing transformative inheritance.

Inquiries’ failure to produce a transformative legacy often indicates political inertia; a kind of inheritance which is passive even as it preserves existing orders of power. Government and state agencies may refuse to adopt new interpretative commitments emerging from interactions (collaborative, compromised or otherwise) between public inquiries and family campaigns.^[219] However, as Ian Loader observes, failure may also indicate damaging consensus; it is evidence of continued official faith in a broken system.^[220] This misplaced faith sustains a form of possessive inheritance. Inquiries are often criticised for recommending technocratic amendments to existing institutional practices.^[221] Here it is instructive that Kirkup himself refused to make detailed local reform recommendations of this kind. This approach, he observed, again invoking the image of repetition over time, ‘has been tried by almost every investigation in the five decades since the Inquiry into Ely Hospital, Cardiff, in 1967–69, and it does not work’.^[222] Instead Kirkup made five broad thematic recommendations; four for national action (concerning more effective monitoring of neonatal care, training to embed the ‘compassion’ which was part of the existing standard of care,^[223] training in teamwork,^[224] and support for a ‘Hillsborough Law’^[225]), and a fifth requiring the Trust to engage with existing NHS England mechanisms and work in partnership with affected parents to improve institutional culture.^[226] Although Kirkup promised to move away from prescribing detailed institution-level technocratic changes, the bulk of his recommendations focused on altering cultures – professional, collegial, managerial and so on – within the Trust. ‘Culture’, as a focus of reform, is a familiar, if under-theorised, framing in public inquiry reports both within and outside the NHS.^[227] It is associated with a systemic analysis which avoids some of the individualisation associated with traditional legalism.^[228] Culture is framed as a pernicious influence, enabling dangerous ‘drift’ away from compliance with state-mandated standards.^[229] Foregrounding culture backgrounds the state and the origins of state violence.^[230] Focusing on institutional culture in isolation, rather than as a dimension of state violence, allows inquiries to frame the state as a progressive reforming force which may act on their recommendations.^[231] When inquiries attribute deaths and injuries to temporary cultural dysfunction or recent bureaucratic inefficiency, they uphold the liberal belief in improvement through reform.^[232]

However, by avoiding core questions of state violence, inquiries undermine any prospect of transformative inheritance. So, while Kirkup’s report identifies a role for the state in regulating culture, it does not examine how structural injustices generated by state policies produce and sustain that culture in the first place.^[233] For instance, Kirkup’s proposals for embedding compassion at East Kent hospitals focus on training and continuing professional development. The report does not critique the wider economic and social policies which undermine any compassionate practices,^[234] particularly those associated with underfunding and privatisation of the National Health Service, and bureaucratisation of caring relationships.^[235] Even if compassion, within an essentially hierarchical care relationship, is the solution to some of the problems diagnosed at East Kent, compassion requires a demanding set of emotional and relational skills and practice which are likely to be suppressed or stunted under conditions of profound inequality, where healthcare professionals are afforded limited time to communicate with patients and one another.^[236] Borrowing from Singleton and Mee we might wonder about recommendations which ‘couple compassion with calculation’, appearing to responsibilise healthcare professionals while disengaging the question of state responsibility.^[237] Now this surprisingly durable neoliberalised version of guided, trained compassion may not be what Kirkup, Ockenden or the families they have worked with had in mind. As Loader again argues, it may be that any consensus embodied in the endless ‘cycle of review and inaction’ exists only on the surface; in other words, that public inquiries, government and indeed families make apparently equivalent demands for change, but from very different political perspectives.^[238] Violence here lies in the unarticulated assumption that ‘compassion’ will not take on a meaning that disrupts the status quo.

Penal abolitionist and anti-carceral scholars often argue that ineffectual public inquiries are ritualised distractions from the realities of continuing state violence. They argue that institutions of social control, such as prisons, police stations, psychiatric institutions and immigration detention sites, are already run on the assumption that the people they hold do not deserve safety, care or even survival.^[239] That is why similar kinds of violence recur across disparate institutions and time periods.^[240] Inherited state violence is systemic and long-term.^[241] I am not arguing that maternity hospitals are directly equivalent to carceral institutions. However, it is worth interrogating some of the incidents which Kirkup analyses in terms of failures of ‘compassion’. Women reported denial of health-preserving or life-saving medical care, and unnecessary infliction of bodily pain and psychological suffering at a time when they were dependent on an institution for their health and survival and for their baby’s health and survival. These are quotes from statements generated in Kirkup’s ‘family listening sessions’.^[242] Women spoke to suffering, fear and indignity: ‘I wanted to die, I was in so much pain.’ ‘My blood was up the walls, on the ceiling; my sheets weren’t changed.’ They spoke to confusion and incomprehension: ‘I just saw them covered in blood, up to their elbows covered in blood, having conversations about me saying, “oh that’s bad, that’s bad, that’s bad”, but not telling me what was going on … I was 100% sure I was going to die.’ They spoke to guilt: ‘A member of staff said to me [after my baby died] “is there anything that you think you could have done better?”, which stuck with me for months and months afterwards, I felt so guilty.’ They spoke of being dismissed in overtly colonial terms: ‘People give birth in Africa in mud huts without pain relief.’^[243] From a feminist perspective attuned to questions of obstetric violence, these experiences suggest long-standing inherited systemic assumptions about death, maternal sacrifice and responsibility^[244] which cannot be reduced to the culture of any one institution or professional ‘team’. An inquiry committed to leaving a transformative legacy for families affected by state violence would begin by confronting that violence, recognising that recommendations for reform are more likely to preserve it in adapted form.

6. Conclusion

The whole point of justice consists precisely in our providing for others through humanity what we provide for our own family through affection.^[245]

This quote opened the report of the Hillsborough Independent Panel. It was chosen by the chair, James Jones, then Archbishop of Liverpool. It is intended to convey the possibility of a different kind of public inquiry; perhaps one which can be moved, or affected, into setting aside defensiveness and impartiality in the interests of justice. This article does not take that vision for reality. Instead, it uses a critical account of inheritance to reframe prevailing debates about families’ role in public inquiries. Rather than make recommendations for reform, I offer a restatement of public inquiries’ known shortcomings and the outline of a critical ethos which may animate future work. The article makes three core contributions to our understanding of ‘inclusive’ or ‘family-centred’ public inquiries and their shortcoming. First, it recognises ‘family’ as an important site of collective legal agency, which has both challenged public inquiry methodology and been shaped by it in turn. Second, it unsettles any assumption that public inquiries are already sufficiently adapted to affected families’ legitimate political demands. Finally, it challenges the sufficiency of essentially procedural demands that families be ‘included in’ or facilitated to ‘participate’ in the public inquiry as an established legal process. Instead, it demonstrates that inclusive inquiries may recognise the harms inflicted by state violence, while denying families much substantive opportunity to transform the conditions which produced those harms. Viewed from the perspective of a critical inheritance, the family-centred inquiry promises something much less like the ‘humanity’ and ‘affection’ invoked by James Jones and more like a softer performance of the possessive inheritance that elsewhere has been called ‘law-preserving violence’.^[246] Even in an ‘inclusive’ mode, public inquiries may separate themselves from families’ losses, reinforce legalist accounts of wrongdoing and secure violent structures under the guise of reform. By resisting demands to ‘move on’ from loss, demanding answers which unearth the structural causes of state violence, and insisting on long-term legacy, family campaigns gesture to the possibility of inheritance as justice.

1. eg Elish Angiolini, Report of the Independent Review of Deaths and Serious Incidents in Police Custody (2017) 22; Graham Jones, Report of the Independent Inquiry into the Issues Raised by Paterson (HMSO 2020) 4; Sir Jonathan Michael, Independent Inquiry into the Issues Raised by the David Fuller Case (HMSO 2023) 8; Brian Langstaff, Infected Blood Inquiry: The Report (HMSO 2024) vol 2, 169. It is also common to acknowledge families’ need to feel a sense of ‘ownership’ over an inquiry: HL Deb 27 January 2025, vol 843, col 38; HC Deb 11 July 2017, vol 627, col 212; HC Deb 16 June 2022, vol 716, col 473. ↑

2. Select Committee on the Inquiries Act 2005, The Inquiries Act 2005: Post-Legislative Scrutiny (HL 2013–14, 143) 49; Statutory Inquiries Committee, Public Inquiries: Enhancing Public Trust (HL 2024–26, 9) 15, 17. For an unusual model, where the inquiry was initially co-designed with affected people, see ‘Independent Panel Truth Recovery NI’ <https://www.independentpanel.truthrecoveryni.co.uk/> accessed 1 March 2026. ↑

3. On the limits of this practice see R (Daniels) v May [2018] EWHC 1090 discussed in Patricia Tuitt, ‘Walter Benjamin, Race and the Critique of Rights’ (2018) 27 Griffith Law Review 453, 465. ↑

4. Statutory Inquiries Committee (n 2) 11. ↑

5. See eg the discussion of core participant status in statutory inquiries in Select Committee on the Inquiries Act 2005 (n 2) 69; Statutory Inquiries Committee (n 2) 12. Non-statutory inquiries may recognise ‘full participants’. Note that a right to family participation arises under Art 2 and, often, Art 3 of the European Convention on Human Rights (ECHR). Inquiries must be sufficiently accessible to enable the family to secure their interests, Jordan v United Kingdom [2001] ECHR 32; Armani Da Silva v the United Kingdom [2016] ECHR 314. Families should have access to legal representation where needed for effective participation, Jordan v United Kingdom [2001] ECHR 32. They should be able to attend the entire proceedings if desired. They must have sufficient access to evidence and may be entitled to have questions put to witnesses, Edwards v UK [2002] ECHR 303. ↑

6. Wendy Brown, Undoing the Demos: Neoliberalism’s Stealth Revolution (MIT Press 2015) 128, 131; Yuvraj Joshi, ‘The Trouble with Inclusion’ (2014) 21 Virginia Journal of Social Policy & Law 207. ↑

7. Jacques Derrida, Specters of Marx: The State of the Debt, the Work of Mourning and the New International (Routledge 2012) 18, 114; Gerhard Richter, Uncontainable Legacies: Theses on Intellectual, Cultural, and Political Inheritance (Edinburgh University Press 2021) 125–27. ↑

8. Rarely, inquiries proceed with limited family involvement, eg Kate Eves, The Brook House Inquiry Report, vol 1 (HC 1789-I, HMSO 2023) <https://www.gov.uk/government/publications/brook-house-inquiry> accessed 1 March 2026. ↑

9. See eg UCPI, ‘Undercover Policing Inquiry’s Tranche 3 (Phase 1)’ (15 September 2025) <https://www.ucpi.org.uk/2025/09/15/undercover-policing-inquirys-tranche-3-phase-1-hearings-start-monday-13-october/> accessed 1 March 2026. Covid-19 UK Inquiry, ‘Impact on Society (Module 10)’ <https://covid19.public-inquiry.uk/modules/impact-on-society-module-10/> accessed 1 March 2026. Sir Jonathan Michael (n 1) 8–48. James Jones, Gosport War Memorial Hospital: The Report of the Gosport Independent Panel (HMSO 2018) 3.73–3.87. ↑

10. See eg Wyn Williams, Post Office Horizon IT Inquiry: Report, vol 1 (HMSO 2025); Langstaff (n 1); Martin Moore-Bick, Grenfell Tower Inquiry: Phase 2 Report (HC 19–VII, HMSO 2024) vol 7. ↑

11. See eg Brian Keith, Report of the Zahid Mubarek Inquiry (HMSO 2006); Toby Harris, Changing Prisons, Saving Lives: Report of the Independent Review into Self-Inflicted Deaths in Custody of 18-24 Year Olds (HMSO 2015); ‘Muckamore Abbey Hospital Inquiry’ <https://www.mahinquiry.org.uk/> accessed 1 March 2026. ↑

12. Examples include the Cumberlege and Kirkup reviews, discussed within. ↑

13. See eg Professor Alexis Jay OBE and others, Child Migration Programmes Investigation Report (HMSO 2018). ‘Independent Panel Truth Recovery NI’ <https://www.independentpanel.truthrecoveryni.co.uk/> accessed 1 March 2026. ↑

14. HC Deb 16 September 2021, vol 700, col 1193; HC Deb 19 November 2013, vol 570, col 1095; HC Deb 14 December 2017, vol 633, col 702; HC Deb 20 June 2018, vol 643, col 335. ↑

15. Sara Ryan, Justice for Laughing Boy: Connor Sparrowhawk – A Death by Indifference (Jessica Kingsley 2017) 100–01. Doreen Lawrence, And Still I Rise (Faber & Faber 2011) 221; James Titcombe, Joshua’s Story: Uncovering the Morecambe Bay NHS Scandal (Anderson Wallace 2015) 131–32, 166–69, 197. ↑

16. HL Deb 13 October 2010, vol 721, col 574; HC Deb 12 October 2011, vol 533, col 344. ↑

17. See eg HL Statutory Inquiries Committee, Statutory Inquiries (2023–24) Q 99 (James Jones). ↑

18. On opposing vulnerability and rights, Maeve O’Rourke, ‘The Manipulation of “Vulnerability:” State Responses to So-Called “Historical” Abuses in Ireland’ (2021) 43 Human Rights Quarterly 435. On the complexity of vulnerability, Sally Day and Elizabeth Stanley, ‘Surviving State-Led Disaster: The Legacies of Hillsborough’ (2021) 10 State Crime Journal 197, 211. ↑

19. HL Statutory Inquiries Committee (n 17) Q 11 (John Saunders). ↑

20. Emma Ireton, ‘Public Inquiries: Irreconcilable Interests and the Importance of Managing Expectations’ (2023) 45 Journal of Social Welfare and Family Law 212, 227–28. ↑

21. HC Deb 18 May 2009, vol 49, col 1301; HC Deb 23 April 2009, vol 709, col 1615; HC Deb 12 October 2009, vol 497, col 53; HC Deb 8 December 2010, vol 520, col 135WH. ↑

22. HL Deb 23 November 2011, vol 732, col 1108; HC Deb 3 September 2025, vol 722, col 132WH; HC Deb 18 July 2001, vol 371, col 289; HL Deb 1 April 2004, vol 659, col 1580; HC Deb 11 July 2017, vol 627, col 176, 181. ↑

23. See eg HC Deb 18 July 2001, vol 372, col 299; HL Deb 6 February 2013, vol 743, col 322; HC Deb 16 June 2022, vol 716, col 475. ↑

24. Statutory Inquiries Committee (n 2) 16. ↑

25. I do not romanticise family campaigning. Campaigns built on family memory may reproduce structural exclusions, Gavin Schaffer and Saima Nasar, ‘Black Lives and the “Archival Pulse”: The Murder of Neil “Tommy” Marsh and Other Stories’ (2023) 27 Rethinking History 637. ↑

26. On the labour of drawing public attention to state failures see Mark Drakeford and Ian Butler, ‘Everyday Tragedies: Justice, Scandal and Young People in Contemporary Britain’ (2007) 46 Howard Journal of Criminal Justice 219. ↑

27. See similarly Ed Kirton-Darling, Death, Family and the Law: The Contemporary Inquest in Context (Policy Press 2022) 152. ↑

28. James Martel, ‘Why Does the State Keep Coming Back? Neoliberalism, the State and the Archeon’ (2018) 29 Law and Critique 359; Chloe Peacock, ‘Amnesia and the Erasure of Structural Racism in Criminal Justice Professionals’ Accounts of the 2011 English Disturbances’ (2023) 71 The Sociological Review 1402. ↑

29. HC Deb 6 July 2010, vol 513, col 175. ↑

30. Penny J Green and Tony Ward, ‘State Crime, Human Rights, And the Limits of Criminology’ (2000) 27 Social Justice 101, 109. ↑

31. Rob Nixon, ‘Neoliberalism, Slow Violence, and the Environmental Picaresque’ (2009) 55 Modern Fiction Studies 443, 456. ↑

32. James Jones, The Patronising Disposition of Unaccountable Power (HC 511, HMSO 2017). ↑

33. HC Deb 25 March 2024, vol 747, col 406WH. ↑

34. Elizabeth Stanley, Tolerating State Violence (Taylor & Francis 2025) 18. See also Andrew D Brown, ‘Authoritative Sensemaking in a Public Inquiry Report’ (2004) 25 Organization Studies 95, 108; Nathan Critch, The Politics of Public Inquiries: Crises, Containment and Contestation (Springer Nature 2026) 144–50. ↑

35. It is also possible to frame inquiries’ refusal of transformation as its own kind of violence. Consider, for example, Robert Cover’s notion of ‘the jurispathic’ as discussed in Vikki Bell, ‘Between Documentality and Imagination: Five Theses on Curating the Violent Past’ (2018) 11 Memory Studies 137, 144, or Walter Benjamin’s notion of law-preserving violence, discussed in Tuitt (n 3). ↑

36. For a similar argument in the context of international criminal law see Leila Ullrich, ‘Should We Pay Wages for Victim Participation? Victims’ Labour at the International Criminal Court’ [2026] British Journal of Criminology 031, 2. ↑

37. Critch (n 34) 150, 173–75. ↑

38. This is core to INQUEST’S practice; ‘Responses and Strategies Outside of the Law’ <https://history.inquest.org.uk/research-guides/responses-and-strategies-outside-of-the-law/> accessed 18 May 2026. ↑

39. On defining public inquiries, Nathan Critch, ‘Britain’s “Favoured Response” to Crises: A Critical Review of Existing Literature on Public Inquiries’ (2024) 19 British Politics 553. ↑

40. For instance, families may reject the kind of political activity that a critical inheritance of state violence arguably requires. See eg Lauren Dempster, ‘“Quiet” Transitional Justice: “Publicness”, Trust and Legitimacy in the Search for the “Disappeared”’ [2019] Sage Journal 246. ↑

41. This sort of argument would require in-depth engagement with families’ first-person accounts of their experiences of public inquiries. On the relative dearth of research about inquiries’ internal workings see Dawn Goodwin and others, ‘What We Do and Do Not Know about Public Inquiries: A Narrative Review’ (2025) 0 Contemporary Social Science 1; Raphael Schlembach and Emily Luise Hart, ‘Towards a Criminology of Public Inquiries: From Cautious Optimism to Contestation in the Brook House Inquiry’ (2025) 25 Criminology & Criminal Justice 374. For rare socio-legal examples engaging families’ experiences, though not asking the questions I suggest are necessary, see Natalie Ohana, ‘The Politics of the Production of Knowledge on Trauma: The Grenfell Tower Inquiry’ (2021) 48 Journal of Law and Society 497; Sally Day and others, ‘From Agnosis to Accidental Activism: Infinite Regress and the Post Office Scandal’ (2026) 53(S1) Journal of Law and Society S25. ↑

42. Ed Kiely and Rosalie Warnock, ‘The Banality of State Violence: Institutional Neglect in Austere Local Authorities’ (2023) 43 Critical Social Policy 316; Dawn L Rothe and Victoria E Collins, ‘The Integrated Spectacle: Neoliberalism and the Socially Dead’ (2016) 43 Social Justice 1, 6–7. ↑

43. On ‘kinship’ across family campaigns, Nadine El-Enany, ‘From Love to Justice: Families’ Interrogation of Racial State Violence’ (2023) 32 Social & Legal Studies 55. ↑

44. A discussion of material objects’ agency as evidence is beyond the scope of this paper. I consider similar issues in Máiréad Enright, ‘Symphysiotomy and Law’s Many-Tailed Binder’ in Catherine Harper (ed), The Stained and Bloodied Cloths of Ireland: A Material Culture View of Irish Shame, Oppression, Morality and Repression (Bloomsbury 2025). ↑

45. The inquiries were constituted under the same legislation; the Tribunals of Inquiry (Evidence) Act 1921. On violent histories of public inquiries in Northern Ireland, Bill Rolston and Phil Scraton, ‘In the Full Glare of English Politics: Ireland, Inquiries and the British State’ (2005) 45 British Journal of Criminology 547. ↑

46. See discussion in Elizabeth Crooke, ‘Memory Politics and Material Culture: Display in the Memorial Museum’ (2019) 12 Memory Studies 617. ↑

47. Mark Saville, Report of the Bloody Sunday Inquiry (HC29, HMSO 2010) 104.448 – 104.450. ↑

48. Judith Halberstam, In a Queer Time and Place: Transgender Bodies, Subcultural Lives (NYU Press 2005) 5. ↑

49. Nick Earhart, ‘“A History of Distorted Memories”: Elizabeth Povinelli Talks about Her Graphic Memoir “The Inheritance”’ (Air/Light, 10 March 2022) <https://airlightmagazine.org/etc/conversations/povinelli-inheritance/> accessed 24 January 2026. Similarly on inheritance as ‘help[ing to] keep old networks of belonging in place’, Sarah Keenan, Subversive Property: Law and the Production of Spaces of Belonging (Routledge 2014). ↑

50. Elizabeth A Povinelli, The Inheritance (Duke University Press 2021) 315. ↑

51. On the family’s scepticism, Lord Gifford, Saville Inquiry (22 November 2000) Transcript TS49, 33. ↑

52. On inheritance as requiring us to transform our own relationship to what is passed down see Donna J Haraway, Staying with the Trouble: Making Kin in the Chthulucene (Duke University Press 2016) 131; Karen Barad, ‘Quantum Entanglements and Hauntological Relations of Inheritance: Dis/Continuities, Spacetime Enfoldings, and Justice-to-Come’ (2010) 3 Derrida Today 240, 264. On families’ sense of having been changed by participating in the Saville Inquiry, Eamonn McCann, The Bloody Sunday Inquiry: The Families Speak Out (Pluto Press 2005) 159, 160, 168, 171. ↑

53. On inheritance as requiring us to accept that we cannot simply repeat ancestral traditions see Gerhard Richter, ‘He Who Inherits, Interprets: 14 Theses’ (2018) 133 Modern Language Notes 474, 477. ↑

54. We commonly think of law as reworking (and thus inheriting) what has gone before. See eg Anne Orford, ‘On International Legal Method’ (2013) 1 London Review of International Law 166, 175. ↑

55. Lyn Spillman and Brian Conway, ‘Texts, Bodies, and the Memory of Bloody Sunday’ (2007) 30 Symbolic Interaction 79, 95. McCann (n 52) 41, 90, 171; Julieann Campbell, On Bloody Sunday: A New History Of The Day And Its Aftermath – By The People Who Were There (Hachette 2022) 385. Similarly, Sara Williams and Dan Kay, With Hope in Her Heart: Fighting for Kevin: The Untold Story of My Mum’s Battle for Justice (Sport Media 2013) 147. ↑

56. Avery F Gordon, ‘Some Thoughts on Haunting and Futurity’ (2011) 10(2) Borderlands 1, 7. ↑

57. Emilios Christodoulidis and Scott Veitch, ‘Reflections on Law and Memory’ in Susanne Karstedt (ed), Legal Institutions and Collective Memories (Hart 2010) 64. ↑

58. For another striking example see Margaret Smith, ‘Jermaine Baker Public Inquiry Hearings’ 148 <https://webarchive.nationalarchives.gov.uk/ukgwa/20240104140435/https://jermaine-baker.public-inquiry.uk/hearings/> accessed 7 January 2026. ↑

59. In Lawrence (n 15). Doreen Lawrence situates the inquiry into her son’s death within the story of his childhood, her own life and those of their ancestors. ↑

60. Lord Gifford (n 51) 24. ↑

61. Jacques Derrida, Elisabeth Roudinesco and Jeff Fort, For What Tomorrow: A Dialogue (Stanford University Press 2004) 4. ↑

62. Samir Haddad, Derrida and the Inheritance of Democracy (Indiana University Press 2013) 69. See also Avery Gordon, Ghostly Matters: Haunting and the Sociological Imagination (University of Minnesota Press 2008) 190; Amy Cortvriend and others, ‘Memory Politics After Disaster: Recovery, Embodied Trauma and the Covid-19 Pandemic’ (2025) 53 Millennium 575 . ↑

63. Berber Bevernage, History, Memory, and State-Sponsored Violence: Time and Justice (Routledge 2013) 4. ↑

64. Órla O’Donovan, ‘Wax Moulages and the Pastpresence Work of the Dead’ (2021) 46 Science, Technology, & Human Values 231. ↑

65. On an experience of survival or endurance, in which one’s existence is conditioned by another’s loss, see Ludovic Glorieux and Indira Hašimbegović, ‘Introduction: Inheriting Deconstruction, Surviving Derrida’ in Madeleine Fagan (ed), Derrida: Negotiating the Legacy (Edinburgh University Press 2007). ↑

66. Joe Sim and Steve Tombs, ‘Deaths and COVID-19: Talk, Silence and Alternative Realities’ (2023) 45 Law Policy 373; Jones (n 32) 13. A vivid example, though technically not involving a government-commissioned public inquiry, is Sara Ryan’s decision to include imagined or partially remembered conversations with her son Conor in her book (later adapted into a play) on the campaign to uncover the truth around his death; Ryan (n 15). For examples of ‘haunting’ in the Infected Blood Inquiry see Langstaff (n 1) 24, 113, 114, 125. See similarly Campbell (n 55) 373, 392; Williams and Kay (n 56) 193. ↑

67. On distinguishing haunting from trauma, Gordon (n 56). ↑

68. Owen David Thomas, Catriona Pennell and Margot Tudor, ‘Making Sense of State Violence: Understanding Public Inquiries as Political Devices’ (2024) 10 Critical Military Studies 249, 251. ↑

69. Sara Ahmed, Queer Phenomenology: Orientations, Objects, Others (Duke University Press 2006) 125–26. ↑

70. Vikki Bell, ‘On Fernando’s Photograph: The Biopolitics of Aparición in Contemporary Argentina’ (2010) 27 Theory, Culture & Society 69. ↑

71. Derrida (n 7) 54; Haddad (n 62) 32. ↑

72. On accuracy as insufficient, Bell (n 70). ↑

73. Saville (n 47) 104.265–104.276. ↑

74. ibid 104.438. ↑

75. ibid 104.417. ↑

76. ibid 104.293, 104.298. See also 104.386, 104.389, 104.391. ↑

77. ibid 104.271, 104.448–104.450. ↑

78. On evidence gathering by Bloody Sunday families and their allies, Campbell (n 55) 351–56; McCann (n 52) 12–13, 15, 16–17. ↑

79. Graham Dawson, ‘Trauma, Place and the Politics of Memory: Bloody Sunday, Derry, 1972–2004’ (2005) 59 History Workshop Journal 151, 173. ↑

80. On Bloody Sunday’s intergenerational impacts see ibid 167. ↑

81. Barad (n 52) 264–65. Jessica Lehman, ‘Inheritance at the Limits’ (2024) 41 Theory, Culture & Society 59, 71–72. Rosalyn Diprose, ‘Derrida and the Extraordinary Responsibility of Inheriting the Future-to-Come’ (2006) 16 Social Semiotics 435, 443. ↑

82. Barad (n 52) 264. ↑

83. See generally Kevin Hearty, ‘Truth Beyond the “Trigger Puller”: Moral Accountability, Transitional (In)Justice and the Limitations of Legal Truth’ (2021) 15 International Journal of Transitional Justice 658. On inquiries’ methodological individualism see Owen David Thomas, ‘Revealing (in)Security: Scandals, Guilty Secrets, and the Promise of Counter-Forensics’ (2026) 57 Security Dialogue 48, 50. ↑

84. ‘Bloody Sunday: PM David Cameron’s Full Statement’ BBC News (15 June 2010) <https://www.bbc.co.uk/news/10322295> accessed 21 January 2026. ↑

85. Kieran Mcevoy, ‘Acknowledging the Past in the Post-Truth Era: Witch-Hunts, Lawfare and the Veterans’ Amnesty in Northern Ireland’ (2026) 53(S1) Journal of Law and Society S42. ↑

86. Nayanika Mookherjee, ‘Introduction: On Irreconciliation’ (2022) 28 Journal of the Royal Anthropological Institute 11. ↑

87. Not all those affected take this position, Tom Bentley, ‘When Is a Justice Campaign over? Transitional Justice, “Overing” and Bloody Sunday’ (2021) 56 Cooperation and Conflict 394. ↑

88. Jim Wray was one victim discussed in The King v Soldier F [2025] NICC 30. ↑

89. On Saville’s efforts to secure families’ rights under Article 2 ECHR, HC Northern Ireland Affairs Committee, Bloody Sunday Inquiry (2010–11, HC 499-I) Q 13, 21 and 41 (Mark Saville). ↑

90. Widgery excluded families so completely that the Wrays’ long-standing demand was less for novel forms of participation than for the ordinary application of independent legal process; Lord Gifford (n 51) 31–33 discussing Jim Wray’s father. Nevertheless, there is a transformative dimension to the families’ reinterpretation of the state’s inheritance of the tribunal form. See similarly, Mary Ann Caws and Isabelle Lorenz, ‘“The Laws of Reflection: Nelson Mandela, in Admiration” (1986): For Nelson Mandela (Derrida 1987c)’ in Barry Stocker (ed), Jacques Derrida: Basic Writings (Routledge 2007). ↑

91. ‘Bloody Sunday: PM David Cameron’s Full Statement’ (n 84). ↑

92. Some preferred to ‘grieve privately or in silence’. Counsel to the inquiry read out their loved ones’ names each time prefaced by the words: ‘So may we remember’; Grenfell Tower Inquiry, ‘Commemoration Hearing 21 May 2018’ Hearing Transcripts (2018) <assets.grenfelltowerinquiry.org.uk> accessed 7 January 2026. ↑

93. ibid 9 (observing 72 seconds to reflect 72 deaths); Sheku Bayoh Inquiry, ‘Transcript Tuesday 10 May 2022’ <shekubayohinquiry.scot> accessed 7 January 2026. ↑

94. See eg Anthony Grainger Inquiry, ‘Procedural Hearing 26 July 2016’ <https://www.graingerinquiry.org.uk/> accessed 7 January 2026. ↑

95. Pen portraits featured in the Azelle Rodney and Anthony Grainger inquiries, which predate Grenfell; Sheku Bayoh Inquiry, ‘Conduct and Procedure Hearing – 12 and 13 June 2025’ (2025) 134–35 <https://www.shekubayohinquiry.scot> accessed 7 January 2026. Inquiry teams may include ‘pen portraits’ in their reports eg Kate Eves (n 9) 16–27; ‘Pen Portraits from Children in the Care of the Nottinghamshire Councils’ (IICSA, 24 July 2019) <https://www.iicsa.org.uk/reports-recommendations/publications/investigation/nottinghamshire-councils/pen-portraits-children-care-nottinghamshire-councilss.html> accessed 5 March 2026. ↑

96. Large inquiries may not permit all families to make an oral statement, though they will commit to reading written statements; ‘Invitation to Participate in Omagh Bombing Inquiry – Omagh Bombing Inquiry’ (23 October 2024) <https://omagh.independent-inquiry.uk/news/invitation-to-participate-in-omagh-bombing-inquiry/> accessed 5 March 2026; Kate Lampard, ‘Hearing Day 09 – Opening Statements and Commemorative and Impact Accounts’ (The Lampard Inquiry – Investigating Mental Health Deaths in Essex) <https://lampardinquiry.org.uk/hearings/hearing-day-09-opening-statements-and-commemorative-and-impact-accounts/> accessed 5 March 2026. ↑

97. See eg Omagh Bombing Inquiry, ‘Hearings – Days 1-14’ <https://omagh.independent-inquiry.uk/hearings/> accessed 5 March 2026; The Cranston Inquiry, ‘Week 4 – Oral Evidence, Family Impact Statements and Closing Submissions’ <https://cranston.independent-inquiry.uk/hearing/week-4-oral-evidence-family-impact-statements-and-closing-statements/> accessed 5 March 2026. ↑

98. INQUEST, ‘Family Reflections on Grenfell: No Voice Left Unheard’ (INQUEST 2019) 6. For an example of family resistance to the COVID-19 Inquiry’s refusal to facilitate commemoration hearings see ‘Bereaved Families Hold Pictures of Loved Ones in Vigil Outside Covid Inquiry’ The Independent (13 June 2023) <https://www.independent.co.uk/news/uk/covid-people-london-government-b2356478.html> accessed 5 March 2026. ↑

99. See Bell (n 70). ↑

100. See eg Rosemary Nelson Inquiry, The Rosemary Nelson Inquiry Report (The Stationery Office 2011) 17 and 27–32. Contrast Herbert Baron Laming, The Victoria Climbie Inquiry (HMSO 2003), where Victoria’s life story is almost immediately framed in terms of her death. ↑

101. From Deborah Coles, ‘Re: Grenfell Inquiry Pen Portraits’ (7 March 2018) <https://www.inquest.org.uk/inquest-key-documents> accessed 7 January 2026. ↑

102. Contrast Hillsborough families’ earlier experiences, Phil Scraton, Hillsborough: The Truth (Random House 2009) 250–51; Jones (n 32) 3. ↑

103. Patrick Williams and others, ‘Omission, Erasure and Obfuscation in the Police Institutional Killing of Black Men’ (2023) 28 Mortality 250, 263. ↑

104. Grenfell Tower Inquiry, ‘Commemoration Hearing 21 May 2018’ (n 93) 8. ↑

105. Grenfell Tower Inquiry, ‘Commemoration Hearing 22 May 2018’ Hearing Transcripts (2018) 86 <assets.grenfelltowerinquiry.org.uk> accessed 7 January 2026. ↑

106. Grenfell Tower Inquiry, ‘Commemoration Hearing 29 May 2018’ Hearing Transcripts (2018) 3 <assets.grenfelltowerinquiry.org.uk> accessed 7 January 2026. ↑

107. Grenfell Tower Inquiry, ‘Commemoration Hearing 30 May 2018’ Hearing Transcripts (2018) 20 <assets.grenfelltowerinquiry.org.uk> accessed 7 January 2026. ↑

108. ibid 80. ↑

109. Grenfell Tower Inquiry, ‘Commemoration Hearing 24 May 2018’ Hearing Transcripts (2018) 3 <assets.grenfelltowerinquiry.org.uk> accessed 7 January 2026. See also Grenfell Tower Inquiry, ‘Commemoration Hearing 23 May 2018’ Hearing Transcripts (2018) 5 <assets.grenfelltowerinquiry.org.uk> accessed 7 January 2026. Contrast the ‘shushing’ of families at the Saville Tribunal; McCann (n 52) 91. ↑

110. Grenfell Tower Inquiry, ‘Commemoration Hearing 30 May 2018’ (n 107) 98. ↑

111. ibid 75. ↑

112. See eg El Alami Hamdan ibid 26. ↑

113. The Lampard Inquiry also adopted this practice. ↑

114. See eg Grenfell Tower Inquiry, ‘Commemoration Hearing 25 May 2018’ Hearing Transcripts (2018) 27 <assets.grenfelltowerinquiry.org.uk> accessed 7 January 2026. ↑

115. Grenfell Tower Inquiry, ‘Commemoration Hearing 30 May 2018’ (n 107) 15, 97. ↑

116. Grenfell Tower Inquiry, ‘Commemoration Hearing 25 May 2018’ (n 114) 19. ↑

117. Lord Turnbull at the Omagh Bombing Inquiry often offered more extensive summaries; David Bolton, Conflict, Peace and Mental Health: A Case Study from Northern Ireland on Addressing Trauma and Loss (2nd edn, Manchester University Press 2025) xxvi–xxvii. ↑

118. On the political dimensions of mourning see Athena Athanasiou, Agonistic Mourning: Political Dissidence and the Women in Black (Edinburgh University Press 2017) 76–77; Rosaura Martínez Ruiz, ‘Mexican Antigones: In Search of a Stolen Mourning’ (2023) 34 differences 129, 134; James R Martel, Unburied Bodies: Subversive Corpses and the Authority of the Dead (Amherst College Press 2018) 62–65. ↑

119. See Rosemary Nagy, ‘Settler Witnessing at the Truth and Reconciliation Commission of Canada’ (2020) 21 Human Rights Review 219, 231–32. ↑

120. Grenfell Tower Inquiry, ‘Commemoration Hearing 30 May 2018’ (n 107) 96. ↑

121. Discussed further at admin, ‘Works of Love and Humanity – Exhibition’ (Collage Arts, 25 January 2018) <https://www.collage-arts.org/works-love-humanity-exhibition/> accessed 13 January 2026. Carayol had previously presented a copy to the then Prime Minister, Theresa May. ↑

122. Grenfell Tower Inquiry, ‘Commemoration Hearing 22 May 2018’ (n 106) 59. Although other inquiries have engaged with art work, it is usually formally commissioned eg ‘These Days’ (These Days) <https://tapestry.covid19.public-inquiry.uk/> accessed 3 July 2026. Often art is used for memorial purposes after the inquiry is over eg ‘Child Sexual Abuse Inquiry Launches Landmark Legacy Project in Westminster’ (23 August 2022) <https://www.iicsa.org.uk/news/child-sexual-abuse-inquiry-launches-landmark-legacy-project-westminster%c2%a0.html> accessed 5 March 2026. ↑

123. Grenfell Tower Inquiry, ‘Commemoration Hearing 25 May 2018’ (n 114) 114. ↑

124. See eg Imran Khan, Grenfell Tower Inquiry (5 June 2018) 130–61 <https://assets.grenfelltowerinquiry.org.uk/documents/transcript/Transcript-of-opening-statements-5-June.pdf> accessed 7 January 2026. For a fuller discussion of the inquiry’s attitude to the structural causes of the fire see Jamie M Johnson, Victoria M Basham and Owen D Thomas, ‘Prefiguring Truth: The Limits of the Grenfell Tower Inquiry’ (2026) 53(S1) Journal of Law and Society S6. ↑

125. Contrast ‘Summary Transcript 2 Grenfell Testimony Week 2024’ (2024) <https://www.testimonyweek.co.uk/s/TW-Summary-Transcript-Version-1-0804.pdf> accessed 7 January 2026. ↑

126. Robert Booth, ‘Empty Seats at Grenfell Inquiry Disappoint Survivors’ The Guardian (28 May 2018) <https://www.theguardian.com/uk-news/2018/may/28/grenfell-survivors-angry-over-lack-of-ministers-at-inquiry> accessed 26 January 2026. ↑

127. Grenfell Tower Inquiry, ‘Commemoration Hearing 30 May 2018’ (n 108) 103; Grenfell Tower Inquiry, ‘Commemoration Hearing 21 May 2018’ (n 93) 12. See similarly (though not in the context of commemoration hearings) UK Covid-19 Inquiry, ‘Transcript of Module 5 Preliminary Hearing on 6 February 2024’ <https://covid19.public-inquiry.uk/wp-content/uploads/2024/02/06151900/2024-02-06-Covid-19-Inquiry-Module-5-Preliminary-Hearing-Transcript.pdf> accessed 7 January 2026. ↑

128. See eg Manchester Arena Inquiry, ‘Protocol on Pen Portrait Evidence’ (2020) <manchesterarenainquiry.org.uk> accessed 7 January 2026. noting that pen portraits are important to the inquiry’s work and findings without specifying how. ↑

129. See eg Pete Weatherby, ‘Submissions on Memorials and the “Listening Project” Covid 19 Bereaved Families For Justice and Bereaved Families’ (2022) 3–5 <https://covid19.public-inquiry.uk/> accessed 7 January 2026, suggesting that pen portraits are not required by Article 2 ECHR. ↑

130. ‘Omagh Bombing Inquiry: Protocol for the Commemorative and Personal Statement Hearings’ (27 June 2024) <https://omagh.independent-inquiry.uk/document/omagh-bombing-inquiry-protocol-for-the-commemorative-and-personal-statement-hearings/> accessed 5 March 2026, distinguishing between the two. On non-adversarial mechanisms for gathering this evidence, see Michael Salter, ‘The Transitional Space of Public Inquiries: The Case of the Australian Royal Commission into Institutional Responses to Child Sexual Abuse’ (2020) 53 Australian and New Zealand Journal of Criminology 213 <https://doi.org/10.1177/0004865819886634>. ↑

131. From Coles (n 101); Martin Moore-Bick, Grenfell Tower Inquiry: Phase 1 Report (HC 49, HMSO 2019) 727. ↑

132. Moore-Bick (n 131) 17. ↑

133. ibid 727. ↑

134. ibid 748. ↑

135. Omagh Bombing Inquiry (n 130). ↑

136. Grenfell Tower Inquiry, ‘Commemoration Hearing 29 May 2018’ (n 106) 19. ↑

137. Grenfell Tower Inquiry, ‘Commemoration Hearing 30 May 2018’ (n 107) 48. ↑

138. ibid 94. ↑

139. Sara Ahmed, On Being Included: Racism and Diversity in Institutional Life (Duke University Press 2012) 117. On spectacles of participation, see similarly Yoav Mehozay, ‘From Offender Rehabilitation to the Aesthetic of the Victim’ (2018) 27 Social & Legal Studies 97. ↑

140. On traditional legal proceedings as vulnerabilising, Gemma Hughes and others, ‘Iatrogenic Injustice: An Institutional Ethnography of Fitness to Practise Hearings’ (2025) 382 Social Science & Medicine 118331. ↑

141. On empowering and depoliticising dimensions of therapeutic interventions, Suvi Salmenniemi, ‘Therapeutic Politics: Critique and Contestation in the Post-Political Conjuncture’ (2019) 18 Social Movement Studies 408, 410–11. ↑

142. But see JUSTICE, ‘When Things Go Wrong: The Response of the Justice System’ (Justice 2020) 98–99. ↑

143. Select Committee on the Inquiries Act 2005 (n 2) 9. Statutory Inquiries Committee (n 2) 3. Matthew Flinders, ‘The New Politics of Public Inquiries’ (2025) 96 Political Quarterly 364, 373. ↑

144. Camillia Kong, Jessica Jacobson and Penny Cooper, ‘The Humanising Imperative for Effective Participation: Humean Virtues and the Limits of Procedural Justice’ (2025) 21 International Journal of Law in Context 453. ↑

145. ibid. ↑

146. Disturbingly, this argument included the suggestion, rejected by the inquiry, that pen portraits are inappropriate unless the deceased was ‘incontestably the victim’; Sheku Bayoh Inquiry (n 95) 134. ↑

147. See eg Mark Moir, ‘Submissions for the Coalition for Racial Equality and Rights’ (2025) [21] <https://www.shekubayohinquiry.scot> accessed 7 January 2026. On ‘apparent bias’ see Andrew Higgins and Inbar Levy, ‘What the Fair Minded Observer Really Thinks About Judicial Impartiality’ (2021) 84 Modern Law Review 81. ↑

148. Julia Cumberlege, ‘First Do No Harm: The Report of the Independent Medicines and Medical Devices Safety Review’ [2020] Department of Health and Social Care 180–84. ↑

149. ibid Annex K 112. ↑

150. Consideration of this issue was outside the scope of the inquiry; see ibid 70. ↑

151. ibid 62–63. ↑

152. ibid 21, Annex J 2. ↑

153. ibid Annex K 107. ↑

154. ibid 32–33. Simon Bennett, ‘Deviance Normalised? An Analysis of British Cover-Ups Informed by Actor-Network Theory’ (2026) 83 International Journal of Environmental Studies 18. ↑

155. For other relevant examples of activist archival research see Cara McGoogan, The Poison Line: A True Story of Death, Deception and Infected Blood (Penguin Books 2023) 253–55, 274–78; Catherine Trundle, ‘Searching for Culpability in the Archives: Commonwealth Nuclear Test Veterans’ Claims for Compensation’ (2011) 22 History and Anthropology 497. ↑

156. Relevant records were discovered at Kew in 2014, and at the Landesarchiv, Berlin, in 2017. ↑

157. Jesse Olszynko-Gryn and others, ‘A Historical Argument for Regulatory Failure in the Case of Primodos and Other Hormone Pregnancy Tests’ (2018) 6 Reproductive BioMedicine and Society Online 34; Cumberlege (n 148) Annex K 109–10. These records did not evidence causation in the sense discussed here. ↑

158. Cumberlege (n 148) Annex K 113–14. ↑

159. ibid Annex K 107–11, 725. The pill launched in the UK in 1961. ↑

160. Kevin Hearty, ‘Law, “Presentist” Agendas, and the Making of “Official” Memory after Collective Violence’ (2022) 49 Journal of Law and Society 495. On the assumption that a successful inquiry will deliver up secrets see Johnson, Basham and Thomas (n 124) S13–S14. ↑

161. We could analyse these issues of interpretation as epistemic injustices. ‘Hermeneutical injustice’ describes the injustice done when a person cannot understand or communicate their experience because of gaps in the available interpretive frameworks. Primodos may pose issues closer to ‘contributory injustice’; families have sophisticated frameworks for interpreting their experiences, but these are not taken up by state mechanisms; Kristie Dotson, ‘A Cautionary Tale: On Limiting Epistemic Oppression’ (2012) 33 Frontiers: A Journal of Women Studies 24. On epistemic issues in public inquiries, see Andrew Williams, ‘Public Inquiry into State Violence: The Epistemic Question’ (2024) 10 Critical Military Studies 388. ↑

162. Cumberlege (n 148) 23. See a similar move in the Infected Blood Inquiry, noted at Richard Gorman and others, ‘The Value of Public Inquiries, Ethical Accountability, and Patient Voices: Reflections on the Infected Blood Inquiry’ (2026) 32 Haemophilia 593, 595. ↑

163. Cumberlege (n 148) 72–73, 76. The precautionary principle was not yet established in regulatory practice in 1967; Michael Bichard and others, ‘Expert Report to the Infected Blood Inquiry: Public Health and Administration’ 14 <https://www.research.ed.ac.uk/en/publications/expert-report-to-the-infected-blood-inquiry-public-health-and-adm/> accessed 19 February 2026. ↑

164. Cumberlege (n 148) 12, 27. ↑

165. Cumberlege warned that litigation had failed families (ibid 213), instead proposing a redress agency for victims of ‘iatrogenic harm’; a broader concept than medical negligence encompassing other dimensions of systemic failure, which can include unforeseeable harms (ibid). ↑

166. Causation’s relevance is not confined to medical controversies; Carson Cole Arthur, ‘Racial Violence in “Action”: Police Storytelling and Narrativisation in the Inquiry of Jermaine Baker’ (2025) 65 The British Journal of Criminology 658; Johnson, Basham and Thomas (n 124). ↑

167. Wilson v Bayer and Others [2023] EWHC 1282 at [84]–[97]. Families began litigation before the Consumer Protection Act 1987 came into force. On causation and ‘mass’ toxic torts see Anita Bernstein, ‘Formed by Thalidomide: Mass Torts as a False Cure for Toxic Exposure’ (1997) 97 Columbia Law Review 2153; Ann Scales, Legal Feminism: Activism, Lawyering, and Legal Theory (NYU Press 2006) 61–62. ↑

168. Wilson (n 167) at [54], [65]. ↑

169. ibid at [62]–[64]. On the relevant law see Maria Lee, ‘Forever Chemicals and Tort Law – Causation’ (2025) 16 Journal of European Tort Law 165, 176 . ↑

170. Cumberlege (n 148) 63, 198, Annex K 114. On consultation towards the terms of reference, see Independent Medicines and Medical Devices Safety Review, ‘News’ <https://www.immdsreview.org.uk/news.html> accessed 7 January 2026. ↑

171. Başak Ertür, ‘Law of Denial’ (2019) 30 Law and Critique 1. ↑

172. Written Question for Department of Health and Social Care UIN7763 House of Commons 11 September 2025. ↑

173. Alissa Overend, ‘Haunting and the Ghostly Matters of Undefined Illness’ (2014) 12 Social Theory & Health 63, 70. ↑

174. ibid 65. See eg Anne-Sophie Guernon, ‘Brief Illness, Haunting Effects: Gestational Diabetes and the Spectrality of Care’ (2025) 49 Culture, Medicine, and Psychiatry 1417. The point is not that scientific expertise must give way to populism, but that scientific issues have social dimensions; Brian Wynne, Rationality and Ritual: Participation and Exclusion in Nuclear Decision-Making (Routledge 2013). ↑

175. Lindsay Ofrias, ‘Invisible Harms, Invisible Profits: A Theory of the Incentive to Contaminate’ (2017) 58 Culture, Theory and Critique 435; Linsey McGoey, ‘Pharmaceutical Controversies and the Performative Value of Uncertainty’ (2009) 18 Scientific Culture 151. ↑

176. Scott Frickel and others, ‘Undone Science: Charting Social Movement and Civil Society Challenges to Research Agenda Setting’ (2010) 35 Science, Technology, & Human Values 444. ↑

177. On risk discourse as obscuring uncertainty see Brian Wynne, ‘Risk and Environment as Legitimatory Discourses of Technology: Reflexivity Inside Out?’ (2002) 50 Current Sociology 459, 469–70. ↑

178. Morten Knudsen and Sharon Kishik, ‘Multiplying Ignorance, Deferring Action: Dynamics in the Communication of Knowledge and Non-Knowledge’ (2022) 36 Social Epistemology 344. On manufacturers’ failure to conduct research see Margaret A Berger, ‘Eliminating General Causation: Notes towards a New Theory of Justice and Toxic Torts’ (1997) 97 Columbia Law Review 2117. ↑

179. Introduced under the Medicines Act 1968. ↑

180. This is a recurring issue in healthcare inquiries, Oliver Quick, Regulating Patient Safety: The End of Professional Dominance? (CUP 2017). ↑

181. Hannah Jones, Violent Ignorance: Confronting Racism and Migration Control (Bloomsbury 2021) 167–68. ↑

182. Cumberlege (n 148) 2. ↑

183. ibid 8–9. ↑

184. For a similar argument applied to the Stephen Lawrence Inquiry’s account of institutional racism see Adam Elliott-Cooper, ‘Abolishing Institutional Racism’ (2023) 65 Race & Class 100. ↑

185. Cumberlege addressed individual bias and conflicts of interest; Cumberlege (n 148) 32–36. On narrow understandings of ‘objectivity’ see Sheila Jasanoff, Science and Public Reason (Routledge 2012) 74. ↑

186. Tanya Serisier, ‘A Precondition for Justice: Political Listening, Feminism and Sexual Violence’ [2024] Social & Legal Studies 09646639241278567, 8. ↑

187. Misrecognition of structural injustice, particularly structural racism, is a recurring problem across inquiries; Anna Morris, ‘Written Opening Statement on Behalf of INQUEST’ (Lampard Inquiry 2024) 5–9 <https://lampardinquiry.org.uk/opening-statements/> accessed 7 January 2026; Simon Peplow, ‘“A Deadly Weapon Aimed at Our Hearts”: The Scope and Composition of Lord Scarman’s 1981 Public Inquiry’ (2024) 10 Critical Military Studies 321; Steve Tombs, ‘Justice After Grenfell? Crime, Harm and Structural Inequality’ [2025] British Journal of Criminology azaf096. ↑

188. Cumberlege (n 148) 23, Annex K 9. ↑

189. On feminist critique of informed consent see Natalie Stoljar, ‘Informed Consent and Relational Conceptions of Autonomy’ (2011) 36 Journal of Medicine and Philosophy: A Forum for Bioethics and Philosophy of Medicine 375. See also Margrit Shildrick, ‘The Disabled Body, Genealogy and Undecidability’ (2005) 19 Cultural Studies 755, 765–66. ↑

190. Jasbir K Puar, ‘Prognosis Time: Towards a Geopolitics of Affect, Debility and Capacity’ (2009) 19 Women & Performance 161, 168. ↑

191. Dayna Nadine Scott, ‘Body Polluted: Questions of Scale, Gender and Remedy’ (2010) Osgoode CLPE Research Paper 21/2010 <https://ssrn.com/abstract=1626352>. ↑

192. Robyn Lee and Roxanne Mykitiuk, ‘Surviving Difference: Endocrine-Disrupting Chemicals, Intergenerational Justice and the Future of Human Reproduction’ (2018) 19 Feminist Theory 205, 218. ↑

193. Sagit Mor and others, ‘The Meaning of Injury: A Disability Perspective’ in Anne Bloom, David M Engel and Michael McCann (eds), Injury and Injustice: The Cultural Politics of Harm and Redress (CUP 2018) 35, 43–44; Janice Richardson, ‘Feminist Perspectives on the Law of Tort and the Technology of Risk’ (2004) 33 Economics & Sociology 98, 114–15. ↑

194. Cumberlege (n 148) 95. This issue is not unique to Cumberlege. On moral arguments for exceptional redress provision see Robert Francis, ‘Compensation and Redress for the Victims of Infected Blood: Recommendations for a Framework’ (2022) 42–44, 58–59 <https://www.gov.uk/government/publications/compensation-and-redress-for-the-victims-of-infected-blood-recommendations-for-a-framework> accessed 18 February 2026. ↑

195. Rob Nixon, ‘Neoliberalism, Slow Violence, and the Environmental Picaresque’ (2009) 55 Modern Fiction Studies 443, 447. ↑

196. Cumberlege (n 148) Annex K 727. ↑

197. ibid 3, 219. On the inquiry’s participant engagement see ibid 221, 223–24, 227–29, Annex K 12. ↑

198. Cumberlege (n 148) 3. ↑

199. Veena Das, ‘Sufferings, Theodicies, Disciplinary Practices, Appropriations’ (1997) 49 International Social Science Journal 563, 570. ↑

200. Phil Brown and others, ‘Embodied Health Movements: New Approaches to Social Movements in Health’ (2004) 26 Sociology of Health and Illness 50. ↑

201. See similarly Williams and Kay (n 55) 145–46. The urge to find answers through research may be part of working through familial inheritance; Jason Evans described his research on infected blood as an attempt to connect with his deceased father: Impact Accelerator, ‘“No Matter Which Party Was in Power, We Saw Resistance to an Inquiry” – Jason Evans’ (27 June 2024) <https://breakthroughimpact.org/no-matter-which-party-was-in-power-we-saw-resistance-to-an-inquiry-jason-evans/> accessed 6 March 2026. ↑

202. Cumberlege (n 148) Annex K 720–21. ↑

203. ibid Annex K 113. ↑

204. ibid Annex K 13, 109. ↑

205. ibid 21. ↑

206. Brian Wynne, ‘May the Sheep Safely Graze? A Reflexive View of the Expert-Lay Knowledge Divide’ in Scott Lash, Bronislaw Szerszynski and Brian Wynne (eds), Risk, Environment and Modernity: Towards a New Ecology (Sage 2004) 50–55. ↑

207. Bill Kirkup, Reading the Signals: Maternity and Neonatal Services in East Kent–the Report of the Independent Investigation (HC 681, HMSO 2022) v. ↑

208. See eg The Thirlwall Inquiry, ‘Review by the Thirlwall Inquiry Legal Team of the Implementation of Recommendations Made by Previous Inquiries into Healthcare Issues’ (2024) <https://thirlwall.public-inquiry.uk/document/review-by-the-thirlwall-inquiry-legal-team-of-the-implementation-of-recommendations-made-by-previous-inquiries-into-healthcare-issues/> accessed 6 March 2026; Morris (n 187) 21–25. ↑

209. Kirkup (n 207) v. ↑

210. Sara Skott and Sara Nyhlén, ‘Speaking With Spectres: Towards a Feminist Hauntological Framework’ (2025) 24 International Journal of Qualitative Methods 16094069251368864, 3. ↑

211. See eg Catherine Trundle, ‘Tinkering Care, State Responsibility, and Abandonment: Nuclear Test Veterans and the Mismatched Temporalities of Justice in Claims for Health Care’ (2020) 45 Anthropology and Humanism 202, discussing nuclear test veterans’ experiences of compromised state care. ↑

212. Ceylan Begüm Yıldız, State-sponsored Violence and Legal Accountability: The Wait for Justice (Routledge 2025). ↑

213. Elizabeth A Povinelli, ‘Indigenous Politics in Late Liberalism’ in Jon Altman (ed), Culture Crisis: Anthropology and Politics in Aboriginal Australia (UNSW Press 2010) 30. ↑

214. Luke Moffett and Nikhil Narayan, ‘Provisional Justice in Protracted Conflicts: The Place of Temporality in Bridging the International Humanitarian Law and Transitional Justice Divide’ (2024) 106 International Review of the Red Cross 1222. ↑

215. Vikki Bell, ‘Between Documentality and Imagination: Five Theses on Curating the Violent Past’ (2018) 11 Memory Studies 137. ↑

216. For a proposed policy solution to ensure implementation of inquiry recommendations see INQUEST, ‘No More Deaths: Learning, Action, and Accountability: The Case for a National Oversight Mechanism’ (2023) <https://inquest.org.uk/site/assets/files/7151/digitalnationaloversightmechanism-inquestbriefingjun23.pdf> accessed 7 January 2026. ↑

217. Sara Ryan’s son Conor Sparrowhawk died as a result of neglect in a learning disability short term assessment and treatment unit in Oxford, Ryan (n 15). ↑

218. Sara Ryan, Critical Health and Learning Disabilities: An Exploration of Erasure and Social Murder (Taylor & Francis 2025) 2. On Grenfell and social murder see Stuart Hodkinson, ‘Grenfell Foretold: A Very Neoliberal Tragedy’ in Catherine Needham, Elke Heins and James Rees (eds), Social Policy Review 30 (Policy Press 2018). ↑

219. On non-implementation see Prudence R Brown and Alastair Stark, ‘Policy Inaction Meets Policy Learning: Four Moments of Non-Implementation’ (2022) 55 Policy Sciences 47. ↑

220. Ian Loader, ‘A Question of Sacrifice: The Deep Structure of Deaths in Police Custody’ (2020) 29 Social & Legal Studies 401. ↑

221. Discussing reforms post-Grenfell, Helen Carr, Dave Cowan and Ed Kirton-Darling, ‘Marginalisation, Grenfell Tower and the Voice of the Social-Housing Resident: A Critical Juncture in Housing Law and Policy?’ (2022) 18 International Journal of Law in Context 10. ↑

222. Kirkup (n 207) v. The Ely Hospital Inquiry was an investigation into the treatment of people with intellectual disabilities in long-stay psychiatric hospitals within the NHS. ↑

223. This expectation was established by the Francis Inquiry; Erica Borgstrom and Tony Walter, ‘Choice and Compassion at the End of Life: A Critical Analysis of Recent English Policy Discourse’ (2015) 136–37 Social Science & Medicine 99, 101. ↑

224. The focus here seems to be on differences in approach to ‘normal birth’ within teams; also a recurring theme in related inquiries, see further Mary J Renfrew and others, ‘Responding to the Ockenden Review: Safe Care for All Needs Evidence-Based System Change – and Strengthened Midwifery’ (2022) 112 Midwifery 103391; Dawn Goodwin, ‘Cultures of Caring: Healthcare “Scandals”, Inquiries, and the Remaking of Accountabilities’ (2018) 48 Social Studies of Science 101. On the role of professional culture within deviant institutional culture see Kerreen M Reiger, ‘“Knights” or “Knaves”? Public Policy, Professional Power, and Reforming Maternity Services’ (2010) 32 Health Care for Women International 2. ↑

225. On how Hillsborough Law may impact the NHS see Elkan Abrahamson and Peter Walsh, ‘Will a New “Hillsborough Law” Fill the Gaps in the Existing “Duty of Candour” in Healthcare?’ (2024) 29 Journal of Patient Safety and Risk Management 225. ↑

226. Kirkup (n 207) 158–64. ↑

227. Dawn Goodwin, ‘NHS Inquiries and the Problem of Culture’ (2019) 90 Political Quarterly 202; Russell Mannion and others, ‘Healthcare Scandals and the Failings of Doctors: Do Official Inquiries Hold the Profession to Account?’ (2019) 33 Journal of Health Organization and Management 221, 234. ↑

228. In practice, inquiry investigations into culture involve considerations of both individual and collective accountability; Justin Waring and others, ‘Healthcare Quality and Safety: A Review of Policy, Practice and Research’ (2016) 38 Sociology of Health & Illness 198. On misunderstandings of culture’s role in institutional failure see Danielle S Rudes and Shannon Magnuson, ‘Scapegoating Culture: Misunderstanding Organizational Culture as the Problem in Carceral Institutions and Beyond’ (2019) 13 Sociology Compass e12657. ↑

229. See Dawn Goodwin, ‘Cultures of Caring: Healthcare “Scandals”, Inquiries, and the Remaking of Accountabilities’ (2018) 48 Social Studies of Science 101, 107–08, tracing this kind of analysis in the Morecambe Bay report. ↑

230. Tom Pettinger, ‘Embodying the Inquiry: Disaster, Affectivity, and the Localized Politics of Security’ (2023) 41 Environment and Planning C: Politics and Space 1282; Mary Bosworth and Laura Haas, ‘The Culture of (Border) Control in Britain: Staff, Precarity and Distress’ [2025] Criminology & Criminal Justice 17488958251348057. ↑

231. See similarly Elliott-Cooper (n 184) 107. Greer and McLaughlin argue that the neoliberal state is no longer closely identified with errant public sector agencies, and can readily distance itself from them by establishing and responding to public inquiries, Chris Greer and Eugene McLaughlin, ‘Theorizing Institutional Scandal and the Regulatory State’ (2017) 21 Theoretical Criminology 112; Eilenberg warns that this role is compatible with further damaging privatisation, if inquiries blame rogue individuals or institutions, rather than critiquing broader patterns of neoliberal governance, Jon Eilenberg, ‘Institutional Deviance in TV News: BBC, ITV and the Mid Staffordshire Hospital Scandal’ (2018) 14 Crime, Media, Culture 485. ↑

232. Williams and others (n 103) 252. ↑

233. See similarly Robert Francis, Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry: Executive Summary, vol 947 (The Stationery Office 2013) [115], which refrained from critiquing the neoliberal policies of the New Labour government that had contributed to distressing conditions at Mid Staffordshire NHS Foundation Trust, Christopher Newdick, ‘From Hippocrates to Commodities: Three Models of NHS Governance: NHS Governance, Regulation, Mid Staffordshire Inquiry, Health Care as a Commodity’ (2014) 22 Medical Law Review 162. ↑

234. See similarly Barclay and Moore, discussing the Ockenden report on Telford and Shrewsbury, suggesting that there is a tendency to ‘black box’ how recommendations will be achieved; Katie Barclay and Vivienne Moore, ‘Institutions and Their Failure to Care: Bureaucracy and the Practice of Emotion’ (2024) 183 Thesis Eleven 69, 73. ↑

235. ibid 74, 78–79. ↑

236. Justin Waring and Simon Bishop, ‘Health States of Exception: Unsafe Non-Care and the (Inadvertent) Production of “Bare Life” in Complex Care Transitions’ (2020) 42 Sociology of Health & Illness 171. ↑

237. Vicky Singleton and Steve Mee, ‘Critical Compassion: Affect, Discretion and Policy–Care Relations’ (2017) 65 Sociological Review <https://doi.org/10.1177/0081176917710587>. ↑

238. Loader (n 220) 407–08. ↑

239. See eg David Scott, ‘Haunted by the Presence of Death: Prisons, Abolitionism and the Right to Life’ Human Rights and Incarceration: Critical Explorations (Springer 2018). ↑

240. David G Scott, ‘Eating Your Insides Out: Cultural, Physical and Institutionally-Structured Violence in the Prison Place’ [2015] Prison Service Journal 58. ↑

241. Sarah Turnbull, ‘Vulnerability, Immigration Detention and (Carceral) Reform’ (2025) 65 British Journal of Criminology 977. ↑

242. Kirkup (n 207) 179. ↑

243. This is a quote from a woman recalling a midwife’s comments during her labour. On how the ‘primitive’ woman haunts Western obstetric medicine see Rachelle Chadwick, Bodies That Birth: Vitalizing Birth Politics (Routledge 2018) 30. ↑

244. Rodante Waal, Birth Justice: From Obstetric Violence to Abolitionist Care (Taylor & Francis 2025) 374. ↑

245. Report of the Hillsborough Independent Panel (HC 581, HMSO 2012) 1. The quote is from the early Christian philosopher Lactantius. On potential resonances between Lanctantius’ thought and accounts of justice as inheritance see Ilsup Ahn, ‘Economy of “Invisible Debt” and Ethics of “Radical Hospitality”: Toward a Paradigm Change of Hospitality from “Gift” to “Forgiveness”’ (2010) 38 Journal of Religious Ethics 243. ↑

246. Tuitt (n 3). ↑