Oral evidence: Inquiry into the recommendations of the Infected Blood Inquiry (Stage 1), HC 113

Oral evidence, 13 October 2026.

Witness

Cindy Butts.

Chair

Good morning, colleagues, and welcome back after what I hope was a successful and enjoyable conference season. I am delighted to welcome Cindy Butts, the independent public advocate. Thank you for finding the time to see us. I am also really pleased to welcome Sarah Russell, our parliamentary colleague from the Congleton constituency, who sits on the Justice Committee. Sarah was involved with the pre-appointment hearing for the role. Sarah, it is delightful that you could be with us this morning. We are grateful to you. We are looking at the role of the IPA, principally in relation to public inquiries. I will kick off with the first questions. You are the first independent public advocate and have been in post for almost a year. How would you describe, hitherto, the main functions that you have been carrying out?

Cindy Butts

First, I was deployed to the Heaton Park synagogue attack four days after starting the role. My role is to be an independent, visible presence, there solely to advocate for the needs of victims, survivors and the bereaved. A big part of that in the immediate aftermath is making sure that people have the support they need, finding out where they do not and being a strong and independent voice. Not to provide it, but to ensure that those organisations that are responsible do, to try to avoid, dare I say, what happened nine years ago in Grenfell, where people were falling through the cracks. That is the immediate role. As you all know, the complicated processes begin to kick in from there: the inquests, the reviews and the public inquiries. It is my responsibility to make sure people understand those processes, can navigate them and are able to play an important, meaningful role in them. The mere fact that they have to navigate them, in and of itself, tells us quite a lot about the recovery and the system, and about the architecture of support that exists in the aftermath, because it is very complicated. In essence, my role is to make sure they can play a meaningful part in those processes.

Chair

You have a tripartite role: a signposter to the services available to those who need them, an advocate to Government service providers on their behalf, and someone who holds service providers’ toes to the fire to make sure they meet demand in a reasonable way.

Cindy Butts

Yes, but not just service providers. The reason my role is officially called the standing advocate is that it is my responsibility to understand the system as a whole, where there are gaps, what systemic and thematic issues are present that are not meeting the needs of people, and to bring those to the attention of Ministers and Government. There is also more systemic learning and challenge that comes with the role.

Chair

It is coming up to a year since you started the job. Has it proved hard to differentiate between not being part of Government, because you are not part of Government, and the office being part of the architecture, if you will, of society, and being an advocate without fear or favour for those who need it?

Cindy Butts

That is a really good question. I do not think it has been hard in the sense of being really clear that my role is independent and I am not there for the comfort of Government; I am in part there to challenge Government, where appropriate and necessary, and to work constructively alongside them. I do not think there has been a difficulty in being able to articulate that, and in people understanding it. Quite frankly, people have been approaching me in droves because they understand the independent nature of my role. The difficulty comes in being such a small outfit. There are three of us, including me. The architecture is that we do not have an independent, physical office; some processes in the way we do things depend on the Ministry of Justice. For example, we do not have our own finance and budget official, so we very much rely on the MOJ to help us with that function. That is where the bureaucracy becomes difficult. It is the very thing that I am sure you will hear from so many other people.

Chair

Yes. Welcome to our world.

Cindy Butts

Quite frankly, there are times when I ask myself how on earth the Government get anything done, because of the tranche of business cases and approvals, going round the houses speaking to this one and that one and then being told, “No, you should have never spoken to me in the first place.”

Chair

Then that one moves mid-conversation. We should form a self-help group or something.

Cindy Butts

We really should. That is a strain on an office that, first, is not properly resourced and, secondly, at times needs to act quickly. I do not have the time because people’s needs are immediate. That is where the administrative challenge comes in, as opposed to the sort of independence piece you mentioned.

Chair

I am sure we will come on to it in later questions, but the first months of experience in a new role are usually the most informative. Do these views—your experiences—get fed into the Secretary of State, the Permanent Secretary or the Treasury?

Cindy Butts

They get fed into various places: the Secretary of State, the Victims Minister, officials or individual Departments, depending on what the issue is. Ultimately, they get fed through to the Minister.

Chair

In your experience, how does the job description bear up to the daily reality?

Cindy Butts

From my experience, having been deployed after only four days in the role, major incidents do not wait for you to be ready. That is the first thing. Being able to respond quickly and have the systems and processes ready to spring into action has reinforced the need for the role to be properly resourced and ready to respond when needed. The Heaton Park synagogue attack was not a Grenfell or a Hillsborough. In the event that we have a major incident that is larger in scale, how we are able to respond to that raises a number of questions, challenges and issues that really need to be resolved.

John Lamont

Good morning, Cindy. You are only able to support people following a major incident, and the major incident is defined by the Secretary of State for Justice. Does that restriction—the definition of major incident—limit your ability to help people?

Cindy Butts

Yes and no. Obviously I support where I have been deployed but there are cases that are, if you like, legacy cases. There are a number of legacy cases where families and campaigners have approached me for help and support. While I cannot support in the way that I do if I am deployed, I have been supporting in ways that I can. The first thing, and one of the things that has become quite stark, is the value of listening to those who might have lost people in the Chinook crash, as a result of the Primodos scandal or, indeed, the Summerland fire in 1973. The value of listening is so important, which is why I have not just been supporting those following the Manchester Arena attack but also listening to those affected by the cases that have gone before that I am not, in a statutory sense, supporting. Also, we know that people’s experience and the learnings do not follow a neat statutory definition, so getting the learnings from people who are still fighting for justice and still waiting for answers is really important because it tells us about the system. The other area that is really important, and it is why I engage with people from those cases, is that it helps to inform how I operate and how the office works. You may or may not be aware of the review that Dame Anne Owers carried out into the death of Harry Dunn. She recommended that the MOJ consult on whether I should have exceptional circumstances provisions to be able to support those families where there might have been just a single death but the impact on that family or the complexity of issues that they might be dealing with are very tricky. For example, in Harry Dunn’s family’s case: international statecraft and Donald Trump. Where the families have to deal with that on their own, and where there is a public interest, I should be able, in exceptional circumstances, to support them through that really difficult process. I support that. The MOJ agreed to consult on it, but it has not done so just yet.

John Lamont

That is helpful. For those legacy cases, is there a threshold for you to determine that it is sufficiently serious to get involved, or are you listening to everybody who comes to you who falls into that legacy category?

Cindy Butts

I try to listen to everybody, to be honest. I sometimes listen to people where, if my role had existed at the point the disaster or the death happened, I may not have been deployed, but it is still really important for me to listen to those experiences because they still tell me something about the system. I recently met Will Powell, who lost his son, Robbie, many years ago. He is still fighting for justice. I listen, I learn and I try to take those messages forward in the work we are doing.

John Lamont

I know others are going to come on to your workload and staffing, but in terms of your workload and the balance between those legacy cases and supporting those affected by major incidents as defined by the Minister, what is the current split?

Cindy Butts

That is a really good question. It is really difficult to define the split. For example, at Heaton Park, the Jewish community was deeply affected. One of my challenges in a new role was to try not just to demonstrate that I am useful and can make a difference as the new kid on the block. I actually had to exercise restraint, because I knew and understood that the community has its own infrastructure and support network. Some of that is because it has been under sustained attack and has had to look after itself, and some is because of religious and cultural needs. Part of our work is about being trauma-informed, and a big part of that is understanding the community first and foremost, recognising where we could add value and exercising restraint so that we are not duplicating what other organisations are meant to be doing or trying to usurp their infrastructure. I say that because, when the attack happened, one of the immediate things I did was check in on them to find out whether they had sufficient trauma-informed support. They said, “Thank you very much, but we have flown in four or five trauma-informed specialists from Israel.” It is about understanding their specific needs. It is about being quiet-ish in the beginning, but then needs emerge over time as the process unfolds. People have been coming forward with issues and concerns that we have been picking up on and trying to pursue. It ebbs and flows, and it depends on need and our ability to respond. When it ebbs, that is when we can spend a bit more time on other cases. It has been a mixture. Sorry, I will try to be a bit more succinct.

Sarah Russell

Your description of your work is immensely impressive, if I might say so, but I am left wondering how you manage all this in two days a week. Is two days a week sufficient for this role?

Cindy Butts

Officially, I am two days a week, and then I go up to full-time when I am deployed. At some point—I am not quite sure when—it is up to the Secretary of State to decide when to stand me down; that is the phrase used in the legislation. I go back up if something happens, then back down, then back up, and so on. I am actually full-time right now because I was deployed four days after, but officially it is part-time. That is not the right thing for a role like this, not least because there is work to be done between deployments. I have already articulated just how important preparedness and resilience are. This role does not just kick in when I am deployed, as important as deployment is, which is a mistake. The structure and the way it is designed can limit the kinds of people who can go for this role. I took this role knowing it was two days, and then it went up and I thought it is madness. I took it anyway, because my view is that you take it and make it different when you are in there. The part-time role would have put so many people off. I am still in the prime of my career. I do not have a rich husband, a rich wife, a lovely pension or whatever to prop me up. I need to earn. The idea that you can just do the role part-time and perhaps get another employer to say, “I will take you on,” knowing full well that you could be off if something happens is for the birds. It designs out people who could be really good at this role, and it is a diversity issue. As I say, I took it anyway, and my view was to take it and make it different for myself and for future IPAs.

Sarah Russell

It seems quite problematic that the role is non-pensionable, but I will leave it there.

Cindy Butts

I should also say that it is so important for a role like this because, although I have two staff—I love them dearly, and they are absolutely brilliant—they are civil servants. He who holds the pen holds the power. As much as I love them, I am not happy for them to be holding the organisation when I am not there. It is about the independence, and that is so crucially important. There is also that issue to consider in terms of full-time or not. Who is holding the pen? Who has the power? This role is about the independence.

Sarah Russell

I quite agree. In respect of that independence, you have said that you have concerns about your staffing levels. For comparison, although the roles are not directly comparable, I note that the Children’s Commissioner is a full-time role with a staff of 28 and, as I understand it, you have a staff of three. Can you talk about how that limits your ability to do your role? I presume that it must.

Cindy Butts

We could do more if we had more resources. I would quite like to get into the depth of some of the systemic policy issues. We could do more work in terms of that. The key thing for me is around being able to scale up when we need to, which is why I have put in a business case for more resources. It would mean that we are able to get to a steady state. At the moment we are not in a steady state because, quite frankly, there was not enough proper scoping and sizing at the beginning to understand what this organisation needs in steady state and what it needs when it needs to scale up. Those are the key issues. I would quite like what the Children’s Commissioner has. Even something that is not quite that but substantially more than what I have. That is what is needed to be able to respond in a way that Parliament expects, and the way that victims, survivors and bereaved families deserve. I am hopeful that the business case will be approved soon.

Chair

Those are two key points for us as a Committee, and for Sarah to take back to the Justice Committee. The two germane points are: first, how can you do the job in two days and then drop everything for potentially four months? That narrows down, by definition, who might apply. Secondly, as far as the public are concerned, the key word is “independent”. Is the role an independent advocate? I echo your respect and admiration for the civil service, but when it holds the pen while you are stood down by the Secretary of State, the civil service is a servant of the Government. How can it be independent of the Government it serves? It is asking too much.

Cindy Butts

The other thing that is important to say is that this is difficult, hard work. You are dealing with people in grief and in trauma. One of the key things that additional funding will allow me to do is to put in place proper trauma-informed support for myself and my staff. That is also linked to the whole issue of part-time and full-time. When I go down to part-time, I am still always switched on because I never know when something will happen and I will need to kick in. I have to remain spiritually—if I can use that word—resilient and ready at all times.

Chair

When can you have comfort and confidence to book a holiday, for example? It can be something like that.

Cindy Butts

I actually have one coming up, mainly because my staff are forcing me to make sure I take a break.

Chair

Do not publicise the dates, because that will put a curse on it.

Charlotte Cane

You have talked about your deployment to the terrorist attack at Heaton Park. In your annual report, you raised how best you could provide useful services without adding further burden when people are already overwhelmed by multiple approaches and requests for engagement. You have touched to some degree on how you managed that. Are there any other lessons that you learned from that deployment?

Cindy Butts

There are a couple of things. I have talked about the issue of understanding the community, exercising restraint and understanding that needs emerge at different times. On your point about burden, one of the strongest messages from people in the community was, “We feel overwhelmed.” DCLG is not the right acronym now, is it?

Chair

It is MHCLG now. I was a Minister in the Department, and it changes its title more than I change my socks. It is something to do with housing and local Government and communities and stuff.

Cindy Butts

MHCLG, the Home Office, the Mayor, organisations such as Victim Support and other people descending on them wanting updates and information. We understand they were working in their best interests. It is not as if they were deliberately trying to overwhelm them. They wanted to know and understand what was going on. The burden they were being placed under was absolutely immense. That reinforced for me why it is so important to be very clear about our added value, not trying to duplicate, and not imposing ourselves on them. Some of the other more specific learning that has come out of Heaton Park is that the synagogue itself was an interested party in the inquest process—as am I—but the synagogue was not able to access legal aid because it is an organisation. That is one of the areas that we have identified. There is clearly a gap there. The synagogue community was at the heart of the attack. It happened there. It has affected that community deeply. It is an interested party within the process, but it does not have access to legal aid. The only way it could access it was through exceptional circumstances applications, which are very complicated, particularly for the volunteers who oversee the synagogue, and they then have to try to get pro bono support. There are systemic issues and gaps that we are identifying. Another gap is around support for carers: people who suddenly become carers by dint of supporting people who have been attacked; there is no proper mechanism for supporting them through that in terms of benefits. Again, we are trying to pursue this by working with the relevant Departments to understand the gap and see how we can plug it. Does that help?

Charlotte Cane

Yes, it does. It goes back to your point that once you are stood down, there is still a lot of follow-up work to make sure those gaps are filled.

Cindy Butts

Absolutely, which is not to mention the fact that I talked about the immediate support and then all the complicated processes kick in, but do they? Sometimes they do, but sometimes it takes ages before those complicated processes kick in. An inquiry could happen years later. The MOJ and I need to do some deeper thinking. I do not sit here before you with all the answers. It has been one year. As I said, in large part it has sometimes felt like I am running just to stand still. I do not have all the answers; there are some things that still need to be worked out, including: how do you stand down? When is the most appropriate support? Is there a hybrid where you stand down but stay ready to support when those other processes kick in? One of the really crucial questions for me is when you get stood down, where is there still a need? Who will pick that up? If not me, then who? There are still some important things that need to be figured out.

Charlotte Cane

You talked earlier about the timescale for people who have suffered from the incident. They may still need you for their own reasons, even if a formal process has not kicked in.

Cindy Butts

In particular, they do not respect the stood-down piece, and neither should they because their needs will emerge whenever their needs emerge, or when they come forward with them. The key is that we can identify other ways, even if it is not me, to help and support them throughout that really long and painstaking journey.

Charlotte Cane

That brings us on to the announcement the Government made yesterday that there is going to be a public inquiry. Could you talk us through how you were involved in the process of making that decision, if you were involved?

Cindy Butts

That is not a decision for me; that is a decision for the Chief Coroner who presided over the inquest. I have counsel that represents the IPA within those processes. We have been involved in those deliberations, and in what the issues are in terms of the security services. We have had disclosures in respect of the thinking around that and the evidence amassed that indicated it needed to go to a statutory inquiry. I have been apprised via that disclosure process and have had the opportunity to make submissions, which I took. I pointed out the drawbacks of going to a statutory inquiry, in that there would be no jury and some evidence would be heard in closed session, and I reinforced the fact that even within those parameters, people affected should be able to understand those processes and play a meaningful part, and that decisions need to be timely. My submissions and my views have really tried to reinforce all that. I am really pleased that the decision was announced yesterday in relatively swift time, which is good, but of course a chair needs to be identified and terms of reference need to be set up, all of which can take time. The longer it takes, the more anxious the community rightly is, and they do not have the answers they so desperately want and deserve. Being able to keep pushing and pressing for that to be done speedily, while making sure that they are at the heart of those decisions even with the constraints that it brings, is important.

Charlotte Cane

Will you be able to input into the terms of reference of the public inquiry, and so on?

Cindy Butts

I hope so. To be clear, the legislation says that wherever I am deployed, I automatically become an IP in an inquest. It is silent in respect of inquiries; it does not say that I ought to immediately become a core participant. Once the chair is appointed, we still need to work out what status I will have. I am still undecided about what status is right, whether core participant status is right. Part of being a core participant is that you service the inquiry chair, if you like. Is that the right thing for the independent public advocate to be doing? It means that you have access to swathes of disclosure: thousands upon thousands of documents. Sometimes servicing the inquiry chair means you need to get beneath all the disclosure documentation if they ask you to look at this or to respond to that on their behalf. You need more than three people to do that. I have not quite worked out my role, but I will. In early November, I am convening a roundtable to look at the issue of public inquiries in all their forms. What is the right thing? Where can I add value to that process? What are the things that victims and survivors would want from me in an inquiry process, whether statutory or non-statutory? I am co-hosting that with Professor Andrew Williams, who I know you have taken evidence from, and other academics, practitioners and people with lived experience to try to get under the skin of it and think more deeply about what our roles should and ought to be. I am happy to report back to you on that if you like.

Charlotte Cane

That is really helpful. Thank you.

Chair

Can I ask a very quick supplementary on standing down? The Secretary of State decides when you should be stood down from an active engagement. I know we are talking hypothetically here because the situation has not arisen, but suppose you take a different view. Suppose you believe that the Secretary of State has it wrong, that there is still work that your office could or should be doing, and that it would be premature to stand you down. Does the Secretary of State have the final say, “No, sorry, you are stood down,” and that is the end of it? Or is there a higher being to whom you can appeal?

Cindy Butts

The statutory guidance says that the Secretary of State’s decision to stand me down is made in consultation with the IPA. There is no higher being, other than I have a relationship with the Justice Committee and I have the ability to produce discretionary reports to Parliament, which is perhaps another lever if I feel strongly that I should not be stood down. There is a need to have a better and more transparent process for standing up, in particular. That is really important. At the minute, it is a bit opaque. People do not really understand it. It could reduce the credibility of my role, if it is very clear that I ought to be stood up but I am not. There is a lack of transparency. It would bring greater public understanding and victim awareness if there were a clear route in which I can give my views, knowing those views have been fed up to the Secretary of State, and that the Secretary of State has to give public reasons for not standing me up. That is really important for transparency. It also protects Ministers. The last thing I want is for them to be accused of using my role as a political football.

Chair

That is very helpful. What is your assessment of the mindset of the Government? It is a new, evolving role. Is it the Government’s position that this is organic and evolutionary and that they will respond proactively to how your role is evolved, defined and expanded as lived experience dictates? Or is it that you have signed on the dotted line, “There is the job description and the job spec,” it is encased in aspic and that is the end of it?

Cindy Butts

They are much more aligned to your first description. It is going to evolve. We have an 18-month review, there will be learning from that, and we will be able to flex and adjust accordingly. That is the camp they are predominantly in. It is certainly the camp that I am in.

Chair

That is helpful. You referenced the good professional working relationship you have with our sister Committee, the Justice Committee. This Committee has general oversight of arm’s length public bodies, and so on. If you make a written submission that is pertinent and germane to our work, and if you think we could be of help, please feel free to make sure this Committee is on the circulation list.

Sarah Russell

Your role is not to give legal advice but to support engagement in relevant processes for victims and their families, to advocate for them and even to act as a spokesperson for them. There are quite a lot of those different processes potentially: coronial inquests, Government reviews, and statutory and non-statutory public inquiries. How do you advise them on which of these routes is most appropriate in their case? Or do you not? How does it work?

Cindy Butts

Thus far I have not had the need to do that. In terms of how it might work in practice, my starting point is that victims, survivors and bereaved families are not a monolith. They have a diversity and range of views of what ought to ensue. An important part of my role is to be able to explain the differences in terms of those processes and, crucially, to try to help them to surface what the issues are that they want answered. That is where it has to start: the context. What are the issues that they want to be addressed? Is this an issue that is really technical that might require a particular kind of set-up where there might be a sole chair supported by technical experts? Or does it require a review process with a wider panel? Might it be better to have a statutory inquiry? For me, the issue starts with what they want answered, what the actual issues are, and helping them to understand the different avenues, the pros and cons of those, where they might be overly lengthy or where they may not best fit the answers that they seek. The place to start is helping them understand those differences and articulate them based on need. Another key value I bring is not trying to package those differences neatly. Sometimes Ministers and politicians want a neatly packaged answer, with a bow, “This is what victim-survivors need.” They want a neat answer, and sometimes there is no neat answer. It is my job to represent those views in all their complexity. It does not mean I would not have conversations with the bereaved and survivors to ask whether we can try to align views that are not far away from where they might be. There might be a proper role for that too, because I also believe that you should try not to give institutions any quarter; if they are together and they are not easily divided, they will be stronger. There is a role for me to try to get coherence, but where that is not possible, it is to represent those views in all their complexity.

Richard Baker

One of the recommendations of the Infected Blood Inquiry was that there should be a role for Parliament in calling for inquiries and that this Committee should have such a role, reflecting support more broadly across Parliament for an inquiry. In those circumstances, how would you anticipate your role interacting with Parliament when it comes to the support that might be there to call for an inquiry?

Cindy Butts

The statutory guidance currently gives me the ability to advise the Secretary of State on what form of review or inquiry ought to take place, having taken soundings from those affected. I have that ability. For me, it goes back to the response I gave earlier. It is about having those discussions, listening to families and survivors, being alert to the fact that there might be really vociferous views, but there might be those who are being ignored because of that, as well as quiet voices in terms of their needs and what they want. To listen and be able to articulate those back to Ministers is an important role that I can play.

Richard Baker

Do you feel you have the flexibility in your remit to have those discussions directly with this Committee or other Committees on the potential for an inquiry if they were considering those matters as well, and on whether there should be a call for an inquiry?

Cindy Butts

Yes. The Chair has invited me to stay in touch and build on the relationship, and that would be one way in which I would expect to do so.

Lauren Edwards

Your annual report highlights the issue of trust. One previous complaint has been that Government Departments and Ministers decide whether to hold a public inquiry, sometimes into their own potential public failures or the failures of their Department. Do you think that the creation of the independent public advocate is enough to combat that criticism, or do you think there is more that can be done to address any perceived conflict of interest concerns?

Cindy Butts

Sorry, can you break that down for me a little?

Lauren Edwards

Do you think the creation of your post and your office is enough to give the kind of independence that is needed around Ministers potentially still having a role in saying whether a public inquiry should go forward, even if they or their Department are involved in the circumstances that led to it?

Cindy Butts

No, I do not think it is enough, which is why Parliament has a really important role to play in scrutinising the decisions that Ministers make on whether to launch a public inquiry. There is a need for greater transparency, particularly where there are calls for an inquiry or a review and those calls are not heeded. Often, the rationale for why an inquiry has not been set up is not given, which erodes trust. People tell me that they want answers. This is an important lesson I have learned. I often meet families face-to-face; I often meet them virtually. One thing that strikes me over and over is how much families become investigators and campaigners, trying to fight for the truth. Not only does the trauma they experience of losing a loved one pass down generationally, but the fight for truth passes down generationally too. I met a woman who lost her father as a result of a major incident. She is fighting for a public inquiry. She inherited that fight from her mum. Her mum no longer fights for it because she is too old. She has passed it on to her daughter. She spoke to me from her living room, and I could see stacks and stacks of papers, documents, correspondence and files. It had become her life. She said to me, “I want to know what happened to Dad because I feel like I owe it to him. Even more than that, I cannot leave that inheritance to my three-year-old daughter, who will then have to fight for the answers.” There is something about understanding the impact of when people do not get answers, and then do not get answers to why an inquiry has not been set up; there is no transparency. I can put my views across, and I will do that vigorously and independently, but there is something about the system that needs to change as well.

Lauren Edwards

You have been very helpful in highlighting your ability to advocate on their behalf, particularly if you feel that an inquiry is needed, and Parliament’s role. Do you think there should be a formal role for those who are affected in the way you have just described, and who may take on that campaigning role?

Cindy Butts

Yes.

Lauren Edwards

What would that look like? How do you envisage that working?

Cindy Butts

There is a question that I should ask you: what do you mean by role? If you mean a formal role in being able to influence what happens in terms of the kind of review, then they have that in part through me. As we develop, I would like to think that could also extend to trying to influence the plumbing and mechanics of any such review and what it might look like, making sure I could see myself being an important advocate, ensuring that the terms of reference, for example, address the issues that they want addressing. There are other ways that I could play a part.

Lauren Edwards

That makes a lot of sense. It is probably something that you will see coming through the process, and something that would maybe be picked up in the 18-month review where you consider the mechanisms and how you can engage with the people who have been affected. You have already talked a lot about the sense of overwhelm that happens when people go through a major incident, so the timing of getting them involved in calls for a public inquiry would be quite important. You also talked a lot about trying to reach those quieter voices. Looking forward to the 18-month review, do you have any thoughts about what you would like to see, or what conversations you would like to have with Government about how you can structure your office in a way that means you could be an even stronger advocate for those people? You have now had experience of it, but I imagine that will continue to build.

Cindy Butts

Those conversations are happening internally. As I said, I am convening the roundtable, which will be a really good opportunity to get under the skin of different inquiries and how we can best represent and be a strong advocate within those processes. A lot will bubble out of that session, and then we will push forward with those views to Government and officials. As I said, I will feed back to you too.

Chair

This is more of an aside than a question. Given the very real lived example of Northern Ireland and the intergenerational longevity of the impact of unanswered events in the troubles, it is extraordinary that any institution in these islands would need to have a masterclass on what happened. You referenced the lady with all the documents and her heartfelt feeling that she did not want to pass on this great burden she had inherited from her mother, and that if the questions about what had happened to her father were not resolved, it was going to be passed down to her child. That is not new. As a country, we have been listening and hearing about the impact of the troubles in Northern Ireland. I find it surprising that officialdom—not your office, but officialdom in broad terms—would need to have a masterclass in defining the varying ways that trauma manifests itself in the human spirit. As I say, this is more of an aside than a question, and it is a worrying one. Let us turn to somebody who is not worrying, Sam Carling.

Sam Carling

Thank you very much for coming in this morning, Cindy. Apologies that I missed the first part of the session. Just thinking about the other end of inquiries—when they have reported and made their recommendations, and when we are monitoring the Government’s implementation of them—I saw in your annual report that you fully support the establishment of a national oversight mechanism or independent body responsible for collating, analysing and following up on these recommendations. Could you expand a bit on your reasons?

Cindy Butts

My reasons are that, all too often, we set up public inquiries at huge expense, not just in monetary terms but all the things we have been talking about: the burden, pressure, unanswered questions and impact on families still waiting for those answers. The inquiries take too long and cost huge amounts of money. We sometimes learn the lessons. Sadly, we all too often do not implement the learnings from those lessons or make sure there is meaningful change. All too often, those reports languish on shelves and nothing is done. There is something else and, again, it goes back to previous conversations. When there is no body charged with making sure that recommendations are implemented and are making the desired change, who takes responsibility? It is the families. They carry that burden to make sure those recommendations are fully implemented. They become super-monitors and monitor the institutions, review websites and try to have meetings and get updates. That burden falls on them, which is not right. That is why I support an independent body that has the expertise, is established in statute as having that responsibility, can be held to account and has a single individual who is held accountable for ensuring that those recommendations are implemented and lead to meaningful change. That is why I support a national oversight mechanism, which I believe is the only way it can be done.

Sam Carling

Do you think it is necessary to have a body apart from Parliament, or do you think it is a function of Parliament and that perhaps this Committee should focus on it in more detail?

Cindy Butts

It is really important to have a separate body. There should be a close working relationship with perhaps a Committee such as yours, working and scrutinising not just that independent body but also the Government and Ministers on enacting and carrying through on recommendations. That should be an oversight role that sits and hovers above a national oversight mechanism, because that independence is so important. The independence and expertise are really important. Frankly, there are swathes and swathes of reviews and recommendations. It is not just out of major incidents; it is out of incidents more broadly. It is inquests and prevention of future deaths reports. It is a lot of work. I just cannot fathom a Committee being able to do it justice. It could do it but it probably would not do it well because it would not have the expertise or independence. The other question is: what gives? You all have a really important role in respect of holding the National Audit Office to account. You named the others. Sorry, I should be able to reel them off. Come on, Clerk. What are the other things that you do?

Chair

There is too much to mention; we could go on until teatime. We are omnipotent in this Committee.

Cindy Butts

What gives if you are doing that and not doing it properly? I am a pragmatist. On the one hand, I think to myself, “Good grief, I can’t imagine Government wanting to set up yet another arm’s length body.” If there were ever a time, function and need for another arm’s length body, in my view it is this.

Sam Carling

You mentioned prevention of future deaths reports, in which I have an interest. Would you say there should be a difference in how recommendations from those, non-statutory inquiries or other investigation bodies should be followed up? Should it be different from inquiries, or should it all be looked at by the national oversight mechanism in one place?

Cindy Butts

I would probably say in one place.

Sam Carling

Would you see a role for you and your office in that body, or would you think it is best kept separate?

Cindy Butts

What I would not support is that we could do the NOM role. I know Professor Andrew Williams made the suggestion, and I thank him for it because I know he has confidence in our work. That would dilute the very purpose and role that we are there to perform. We could work closely with them in partnership without assuming that responsibility ourselves. Again, feeding in the views and experiences of those who are affected is where we could play a meaningful role.

Peter Lamb

This has been touched on in various ways, largely in terms of what it should not be rather than what it should be. What do you feel the role of Parliament should be in monitoring the implementation of recommendations in the event that we have this national oversight body? Presumably there is still a role for Parliament there.

Cindy Butts

Yes, there is a role for Parliament. The body ought to report to Parliament as a whole; there is value in that. Parliament can play a really important role in scrutinising and challenging Government on their response to recommendations, whether that is Departments or Ministers themselves.

Peter Lamb

Thinking about central Government, given that to some extent all this comes about because there are failures in central Government and the way in which they try to respond to recommendations, how do you think that role could be improved in future? Is it purely through having greater watchmen ensuring that this thing is being carried out, or is there something else that we could try to implement to improve the way Government approach it?

Cindy Butts

What is something else?

Peter Lamb

I do not know. That is what I am asking you.

Cindy Butts

Something else is good. I am trying to think of what that something else ought to be. It is a good question.

Peter Lamb

From the Government’s perspective, their view of inquiries is that once one is commissioned, it is out of their hands and off to someone else.

Cindy Butts

That is a good trigger for my slow brain. There is a need for greater accountability and transparency in terms of recommendations. I know there is a tracker and all that, but there can be better clarity earlier on from Government around the recommendations they accept and those that they do not accept, giving public reasons as to why they do not accept them. That is really important, as is doing it in a timelier fashion. There is definitely room for improvement on that front. Of course the tracker, in and of itself, is a welcome development, but it does not give clear timescales so there is room for improvement in that regard. I will zip it there and maybe come back to you after this meeting.

Peter Lamb

By the time most of these inquiries conclude, at the very least a different Minister is in post compared with when the action or inaction took place. It is very often a different Government, so they do not necessarily feel political culpability even if they have to wrestle with the financial costs involved in making it right. Very often the Department is still there and still has whatever processes were in place before. Do you find, or have you observed in your role, a difference in how Ministers and civil servants react to these things? In terms of ensuring that recommendations are carried out, presumably it is going to be the civil service. The Minister has ticked the box, “Right, this is all solved.” It is going to be the civil servants who are tasked with working with whomever to ensure that they are implemented.

Cindy Butts

I cannot say that I have picked up a discernible difference between the two. Given a lot of what you have just said, it comes back to interest waning or people moving on. In part, that comes down to the more fundamental question we have been talking about, which is making sure that the right things are reviewed and investigated, using the right structures—that is really important—and mechanisms, and trying to be more considered in the inquiries that are launched. We know that statutory inquiries take inordinate amounts of time, yet they are seen as the gold standard. Sometimes—only sometimes—families want answers more quickly, and some answers actually can be given more quickly. What I am saying is that there is a need to move away from this one-size-fits-all to try to resolve some issues that you talked about in terms of timeliness. I am not sure if I was as clear as I perhaps could be.

Peter Lamb

That is an interesting thought, which I suspect we do not quite have time to explore here in terms of different modes of inquiry.

Cindy Butts

That is really fundamental. What is the problem you are trying to solve? What is it that you are trying to understand?

Peter Lamb

Kicking it into the long grass is usually the answer to that.

Cindy Butts

Kicking into the long grass?

Peter Lamb

It is a typical answer, is it not? You set up an inquiry with a clear idea as to what the outcome is going to be and then someone else will have to deal with it down the line.

Cindy Butts

That serves no one.

Peter Lamb

Yet it is what people in ministerial roles say at the time.

Cindy Butts

I know, but you and we need to make it different.

Chair

I advocated a public inquiry, because royal commissions take a hell of a long time and do not do very much—I was going to say something quite rude.

Cindy Butts

There are international examples where countries have been really swift, nimble and clear. Not us. There are lessons from that.

Chair

A review of inquiries.

Richard Baker

Cindy, you are the IPA for England and Wales. I know you are visiting Scotland soon, which is very welcome. How can any system best take account of the role played by the devolved Executives and legislatures, particularly in major incidents that occur across the borders?

Cindy Butts

I am not the independent public advocate for England, Scotland and Wales. I am still visiting Scotland, but I am the IPA for England and Wales. Actually, I am due to be in Wales in December hopefully. What is really important for me in my role is to understand the particular structures, needs and infrastructure that exist in Wales. Some will be similar to England; some will be different. What is important for me is to understand the systems, structures, responses, individuals and communities, again learning from past incidents that happened in Wales. I have been talking to families who have been so terribly impacted by Aberfan. For me, it is about really understanding the Welsh system and building those relationships in Wales. At some stage I will be recruiting additional advocates. The legislation allows for mini-mes, if you like, a pool of people who can be deployed. I am absolutely sure that I will need somebody who knows and understands Wales. I intend to make sure that one of those additional advocates knows and understands Wales so that I can be as effective in Wales as I am in England. The other thing to note is that trauma and its effect on victims, families and the bereaved do not know any boundaries. We know with the Manchester Arena attack, for example, that people travelled from across the country to attend that concert. It is not always easily mappable, if you like, across geographical areas. I am very conscious of it and want to make sure that my team and I do not forget that we represent England and Wales.

Richard Baker

In Scotland, many victims of infected blood and their families are still seeking justice and answers. There is not the same provision, but do you feel that you could work with the Scottish Government and agencies in Scotland in those inquiries?

Cindy Butts

Yes.

Luke Taylor

You gave evidence on the Hillsborough law. As it stands, how important is that legislation in changing the culture to one that is less defensive and more willing to learn lessons from where things have gone wrong?

Cindy Butts

It is hugely important. It is such a seminal bit of legislation that has the real potential to deal with the issues that families, survivors and the bereaved talk to me about all the time. They are having to deal with defensiveness, delay, not getting the answers, being shifted and moved around from pillar to post and, in the case of Hillsborough, being blamed for the loss of their loved ones. It has real potential to deal with that issue of truth-telling, which is at the heart of the Public Office (Accountability) Bill, as well as being able to deal with what we know is an inequality of arms between families and the state and state institutions. There will be greater parity in terms of legal representation. It is absolutely fundamental, but it will not bring about change in and of itself. The culture of institutions, the leaders within those institutions, the framework, leadership and values that sit around the Bill are equally if not even more important. The IPA of course is not mentioned in the Bill, which is a huge mistake. I see the duty of candour—making people tell the truth—as the flip side of my role, which is ensuring that they do, at least in terms of major incidents of course—we know the Bill is bigger than that. It is a really poor decision not to make sure there is greater coherence between the Victims and Prisoners Act 2024, which gave birth to my role, and the Public Office (Accountability) Bill. There is still time to change that, because it matters. Making sure that institutions have a duty to tell the truth and act with candour in their dealings with me is important and is an important safeguard for the public.

Chair

Why do we as a Committee not undertake to write to the Bill Minister to ask if it is a deliberate decision, or possibly an oversight that could be rectified?

Cindy Butts

Without being cheeky, you might want to apprise yourself of the discussions and debates that have been going on in the other place, because I have managed to get good cross-departmental support. In fact Theresa May introduced her amendment yesterday. She was not there physically, but it is her amendment. Apprise yourself of all that is going on, and then fight for it.

Chair

Sometimes, if a Minister knows they are getting it from both ends, as it were, then it helps to concentrate the mind. I have just realised the potential for misinterpretation of that phrase, so I apologise unreservedly if anybody got the wrong end of the stick, not least the Ministers themselves. Luke, was there anything else you wanted to ask?

Luke Taylor

No, thank you. That was very helpful.

Chair

Thank you for your time and for taking our questions. More importantly, in what is a complicated and under-resourced role, thank you for stepping up to the plate to fulfil it. We are very grateful to you for your time this morning.