SAFECHAIN™ Evidence Repository | Public Inquiries
SAFECHAIN™ EVIDENCE REPOSITORY™
Building the Evidence Base for Institutional Integrity, Safeguarding, and Systems Reform
About This Repository
The SAFECHAIN™ Evidence Repository™ is the central research resource supporting every publication, framework, professional programme, audit methodology, implementation model, and governance standard within the SAFECHAIN™ ecosystem.
The Repository enables visitors to understand not only what SAFECHAIN™ concludes, but the evidence that informs those conclusions. Each hub page in the Repository corresponds to a distinct category of evidence. Within each hub, individual entries are added over time as the Repository grows — creating a scalable, navigable knowledge architecture that connects evidence to frameworks, frameworks to professional guidance, and professional guidance to implementation.
This page is part of the SAFECHAIN™ Evidence Repository™ architecture. Contact samantha@safe-chain.org to suggest additions or to contribute to the Repository's development.
SAFECHAIN™ EVIDENCE REPOSITORY™
HUB 5: PUBLIC INQUIRIES
Curator: Samantha Avril-Andreassen FRSA
Series: SAFECHAIN™ Evidence Repository™
Category: Statutory and Non-Statutory Public Inquiries
Last Updated: July 2026
Contact: samantha@safe-chain.org | safe-chain.org
ABOUT THIS HUB
Public inquiries are among the most powerful sources of evidence about institutional failure in the SAFECHAIN™ evidence base. At their best, they document in detail and with independence what went wrong, why it went wrong, and what structural conditions produced the failure — making them the closest available equivalent to the systemic diagnostic analysis that the SAFECHAIN™ Research Methodology™ (METHOD-001) prescribes.
The inquiries catalogued in this hub are selected for their direct relevance to the SAFECHAIN™ programme's analysis of institutional failure, accountability dissolution, governance fragmentation, and the Architecture of Preventable Harm™. They are not presented here as evidence of failure for its own sake — they are presented as evidence that the structural conditions the SAFECHAIN™ framework addresses are real, documented, and consequential.
CORNERSTONE PUBLIC INQUIRIES
INDEPENDENT INQUIRY INTO CHILD SEXUAL ABUSE (IICSA) — FINAL REPORT 2022
The IICSA conducted the most extensive public inquiry into institutional responses to child sexual abuse ever conducted in the United Kingdom. Its final report documents, across multiple institutional contexts — the Church of England, the Roman Catholic Church, the BBC, Westminster, schools, children's homes — the same recurring pattern of institutional failure: intelligence existed; it was not shared; accountability was diffuse; and the governance culture prioritised institutional reputation over child protection. The IICSA findings are one of the strongest documented evidential foundations for the SAFECHAIN™ Architecture of Preventable Harm™ analysis. SAFECHAIN™ Companion: Architecture of Preventable Harm™ (GLOSS-001); PROTO-004; NOM-001; ECON-001.
INFECTED BLOOD INQUIRY — ONGOING (INTERIM AND FINAL REPORTS)
Sir Brian Langstaff's Infected Blood Inquiry is examining the contaminated blood scandal in which NHS patients were given HIV and hepatitis C-infected blood products. The inquiry's documented findings — of institutional cover-up, accountability dissolution, and systemic governance failure across multiple NHS bodies and government departments over decades — constitute one of the most significant bodies of evidence for the SAFECHAIN™ programme's analysis of how institutional cultures that prioritise self-protection over accountability produce sustained, catastrophic harm. SAFECHAIN™ Companion: AUDIT-002 (Institutional Decay Audit™); AUDIT-004 (Remedy Integrity Assessment™); Accountability Dissolution™ (GLOSS-001); NOM-007.
GRENFELL TOWER INQUIRY — PHASE 1 AND PHASE 2 REPORTS
The Grenfell Tower Inquiry documented systemic failures in building safety governance — failures in inspection, in accountability, and in the communication of risk intelligence across institutional boundaries — that produced the catastrophic outcome of 72 deaths. Phase 2's analysis of the governance failures across the supply chain, the regulatory framework, and the responsible bodies is directly relevant to the SAFECHAIN™ analysis of how the absence of cross-institutional accountability architecture produces emergent, systemic failure rather than identifiable individual misconduct. SAFECHAIN™ Companion: DESIGN-001 (Resilience by Design); INTEL-001 (Anticipating Institutional Failure); AUDIT-002; Accountability Dissolution™ (GLOSS-001).
POST OFFICE HORIZON INQUIRY — ONGOING
The public inquiry into the Post Office Horizon IT scandal — in which over 700 sub-postmasters were wrongfully convicted on the basis of faulty IT evidence that Post Office management knew or should have known was unreliable — provides one of the most documented examples of institutional intelligence suppression in UK history. The inquiry's analysis of how the Post Office's governance culture actively prevented accurate intelligence about the Horizon system's failures from reaching accountability scrutiny is directly relevant to the SAFECHAIN™ INTEL-001 analysis of governance drift indicators and the DESIGN-001 accountability by design principle. SAFECHAIN™ Companion: INTEL-001; DESIGN-001; AUDIT-002; GOVERN-001 (Independence of Governance from Preference).
MANCHESTER ARENA INQUIRY — VOLUME 1, 2, AND 3 REPORTS
Sir John Saunders' inquiry into the Manchester Arena bombing of 2017 examined, in Volume 2, the emergency service response — finding significant failures in multi-agency coordination, intelligence sharing, and communication that resulted in preventable deaths. The inquiry's analysis of how the absence of effective cross-institutional intelligence exchange architecture produced failures in the critical first hour of response is directly analogous to the SAFECHAIN™ analysis of how Institutional Amnesia™ produces failures in safeguarding transitions. SAFECHAIN™ Companion: Institutional Amnesia™ (GLOSS-001); NVI-003 (NSIE™); SIS-003 (Continuity Intelligence™); DESIGN-001 (Resilience by Design).
DOMESTIC HOMICIDE REVIEWS — AGGREGATE FINDINGS
Domestic Homicide Reviews (DHRs) are not a single inquiry but a statutory programme — approximately 200 to 250 annually across England and Wales — that collectively constitute the most significant ongoing documentary evidence base for the SAFECHAIN™ programme. The aggregate findings across DHRs, documented in the Home Office's DHR Oversight reports and in independent academic analyses, consistently identify the same structural failures: intelligence existed; it was not shared; the accountability architecture did not make omissions visible; the governance culture normalised the gap between stated standards and actual practice. The DHR evidence base is the empirical foundation for the SAFECHAIN™ programme's five structural failure analysis in PROTO-004. SAFECHAIN™ Companion: PROTO-004; ECON-001; NOM-001; Architecture of Preventable Harm™ (GLOSS-001).
HOW TO USE THIS HUB
Public inquiry reports are available through their dedicated inquiry websites or through the National Archives. SAFECHAIN™ Companion references identify the SAFECHAIN™ publications that engage analytically with each inquiry's findings.
Individual inquiry pages will be added beneath this hub as the Repository develops.
Contact: samantha@safe-chain.org — 'Evidence Repository — Public Inquiries' in subject line.
© 2026 Samantha Avril-Andreassen FRSA. All rights reserved.
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samantha@safe-chain.org | safe-chain.org
The SAFECHAIN™ Evidence Repository™ provides curated access to publicly available evidence sources. All linked materials remain the intellectual property of their original publishers. SAFECHAIN™ claims no ownership over third-party sources. Repository curation, commentary, and framework connections are the proprietary intellectual property of Samantha Avril-Andreassen.