The situation at the end of February 2020

¶Figure 2: Reported cases in selected European countries in February 2020

¶Source: Our World in Data, World Health Organization (https://ourworldindata.org/coronavirus)

¶2.163. By the end of February 2020, the number of confirmed cases globally had risen to more than 83,000, with more than 4,500 outside China.³⁸⁸³⁸⁸ INQ000251645_0086 para 7.76 Almost 3,000 deaths had been confirmed globally, of which 73 had occurred outside mainland China.³⁸⁹³⁸⁹ INQ000049464_0002-0003; INQ000237603_0001 The total number of confirmed cases in the UK had increased to 23.³⁹⁰³⁹⁰ INQ000049470_0006

¶2.164. According to Professor Edmunds:

" [T]he risk for an individual in this country in February was very, very low … So could you take national restrictive measures, would people come along with that? … I think that would be difficult. I think it would be a hard sell … you're kind of jumping to the nuclear option."³⁹¹³⁹¹ John Edmunds 19 October 2023 53/23-54/9

¶The Inquiry considers that the answer lies in adequate planning, ensuring the available options are clearly understood by decision-makers and, when the time comes, preparing the public for the threat on the basis of considered advice.

¶2.165. The available data might not have shown many confirmed cases but, given the lack of testing capacity, the potential scale of asymptomatic infection and delays in receiving accurate data, there was a real possibility that the data were masking the real picture. Indeed, genomic analysis published in 2021 showed Covid-19 had been circulating undetected in Scotland one to two weeks before the first detected cases.³⁹²³⁹² Incident Management Team Report Conference Outbreak – March 2020, Public Health Scotland, 5 October 2021, p31 (https://publichealthscotland.scot/media/9575/incident-management-team-report-conference-outbreak-march-2020-oct21-english.pdf; INQ000147544) It is now also understood that widespread importation of cases from Spain,

¶Italy and France into the UK had occurred from mid-February 2020.³⁹³³⁹³ INQ000251645_0086 para 7.76 As Professor

¶Van-Tam observed in relation to the first two confirmed cases of community transmission in the UK on 28 February 2020, "it was inevitable and … this was just the beginning".³⁹⁴³⁹⁴ INQ000269203_0058 para 6.72

The adequacy of plans

¶2.166. The lack of planning for issues concerning border control is unsurprising given that, at the end of February 2020, the plan for the response to Covid-19 was still being developed. Mr Hancock had nevertheless emphasised to the UK Cabinet "time and time again" that the UK was well equipped to respond to Covid-19.³⁹⁵³⁹⁵ INQ000273841_0020 para 32(vii); INQ000056137_0006; INQ000056138_0007 As considered in the Inquiry's Module 1 Report, this was likely in part as a consequence of assurances and reassurance he had received that the UK was well prepared – for example, by virtue of the existence of the UK Influenza Pandemic Preparedness Strategy 2011, by the World Health Organization or by the UK's ranking on the 2019 Global Health Security Index.³⁹⁶³⁹⁶ Module 1: The resilience and preparedness of the United Kingdom, UK Covid-19 Inquiry, July 2024, Chapter 4 (https://covid19.public-inquiry.uk/documents/module-1-full-report); UK Influenza Pandemic Preparedness Strategy 2011, Department of Health, 10 November 2011 (https://assets.publishing.service.gov.uk/media/5a7c4767e5274a2041cf2ee3/dh_131040.pdf; INQ000022708)

¶2.167. Helen MacNamara, Deputy Cabinet Secretary from January 2019 to February 2021, understood Mr Hancock to mean that he was well versed with the plans. She:

" assumed he'd seen them and been through them and thought they were adequate. I thought that's what he was saying."³⁹⁷³⁹⁷ Helen MacNamara 1 November 2023 27/2-4

¶2.168. Any confidence that there were detailed and carefully considered procedures in place was misplaced. As Mr Cummings explained:

" [I]n the course of February we realised gradually, as we pushed and probed and asked questions for these plans, that they fundamentally didn't exist."³⁹⁸³⁹⁸ Dominic Cummings 31 October 2023 159/24-160/2

¶2.169. Such departmental plans that existed had not been shared with the Civil Contingencies Secretariat and the Cabinet Office.³⁹⁹³⁹⁹ INQ000272142; INQ000048313_0009 There was no overarching plan beyond the UK Influenza Pandemic Preparedness Strategy 2011.⁴⁰⁰⁴⁰⁰ UK Influenza Pandemic Preparedness Strategy 2011, Department of Health, 10 November 2011 (https://assets.publishing.service.gov.uk/media/5a7c4767e5274a2041cf2ee3/dh_131040.pdf; INQ000022708) The work that was under way was predominantly approached as a health issue, with limited if any planning across other departments. Professor Whitty described the UK Influenza

¶Pandemic Preparedness Strategy 2011 as "woefully deficient" – it did not give him

¶"much that was of any great use".⁴⁰¹⁴⁰¹ Christopher Whitty 22 June 2023 95/7-10; Christopher Whitty 21 November 2023 121/1-7; UK Influenza Pandemic Preparedness Strategy 2011, Department of Health, 10 November 2011 (https://assets.publishing.service.gov.uk/media/5a7c4767e5274a2041cf2ee3/dh_131040.pdf; INQ000022708)

¶2.170. It is likely that Mr Johnson, acting in accordance with his own optimistic disposition, was content to accept the assurances of others, in particular those of Mr Hancock, that all reasonable precautions were being taken. The Inquiry saw no evidence that Mr Johnson challenged the assurances that he was receiving.

¶2.171. The response from the devolved governments was also inadequate.

¶2.172. There was an absence of any real strategy pursued by the Welsh Government in January and February 2020. Dr Goodall told the Inquiry that, although he did not recall the Welsh Government:

" specifically deciding to formally trigger the Pan Wales Response Plan, this plan did inform and form the basis of much of our action during this initial phase".⁴⁰²⁴⁰² INQ000396878_0081-0082 para 318

¶Dr Sandifer did "not recall being informed that the Pan Wales Response Plan had been activated, if that was the case".⁴⁰³⁴⁰³ INQ000267867_0036 para 150 Mr Drakeford said there was "no plan to prevent the virus from spreading into Wales" and it was from 25 February that there were "very practical things being discussed about how we would respond to coronavirus when it arrives".⁴⁰⁴⁴⁰⁴ Mark Drakeford 13 March 2024 61/19-62/25

¶2.173. In Northern Ireland, there was no cross-government strategy in January and February 2020. This period coincided with the restoration of power-sharing and there was little meaningful, cross-governmental coordination in relation to Covid-19. The Department of Health (Northern Ireland) was leading on the response, and its general approach in these early months is perhaps best encapsulated in Professor McBride's email to Professor Whitty on 25 January 2020, in which Professor McBride noted:

" As ever you are/will be doing a lot of the heavy lifting for us and providing much appreciated expert advice."⁴⁰⁵⁴⁰⁵ INQ000047559_0004

¶2.174. In Scotland, Ms Sturgeon said:

" Between January and March, a considerable amount of work was done to ensure that Scotland was as prepared as possible for the situation that was developing."⁴⁰⁶⁴⁰⁶ INQ000339033_0058 para 151

¶The Scottish Government Resilience Room had been activated. However, in this early period, there appears to have been no real strategy other than monitoring the situation.

¶2.175. The devolved administrations failed adequately to conduct their own planning with regard to the implications of Covid-19. Although the Inquiry acknowledges that they were entitled to rely upon advice and assistance from the UK government in combatting an unknown common threat, the devolved administrations became too dependent on the UK government response, which resulted in each devolved administration being significantly underprepared for what was to come.

Lack of leadership

¶2.176. Mr Hancock had chaired the first five COBR meetings in January and February 2020, in accordance with guidance that COBR may be chaired by the Prime Minister or any minister (or indeed by a civil servant whose brief is most directly affected). Mr Johnson described Mr Hancock as "the right chair for the job" and neither Mr Johnson nor his advisers suggested that Mr Johnson chair COBR until the end of February.⁴⁰⁷⁴⁰⁷ INQ000255836_0010-0011, 0021 paras 25, 85; INQ000136747_0001

¶2.177. Mr Johnson stated that, on 27 February 2020, he asked to chair a full COBR meeting in person.⁴⁰⁸⁴⁰⁸ INQ000255836_0021 para 84 Mr Glassborow responded on the same day, agreeing and noting that this would "signal your active involvement on this issue", although they proposed that Mr Hancock should afterwards resume chairing.⁴⁰⁹⁴⁰⁹ INQ000136747_0001 Mr Hancock said that he contacted Mr Johnson directly on 28 February, telling him that he "had to show that he was engaged on this and that he had to chair a COBR meeting".⁴¹⁰⁴¹⁰ INQ000232194_0053 para 222

¶2.178. While it was not wrong for Mr Hancock to chair initial COBR meetings, the fact that it met so regularly, together with the obviously escalating nature of the crisis, made it surprising that COBR was not chaired by the Prime Minister until early March 2020. Alex Thomas, expert witness on political and administrative decision-making, told the Inquiry that, had the Prime Minister chaired an earlier COBR meeting, it would have sent a signal that:

" this required a whole-government response, the Prime Minister was personally engaged in that, and that all departments needed to give their maximum possible attention to this crisis".⁴¹¹⁴¹¹ Alex Thomas 13 October 2023 30/5-16

¶Mr Johnson should have been advised – and should himself have appreciated earlier – that this was an emergency that required prime ministerial leadership. At the latest, he should have chaired COBR on 18 February 2020. The chairmanship and authority of the Prime Minister would have conveyed how serious the matter was and would likely have added greater impetus to the UK government's response.

¶2.179. The leaders of the devolved administrations also did not attend all the COBR meetings.

¶2.180. The Welsh Government was represented by Mr Gething at the first three COBR meetings.⁴¹²⁴¹² INQ000391237_0038 para 152 Mr Drakeford did not attend until 18 February 2020 because the "meetings focused on health-related issues and that was [Mr Gething's] portfolio".⁴¹³⁴¹³ INQ000273747_0007 para 20 Sir Frank Atherton reflected more generally that, in Wales, Covid-19 was "managed too long as a health issue rather than as a cross-government issue".⁴¹⁴⁴¹⁴ Frank Atherton 4 March 2024 27/15-18

¶2.181. Ms Sturgeon did not attend a COBR meeting on behalf of Scotland until 2 March 2020. She stated:

" The attendance of my Health Secretary at the first five COBR meetings was considered appropriate as these meetings were chaired by her counterpart, the UK Health Secretary and attended by relevant Health Ministers of the other devolved governments … In my judgement, this has no impact on the effectiveness of governments' response to risks and threats."⁴¹⁵⁴¹⁵ INQ000235213_0006 para 18

¶2.182. Ms Foster and Ms O'Neill also did not attend COBR until the Prime Minister first chaired it – an assumption having been made that Mr Swann should attend because Mr Hancock, his equivalent, would chair.⁴¹⁶⁴¹⁶ Michelle O'Neill 14 May 2024 42/2-17 Mr Swann told the Inquiry that the attendance from the outset of the Prime Minister and the First Minister and deputy First Minister of Northern Ireland would have created a stronger sense of cohesion.⁴¹⁷⁴¹⁷ INQ000412903_0069 para 217; Michelle O'Neill 14 May 2024 41/23-42/17; INQ000317453 Given the obviously escalating nature of the crisis, in addition to the Prime Minister, all the First Ministers (including the deputy First Minister of Northern Ireland) should also have attended COBR by the middle of February 2020 – only Mr Drakeford did. The attendance of the senior leadership of all four nations would have signified the importance of dealing with the crisis and facilitated lines of discussion. It could potentially have prompted an earlier recognition of the need for a robust cross-government response, in particular for Northern Ireland, which might then have activated NICCMA earlier.

Lack of urgency

¶2.183. The highest levels of the UK government failed to respond with sufficient urgency in early and mid-February 2020. As the chronology above demonstrates, there was an element of drift and a failure to take control of the emerging crisis. There were, for example, no COBR meetings between 6 and 17 February (during the school half-term holidays) and Covid-19 was not officially on the agenda for the Cabinet meeting of

¶25 February. According to Mr Cain, this lack of political engagement reflected "the perceived importance of Covid-19 from those inside Downing Street".⁴¹⁸⁴¹⁸ INQ000252711_0005 para 21

¶2.184. Mr Glassborow recalled that it was "business as usual" in 10 Downing Street until late February 2020.⁴¹⁹⁴¹⁹ INQ000302484_0017 para 62(a) Ms MacNamara became "increasingly concerned about the confidence of the tone of any discussion about the virus".⁴²⁰⁴²⁰ INQ000273841_0014 para 26 She described the atmosphere of the Prime Minister's morning meetings as "confident and macho".⁴²¹⁴²¹ INQ000273841_0015 para 27 Professor Edmunds agreed that the UK government:

" did not really take the pandemic very seriously until March, by which time it was very late. Much of the lead time had been wasted."⁴²²⁴²² INQ000273553_0103-0104 para 16.5

¶2.185. Mr Johnson suggested that, in January 2020, there was "no loud klaxon of scientific alarm, certainly not in the heart of government", and that even by the middle of February 2020 this was still not being communicated.⁴²³⁴²³ INQ000255836_0015 para 48; Boris Johnson 6 December 2023 70/2-71/23 However, Mr Hancock, as well as Professors Whitty and Vallance, had sought to impress upon Mr Johnson the gravity of the situation; Mr Johnson's advisers had received briefings to similar effect; and Professor Whitty had advised that the country was looking realistically at two scenarios, one of which had the potential to spiral rapidly in weeks into a pandemic. The threat level to the UK population had been raised to 'medium', NHS England had already declared the highest level of emergency and the first cases of Covid-19 had been detected in England. There was evidence of sustained transmission in China and Italy and credible estimates of the case and infection fatality ratios, along with the potential for 80% of the population to be infected. This, accompanied by the experience of lockdown in Italy, should have prompted a far higher level of concern and action.

¶2.186. Nonetheless, Mr Johnson maintained that the scientific community had not made the risks clear.⁴²⁴⁴²⁴ Boris Johnson 6 December 2023 70/2-71/23 He said: "I am afraid at that stage there were just too many things we did not understand or underestimated." However, he accepted that:

" It is clear that we were far too complacent about what might happen, and about the state of our national preparedness. It was not the case that I was somehow distracted by other things."⁴²⁵⁴²⁵ INQ000255836_0020 paras 78-79

¶2.187. Mr Johnson's failure to appreciate the nature of the impending crisis was, in part, because of 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 – with Covid-19 not even being in the top five issues crossing his desk in early to mid-February 2020. This was most likely exacerbated by the assurances he was receiving that plans were in place.

¶2.188. That said, even as late as 28 February 2020, Mr Johnson was being advised by the Civil Contingencies Secretariat that "Covid-19 looks increasingly likely to become a global pandemic, although this is not yet certain."⁴²⁶⁴²⁶ INQ000146569_0001 para 1 The focus on certainty was reflected in and compounded by the nature of the scientific advice. Professor Edmunds stated that SAGE's advice "attempted to be neutral".⁴²⁷⁴²⁷ INQ000273553_0102 para 16.2 It did not generally recommend interventions but advised on efficacy. For example, on 27 February 2020, SAGE noted that modelling suggested "earlier and or combined interventions will have more significant impact".⁴²⁸⁴²⁸ INQ000061519_0004 para 13 As Professor Edmunds remarked, this "implies that a package of interventions should be introduced quickly but falls short of actually recommending it".⁴²⁹⁴²⁹ INQ000273553_0102 para 16.2 SAGE's advice was also tempered by an anticipation that "certain measures would be unpalatable or difficult to implement".⁴³⁰⁴³⁰ INQ000273553_0102 para 16.2 Professor Edmunds observed:

" The neutral (scientific) tone of the advice from SAGE met with this optimistic outlook, may well have led to significant delays to effective action taking place."⁴³¹⁴³¹ INQ000273553_0102 para 16.2

¶In the view of Professor Dame Angela McLean (Chief Scientific Adviser to the

¶Ministry of Defence from 2019 to 2023 and Government Chief Scientific Adviser from

¶April 2023), "advisers should err on the side of giving unequivocal advice earlier in the context of advising on time-sensitive matters".⁴³²⁴³² INQ000309529_0038-0039 para 129

¶2.189. The Inquiry acknowledges the expertise and skill of SAGE. Its advice was – and must remain – evidence-based, measured and objective, providing "a unified, rounded statement of scientific advice" as described by Dame Deirdre Hine in her July 2010 review of the UK response to the swine flu pandemic.⁴³³⁴³³ INQ000238826_0015-0016 para 35; The 2009 Influenza Pandemic: An Independent Review of the UK Response to the 2009 Influenza Pandemic, Dame Deirdre Hine, para 4.49, recommendation 10 (https://assets.publishing.service.gov.uk/ media/5a7975f1ed915d0422068a10/the2009influenzapandemic-review.pdf; INQ000022705_0077) However, the advice given to the UK government by SAGE, although making clear the available information and the risks posed by the virus, failed to reflect the need for immediate action. In part, this could have been due to the constraints on SAGE's own functions – SAGE did not regard itself as empowered to recommend specific actions.⁴³⁴⁴³⁴ Christopher Whitty 21 November 2023 48/16-49/3, 57/10-59/23; INQ000251645_0020 para 2.42

¶2.190. This resulted in a disconnect between the way in which SAGE's advice was imparted and the way in which it was received. With regard to the latter, this might have been because, as Professor Whitty stated, the system underplayed "relative to other threats … natural threats, including health threats" – with these not being understood to be as tangible or 'real' as, for example, threats to national security.⁴³⁵⁴³⁵ Christopher Whitty 21 November 2023 163/1-164/24

¶Nevertheless, the overarching system under which ministers received technical and scientific advice – and acted accordingly in light of all the available information – failed to lead to sufficiently speedy and robust action being taken to respond to the virus. This had extremely serious consequences.

¶2.191. Similarly, the communication of risk might also have contributed to a false sense of security and affected some decision-makers, who suffered from what Professor Woolhouse described as "optimism bias".⁴³⁶⁴³⁶ INQ000250231_0020 para 105

¶2.192. Risk levels rose from 'very low' at the outset of the pandemic in January through to 'moderate' in February 2020. Professor Van-Tam told the Inquiry:

" [ W]here the risk assessment system has failed us … is that it relates to the current moment and that, unfortunately, when you then try to say, 'Oh, what does it mean for the future?' you get into massive uncertainty … I think it's very unfortunate that this can be read as 'Oh, well, it's low, just forget about it'."⁴³⁷⁴³⁷ Jonathan Van-Tam 22 November 2023 173/4-25

¶2.193. The nature of the reasonable worst-case scenario also remained elusive for those who were not experts and resulted in a similar discounting of risk. In the Cabinet Office, it was not understood that the reasonable worst-case scenario was a scenario that was to be planned for, rather than a possible projection. Lord Sedwill told the Inquiry:

" I think we wouldn't have understood that to be inevitable … this was a discussion of the reasonable worst-case scenario and in late January, early February, I think Cabinet, for example, the Chief Medical Officer, gave that around a 1 in 10 probability, and by the end of February I think it was about 1 in 5."⁴³⁸⁴³⁸ Mark Sedwill 8 November 2023 30/1-9

¶He also noted:

" [T]he scientific advice is essentially suggesting that the worst-case scenario is unlikely, is indeed very unlikely, and so that undoubtedly will have informed the way ministers were thinking about this."⁴³⁹⁴³⁹ Mark Sedwill 8 November 2023 48/6-9

¶2.194. The low statistical likelihood appears to have given false reassurance. Mr Johnson said that, by mid-February 2020, the UK government was "not yet believing that the [reasonable worst-case scenario] or anything like it [was] going to happen".⁴⁴⁰⁴⁴⁰ Boris Johnson 6 December 2023 76/1-3 Sir Simon Stevens, Lord Stevens of Birmingham, Chief Executive of NHS England from April 2014 to July 2021, told the Inquiry:

" There was too much ambiguity about what the status of this reasonable worst-case scenario was during the course of February and the first part of March and the probability that the reasonable worst case was actually going to become the case … there needs to be much greater clarity about what is the probability that is being assigned to these different potentials, so that policymakers can understand what exactly they're being told."⁴⁴¹⁴⁴¹ Simon Stevens 2 November 2023 39/17-21, 40/7-10

¶2.195. Professor Whitty acknowledged that the reasonable worst-case scenario is a "slippery concept".⁴⁴²⁴⁴² Christopher Whitty 21 November 2023 187/2-3 It was insufficiently clear. As he explained, efforts to communicate its meaning to "people who are not used to it" can cause considerable confusion, because "they will say: well, how likely is that? To which the answer is: extraordinarily unlikely, and then everyone relaxes."⁴⁴³⁴⁴³ Christopher Whitty 21 November 2023 184/11-13, 183/9-12 It led to differing understandings of what was actually meant and contributed to governments failing to act with sufficient urgency. The emphasis on the 'worst-case' scenario was an unhelpful distraction. As set out in Recommendation 3 of the Inquiry's Module 1 Report, there must be a better approach to risk assessment, including the communication of risk.

¶2.196. The lack of understanding of the risks posed, the neutral tone adopted and the focus on certainty in a situation beset with uncertainties and imperfect data are likely to have contributed to the UK government's – and in particular Mr Johnson's – failure to appreciate the urgency of the situation.

¶2.197. In Scotland, throughout February 2020, Professor Woolhouse continued to contact Dr Calderwood to offer assistance and advice, including meeting with her and providing briefing papers regarding developments.⁴⁴⁴⁴⁴⁴ INQ000103216; INQ000352140; INQ000352261 Professor Sir Gregor Smith (interim Chief Medical Officer for Scotland from April to December 2020 and Chief Medical Officer for Scotland from December 2020) told the Inquiry that the advice Professor Woolhouse was giving was "straight out of the health protection playbook".⁴⁴⁵⁴⁴⁵ Gregor Smith 22 January 2024 111/15-112/14 Professor Woolhouse's impression was that Dr Calderwood had not engaged adequately with his concerns.⁴⁴⁶⁴⁴⁶ Mark Woolhouse 24 January 2024 30/24-31/21 Although Dr Calderwood shared Professor Woolhouse's concerns with the Chief Medical Officers for England, Wales and Northern Ireland – and eventually met Professor Woolhouse – Dr Calderwood did not herself advise the Scottish Government to implement the type of actions that Professor Woolhouse was recommending. Although steps were being taken to ensure that health boards across Scotland were making immediate preparations, Covid-19 received insufficient or no attention in Scottish Cabinet meetings. The Scottish Government's approach during this period was broadly one of monitoring the situation and resting on the existing plans for an influenza pandemic.⁴⁴⁷⁴⁴⁷ INQ000238704_0004 para 19; INQ000339033_0059 para 153

¶2.198. Mr Drakeford, Mr Gething and the Welsh Government also failed to sufficiently engage with the risk until late February 2020. Although a Technical Advisory Cell was established (which evolved later into a coordination function and an expert advisory group), the risk was not discussed at Cabinet before 25 February and Public Health Wales was not adequately consulted at a ministerial level.⁴⁴⁸⁴⁴⁸ INQ000129852; Mark Drakeford 13 March 2024 57/14-25 Given the warning sounded by Dr Atherton on 24 January 2020 and the clear signs of the virus's growing threat, this was too late. Discussing Covid-19 at a Welsh Cabinet level might have led to a quicker cross-government response, and Mr Drakeford, as First Minister, should have brought Covid-19 to official meetings of the Cabinet prior to the final week of February.

¶2.199. Both Mr Drakeford and Mr Gething relied significantly upon the UK government and on UK-wide risk assessments, without adequately considering the specific circumstances in Wales. Mr Drakeford told the Inquiry that his belief throughout the period from 1 January "right up until 20 March" 2020 was predicated on the basis that:⁴⁴⁹⁴⁴⁹ Mark Drakeford 13 March 2024 38/15-16

" the essential decisions would remain in the hands of the UK Government and that devolved governments would be implementers of those decisions".⁴⁵⁰⁴⁵⁰ Mark Drakeford 13 March 2024 38/15-19

¶He said that the virus had no direct impact in Wales in January and February 2020 and that "as we entered March 2020, Covid-19 and its seriousness became more apparent".⁴⁵¹⁴⁵¹ INQ000273747_0006 para 16; Mark Drakeford 13 March 2024 46/19-24

¶2.200. Mr Drakeford's belief that "the response to Covid-19 would be a UK response and the decisions would be taken by the UK Government" is not surprising.⁴⁵²⁴⁵² INQ000273747_0007-0008 para 22 The central structures of the UK government, including COBR and SAGE, could only be activated by the UK government and were better equipped to respond to an emergency that would potentially impact the entirety of the UK. However, this did not mean that the Welsh Government should not have recognised the severity of the situation in January and February 2020 and taken its own steps to prepare for the arrival of Covid-19 in Wales. Mr Gething and Mr Drakeford were aware of the growing risks from Covid-19. Mr Gething attended the first three meetings of COBR and the outcome of those meetings was reported back to Mr Drakeford. Mr Drakeford chose to attend the next meeting of COBR because "the situation escalated".⁴⁵³⁴⁵³ INQ000371209_0024 para 74

¶2.201. The ability of the Northern Ireland Executive to respond to the emerging virus was undoubtedly and obviously impacted significantly by the prolonged period without a functioning government. As Sir David Sterling suggested, the absence of political direction in Northern Ireland between 2017 and 2020 had left public services in a state of "decay and stagnation".⁴⁵⁴⁴⁵⁴ INQ000449440_0003-0004 para 4 The depletion in the capacity of the Civil Contingencies Policy Branch – which was responsible for the regular review of plans prepared by individual departments and public authorities – was part of that stagnation. It had "a critical staff resources, experience and skills deficit" and was impacted by "EU exit preparations".⁴⁵⁵⁴⁵⁵ INQ000183597_0001; INQ000183632; INQ000092712_0001-0002 para 3 Its lack of capacity was not remedied prior to the end of February 2020. As accepted by Mr Stewart, the Northern Ireland Executive "ought not to have been 18 months behind in our planning for an influenza pandemic".⁴⁵⁶⁴⁵⁶ Chris Stewart 2 May 2024 53/23-54/11

¶2.202. Despite the gravity of the situation, by the end of February 2020 only one meeting of the Civil Contingencies Group (Northern Ireland) had taken place and the need for any central civil contingency arrangements was yet to be declared. This was, plainly, inadequate. A number of senior officials suggested that this was because they were not needed at this stage or that their instigation would have required too many officials being taken from other departments.⁴⁵⁷⁴⁵⁷ David Sterling 1 May 2024 103/10-24, 150/12-20 The reality is that neither ministers nor officials comprehended the risk that Covid-19 posed to Northern Ireland. There was little or no concept that responding to a prospective pandemic would require cross-government planning, encompassing every government department.

¶2.203. In part, this absence of cross-government response from January until the end of February 2020 reflected the fact that Northern Ireland government departments operate with a significant degree of autonomy and operational independence. This, compounded by its role as lead government department, meant that the Department of Health (Northern Ireland) had very substantial control over the initial response to the pandemic in Northern Ireland and that there was very little meaningful oversight or interrogation as to what its preparations for the pandemic were. On the other hand, the fact that the Department of Health (Northern Ireland) was the lead government department gave licence to other ministers to view the pandemic as a health crisis that required a health response. As such, this failure is not that of the Department of Health (Northern Ireland) alone. The risks of Covid-19 to Northern Ireland ought to have been apparent to all ministers. Ms Foster and Ms O'Neill, as well as the Northern Ireland Executive Committee, ought to have led a robust, coordinated response to the situation that was developing throughout February. They should have interrogated advisers as to what arrangements were being made (eg for testing) as the pandemic gathered momentum. While it is recognised that the Executive Committee had just recently been re-established and was therefore in the process of agreeing a Programme for Government and establishing working relationships, the Executive Committee ought to have considered, at the earliest point, how it was going to discharge its responsibilities to the people of Northern Ireland in light of these risks and how it was going to oversee the cross-government preparations (including those of the Department of Health (Northern Ireland)) and response to the pandemic.