- 7 May 2026
Read time: 5-6 minutes
Summary: Eleanor Gray is the Director of Inquiry for NHS England. In this comment blog she explores how public inquiries examine whether organisations can clearly evidence their decision-making, risk management, and culture under scrutiny, and why consistent, transparent processes are critical to demonstrating accountability.
A common misconception is that public inquiries are exceptional events. In reality, they are becoming increasingly common and cover a wide range of areas of public interest and policy. Inquiries assess whether organisations have been doing what they should already be doing to deliver safe and effective services to the public: identifying and managing risk, seeking assurance, applying challenge, and making informed decisions. For those working across the NHS and wider public sector, inquiries are better understood as moments of intensified scrutiny applied to existing accountability, designed to learn lessons and improve outcomes for citizens and patients.
Within NHS organisations, inquiries can bring governance and safety into sharp focus. They examine how decisions were made, how risks were understood, and whether assurance processes and decisions were robust, transparent, and effective. Most of what is scrutinised already exists within routine board activity. The difference lies in the depth and intensity of the public inquiry process, which unlike litigation can examine not just the lawfulness of actions but also the culture in which they were taken and the operational impact.
When an inquiry begins, organisations are required to demonstrate clearly what decisions were made, when they were made, who was involved, and what information was considered at the time. Where this evidence is incomplete or unclear, gaps can quickly become visible. These gaps are typically not about the absence of activity, but about the absence of a clear, consistent record. Without that, it becomes difficult to demonstrate how decisions were reached or why certain levels of confidence were justified. This is why it is important that organisations are well prepared for the scrutiny an inquiry might bring.
Understanding the nature of inquiry scrutiny
The distinction between statutory and non-statutory inquiries is important because it shapes how scrutiny is applied, but both ultimately draw on the same underlying evidence. Statutory inquiries, established under the Inquiries Act 2005, have formal legal powers to compel evidence and witness testimony under oath. This gives them a highly structured and forensic character, often extending over several years and involving extensive documentation. Their focus is typically broad, addressing systemic or national issues rather than isolated events, and their findings often lead to significant policy and regulatory reform.
Non-statutory inquiries, or independent reviews, operate without legal compulsion. They rely on cooperation and can therefore be established more quickly and adapted as circumstances evolve. This makes them particularly effective in areas where risks are ongoing, such as patient safety or clinical governance. While they may be less formal, their impact can be just as significant, particularly in shaping practice and culture in real time. From a governance perspective, the key point is that both forms of inquiry ultimately examine the same foundations: how organisations make decisions, manage risk, and demonstrate accountability.
Across both types, consistent patterns emerge. Inquiries repeatedly highlight failures to listen, weaknesses in board oversight, inadequate escalation of concerns, and cultural barriers to openness. The persistence of these themes is striking. It suggests that the challenge is not understanding what good governance looks like but ensuring that it is applied consistently in practice.
Evidence and decision-making
The role of the Board Assurance Framework (a tool that enables boards to assess and monitor strategic risks) is central in this context. When it is actively used, it provides a structured, real-time view of risks, controls, and sources of assurance, linking strategy to operational delivery. However, when it is treated as a static or compliance exercise, it loses its effectiveness. Under inquiry scrutiny, this distinction becomes critical. Organisations must be able to evidence not only that risks were identified, but how they were understood, prioritised, and managed over time.
Importantly, inquiries focus on the facts, the systems and the process behind decisions. They examine whether there was meaningful challenge, whether alternative options were considered, whether risks were explicitly discussed, and whether the rationale for decisions was clearly considered. This reflects a fundamental principle of governance: transparency and accountability depend on process as much as outcome.
Documentation, therefore, becomes essential. Inquiry teams review large volumes of material, including board papers, minutes, risk registers, and assurance reports, to reconstruct organisational understanding at a specific point in time. The purpose is not simply to catalogue decisions, but to understand the context in which they were made.
Good governance does not require excessive documentation, but it does require a clear narrative. Board papers should set out issues in a structured and analytical way, minutes should capture the substance of the discussion, including any challenges, and there should be an explicit link between risk, strategy, and decision-making. Without this, even well-managed organisations may struggle to demonstrate their effectiveness under scrutiny.
Culture and behaviour
While processes and documentation are critical, organisational culture is often the most revealing element of any inquiry. Culture determines how information flows, how concerns are raised, and how challenge is received. It shapes whether governance processes are meaningful or merely procedural.
In organisations where openness is embedded, governance tends to be more resilient. Risks are escalated early, challenge is visible within discussions, and assurance is actively tested rather than passively accepted. There is a clear willingness to engage with uncertainty and to surface difficult issues. This does not prevent problems from arising, but it ensures they are addressed more effectively.
In contrast, where culture is more closed, hierarchical or defensive, governance weaknesses become more apparent. Issues may be trivialised, minimised or escalated late, challenge may not be clearly articulated or recorded, and there may be an over-reliance on limited sources of assurance. Inquiries consistently show that the key issue is not whether problems exist, but how openly and effectively they are recognised and managed.
Certain governance behaviours frequently emerge as contributing to risk. These include accepting assurance without sufficient scrutiny, failing to follow through on questions, relying on a narrow range of perspectives, and lacking clear ownership of risks or actions.
Public inquiries are, at their core, the most concentrated test of governance maturity in the NHS. Scrutiny should be expected, and organisations must confidently demonstrate how they are meeting their responsibilities to patients, the public, and staff. What distinguishes strong governance is discipline, consistency, curiosity, challenge, and reflection. It is the ability to connect disparate pieces of information into a coherent picture of risk and performance. Above all, it is the willingness to make uncertainty visible and to address it directly, ultimately improving outcomes for all.
Join the upcoming CGIUKI webinar: Public Inquiries: How to Prepare Your Organisation to learn more about how to prepare your organisation, support your teams, and navigate the complexities of inquiry response with confidence
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