Both the Scottish and UK governments “failed their citizens" by not adequately preparing for Covid-19, the UK wide public inquiry into the pandemic 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 foreseeable”.

It also found Scottish ministers adopted flawed UK government resilience plans without adapting them for Scotland’s needs.

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reams of documentation, planning guidance was insufficiently robust and flexible, and policy documentation was outdated, unnecessarily bureaucratic and infected by jargon.”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

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

She said lessons must be learned because, “unless we are better prepared”, the next pandemic will “bring with it immense suffering and huge financial cost, and the most vulnerable in society will suffer the most.”

She added that the belief that the UK was one of the best-prepared countries in the world to respond to a pandemic was “dangerously mistaken” and in reality, the UK was “ill-prepared”.

She added: “There were serious errors on the part of the state and serious flaws in our civil emergency systems. This cannot be allowed to happen again.”

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, co-ordination and oversight”. Ministers “failed to challenge sufficiently the advice they did receive from officials and advisers”, there was “groupthink” and they did not receive a broad enough range of scientific opinion and policy options.

– Scientific committees advising ministers may have been affected by “groupthink”, there was too little challenge to what was said, experts were limited in what they could advise, and “expert advice on pandemic preparedness was overly weighted in favour of biomedical science”.

– 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”.

– There was no consideration of whether controls at the UK border would work.

– There was a use of “jargon and euphemism to disguise…tasks that had not been completed”, growing bureaucracy within Government and a “failure of leadership to implement solutions”.

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”.

Prime Minister Sir Keir Starmer said in a statement: “The memories brought about by the inquiry will be very difficult for many people. My heartfelt sympathies go out to all those who lost a loved one during that time.

“The pandemic showed us that the backbone of Britain is made up of those committing their lives to service – key workers like carers, nurses, paramedics, cleaners and teachers.

“They put themselves in the eye of the storm, and together with people up and down the country, many of them lost their lives or are still living with the impact of the virus.

“Today’s report confirms what many have always believed – that the UK was under-prepared for Covid-19, and that process, planning and policy across all four nations failed UK citizens.

“The safety and security of the country should always be the first priority, and this government is committed to learning the lessons from the inquiry and putting better measures in place to protect and prepare us from the impact of any future pandemic”.

First Minister John Swinney said: "The Scottish Government will carefully consider the recommendations made by Baroness Hallett in the UK Covid-19 Inquiry report and provide detailed responses to the recommendations within the timescales that have been set out.

“Families across the country lost loved ones to the Covid-19 pandemic, and we offer our deepest sympathies to all those who have experienced pain and grief as a result.

“It is with their loss in mind that we continue our efforts to make effective, practical and measurable improvements in pandemic planning and preparedness.

“The implementation of recommendations will require collaborative action with our counterparts across the four nations, and the Scottish Government is committed to working together, at all levels, in a way which allows us to best prevent, prepare for and respond to future civil emergencies.”

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’.

“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.”