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Solicitor and this week's Analysis presenter - Ann Alexander
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BBC Radio 4's Analysis: Public Inquiries is broadcast on Thursday 30th October at 20:30 GMT and repeated on Sunday 2nd November at 21.30 GMT.
Public inquiries are a key tool for learning lessons when things go wrong, whether through disasters, mistakes or abuse.
But how exactly do they work - and how do they fail?
Solicitor Ann Alexander, who has acted in several major public inquiries, investigates the system, with rare interviews with two inquiry chairs.
She finds out how inquiries start, talking to three people closely involved in the scandal of deaths of children at Bristol Royal Infirmary.
She speaks to Michaela Willis, who lost her son Daniel after heart surgery at the Infirmary.
Ms Willis explains how the families refused to accept a closed inquiry and - after 6 years - managed to have a fully public process.
Frank Dobson, the then health secretary, describes an emotional meeting with the parents at the very start of the process.
And Sir Ian Kennedy reveals that the decision to appoint him as chair of the Bristol inquiry was made in just two brief phone calls.
The increasing cost of public inquiries has become a matter of controversy, particularly due to the expense of the Saville Inquiry into Bloody Sunday.
Lord Laming, who chaired the inquiry into the death of Victoria Climbie, defends this use of public money.
"As long as the business is conducted in an efficient and speedy manner and that the recommendations that come from an inquiry can improve the quality of life for everyone in society and give us greater confidence in services, I believe that there should be more rather than fewer public inquiries," he says.
How can public inquiries ensure that tragedies aren't repeated?
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The purpose of inquiries is to produce recommendations on which the government then acts - but there are growing doubts about how effective this process is.
Richard Lissack QC, who has acted in many public inquiries, tells Ann that there needs to be a continuing process after the formal inquiry ends.
"It would be an extremely good idea to build into the inquiry process someone to be charged with seeing through the recommendations for change."
But Frank Dobson argues that "recommendations are recommendations. They aren't the law."
"I've always taken the view that any secretary of state would be foolish to say in advance that they would without fail implement all the recommendations of any form of inquiry."
Presenter: Ann Alexander
Producer: Jim Frank
Editor: Hugh Levinson
Coming up
In next week's programme, Michael Blastland examines certainty in politics and asks if a little more doubt wouldn't be a good thing.
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