The UK Government and the civil service “failed” the public due to “significant flaws” in preparing for the Covid-19 pandemic, a public inquiry has found.

In its first report into preparedness for a pandemic, the UK Covid-19 Inquiry said there was a “damaging absence of focus” on the measures and infrastructure that would be needed to deal with a fast-spreading disease, even though a coronavirus outbreak at pandemic scale “was forseeable”.

A major flaw, according to the inquiry, was the lack of “a system that could be scaled up to test, trace and isolate” people.

The report added: “Despite reams of documentation, planning guidance was insufficiently robust and flexible, and policy documentation was outdated, unnecessarily bureaucratic and infected by jargon.”

The inquiry said it had “no hesitation” in concluding that the “processes, planning and policy of the civil contingencies structures within the UK government and devolved administrations and civil services failed their citizens”.

The Covid inquiry, which is being chaired by Baroness Heather Hallett, published its 217-page report on Thursday.

In her foreword to the report, she said lessons must be learned and “never again can a disease be allowed to lead to so many deaths and so much suffering”.

The report found:

– The UK “prepared for the wrong pandemic”, namely a flu pandemic. Furthermore, this flu plan was “inadequate for a global pandemic of the kind that struck”.

– In the years leading up to the pandemic, “there was a lack of adequate leadership, coordination and oversight”. Ministers “failed to challenge sufficiently the advice they did receive from officials and advisers”, and they did not receive a broad enough range of scientific opinion and policy options.

– Groups advising the Government “did not have sufficient freedom and autonomy to express dissenting views”, there was a lack of challenge to what was said, and the advice was often undermined by “groupthink”.

– The institutions and structures responsible for emergency planning throughout government were “labyrinthine” in how complex they were.

– There were “fatal strategic flaws” in the assessment of the risks facing the UK, including a future pandemic.

– Emergency planning generally failed to account for how the vulnerable would be looked after, as well as those at most risk due to existing poor health, and the deprivation and societal differences already present in the UK.

– There was a “failure to learn sufficiently” from past exercises designed to test the UK’s response to the spread of disease.

– The “recent experiences of Sars and Mers meant that another coronavirus outbreak at pandemic scale was foreseeable. It was not a black swan event. The absence of such a scenario from the risk assessments was a fundamental error of the Department of Health and Social Care and the Civil Contingencies Secretariat. The UK government and devolved administrations could and should have assessed the risk of a novel pathogen to reach pandemic scale”.

– Prior to the Covid-19 pandemic, “there was no exercising of measures such as mass testing, mass contact tracing mandated social distancing or lockdowns”.

– The scenario of an emerging infectious disease reaching pandemic scale and requiring contact tracing as a first step to controlling its spread “was not considered”.

The report found that the UK’s pandemic plan for flu was written in 2011 and “was outdated and lacked adaptability”.

It added: “It was virtually abandoned on its first encounter with the pandemic.”

In her recommendations, Lady Hallett called for a new pandemic strategy to be developed and tested at least every three years, with a UK-wide crisis response exercise.

She said the Government and political leaders should be properly held to account on a regular basis “for systems of preparedness and resilience”.

She also said external experts from outside Whitehall and government should be brought in to challenge and guard against “the known problem of groupthink”.

There were more than 235,000 deaths involving Covid-19 in the UK up to the end of 2023.

In her foreword, Lady Hallett said: “It is not a question of ‘if’ another pandemic will strike but ‘when’.

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“The evidence is overwhelmingly to the effect that another pandemic – potentially one that is even more transmissible and lethal – is likely to occur in the near to medium future.

“Unless the lessons are learned, and fundamental change is implemented, that effort and cost will have been in vain when it comes to the next pandemic.

“There must be radical reform. Never again can a disease be allowed to lead to so many deaths and so much suffering.”