Recommendation 48

Although it is reassuring to know that the Government values lesson learning and that there are a number of systems in place for regular investigations into deaths in health and care settings, this is not a sufficient response to their duties under Article 2. The systems referred to by the Government are not designed to review a complex and wide-ranging response to a pandemic. The response to the Coronavirus outbreak has necessarily not been equivalent to a standard response to an individual death in NHS care. The response has affected the entire population in profound (and profoundly different) ways. Therefore, the reviews and processes in place for individual deaths are obviously ill-adapted to the sort of review required in relation to a complex and wide-ranging response to a pandemic. (Paragraph 211) 78 The Government’s response to COVID-19: human rights implications