Executive summary

¶This Report concerns the core political and administrative decision-making across the UK in response to the Covid-19 pandemic, drawing on the work of four of the Inquiry's modules: Module 2 (UK), Module 2A (Scotland), Module 2B (Wales) and Module 2C (Northern Ireland). This has provided the Inquiry with the opportunity to compare and contrast the different choices made by the four governments in responding to the same emergency and to identify the most important lessons for responding to future UK-wide emergencies.

¶The Inquiry finds that the response of the four governments repeatedly amounted to a case of 'too little, too late'. The failure to appreciate the scale of the threat, or the urgency of response it demanded, meant that – by the time the possibility of a mandatory lockdown was first considered – it was already too late and a lockdown had become unavoidable. That these same mistakes were repeated later in 2020 is inexcusable. While the nationwide lockdowns of 2020 and 2021 undoubtedly saved lives, they also left lasting scars on society and the economy, brought ordinary childhood to a halt, delayed the diagnosis and treatment of other health issues and exacerbated societal inequalities. The Covid-19 lockdowns only became inevitable because of the acts and omissions of the four governments. They must now learn the lessons of the Covid-19 pandemic if they are to avoid lockdowns in future pandemics.

Key events from January 2020 to May 2022

The emergence of Covid-19 (Chapter 2)

¶The initial response to the pandemic was marked by a lack of information and a lack of urgency. When the first cases of Covid-19 had been confirmed outside China, the significant degree of scientific uncertainty – in particular, whether there was sustained person-to-person transmission and whether the virus could be transmitted by individuals without symptoms (asymptomatic transmission) – meant that the level of risk that the virus posed was not fully appreciated.

¶Once the scientific community and the scientific advisers for each nation became aware that the virus had spread from China, and that it was causing substantially more cases of moderate or severe respiratory illness in China than were being officially reported, the tempo of the response should have been increased and threat levels raised.

¶By the end of January 2020, when thousands of cases had been identified outside China and the first few cases of Covid-19 had been confirmed in the UK, it should have been clear that the virus posed a serious and immediate threat. However, the limited testing capacity in the UK and a lack of adequate surveillance mechanisms, combined with a failure to assume that there was asymptomatic transmission, meant that decision-makers did not appreciate the extent to which the virus was spreading undetected.

¶The political system across the four nations lacked urgency and treated the emerging threat as predominantly a health issue. The obviously escalating nature of the crisis made it surprising that COBR, the UK government's crisis coordination committee, was not chaired by the Prime Minister, Boris Johnson MP, until 2 March 2020 and that neither COBR nor the UK Cabinet met during the half-term holidays in mid-February 2020. Mr Johnson should have appreciated sooner that this was an emergency that required prime ministerial leadership to inject urgency into the response. Mr Johnson's own failure to appreciate the urgency of the situation was due to his optimism that it would amount to nothing, his scepticism arising from earlier UK experiences of infectious diseases, and, inevitably, his attention being on other government priorities. This was compounded by the misleading assurances he received from the Cabinet Office and the Department of Health and Social Care that pandemic planning was robust, as well as the widely held view that the UK was well prepared for a pandemic. As the pandemic unfolded, the Secretary of State for Health and Social Care, Matt Hancock MP, gained a reputation among senior officials and advisers at 10 Downing Street for overpromising and underdelivering.

¶The devolved administrations similarly failed to engage with the threat posed to their nations and were overly reliant on the UK government to lead the response. Covid-19 received no attention in Welsh Cabinet meetings before 25 February 2020. After the first case was identified in Wales on 28 February, the First Minister of Wales, Mark Drakeford MS, chose to attend St David's Day celebrations in Brussels rather than the Welsh Cabinet meeting on 4 March 2020. In Northern Ireland and in Scotland, Covid-19 was only discussed under 'any other business' in meetings as late as 24 and 25 February respectively. It should have been equally apparent to the First Ministers and deputy First Ministers of the devolved administrations that, by this point, Covid-19 was the most pressing issue facing their governments.

¶Ministers and officials in the UK government had been given clear advice that, in the reasonable worst-case scenario, up to 80% of the population would be infected – with a very significant loss of life – but did not appreciate the increasing likelihood of this scenario materialising. At the same time, it was clear that the test and trace system was inadequate for a pandemic. The lack of urgency on the part of all four governments, and the failure to take more immediate emergency steps, are inexcusable.

¶The spread of the virus globally and, in particular, the escalating crisis in Italy were clear warning signs, which should have prompted urgent planning across the four nations. Instead, the governments did not take the pandemic seriously enough until it was too late. February 2020 was a lost month.

The first UK-wide lockdown (Chapters 3 and 4)

¶The Coronavirus: Action Plan, published on 3 March 2020, outlined the initial plan to respond to Covid-19, first by 'containing' its spread through testing, contact tracing and isolation of infected individuals, and then by 'delaying' its spread through introducing restrictions such as social distancing. Based on the strategy for pandemic influenza, the plan made a similar assumption that it would only be possible to slow, rather than prevent, the spread of the virus.

¶This approach was expected to lead to a degree of population immunity (otherwise known as 'herd immunity'), where the spread of the virus through the population reduced its vulnerability to further infections. Despite a lack of clarity in media appearances, the UK government's strategy was not to encourage the spread of the virus with the aim of achieving population immunity sooner – rather, population immunity was seen as the eventual outcome of an inevitable and widespread wave of infections.

¶At this stage, the Scientific Advisory Group for Emergencies (SAGE) was advising the UK government that restrictions should not be introduced until the spread of the virus was nearer its peak. This was driven partly by concerns about the negative social and economic consequences of introducing restrictions and wanting to minimise the amount of time such restrictions were in place, but also by concerns expressed by Professor (later Sir) Christopher Whitty (Chief Medical Officer for England) and Professor Sir Patrick Vallance (later Lord Vallance of Balham), Government Chief Scientific Adviser, that the public would not maintain compliance with restrictions over a long period. This concept of 'behavioural fatigue' had no grounding in behavioural science and proved damaging, given the imperative to act more decisively and sooner.

¶It is clear that the Coronavirus: Action Plan was already out of date by the time it was published. Containment had failed, as belatedly recognised by the UK government. Although there were only 39 official cases of Covid-19 in the UK by this point, the known lack of capacity for testing meant that this was clearly a significant underestimate. As the country moved to the 'delay' stage, from 13 March 2020, anyone with coronavirus symptoms was advised to self-isolate at home for at least seven days. However, this first restriction was too little, too late.

¶The lack of testing capacity had, by this point, resulted in the stopping of community testing. This meant that the UK government and the devolved administrations had no real understanding of the spread of the virus in the community. Some scientists – and some civil servants and advisers within the UK government – were increasingly alarmed by the lack of urgency and the failure to act more robustly. It became clear that any opportunity to get on top of Covid-19 had been lost.

¶Friday 13 March 2020 was a watershed moment in the UK's response. SAGE had concluded that the number of cases was several times higher than its previous estimates and that there were potentially thousands of cases occurring each day. The pandemic was moving faster than previously anticipated, and modelling indicated that the capacity of the NHS would be overwhelmed by the scale of infection, even if self-isolation and social distancing measures were introduced. If NHS capacity were to become overwhelmed, then far higher numbers of people would die from being unable to access medical treatment, both for Covid-19 and for other medical conditions. The plan to wait to implement restrictions until nearer the peak of the virus was no longer sustainable.

¶Over the next few days, decision-makers concluded that stringent measures were needed to reverse the growth of the virus. The focus remained on a package of advisory measures including self-isolation, household quarantine and social distancing. The advisory measures came into effect from 16 March 2020 and became increasingly stringent in the subsequent days, with the closure of schools and hospitality businesses from 20 March.

¶By 23 March 2020, SAGE estimated that the number of cases was doubling every three to four days and intensive care units in London were on track to reach capacity within ten days. Almost 300 people had died, with more than 100 of those deaths occurring in the previous two days. The situation was rapidly escalating and it was not clear that the advisory measures in place would be sufficient to prevent the NHS from being overwhelmed. A mandatory lockdown had become unavoidable.

¶The measures announced on Monday 16 March 2020, and strengthened through the week with the closure of schools and hospitality, should have been implemented much sooner. Had more stringent restrictions, short of a 'stay at home' lockdown, been introduced earlier than 16 March – when the number of Covid-19 cases was lower – the mandatory lockdown that was imposed might have been shorter or conceivably might not have been necessary at all. At the very least, there would have been time to establish what effect the restrictions had on levels of incidence and whether there was a sustained reduction in social contact. However, with measures not introduced sooner, a mandatory lockdown was the only viable option left.

¶The Inquiry recognises that the lockdown decision was as difficult a decision as any UK government or devolved administration has ever had to make. However, the Inquiry accepts the consensus of the evidence before it that the mandatory lockdown should have been imposed one week earlier. Had a mandatory lockdown been imposed on or immediately after 16 March 2020, modelling has established that the number of deaths in England in the first wave up until 1 July 2020 would have been reduced by 48% – equating to approximately 23,000 fewer deaths.

¶However, the Inquiry rejects the criticism that the four governments were wrong, in principle, to impose a lockdown. In any event, the UK government and the devolved administrations had received clear and compelling advice by this time that the exponential growth in transmission would, in the absence of a mandatory lockdown, likely lead to loss of life on a scale that was unconscionable and unacceptable. No government, acting in accordance with its overarching duty to preserve life, could ignore such advice or tolerate the number of deaths envisaged. The governments acted rationally in taking the ultimate step, a mandatory lockdown, in the genuine and reasonable belief that it was required. Nevertheless, it was only through their own acts and omissions that the four governments had made such a lockdown inevitable.

Exiting the first lockdown (Chapter 5)

¶Upon entering the first lockdown, neither the UK government nor the devolved administrations had a strategy for when or how they would exit the lockdown. These considerations should have been at the forefront of decision-makers' minds from the moment imposing a lockdown was contemplated. Up until this stage, the four governments had acted in unison, with the same measures applying across the whole of the UK, but they each devised their own approaches to ending the lockdown.

¶The easing of the majority of restrictions in England took place on 4 July 2020, despite Mr Johnson being informed by scientific advisers that this was an inherently high-risk approach as it would create an environment where infections could grow more quickly and overwhelm the ability of test and trace systems to control further outbreaks. A more cautious approach should have been taken by the UK government. Mr Johnson acknowledged that a second lockdown would be a disaster, but the approach to releasing restrictions increased the risk of this being necessary.

¶In contrast, the governments of Wales, Scotland and Northern Ireland adopted a more gradual approach to the relaxation of restrictions throughout the summer of 2020. This more cautious approach was taken in the context of different epidemiological circumstances, but created a greater prospect of further lockdowns not being necessary or, if they were, of them not being necessary for so long. However, as there was nothing to prevent people resident in England from travelling across the internal borders of the UK, the approach adopted by the UK government risked undermining the effectiveness of the more cautious responses of the devolved administrations.

¶Nonetheless, in each of the four governments, insufficient attention was given to the prospect of a second wave of the virus, with only limited contingency planning in place for reintroducing restrictions if a second wave emerged.

The second wave (Chapters 6 and 7)

¶In the autumn of 2020, infection rates varied significantly across the UK, leading to more significant divergence in approach as all four governments tried to manage the increasing case rates at a local level. The UK government, Welsh Government and Northern Ireland Executive had all failed to learn from the experiences of the first lockdown. Local restrictions were introduced too late, were not in place for long enough or were too weak to control the spread of the virus.

¶Ministers are required to weigh up all competing factors in their decision-making and do not always need to follow scientific advice. However, the reasons for rejecting scientific advice – and the implications of doing so – must be clearly understood.

¶Throughout September and October 2020, Mr Johnson repeatedly changed his mind on whether to introduce tougher restrictions and failed to make timely decisions. For those restrictions that were introduced, such as the 'rule of six', SAGE had warned that they were unlikely to be effective, but Mr Johnson continued to reject SAGE's advice to implement a 'circuit breaker' lockdown. The weakness of the restrictions used and Mr Johnson's oscillation enabled the virus to continue spreading at pace, and ultimately resulted in a four‑week lockdown from 5 November 2020.

¶Mr Johnson should have ordered the imposition of a circuit breaker lockdown in late September or early October 2020. Had a circuit breaker been utilised at that time, the second lockdown in England could have been reduced in length and severity – and might conceivably have been avoided altogether. In the event – with the opportunity to regain control having been lost – the second lockdown should have been imposed more quickly. Unlike the circuit breaker or 'firebreak' restrictions in Wales and the circuit breaker restrictions in Northern Ireland, the second England-wide lockdown was not timed to coincide with the school half-term holidays. Schools did, however, remain open.

¶The Welsh Government's approach of targeted local restrictions was ultimately unsuccessful and led to the imposition of the firebreak. Despite receiving clear advice on 5 October 2020 that the reproduction number (the average number of people that one person with a disease infects) was above 1 and that further restrictions were needed to avoid hospital capacity being exceeded, modelling of the proposed firebreak was not sought until 11 October and the firebreak was not implemented until 23 October. From August to December 2020, Wales had the highest age-standardised mortality rate of the four nations. It is likely that this was the result of a combination of failed local restrictions, imposing the firebreak too late and the decision to relax measures more quickly than scientists advised.

¶Notwithstanding the imposition of circuit breaker restrictions, the decision-making in Northern Ireland was chaotic. Despite having been advised that a six-week intervention was required, the Northern Ireland Executive Committee opted for a four-week circuit breaker, which commenced on 16 October 2020. This ultimately proved inadequate. In the weeks that followed, Executive Committee meetings were deeply divided along political lines and beset by leaks, leading to an incoherent approach in which the circuit breaker restrictions were extended for one week, then lapsed for one week, before being reintroduced for two further weeks – with the one-week lapse in restrictions correlating with a 25% increase in cases.

¶The number of cases in Scotland in the autumn of 2020 did not reach the peaks experienced in the rest of the UK. By swiftly using stringent, locally targeted measures to deal with outbreaks, case numbers grew much more gradually and the need for a nationwide lockdown in the autumn was avoided.

¶Although it was not formally identified until December 2020, the more transmissible Alpha variant emerged in Kent during the autumn and drove a rapid rise in cases. The emergence of a more transmissible variant was entirely foreseeable, but all four governments failed to take decisive action in response. Rather than recognising the threat early on and introducing measures to control the virus, the governments continued to press on with plans for relaxing measures over Christmas while cases grew rapidly, only to change course on 19 December when levels of infection became critical. The mistakes of February and March 2020 were repeated – the failure to take sufficiently decisive and robust action in response had created a situation in which a return to lockdown restrictions had once again become unavoidable.

The vaccination rollout and Delta and Omicron variants (Chapters 7 and 8)

¶In December 2020, the UK was the first country in the world to approve a vaccine and commence a vaccination programme for Covid-19. On 2 December, temporary authorisation was granted by the Medicines and Healthcare products Regulatory Agency for the Pfizer/ BioNTech vaccine and the vaccine rollout commenced on 8 December. Authorisation for the Oxford/AstraZeneca vaccine swiftly followed on 30 December and the Moderna vaccine on 8 January 2021. This was a remarkable achievement and a decisive turning point in the pandemic.

¶This development enabled the four governments to take a different approach in their plans to exit their respective lockdowns, balancing the scale of infection against the additional protection from serious illness now being offered by vaccines. Plans were led by data rather than fixed dates and when the Delta variant emerged in March 2021, all four governments sensibly heeded the scientific advice to delay the planned relaxation of restrictions to allow time for the vaccine rollout to progress further. In this respect, the four governments had learned from the experience of earlier lockdowns.

¶Although the Omicron variant that emerged in the winter of 2021 was a less severe variant, it was much more transmissible and an estimated 5 million people in the UK were infected at the peak of the Omicron wave. Despite the enhanced protection offered by the vaccine rollout, the sheer volume of cases still led to more than 30,000 people dying with Covid-19 in the UK between November 2021 and June 2022. By the time the Omicron variant was identified, all adults had been offered two doses of the vaccine and the programme of booster doses was sensibly accelerated to offer further protection against serious illness and hospitalisation.

¶The approach of all four governments in the second half of 2021 carried with it an element of risk. The potential for a variant that escaped the immunity conferred by prior infection or by vaccination had been repeatedly identified as the biggest strategic risk. The sheer number of infections demonstrates that, if the vaccines had been less effective or the Omicron variant as severe as previous variants in terms of morbidity and mortality, the consequences would have been disastrous.