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The Post Office Horizon IT Inquiry
Thursday, 13 October 2022
(10.00 am)
MR STEIN: Sir, good morning. We are about to start the
day's proceedings, are you receiving us loud and clear?
SIR WYN WILLIAMS: II am receiving you but not exactly loud
and clear, Mr Stein. Could you go a little near your
microphone?
MR STEIN: Ican. Sir, ifI may begin.
SIR WYN WILLIAMS: Of course. Can I say that if at any
appropriate moment during your submissions you wish to
take a break, please do so.
Opening statement by MR STEIN
MR STEIN: Thank you, sir.
Sir, as we know, the actions of the Post Office,
Fujitsu, and the Department of Business, has brought
shame and disgrace into the long and previously
respectable history of the Post Office. It seems that
people within the Post Office did everything possible to
protect the reputation of the Post Office and, whilst
doing so, did everything possible to destroy the
reputation of their own staff.
The Post Office broke people. They broke good,
honest, people. Some did not survive.
It's almost impossible to believe that here we are,
ina public inquiry, speaking about the Post Office, the
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was finally exposed in 2019 in the High Court
litigation. That was only as a result of our clients
taking a stand against what was then described as the
nation’s most trusted brand.
Not only did this scandal last for a generation it
touched all four comers of the United Kingdom. In
Northern Ireland, Deirdre Connolly was a subpostmistress
from the town of Strabane in that part of Ireland just
south of Londonderry, on the banks of the River Foyle.
She said it was her “forever job".
In 2009, the Post Office area manager asked her if
she would take on two outreach offices in rural
communities. The people who had been running these
outreach post offices were too afraid to continue due to
the threat of so-called "tiger" kidnappings, and that's
where paramilitaries kidnap the family member of
a subpostmaster to compel them to hand over Post Office
money.
Despite that risk, Deirdre agreed to take on these
rural post offices. She experienced shortfalls in the
Horizon system. She was interviewed under caution by
the Post Office and, during that interview, she was
accused by the Post Office interrogators of giving money
to paramilitaries.
Deirdre says that "The allegation about giving money
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staple of the community, the focus of where people live
near their homes. It's like finding out your
grandmother's a criminal.
Now whilst, of course, this Inquiry will be looking
at the Horizon computer system, it's procurement, its
failures and faults, in truth, this Inquiry is about
human decisions, human fault and human culpability.
Chair, last week we sent our written opening
submissions to the Inquiry.
I don't propose to repeat the detail which we
already set out before you in some 65 pages
Our clients gave evidence before you in the human
impact hearings earlier this year. Those who felt
unable to relive their traumatic experiences through
giving live evidence had key passages read from their
statement read into the record by Mr Enright and myself.
The human impact evidence which the Inquiry has.
received has been powerful and moving and we wish to
acknowledge the bravery of those who have relived their
experiences through the preparation of witness
statements and, in many cases, telling you in person
about what has happened to them and their families.
Itis clear from the Phase 1 evidence that this was
a scandal which went on for 20 years. It started with
the rollout of Horizon in 1999 and continued until it
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to paramilitaries terrified us. We felt ike we had to
pay the Post Office or risk death".
In Scotland, Chris Dawson was a subpostmaster of
Pitlochry sub post office, that's just south of the
Caimgorms National Park. Post Office auditors accused
him of a shortfall of £17,500. Post Office bully boys
interviewed him under caution in his own living room
whilst his wife and child were cowering upstairs.
He was suspended without pay for six months before
being forced to resign. Chris says:
"Llost my livelihood, my business, my marriage, my
home and my reputation. I was a young man of 36 when
this happened, I had my whole life ahead of me. I was
ambitious, I was driven, and all this was taken from me
through no fault of my own."
Mr Dawson's mother went into hospital on the day he
gave his human impact statement but passed away before
she could see his evidence before you and this Inquiry.
In England, Sue Palmer was the post mistress of the
Grange Post Office in Rayleigh, Essex. She was
prosecuted by the Post Office for theft and fraud. She
fought the charges and, after a three-day trial, she was
acquitted. Despite this, she lost her position, her
business and her home and her plight continues.
Sir, in your update report of 15 August, you
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recommended that subpostmasters, mistresses and
managers - and I will use the same term my learned
friend, Mr Beer, did to describe everybody, whether
they're a postmaster or mistress or manager, as
a "subpostmaster". On 15 August, you recommended that
subpostmasters, such as Ms Palmer, who were prosecuted
and acquitted, be provided with an enhanced interim
compensation payment.
Sir, as you will know from our correspondence, thus
far, Ms Palmer has received nothing and, thus far, the
Department of Business has refused to confirm it will
give effect to your recommendation.
In Wales, Pamela Lock operated a post office in
Swansea for 26 years without incident, before the
introduction of the Horizon IT System. Within
six months of the introduction of Horizon, she was
accused of theft and fraud of £31,000. She was
convicted within a year. Her face and name were
plastered across the front page of the South Wales
Evening News. She waited 20 years to have her good name
vindicated finally in the Court of Appeal.
These are not historic cases. The mental health
impacts on the victims of this scandal are ongoing,
Sir, as you're aware, last week my instructing
solicitors, Howe+Co, received a study which has been
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Office has inflicted on our clients is very substantial.
The Post Office, we suggest, must bear this in mind
when apologising personally and locally to each and
every one of their victims, which is something we say
they must do.
Let me turn briefly to the issue of compensation.
The issue of the severity of damage inflicted feeds
into the important issue of compensation for
subpostmasters. Perhaps, with this knowledge of
heightened mental health impacts on our clients, BEIS.
and the Post Office will start to treat the
implementation of the GLO ~ that's the High Court
compensation scheme -- with the urgency that the matter
clearly deserves,
Our clients, sir, firmly believe that it was through
the intervention of the Inquiry and pressure brought to
bear, that BEIS and the Post Office have finally
conceded that the litigants at the High Court were sold
short in a settlement process and should be properly and
fairly compensated.
We wish to place on record the gratitude of my
clients to the Inquiry for bringing this issue forward
and holding the hearings in July of this year. They are
also grateful to you, sir, for the announcement that the
Inquiry will sit again on 8 December this year to
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sent to this Inquiry, undertaken by Professor Richard
Moorhead and his team at Exeter University and you will
recall the submissions that Professor Moorhead made
before the Inquity at the first hearing in November last
year.
The Exeter University team surveyed
101 subpostmasters and subpostmistresses and concluded
that victims of the Post Office scandal experienced
mental health illness symptoms at worryingly high
levels. That's against the general population. They
found that the majority of respondents, that's 67.3, met
the clinical cut-off for post-traumatic stress symptoms
and depressive symptoms, and also reported high levels
of post-traumatic negative cognitions. For example,
views such as "People can't be trusted” or "I have no
future"
What is particularly relevant is that the levels of
post-traumatic stress and depressive symptoms found in
subpostmasters are significantly higher than members of
the UK forces personnel, at 4.8 per cent and
3.7 per cent for PTSD and major depressive order
respectively.
The corresponding figures for frontline workers in
the UK during the Covid pandemic are 2 per cent and
27 per cent. This shows that the damage that Post
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resolve some of the problems that BEIS appears to be
having in giving effect to the recommendations that you
made in August of this year in your update report on
compensation.
Keeping pressure on BEIS and the Post Office must be
done. I read from an email from Deirdre Connolly, dated
only a couple of days ago on 11 October, sent to
Mr Enright, my instructing solicitor at Howe+Co:
“Hi David. The last three weeks have been truly
heartbreaking and frustrating for myself and my family.
After finally hearing the Government telling us we're
getting a payment, albeit only an interim payment, we
saw a light at the end of the tunnel, a tunnel I've been
in for 12 years now. We had, as is natural, thought of
the difference this could make to our lives, especially
now when the cost of living is going through the roof.
To then be told completely out of the blue, not by the
Government but through the JFSA [that’s Justice for
Subpostmasters Alliance] that because someone has now
12 years later deemed my case complex, I am now not
getting any interim payment.
“Then the Government told me that BEIS is in talks
with the Insolvency Department [the same thing, she
thinks] about getting my bankruptcy annulled. Having
been given a date of last Friday, 7 October, that I'd
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get an answer for my bankruptcy to be sorted, then
getting zero correspondence and another weekend of pure
anguish, to finally then be let down once more.
“This is just sapping my mental health. Again and
again, just when I think I'm getting out of this
nightmare it just draws me in deeper. I'm really at my
wits’ end. I can't begin to tell you how much I need
this to be over.”
We know, sir, that the issue of compensation is
going to be monitored carefully by the Inquiry, by you,
sir, and scrutinised as this Inquiry progresses and we
will endeavour to keep the Inquiry updated on the
further obstacles, unreasonable delays or obfuscation by
BEIS.
Nobody, as yet, has been held accountable. Aside
from the issue of compensation, our clients’ greatest
wish is for the Inquiry to uncover who was responsible
for the abuse and suffering that was inflicted on them,
and to have them exposed and brought before the criminal
courts, where, with true irony, they will receive better
treatment than our clients ever did when they were
unfairly prosecuted.
It remains the case that, notwithstanding the
enormity of the scandal, not one individual within the
Post Office has been held accountable, responsible or
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"The question was posed internally at the Post
Office. Given the current media and in particular the
BBC's attention on Horizon, do you think it's worthwhile
looking into this alleged flaw with Horizon that this
subpostmaster has highlighted to pre-empt any enquiries
from his MP2"
Paragraph 218, Mr Justice Fraser went on to say:
"The ultimate response from Andrew Winn of the Post
Office was that the claim could not be investigated
without further details and Fujitsu involvement, that
Mr Winn did not understand the purpose of the call by
the subpostmaster and also stated: 'My instinct is that
we have enough on without people asking us to look at
things’."
Paragraph 219, Mr Justice Fraser continued:
"Mrs van den Bogerd agreed in her evidence before
the High Court that this was an inadequate response.
She said it would have been very easy for Mr Winn to
have contacted the branch and obtain further details and
he should have done so."
Mr Justice Fraser commented as follows:
"In my judgment, the stance taken by the Post Office
at the time in 2013 demonstrates the most dreadful
complacency and total lack of interest in investigating
these serious issues, bordering on fearfulness of what
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otherwise censured. Our clients’ lives and reputations
have been ruined by this scandal. They need to know
that those who are responsible for these tragedies will
be held to account for their actions. That is one of
the ways that this Public Inquiry will be able to afford
a degree of closure to them
Let me turn to the High Court findings by
Mr Justice Fraser.
They are the starting point. The terms of reference
of this Inquiry state that the Inquiry will draw on the
findings made by Mr Justice Fraser from the Bates and
Others v Post Office Limited Group Litigation and, in
particular, no doubt we pay particular care and
attention to the judgment number 3, Common Issues and
judgment number 6, Horizon Issues. You will also be
considering, as we all will, the judgment of the Court
of Appeal Criminal Division in Hamilton and Others.
For example, the judgments of Mr Justice Fraser
refer to the Post Office and its continual efforts over
time to bury of avoid the truth. Briefly, I'l read
from judgment number 6, on 16 December 2019,
paragraphs 217, 218, 219
These paragraphs relate to a subpost master who asked
for an issue, in fact not causing a loss, to be looked
at, believing it to be a Horizon flaw in July 2013:
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might be found if they were properly investigated.”
Mr Justice Fraser was there talking about events
that relate to the evidence of, and concerning matters
that touched, the Post Office and a subpostmaster in
2013. But that is not all.
In judgment number 3 on 15 March 2019,
Mr Justice Fraser confirmed the attitude of the Post
Office even at that time in 2019: paragraph 8. The
different claimants all had different experiences with
Horizon over different periods of time, however there is
at least one common theme: at the time, these accounting
shortfalls that came to the notice of the Post Office
were pursued, yes, as exactly that: shortfalls, with the
relevant claimants.
The Post Office's stance, both then and now, was and
is that the claimants were responsible for these
shortfalls and that the shortfalls represented actual
amounts of money missing from the claimants’ accounting.
Mr Justice Fraser continued and said:
“An alternative way of putting what may amount to
the same point but using the approach of the pleadings
is that the Post Office maintains it is for individual
subpostmasters to prove that the shortfalls were not
their individual responsibility and, failing proof of
that by an individual subpostmaster, then the shortfalls
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were their individual responsibility and the
subpostmaster in question would have to pay the relevant
sum to the Post Office and face the consequences.”
We are not talking about historical examination of
evidence. As the litigation in the High Court only
couple of years ago tells us, the attitude of the Post
Office continued right the way through
Now, the settlement in the Group Litigation
prevented Mr Justice Fraser from ultimately resolving
the degree to which either or both Fujitsu and the Post
Office expressly or constructively knew exactly where
and when. This Inquiry will be considering the
settlement in the later stages of its investigations and
looking at whether the Post Office and BEIS deliberately
and cynically used the prolonged litigation to break the
will of the 555 litigants and therefore empty the
pockets of their investigation funders in an effort to
limit the damage to the Post Office.
The findings of Mr Justice Fraser are vital to this
Inquiry.
Itis important that the institutional Core
Participants understand that a line has been drawn. The
findings made by Mr Justice Fraser are detailed and
comprehensive. They have not been appealed and they
stand as a basis upon which this Inquiry was set up and
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Aujard, in relation to the Mediation Scheme and, when
considering the issues in Phase 5 we consider that
Lord Arbuthnot will be well placed as a witness to
communicate the views of MPs at the time of that scheme,
as well as what they were being told. Sir Anthony
Hooper would also provide helpful evidence to the
Inquiry on such issues.
We also respectfully invite the Inquiry to consider
calling Ms Kay Linnell, the mainstay of the JFSA and who
has worked tirelessly behind the scenes on behalf of
subpostmasters, and we suggest that she would provide
useful evidence in regard to Phase 5.
From the point of view of the litigants we suggest
the Inquiry considers calling our clients Pamela Stubbs,
Elizabeth Stockdale and Louise Dar, all of whom gave
evidence as lead claimants in the Common Issues trial.
Their accounts and the evidence adduced in support of
those accounts were considered in much detail by
Mr Justice Fraser. We suggest that, in calling them,
the Inquiry will be able to build on the findings made
in that evidence with respect to the issues which the
Inquiry must deal with and address but which were
outside the remit of the matters considered by
Mr Justice Fraser.
Let me turn now to deal with three aspects of this
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on which it proceeds. Fujitsu and the Post Office must
understand that any attempt to seek to go behind the
judgments cannot be permitted.
Let me deal with some matters that relate to
witnesses to be called before this Inquity.
We ask that the Inquiry calls evidence from those
who appeared before Mr Justice Fraser, including
Mr Godeseth of Fujitsu, Mr Henderson of Second Sight,
and Ms Angela van den Bogerd, who was the subject of
much criticism at the High Court.
There are a number of other potential witnesses for
this Inquiry who did not give evidence in the High Court
but who played a significant role in the scandal. Our
clients would wish to have questions put to Ms Vennells,
who must bear significant responsibility, we say, for
allowing the scandal to continue and for engaging in
what can only be described as a cover-up.
Our clients wish to hear evidence, oral evidence,
from Dr Gareth Jenkins, whose evidence played
a significant role in the prosecution of subpostmasters,
and whose absence from the list of witnesses called by
the Post Office was commented upon by the High Court
judge in the Horizon Issues judgment.
Sir, as you're aware, we have also asked that the
Inquiry hears evidence from Susan Crichton, Chris
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scandal which are truly remarkable: the abuse of power:
criminalisation of subpostmasters; and the position
taken in the litigation.
Firstly, abuse of power: the abuse of power and
bullying behaviour employed by the Post Office with the
support of BEIS towards subpostmasters and many like
them. The Inquiry has heard in the Phase 1 hearings
that the Post Office deliberately set out to destroy
good reputations, I remind you of Peter Holmes, a hard
working and honest former policeman. They told ~ given
by his wife, Marion Holmes; of course he died.
They told subpostmasters who had been selected by
the Post Office as people of good character that unless
they paid monies which the Post Office knew they were
not owed, they would be prosecuted and imprisoned.
You've also heard evidence in the human impact
hearings that Post Office auditors conducted raids of
branches in full view of customers and how the Post
Office spread rumours in the local press. There was the
divide and conquer strategy, this appears as
an overriding theme in the evidence from the human
impact hearings. This is where subpostmasters were
deliberately lied to and told that they were the only
ones experiencing problems with the Horizon System. We
say the divide and conquer strategy was key to the Post
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Office's campaign against subpostmasters, otherwise it
would have been necessary for the Post Office to justify
its actions on the outrageous basis that hundreds of
subpostmasters who were all persons of good character,
and had been selected by the Post Office on that basis,
had suddenly decided to tum to crime.
The criminalisation of subpostmasters. The second
remarkable aspect of this scandal is the use of the
criminal justice system by the Post Office to
criminalise hardworking people dedicated to serving
their local communities. I represented some of the many
appellants in the Court of Appeal whose convictions were
overturned. Those appeals arose, as you well know, sir,
as a result of a CCRC referral, following the findings
made by Mr Justice Fraser in the Group Litigation.
The judgment of the Court of Appeal is dated
23 April 2021, three of the appellants, including
Mr Holmes who I've just mentioned, did not live to see
the outcome of his appeal and died before their names
and reputations were cleared.
Chair, we know that you followed and indeed attended
that appeal. You will recall that the Post Office
conceded that it had failed to disclose to
subpostmasters the existence of 30 bugs, errors and
defects on the Horizon System and had inadequately
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bugs and errors encountered in the system were common.
Their evidence tells us that because those bugs and
errors were so prevalent, the subpostmasters had to
routinely cope with them by adding their own money to
make the system balance. You will recall the evidence
that this meant that many had to borrow money from
friends, family or loan sharks.
The evidence from our clients also tells us that the
helpline was useless, often knowing less than the
subpostmasters. Our clients were told that the Horizon
System was fine and, if there was missing money, it was
their fault and their responsibility to make up for the
loss and make it balance.
Subpostmasters, who had worked at their branches
before the installation of the Horizon System, said that
these errors and balancing issues did not happen before
Horizon.
So where were all these errors and bugs coming from?
What within the Horizon System was going wrong? The
High Court never had the chance to establish all of the
bugs and didn't hear from all of the witnesses as the
matter never went to a final resolution. But our
clients have given evidence before you and they provided
solid evidence of multiple bugs and errors. Is it
really the case that Fujitsu are saying they weren't
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investigated its own data.
Post Office conceded that convictions were unsafe
because the trial process had been unfair.
Significantly, the matter did not end there. The Court
of Appeal also found that the evidence, together with
Mr Justice Fraser's findings, showed that it was
an affront to the public conscience for the appellants
to face prosecution. This category of abuse of process
forms an exceptional class of case and findings of this,
highly serious type of abuse are so rare as to make
hens’ teeth near commonplace in comparison
So it is absolutely right to say that the
convictions of subpostmasters and many others, such as
Mr Holmes, Mr Darlington, Ms Lock, Ms White, so many
others, are part of the worst miscarriage of justice in
British legal history.
Sir, as you know, I have some experience working in
public inquiries. There's a tendency, I suggest, with
public inquiries, to sympathise with accounts given by
victims, to feel very sorry for what has happened to
them and what has been brought to their door. That
sympathy, on occasions, can sometimes cloud the
consideration of their evidence. We need to remember
the evidence from our clients tells us collectively and
over the time of the Horizon System's operation that
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aware of it and that they truly did not know about them?
Did they get worse after the Horizon System was in
‘operation for some time?
It seems possible that part of the answer to these
questions might be that the postmasters did report them
but not all of them because the helpdesk was designed to
put them off and told them it was their fault and they
must pay up. Once you're told that repeatedly, imagine
the effect.
Other questions arise from our clients’ evidence in
the earlier phase's hearings. Why would some
subpostmasters have big errors and some have small
errors? Well, the Horizon System doesn't make
decisions. It doesn't decide to make the error high for
one person and not another. It's a machine. For some,
sometimes the error will be small enough but would mount
up into thousands and, for other subpostmasters, the
error would be thousands in one time.
Let me now turn to the Simon Clarke Advices and I'll
also be mentioning the advices and reviews conducted by
Mr Altman, King's Counsel
Asa result of the Simon Clarke Advice or Advices,
the Post Office did stop prosecuting and, because there
was then no police involvement and no CPS oversight,
there was no formal investigation, in that sense, into
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what happened next.
Now, this is part of the effect of what happens when
the Post Office is its own prosecutor. The Post Office
prosecutors, the Post Office experts, had been aware
that subpostmasters said the system was in error. I am
going to take you, sir, to some quotes from the Simon
Clarke Advice of 15 July and hopefully we can have it on
our screen, POL00006798 at page 2, paragraphs a to d.
Mr Clarke in this advice on 15 July set out ~ this
is his description of the generality of what was being
encountered by the Post Office prosecutors, by the Post
Office expert witnesses, working at Fujitsu. What he
said was this:
"The defendant will raise issues attacking Horizon,
suggesting in general and often ill-defined terms" —
Sir, do you have this on the screen?
THE CHAIRMAN: Yes, I do. Sorty about the delay but I keep
myself mute in case there's some background noise. But,
yes, I do.
MR STEIN: I'm grateful. Mr Clarke described what was known
by the prosecution, by Fujitsu and the Post Office.
He's talking about what has happened in the currency of
previous prosecutions and what has been raised in the
past. This is set out on that page at paragraphs
atod
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issue when trying to balance, that post masters,
postmistresses and managers could not explain. The
issue -- so very well described by my learned friend
Mr Beer, King's Counsel, yesterday -- of training is
writ large upon this matter as well: the inadequacy of
training, the inadequacy of the helpline.
Although Dr Jenkins, and others, was in a position
to consider what so many of the people who were being
prosecuted were saying, fatally, he was Fujitsu to the
core. He was not even remotely an independent expert
witness. Again, from the Simon Clarke Advice from
15 July, so same reference, please, ending in 6798,
page 14, paragraph 14.
I can’t see on my page, is that page 14,
paragraph 14? ll read the quote instead, sir.
Mr Clarke set it out this way:
“For many years, both RMG and latterly the Post
Office has relied upon Dr Gareth Jenkins for the
provision of expert evidence as to the operation and
integrity of Horizon. Dr Jenkins describes himself as
an employee of Fujitsu Services Limited and its
predecessor company, ICL, since 1973. He holds a number
of distinguished qualifications in relevant areas. He
has worked on the Horizon project since 1996. He is
accordingly a leading expert on the operation and
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“The defendant will raise issues attacking Horizon,
suggesting in general and often ill-defined terms that
the shortfalls giving rise to prosecution are
inexplicable and thus must rest with Horizon. Here the
defendant does not specify the Horizon failing, he or
she merely asserts that because they did as they should,
the system itself must be at fault;
"b. An express assertion that Horizon has failed in
some way:
“c. In admitting Fraud or False Accounting (but NOT
theft), that either a or b above is true, their
culpability being limited to the covering-up of
otherwise inexplicable losses rather than revealing what
is a genuine (on their account) problem to [the Post
Office]. Here the issue is that of sentence, Judges
being required to consider the quantum of losses when
determining the appropriate punishment.
"d. Inall three of the scenarios noted above,
a defendant often complains of a lack of training on
Horizon and/or inadequate customer suppor.”
The Post Office, the Post Office prosecution team,
Fujitsu, Fujitsu's experts, all had consistently, from
people that were being prosecuted, the ingredients of
things that were going wrong, inexplicable losses from
a Horizon system that was riven with bugs, that caused
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integrity of Horizon."
Dr Jenkins is a true Fujitsu, Pathway, Horizon
insider, not even remotely independent.
Sir, you heard from my learned friend, Mr Beer,
yesterday in reference to two points that he detailed
and indeed showed on the screen. I'll give you the
reference but read you the quotes. The same advice from
Mr Clarke, ending with the number 6798, page 13,
paragraph 38, and I'l only read the top two bullet
points.
Mr Clarke set out the fact that Dr Jenkins failed to
disclose material known to him but which undermines his
expert opinion. This failure is in plain breach of his
duty as an expert witness. "Accordingly", Mr Clarke
went on to say:
"Accordingly, Dr Jenkins's credibility as an expert
witness is fatally undermined. He should not be asked
to provide expert evidence in any current or future
prosecution."
But, sir, as you are aware, this is not all that has
been written about the position left after the Post
Office had been made aware by Mr Clarke about the
serious issues concerning Dr Jenkins. Mr Altman, King’s
Counsel, advised the Post Office from 2013 and he also
represented the Post Office in the Court of Appeal as.
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regards the criminal appeals.
Now, he set out his conclusions in the review dated
31 October 2013. I'll read the reference and ask for it
to goon the screen please. It's POLO0006358, page 39,
paragraphs 105 and 106. I'm grateful
Just as a reminder, this is October 2013, Mr Altman,
King's Counsel:
"It may be thought that POL's prosecution role is,
anachronistic, and highly problematic in light of recent
events. Its prosecution role today is certainly based
upon the historical protection afforded to the mail,
which I assume was itself founded upon the historical
importance of protecting an important means of
communication and commerce. The role today is couched
in terms of guardianship, and the protection of assets,
integrity and reputation."
We may want to remember those words:
"However, the recent events have to be seen in their
proper context. The serial non-disclosure of relevant
material occurred in circumstances in which POL asserts
that it and its advisers were wholly unaware that there
might be disclosable material or information, and so,
whatever the reason, were not placed in a position
whereby they knew of its existence and could deal with
it appropriately."
25
Office, who haven't set out their position on such
matters.
What we do know is that the Fujitsu experts and
staff members were uniquely placed to consider and
investigate what was wrong with the system. The Post
Office investigators, the Post Office prosecutors, they
also knew, and the Post Office knew, from repeated
information from the subpostmasters, that the system did
not work properly but no one listened.
The subpostmasters were saying, the people who were
prosecuted were saying, "This system is buggy, we can’t
explain it". This a cohort of people saying that they
don't know what's going on, that there's a problem with
the Horizon System; no one listened.
For years and years after Mr Clarke and Mr Altman,
King's Counsel, had set out their views about Mr Jenkins
and bugs within the system, the Post Office preferred to
pretend that the Horizon System was fine and fought the
High Court case on that basis
That's despite the advice from Mr Clarke, underlined
by Mr Altman, King's Counsel, that Dr Jenkins's
evidence, Dr Jenkins's credibility as an expert witness,
is fatally undermined, and, as Mr Clarke went on to say,
he, Dr Jenkins:
"... should not be asked to provide expert evidence
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2013, Mr Clarke and Mr Altman, King’s Counsel, were
warning about the dangers of any possible reliance upon
Dr Jenkins. They were making sure that the Post Office
understood the nature of this calamity.
What should the Post Office have been done at this
stage? What should have been the advice to the Post
Office at this particular point? Do any of us think
that the answer from the Post Office at this stage is to
carry on denying that there is anything wrong with the
Horizon System, as they did at the High Court? Or
should the Post Office have done what anyone else should
have done, let alone a respected, public institution,
which is called the police?
We also wonder whether the paragraph, paragraph 106,
where Mr Altman is setting out, no doubt from his
instructions, that serial non-disclosure of relevant
material occurred in circumstances in which the Post
Office asserts that it and its advisers were wholly
unaware that there was disclosable information. Does
that set up what we are going to hear through this
Inquiry: the Post Office casting blame upon Fujitsu and
no doubt an internecine war backwards from Fujitsu to
the Post Office saying "Yes, they did, they knew all
about it, it was their decisions?" Well, we are not
helped by the written submissions made by the Post
26
in any current or future prosecution."
Well, that's pretty clear, isn't it? That should
put paid to any input that Dr Jenkins should have in any
proceedings in the future. Butno. The Post Office
chose to use his evidence as a source of evidence before
the High Court. Let's just pause to remind ourselves.
Mr Justice Fraser was not in a position to know,
understand, think about, take into account, what was
being said by Mr Clarke or indeed Mr Altman. That was
not before him
Judgment number 6, paragraph 509, the judgment of
Mr Justice Fraser:
"When the Post Office served its evidence of fact
there was no witness statement from Mr Jenkins, although
many of their witnesses relied upon him as their source
of information. He was referred to very often, and he
obviously knew a great deal about Horizon."
It is clear, we suggest, Mr Clarke and Mr Altman,
must be called before this Inquiry. We need to hear
from them what they were told, what instructions they
had, what material they were provided with over the time
of their involvement with the Post Office and their
reviews and advices as regards evidence. We need to
know why it was, at the Court of Criminal Appeals, there
had been disclosure of the Clarke Advices but, as far as
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we are aware at that stage, not disclosure of the
reviews or advice from Mr Altman, King's Counsel, who of
course was prosecuting or responding on behalf of the
Post Office at the Criminal Court of Appeals.
So what does this mean? Well, no one, not Second
Sight, not Mr Justice Fraser, no police investigation,
no one before this Inquiry has ever heard of the extent
of the complaints about the Horizon System that you have
heard. Fujitsu: did they want to know? Did they want
to listen? Has this been in part the effect of the
PFI — the private financial initiative model ~ putting
all design, installation and running of the system upon
Fujitsu, also upon Fujitsu to bare any costs arising?
For the Post Office, is this all about the fact that
it cared about only one thing, which is protecting its
own image? The effect during the time of the worst
parts of the Horizon System's operation was not only
were people prosecuted through the criminal and civil
courts but that the bugs were allowed to continue,
unresolved, leading to more and more subpostmasters
being put through the same wash cycle time and time and
time again
We also need to know and we need to discover, not
just that people within the Post Office deliberately
concealed the truth from their own staff and the courts
29
should have led to a thorough nook and cranny search
through every box and every available amount of
information that could possibly bear upon these issues
That is why the reaction from our clients to the
failures in disclosure that have been discussed earlier
this week does not surprise a single subpostmaster. But
it requires analysis and the obtaining of all of the
missing material because it has the capacity to show
that the Post Office is simply continuing on with its
contemptuous behaviour. In other words, we ask this
Inquiry to consider these failures and recent failures
in disclosure not only to find out and establish what
the material is, but to consider evidentially what it
tells us about the Post Office in 2022
Touching upon one matter that appears in the opening
statement on behalf of the Post Office, and I'l read
its Relativity reference, SUBS0000005, I don't ask for
this to go on the screen. Reference is made in this
document on behalf of the Post Office, dated 4 October,
paragraphs 11 and 12:
“In addition to action points relating to
allegations against specific individuals, POL has
carried out, or is in the process of carrying out.
internal investigations and reviews of contemporaneous
documents to verify other broader points raised by Human
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for many years but what did BEIS know about this, what
did UKGI know about their investment in the Post Office
and how it was operating? What were ministers told,
what were the MPs told? What information was being
released?
Yesterday we heard from Mr Beer, King’s Counsel, in
reference to various points of advice being given from
eminent jurists, Lord Neuberger was mentioned.
Perhaps the Post Office needs to leam, as so many
people do in the police station, that advice is only
advice. If you know what you're doing is hurting
people, the people that trust you, that think that you
might be there to look after them, if you know that
that's what you're doing, you think very carefully about
taking legal advice. You may think, therefore, sir,
that it is incredible important to know what the lawyers
were told, what information they had on which they could
base their advice and, if they got it wrong, then they
need to come to this Inquiry and accept that fault also
lies at their door.
So, of course, you'll have appreciated earlier this
week, we do take exception on behalf of our clients to
the fact that the Post Office has yet again, we suggest,
been seeking to keep back evidence, that they must have
appreciated, since the very first Clarke Advice, that
30
Impact witnesses. These include, for example, alleged
conduct by Fujitsu
"POL anticipates that the outcome of a number of
these investigations will be relevant to forthcoming
phases of the Inquiry and it will, of course, be
disclosing all relevant information and outcomes in that
context."
Sir, the Post Office is saying that it is genuinely
going to investigate and be carrying on investigation
alongside this Inquiry. We respectfully ask this
Inquiry to ensure that it maintains a careful overview
of what is going on with the Post Office's
investigations. We respectfully ask this Inquiry to
establish what investigations are currently ongoing,
against whom, about what and when will be the delivery
time.
We ask, sir, that you take this step because we can
see, we respectfully submit, what is going to happen
otherwise. Witnesses may be called that are subject to
investigations that we don't know about, reports or
investigations information provided late and too late
for this Inquiry to see such material and consider it
properly.
Sir, as you know and as I've already said,
Dr Jenkins and other members of his team at Fujitsu
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should be called, statements taken from counsel,
solicitors who acted in the High Court matter, as well
as Mr Altman, who gave advice and reported internally to
the Post Office.
We probably don't need to underline this point any
more but let's just turn, for a moment, to paragraph 512
of the Horizon Issues Judgment. It's always worthwhile
remembering the dates of these judgments. This is not
long ago. Mr Justice Fraser said this ~ this about the
failure to call Dr Jenkins, paragraph 512:
"This explanation by the Post Office included the
following passages in its written submissions [internal
references, page 144, the claimants]. The claimants
understandably complained that Mr Jenkins and the other
source of Mr Godeseth's information could have given
some of this evidence firsthand. However [and refers to
a paragraph 114.1], taking into account that
Mr McLachlan's evidence specifically addressed things
said or done by Mr Jenkins in relation to the Misra
trial, Post Office was concerned that the Horizon Issues
trial could become an investigation of his role in this
and other criminal cases."
What was being put forward by the Post Office was
an excuse as to the reasons why Dr Jenkins was not
called in the High Court case. They were not saying
33
phantom sales which emerged as early as 2000 and which
Royal Mail engineers had tried to rectify. Yet the Post
Office, apparently unquestionably, accepted Fujitsu's
views there was no fault in Horizon and the explanation
lay in operator error.
Mr Justice Fraser also found that there had been
problems with Horizon from the outset and that there
were 22 bugs which had caused lasting impact, in
particular the RPM bugs, receipts and payments mismatch
bug was the subject of a 2010 note produced from a
meeting attended by both Fujitsu and the Post Office, in
which it was accepted that it could potentially
highlight to branches that Horizon can lose data.
Mr Justice Fraser went on to say this:
"In reference to the material in that note, the
identified risk was that there were huge moral
implications to the integrity of the system, as there
are agents that were potentially due a cash gain on
their system.”
That's from the Horizon Issues judgment at
paragraph 49; "huge moral implications to the integrity
of the business", 2010.
Itis absolutely clear that the Post Office was
aware of the failings in the Horizon System and
approached the civil litigation in the same matter as it
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that they had every good reason to distrust him. They
are not saying that they believe his credibility is
damaged and dented by revelations made to Mr Clarke.
They are not saying that Mr Altman has advised that
there are real issues with Dr Jenkins, his credibility
and the POL investigation team. That's 2019.
What instructions were given to which lawyers, to
which parts of the counsel team, so that these matters
were put forward? It seems entirely possible that
individuals within the Post Office conspired to pervert
the course of justice by giving factually incorrect
instructions to their lawyers. This is an extremely
serious issue which the Inquiry should consider.
The position taken in the Group Litigation
The third aspect of this scandal which sets it apart
from all others is the conduct; of the Post Office in
the Group Litigation. Mr Justice Fraser described the
litigation as "bitterly contested". Throughout the
litigation, Post Office maintained that the Horizon
System was robust and that none of the 555 claimants had
experienced shortfalls or discrepancies in their
accounts as a consequence of Horizon.
However, the findings in the Horizon Issues judgment
show that the Post Office's position before the court
was untenable. For example, there were reports of
4“
approached complaints by subpostmasters concerning
Horizon, with the primary objective of defending a lie.
The conduct of the Post Office is all the more
reprehensible because these were the actions of
a publicly owned body using public money to defend the
indefensible and maintained that it was entitled to
inflict the most appalling harm to innocent hard working
subpostmasters and their families. So why was the Post
Office so fixated on maintaining the lie in the Group
Litigation and denying entirely justified claims for
‘compensation?
Who within the Post Office has made the decision to
spend, reportedly, over 70 milion, a figure we draw
from the Post Office annual and consolidated financial
statements of 2020/21, that money being used to fight
the High Court litigants with so much energy?
SIR WYN WILLIAMS: Sorry, Mr Stein in the written
submissions, which I have before me, I think you use
a figure of 20 million
MR STEIN: We did, sir. We have looked at this and we
checked it and this is why we went to the Post Office
annual reporting consolidated financial statements. In
fact, I'm grateful for you drawing our attention to that
again because we would like to correct that to that
figure.
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SIR WYN WILLIAMS: That's fine. Thank you.
MR STEIN: I'm grateful, sir, for you raising it.
Who within the Post Office decided that it was
a good idea to make an application to the Court of
Appeal to recuse Mr Justice Fraser on grounds of
apparent bias? Well, we heard something yesterday from
Mr Beer about that: an application that Lord Justice
Coulson described as “absurd”. We will need to consider
the circumstances of the advice from Lord Neuberger and
what he had been told or not been told.
Sir, we have made detailed representations in on the
upcoming Phases 2 to 7 in our written submissions. Now
clearly, at the moment, such detail as we would like to
get to is limited, as this Inquiry is disclosing
matters, to an extent, in phases and we cannot get yet
to the extent of detail we would like. But what we do
50, overall, is that subpostmasters' lives have been.
very badly affected, as you know, and the public are
entitled to know who knew what and when.
We note that under paragraphs 12 to 14 of the Post
Office shareholder relationship framework, the Post
Office were required to provide quarterly updates to
BEIS's representative on any active litigation and any
threatened or reasonably anticipated litigation. So
BEIS should have been aware of these issues. Currently,
37
SIR WYN WILLIAMS: Fine
MR STEIN: The Phase 2 evidence demonstrates that the
Horizon project was blighted from the outset. It was
over ambitious in terms of the technology available at
the time and poorly thought out.
A Parliamentary Select Committee found in 1999 that
the project had effectively been a financial quagmire
and, after the withdrawal from the Benefits Agency that
year, regarding the restoration of the scheme, they said
the impression was of an essentially political deal to
ensure that ICL has a substantial contract with the Post
Office at a price which seems to have been largely
determined in advance of contractual negotiations or
renegotiations, as a means, however, inadequate of
making up some of the £180 million written off by ICL in
their ‘98/99 accounts. That's the House of Commons
Trade and Industry 11th Report
You will isten with interest, we suspect, to the
evidence of Mr Roberts and other witnesses. Mr Roberts
was a CE, chief executive, of the Post Office. I'll
give his statement reference and paragraph reference,
but don't ask for it to go on the screen. WITN03390100,
and the reference is at paragraph 17.
He refers at that point to the fact that, in his
view of what he could see, the Benefits Agency did not
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we note there are a number of directors who are stil in
place who were appointed well before the High Court
action.
Now, putting aside the question of whether the Post
Office should still have directors in place who are
party to decisions made within the High Court action,
the Inquiry should discover what those directors had
been told, what decisions were they party to and what
did they know or not know?
The past directors of the Post Office should be
asked these and many other questions.
Now, sir, 'm going to turn to some points we make
regarding the individual phases. I note the time is
11 o'clock. Sir, if we can have a short break now, I'll
be very grateful.
SIR WYN WILLIAMS: Yes, certainly. Is ten minutes enough,
Mr Stein?
MR STEIN: Yes, thank you, sir.
SIR WYN WILLIAMS: Allright then, 11.10, everyone. Thank
you very much
MR STEIN: Grateful.
(14.01 am)
(A short break)
(14.10 am)
MR STEIN: Sir, if you're ready I'l restart.
38
want Horizon and they instead wanted to move to ACT,
Automated Credit Transfer, instead.
What had happened to the position in relation to the
negotiations to advance Horizon when, in fact, the
Benefits Agency is said to have long wanted to move to
a different type of system entirely?
The Horizon scheme was never robust. It should have
been abandoned after the Benefits Agency withdrew. It
is, we suggest, no accident that a pared down system,
with the financial burden resting upon Fujitsu Pathway,
meant that the system was going to lose functionality.
Itis no accident that there was no dispute button or
function for subpostmasters built into the Horizon
System
What did the auditors, who were charged with
investigating shortfalls in subpostmasters branches,
often and too often doing so in a thuggish manner -- did
they have anything near the requisite levels of
technical knowledge to make informed decisions about the
system?
Mr Cipione, who is going to be the first witness in
Phase 2, will no doubt confirm what he says in his
report. I'l give the reference, I again don't ask it
to go on the screen: EXPG0000001. Mr Cipione states in
his report that there were conflicting intentions of the
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Post Office and Pathway and that let to disruptions at
management levels and that affected the implementation
of the Horizon IT System.
Importantly for our clients, Mr Cipione refers to
poor training and lack of support from the helpdesk as
self-inflicted wounds, that’s at paragraph 1.1.9 at
page 5 of his report.
He says that recurrent balancing problems
experienced by subpostmasters directly degraded the
accounting integrity of the Horizon IT System,
paragraph 1.1.9, again at page 5.
We, of course, note that his report looks at issues
primarily up to the year 2000 but not beyond that year.
It's significant, therefore, to remind ourselves that
you have heard the evidence in statement form and
evidence lies before you of so many subpostmasters who
explained their experience with Horizon after the year
2000.
Sir, the problems manifested themselves from the
pilot scheme from the very outset. In summary, we
suggest that Horizon was always deeply flawed. It was
procured as the cheapest option to the Government within
the overly-ambitious Pathway programme.
After the withdrawal of the Benefits Agency and
after the scheme was leff to limp onwards, it was rolled
1
she should contact the helpline for any help or advice
on any issues experienced at the branch.
Let me turn to the helpline. The helpline was
unable to assist subpostmasters when they reported
shortfalls. Mr Abdulla, another lead claimant who gave
evidence in the common issues trial, gave evidence on
this point before that court, and said that he would
contact the helpline about six or seven times a month,
and was shocked at the inadequate support.
He would often experience shortfalls on the days
when he would perform balances but could rarely get
through to the helpline on these occasions. He thought
the advisers were ill-informed, and would often give the
impression of reading off a script. Even his area
manager could not help and he was told by his area
manager that he should just pay the shortfalls and wait
to see if transaction correction was issued in his
favour.
You will be interested, sir, we respectfully
suggest, in the question of whether there was a script
for the helpline advisers. Did they have standard
answers? What did those answers contain? What was the
motivation behind them?
Those scripts if they exist, or directions or
guidance in whatever form should be considered, if they
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out to unsuspecting subpostmasters, after a number of
errors and defects had been identified in the pilot
period.
Quite simply, we say the evidence shows, as a whole,
that Horizon was not fit for purpose when it was rolled
out. You've heard the evidence from what happened from
the subpostmasters' perspective and the way that the
system worked thereafter.
Witnesses from Fujitsu may seek to maintain
otherwise but that position, in the words of Mr Justice
Fraser, would be the 21st century equivalent of
maintaining that the earth is flat.
In Phase 3, the Inquiry will consider the issue of
training. Sir, you have heating very many accounts of
subpostmasters in the hearings to the effect that the
training that was given on Horizon was woeful
(One example arises from the Group Litigation.
Pamela Stubbs, whom we represent, gave evidence in the
High Court on the extent of training that she and her
assistants had received. She had one day of training in
‘a pub, about two weeks before Horizon was installed in
her branch. Her assistants each had half a day. The
training did include balancing for her but did not
included shortfalls or how to get to the root cause of
them or how they could be disputed. She was simply told
42
can be found, and evidence taken from helpline advisers
as to what it was that they would say and how they would
deal with matters, what training they had.
It emerged in the Common Issues trial that the only
way a subpostmaster could dispute a discrepancy was via
the helpline. Importantly, it came out in the Group
Litigation that if a subpostmaster decided to settle
centrally ~ and sir, you will recall hearing about that
matter from Mr Beer yesterday ~ if a subpostmaster
decided to settle centrally, the disputed sum was
treated by Post Office as a debt owed to Post Office by
the subpostmaster. It would then be subject to debt
recovery procedures
So the only route to challenge Horizon was through
the helpline but the helpline did not offer advice in
away that enabled dispute to be resolved. Elizabeth
Stockdale and Pam Stubbs gave evidence before Mr Justice
Fraser on the failure of the helpline to investigate
disputed shortfalls
The procedure adopted by the helpline was simply to
do nothing, and Mr Justice Fraser said this at
paragraph 558 in the Common Issues judgment:
“It is therefore the case that on the evidence
before me the helpline did not operate for the lead
claimants in the manner that the Post Office contended
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for.
What was presented to the court by the Post Office,
in respect of disputes notified to the helpline, show
that, for the first part, initially the subpostmaster in
these individual cases was told they would have to pay
the shortfall. Even when persistent, all that would
happen is the sum would be settled centrally and, after
a period of weeks, the subpostmaster would be chased by
the Post Office for that sum as though it were a debt.
There is a pattern, we suggest, in the evidence that
shows that the helpline may have been deliberately
obstructive.
Now, Mr Cipione states in his report, that the
support system theoretically had three levels through
Which help could be provided to a subpostmaster but the
evidence from the subpostmasters is that they only got
to the first level and they weren't aware, except in
very rare occasions, that there were other levels on
which matters could be pursued
A stark feature of the human impact hearings was
evidence of the seemingly routine practice of telling
subpostmasters that they were the only ones who had
experienced shortfalls. This seems to have been
a centrally coordinated approach. Immediately after the
judgments had been handed down in the criminal appeals,
45
Our clients hope that there is some sort of
explanation to account for what appears to be a union
who is dancing to the employer's tune.
If I can turn to the knowledge and rectification of
errors in the system.
The Inquiry will consider the issue of knowledge and
rectification in relation to the errors in the system,
and this arose, of course, in the Group Litigation,
where the court considered a large number of PEAK
reports. Sir, as you know, PEAK reports, the previous
version of those were PinICLs, and PEAK reports and
PinICLs were then put into KELs, discussed by my learned
friend, Mr Beer, yesterday
Now, these are reports within the system, within the
Horizon System, of technical and error issues.
The evidence in the Group Litigation demonstrated
that Fujitsu and the Post Office knew that
subpostmasters were not responsible for shortfalls.
Mr Justice Fraser noted number of unguarded comments
including from Anne Chambers, a Fujitsu employee, who in
February 2006 stated "This problem had been around for
years and affects a number of sites for most weeks.
This appears to be a genuine loss".
Our clients’ position is that the Post Office and
Fujitsu knew the true position all along but had failed
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I recall very well speaking to an appellant who, in
tears, was repeatedly saying, "I thought I was the only
one".
If can tur to the position of the NFSP, the
National Federation of SubPostmasters.
Of course, another way that subpostmasters could
have challenged the alleged shortfalls and discrepancies
was through the support of their union. However, in
this case, perhaps uniquely, the union sided with the
employers rather than its own membership. At
paragraph 368, Mr Justice Fraser said:
“Itis obvious in my judgment that the NFSP is not
remotely independent of the Post Office nor does it
appear to put its members’ interests above its own
separate commercial interests.”
This is an appalling state of affairs for any
representative body.
You will recall that our client, Wendy Martin, has
stated she received enormous help from the Communication
Workers Union, of which she wasn't even a member.
Ms Martin's evidence of the support provided from the
CWU, the Communications Workers Union, and that of other
witnesses, brings out the contrast between a genuine
union and an organisation who appears to be in the
pocket of the employer.
46
to act and that is what the High Court findings show.
Another issue that arose in the Group Litigation
concems audit data. It has always been possible for
the Post Office to check what a subpostmaster had done
because Fujitsu held complete and accurate record of all
key strokes made by a subpostmaster or assistant when
using Horizon. This is known as an audit or ARQ data.
Yet it was established in the evidence in the Group
Litigation that the Post Office did not consult ARQ data
and we need to consider that within these hearings. Is
that right?
The ARQ data, the very evidence that would have
satisfactorily have resolved disputes potentially when
deciding how to deal with discrepancies and issue
transaction corrections, TCs, and when responding to any
complaints about Horizon System
Is it possible that the Post Office failed to use
audit data because of charges raised by Fujitsu for
access to such information? We say that the Post Office
were happy to require subpostmasters to make good
apparent shortfalls in the knowledge that the
discrepancies were caused by the Horizon System because
the Post Office had an incentive, it seems, to avoid
paying Fujitsu to investigate or rectify errors causing
shortfalls.
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Sir, you're also aware that, in the Group Litigation
it became very clear, as decided by Mr Justice Fraser,
that Fujitsu could remotely insert a transaction into
the accounts of a branch using a counter number which
was the same as the counter number actually in use by
the subpostmaster or an assistant. This would appear to
the subpostmaster from the records that they could
see -- and anyone looking at those records -- as though
the inserted transaction had been performed in the
branch itself.
This is another matter which we ask the Inquiry to
investigate thoroughly. Was this evidence disclosed
within the criminal proceedings? What would have been
the effect upon advice given to a subpostmaster if it
had been known and understood within criminal
proceedings or civil litigation that, actually, the data
could be changed in a way that made it look like the
branch did it?
Phase 4, we'll be considering the actions against
subpostmasters and others. The conduct of POL, the Post
Office, in taking actions against subpostmasters, was
oppressive. The Post Office was unrelenting in pursuing
subpostmasters for shortfalls which it knew were caused
by Horizon. In the period from April 2013 to June 2018,
the number of subpostmasters who were suspended was 626.
49
Stockdale's documents after she had been suspended and
it even refused to give any documents to one of their
auditors who was investigating a shortfall claimed by
Mrs Stockdale
In addition to the rate of suspensions and
terminations, the Post Office prosecuted subpostmasters
at an alarming rate. Mr Beer, King's Counsel, told the
Inquiry in February that between 2000 and 2015, the Post
Office brought a total of 844 prosecutions, resulting in
705 convictions. Sometimes, the Post Office brought
POCR proceedings, going after what they are suggesting
is the money lost, claims against those convicted,
allowed to seize assets and bankrupt people.
As to civil proceedings, many subpostmasters were
made bankrupt through the Post Office taking actions for
recovery of the apparent shortfalls. Many
subpostmasters remain bankrupt today as a consequence of
these actions and enforcement taken through civil
judgments by the Post Office.
Were these actions taken as part of a cohesive
policy against subpostmasters by the Post Office?
Certainly it seems that those actions were applied on
a uniform basis throughout the Post Office. Some of the
procedures described emanated from the modified
subpostmaster contract.
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This equates to about ten subpostmasters being suspended
per month. Mr Justice Fraser found, amongst other
things, the Post Office frequently misrepresented the
subpostmasters' liability for losses when demanding for
apparent shortfalls.
There is also the question of whether subpostmasters
were permitted legal representation by the Post Office
when they were interviewed in connection with alleged
shortfalls. Were they denied legal representation at
that time because that's what it appears? They were
certainly not permitted access to information conceming
the allegations that had been made against them. They
were allowed to take friends with them but if that
friend, I quote, "interrupted in any way, by word or
signal, they would be required to leave". Bizarrely,
the Post Office justified these procedures by relying on
the Official Secrets Act.
The Post Office appears to have sought to cover up
its actions even at the point of suspending
a subpostmaster. For example, Mr Justice Fraser
accepted the evidence of Pamela Stubbs that the
temporary subpostmaster who replaced her was told to
destroy all documentation in the branch that related to
her appointment. Mr Justice Fraser also found that the
Post Office had deliberately destroyed alll of Elizabeth
50
Is it possible that Post Office had a policy or
policies which directed these actions being taken
against subpostmasters?. We ask that we keenly consider
the question of whether policies exist and their
disclosure, if they do exist, within the Phase 4
hearings, and who is responsible for creating such
policies, guidance or documents that relate to the way
that matters are taken against subpostmasters.
Of course, we anticipate that the culprits might not
be forthcoming in disclosing material, which might be
considered reputationally damaging. That, again, is one
of the reasons why we are more than keen that this
Inquiry is rigorous, as you have said you will be, in
ensuring that the Post Office, BEIS and Fujitsu comply
with any request made of them.
I turn now to Phase 5. Our clients were involved in
the Mediation Scheme and believe that the breakdown of
this process marked at least one part of the Post
Office's cover-up. Itis possible to consider that the
cover-up might be seen as the greater scandal than the
IT failure. The Post Office realised that they have
known about the defects in Horizon for years and tried
desperately to prevent that knowledge from ever becoming
public
In July 2012, the Post Office came under renewed
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press interest and pressure from a group of MPs led by
James, now Lord Arbuthnot. Consequently, the Post
Office met with group of MPs and agreed that
an independent firm of forensic accountants should be
appointed by the members of Parliament to conduct
an independent assessment of Horizon, and the Post
Office agreed to fund the process. This led to the
instruction of Second Sight.
The partners in Second Sight specialised in banking
fraud and IT systems so, in fact, were a good fit for
the problems they were being asked to investigate.
Itis important to understand that Second Sight
were, at all times, answerable to the MPs who had
commissioned them and not to the Post Office, who funded
the project.
You will recall, sir, hearing oral submissions from
Mr Henderson of Second Sight in relation to the
independent assessments that they were instructed to
carry out by the group of MPs, he told the Inquiry that
their work started in the summer of 2012, and that,
initially, Post Office were cooperative and appeared
committed to the agreed goal to seek the truth,
irrespective of the consequences. However, as their
work progressed, the attitude of the Post Office
changed. Was this the result of legal advice? Was it
53
general counsel and we are advised that he adopted
an obstructive and litigious attitude. He sought to
rely on limitation periods and removed subpostmasters
from the scheme.
The situation deteriorated further in 2014. We say
this is because the Post Office had become aware that
Second Sight were getting closer to the truth and you
will need to consider, as we will, that issue.
Second Sight were due to deliver a report in April
2015. However, on 10 March 2015 the Post Office bought
the Mediation Scheme to an end and gave Second Sight
a month's notice. We're not sure to what extent the
Post Office was entitled to act in this way, given that
Second Sight were answerable to the MP group and not to
the Post Office.
‘These events appear to be part of the lamentable
concerted attempt by the Post Office to cover up
wrongdoing. We ask that the Inquiry focuses on this
cover-up over time, what happened in relation to Second
Sight and identifies those Post Office individuals, the
officials -- Fujitsu officials and individuals - who
were involved, and any knowledge by BEIS or involvement.
Phase 6, regarding the monitoring of Horizon and
internal and external audit. We know from the evidence
before Mr Justice Fraser and before this Inquiry that
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a change of view? Who was responsible?
In August 2013 the Post Office set up the initial
Complaint Review and Mediation Scheme, which was
intended to operate as a formal mediation between
aggrieved subpostmasters, managers and assistants, who
had complained to their MPs, and the Post Office. The
Mediation Scheme was overseen by a working group which
comprised the Justice for Subpostmasters Alliance, the
JFSA, headed by Mr Bates and Ms Linnell, Second Sight
and Post Office. The independent chair of the working
group was Sir Anthony Hooper, a retired Court of Appeal
judge.
Unfortunately, the scheme floundered in November
2013 when Susan Crichton left the Post Office. She was
the internal legal adviser who had instigated the
process. Ms Linnell, who we represent, met her by
chance once in Birmingham and was impressed by what she
heard from Ms Crichton as to her wish to collaborative
and her problem-solving approach to the process.
Susan Crichton was replaced by Chris Aujard. We
don't know why Ms Crichton left -- she should be
called -- but it is probably not a coincidence that her
departure took place around the same time that the Post
Office realised its position had become difficult.
Ms Crichton was replaced by Mr Aujard as Post Office
54
Fujitsu monitored Horizon from the outset and liaised
with the Post Office throughout. We know about the
year 2000 Fujitsu reporting phantom sales on the system.
Mr Justice Fraser found that the Post Office sent over
100,000 transaction corrections to subpostmasters each
year since 2006, which amounts to more than 2,000 per
week. An unusual feature of the Horizon Issues trial
was that Fujitsu had provided and disclosed 5,000 KELs
but only in September 2019, months after the trial had
ended.
However, whilst the system was being monitored, the
findings in the Horizon Issues judgment demonstrate that
the Post Office refused to monitor and investigate
Horizon when its systemic problems threatened to enter
into the public domain.
We maintain that the Post Office did monitor
Horizon, did receive information, but did not want to
actively investigate the defects.
Can I turn briefly to whistleblowers. There must
have been hundreds of helpline workers, contract
managers, auditors, intemal lawyers and Post Office
officials who would have been aware of the defects and
the bugs within the system, aware of the cover-up and
scandal that surrounded the Horizon System. BEIS and
Fujitsu must also have been aware of the unfolding
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scandal. Yet there appears to be only one whistleblower
of any note, Richard Roll of Fujitsu. It is important
that the Inquiry ascertains why so many others knew and
kept silent. What were the whistleblowing procedures?
What guidance was there? What had been set up or not
set up by the Post Office or Fujitsu to allow
whistleblowers to come forward? Were people afraid to
disclose what was unfolding?
Is there a more sinister reason? Was there
a culture at the Post Office which prevented
whistleblowing?
There was indeed a procedure of excessive secrecy at
the Post Office, extraordinarily the evidence in the
Common Issues trial demonstrated that the Post Office
sought to use the official secrets act to justify
seizure of documents and equipment when suspending
a subpostmaster.
Furthermore the modified subpostmaster contracts,
section 15, clause 19, prevents any communication
concerning interviews by Post Office investigators, as
such communication might constitute a breach of the
Official Secrets Act.
Mr Justice Fraser found, at paragraph 723, that it
was somewhat unusual and potentially oppressive that the
Post Office could seek to use the Official Secrets Act
57
This, of course, gives rise to potential issues for
the future. We suggest that it is not inconceivable
that another set of circumstances could arise in the
future where powerful institutions will make false or
mistaken allegations of systemic robustness of an IT
system at the expense of livelihoods and reputations of
individuals who are affected by such IT systems. Anyone
knowing even the remotest part of what has happened in
relation to Horizon would be at this time wondering
whether IT systems could be trusted at all.
Can I deal with some procedural matters.
Firstly, 'm instructed to request and ask that, on
behalf of our clients, we are permitted to make brief
closing submissions at the conclusion of the hearings of
each phase of the Inquiry. If permitted, it might be
that we would consider the position and not require or
not ask that we'd make such submissions. But the
reasons for leaving this as a request that we may ask
that this Inquiry allow us to do so, is that we can only
address you on the written and oral evidence that is
before us at any given time. This Inquiry is going to
be dealing with disclosure as we go onwards. We don't
have it all at this stage because the Inquiry, for very
good reason, wants to make good progress
As matters stand, we will not be able to give voice
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in that way.
We ask the Inquiry to examine whether the Post
Office sought to apply that same legislation in respect
of any disclosures made by employees. Is that part of
the reason why we have not heard from whistleblowers?
Phase 7, current practice and procedure
recommendations for the future.
In reality, this Inquiry is not about the Horizon
System, with all of its faults and problems, but about
a sickness which lay at the core of the Post Office.
The Post Office was employer, victim, investigator and
civil and criminal prosecutor and it is now the arbiter
of which of its victims should receive compensation and
how much. It held extraordinary power over each and
every one of its subpostmasters and wielded that power
with impunity and, we suggest, in bad faith.
The Terms of Reference for this Inquiry say that we
will be assessing whether the Post Office has learned
the lessons from criticisms made by Mr Justice Fraser in
his judgments. Our clients are very concemed that all
that has changed within the Post Office is that Paula
Vennells, Angela van den Bogerd and others, have been
found out. Itis important that the Inquiry delves into
the issue of whether there has been real cultural
change
58
to our clients’ instructions on the evidence or comments
as that evidence emerges, until the very end of the
Inquiry, much later next year. By allowing us the
potential opportunity to make such submissions at the
close of the phases, we suggest that is helpful for you
sir, in keeping the subpostmasters at the centre of this
Inquiry.
Our clients are, frankly, expecting to be taken by
surprise and outraged by some of what they hear from
institutional witnesses. They do not want to have to
sit on their hands and, after having been kept silent
for so long, they wish to instruct their own legal team
to convey their instructions or responses at the close
of phases if it is appropriate, rather than just in
final closing submissions. For clarity, we don't ask to
make written submissions at such stages, simply
an opportunity to make short closing, oral submissions.
Second procedural matters relates to the issue of
compensation. As you know, this issue impacts very
greatly on our clients. We saw that in July of this
year how quickly BEIS were able to act when the Inquiry
held their feet to the fire through holding specific
hearings on the question of compensation.
None of our clients have any doubt that itis only
through the resolve of you, sir, and through this,
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Inquiry process that a new compensation scheme for the
High Court litigants is under way and that some of the
fundamental problems relating to the HSS and historic
conviction schemes have also been addressed.
However, sadly, very little has been achieved since
the July hearings. Following letters written by
Howe+Co, my instructing solicitors, and possibly others
we will have another compensation hearing on the
8 December 2022
What we can tell from our experiences earlier this
year is that, if that is anything to go by, we can
expecta flurry of activity and announcements in the
first week of December this year. These points will
demonstrate, as were demonstrated in the July hearings,
that the scrutiny by this Inquiry process is essential
to make any movements forward on the vital issue of
compensation.
We cannot state, we cannot overstate, how concerned
our clients are that, if this Inquiry is no longer able
to monitor BEIS in August or later next year, after
which BEIS will have no access to funds in this matter,
they will be forced to relive their experiences a third
time through further litigation in the courts.
Itis essential that the matter of compensation be
kept in sight and under review at all times and, if that
61
time.
The process, therefore, is one that we ask you to
consider, and the progress of this Inquiry, with great
care. If there needs to be gaps, there needs to be time
out so that we make sure we have the material that we
need for the particular phases, then we ask you to take
that time and trouble.
Sir, I come therefore to conclusions and requested
outcomes. What can our clients expect? Well, firstly,
they wish that this Inquiry continues to exercise
oversight of the compensation schemes. Secondly,
restorative justice, that each and every subpostmaster
who is affected by the Horizon System has the
opportunity to meet face-to-face with a senior Post
Office official, to have the full opportunity to recount
their experiences and the impact that they have had on
them, and their family, to have those experiences
genuinely acknowledged and to receive a genuine apology.
We have experience in other public inquiries of how
important personal apologies are to victims and
survivors of institutional abuse. Ministerial
announcements and press releases from the Post Office
are not cathartic and do not provide closure. Our
clients wish to see senior Post Office officials come to
them, see the localities where their reputations were
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means, sir, that we ask at a later stage for further
hearings on compensation as we go through, we hope you
look kindly on such a request.
The third procedural matter relates to the pace of
the Inquiry process. Now, we recently learnt and
discussed the question of disclosure from Post Office
That undoubtedly, in some ways, is going to lead to the
delay in the process of the Inquiry. We do not wish the
Inquiry to proceed to continue very important matters
without being able to take into account all of the
relevant material and, sir, you have already indicated
this week that you regard the process of an Inquiry to
be much more flexible than litigation and, indeed, said
that that is one of the advantages of a statutory
Inquiry.
We ask that great care is given to consider the
timing and the pace of process of this Inquiry. We all
know from long experience before the courts that the
danger of allowing the witness to give evidence and then
to allow the possible re-call means, that there will be
discussion between the parties, "Do we really need that
witness? Should that witness come back?" always leading
to the position whereby, if the witness doesn't come
back, someone is going to be dissatisfied because the
evidence should have been put before them the first
62
attacked and understand the real suffering that was
caused. We cannot impress upon the Inquiry how
important that process is.
Thirdly and lastly, our clients ask that those who
are responsible for this tragedy are identified and
publicly named. We suggest that they should never hold
or wield power and responsibility again. Not only would
that provide a measure of justice to our clients but it
will enable the public to move on from this scandal with
confidence that the institutional culture which gave
rise to this scandal has been addressed and that
mistakes of the past will not be repeated.
Sir, that brings me to the close of my submissions.
I'm very grateful for being allowed the time to make
those submissions and I now cede my place to my learned
friends
‘SIR WYN WILLIAMS: I I'm very grateful to you for your
submissions, Mr Stein, and, insofar as the first of your
procedural points is concerned, you didn't invite me to
make any kind of even provisional decision about that.
What I will say is that I will clearly keep that under
review throughout the phase, and if I think it important
that you should have some short time to make
submissions, I'l give it to you, but I'l keep it under
review.
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MR STEIN: Very grateful, sir. Thank you.
SIR WYN WILLIAMS: So is it Mr Moloney next?
MR MOLONEY: tis, sir, yes. I'm content to make a start
or take a short break, whichever you would prefer, sir.
SIR WYN WILLIAMS: II don't mind. I think perhaps a short
break because I'm going to retrieve your opening
statement, so that, as I was doing with Mr Stein, I can
follow both your oral and written submissions at the
same time.
MR MOLONEY: I'm obliged, sir.
SIR WYN WILLIAMS: Just five minutes will be enough? Yes.
MR MOLONEY: I think if we start at 12.00, sir, I should
finish at 1.00.
SIR WYN WILLIAMS: That's fine.
(14.53 am)
(A short break)
(12.00 pm)
MR BEER: Sir, good afternoon, you didn't expect to hear
from me. The reason for the short delay and why we
didn't start at 12.00 was a problem with the live time
transcription. I have been told that that is going to
take about another 15 minutes to cure, and we wondered
therefore, whether you would give us 15 minutes to allow
that to happen, in order that the transcript can be
broadcast live but also to ensure that the transcription
65
SIR WYN WILLIAMS: Thank you.
Opening statement by MR MOLONEY
MR MOLONEY: Thank you, sir. These submissions in opening,
as you know, sir, are made on behalf of 64 Core
Participants represented by Hudgells Solicitors, each of
whom was convicted following prosecution by the Post
Office on the basis of Horizon evidence and each of whom
has since had their conviction quashed
Sir, the Inquiry heard a powerful summary of the
unprecedented miscarriage of justice suffered by our
clients and the events which led to it in Counsel to the
Inquiry's opening in Phase 1, starting on 14 February of
this year, and Counsel to the Inquiry, Mr Beer, King's
Counsel, has provided over the last two days a further
comprehensive introduction to the events of the last
two decades and the evidence the Inquiry will hear.
We noted, and continue to note, sir, your guidance
that openings by Core Participants are not expected to
cover every phase and we do not attempt to do so at this
stage. We don't repeat, moreover, the entirety of our
written submissions, not least because a number of the
issues we highlight therein have been raised by Mr Beer
in what we, if we may say, was an excellent opening to
these proceedings.
However, we gratefully take the opportunity to
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is actually working, ie a note is being taken of what is.
being said.
SIR WYN WILLIAMS: Yes, well I think that seems inevitable,
if I may say so Mr Beer, so yes, keep me posted.
MR BEER: The only reason for coming on the camera now is so
that other people who are watching know what's going on,
even though you did.
SIR WYN WILLIAMS: That's important. You're quite right to
make it public in that way. So perhaps, so that I can
just know what's going on, and so forth, if in
15 minutes’ time, you only need another minute or two,
that's fine, but if there's going to be any kind of
further substantial delay, maybe we should come back on
camera again at that point, so you can explain it.
MRBEER: Thank you, sir. In the meantime, we will maintain
email contact with you.
SIR WYN WILLIAMS: Yes, and I won't go far from the screen
so that if, happily, things work out quickly, I shall be
ready to resume.
MRBEER: Thank you, sir
(12.08 pm)
(A short break)
(12.47 pm)
MR BEER: Sir, we are ready to resume, so over to
Mr Moloney.
66
underline matters of considerable importance for our
clients, and we well try to focus, sir, essentially, on
what is to come, the opportunities this Inquiry presents
to our clients, in fully investigating and addressing
the injustice they have endured.
Briefly, sir, our submission follows, in the same
way that our written submissions did, four themes: the
significance of the Inquiry; the priorities for Phase 2,
the questions for Phase 3 and beyond; and, finally,
redress and responsibilty.
May I commence with the significance of the Inquiry,
sir, and that significance is obvious. Mr Beer said on
14 February that the Inquiry may, in due course,
conclude that the prosecution and conviction of our
clients is the worst miscarriage of justice in recent
British legal history.
We agree, sir, and say that the Inquiry may well
conclude that what happened after the introduction of
Horizon was the worst miscarriage of justice in modern
legal history and, while it may have taken decades for
the Post Office and the Government to accept that
Horizon was not remotely robust, the Post Office has
since accepted that it secured a great many convictions
based on Horizon data. The Inquiry, sir, we say, has
admirably encouraged those who may have been affected to
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come forward.
For example, you, sir, noted on 15 February that the
number of people who have had their convictions quashed
is considerably less than those who were convicted and
in Phase 4 of the Inquiry, sir, you encouraged witnesses
who gave evidence to share how it was that they came to
speak out.
We also say, sir, that the role of the Criminal
Cases Review Commission must not be forgotten in all of
this. It similarly has taken significant steps to try
to secure justice for those who continue to live with
a wrongful conviction.
As I've said, we represent subpostmasters whose
convictions have been quashed. We recognise that the
80 convictions quashed so far represent only a fraction
of the total number of lives destroyed ~ and they were
destroyed -- by the Post Office's approach to Horizon.
The opening of this next stage of the Inquiry’s work
presents a further opportunity to encourage others to
come forward to be heard to tell their stories and clear
their names. But, sir, we, and those we represent,
appreciate that many may not have had the resilience to
reopen a now decades old trauma. Our experience is that
our clients have great difficulty speaking about the
things that happened to them and, as our clients have
69
It would be disproportionate, and so we don't do it,
to underline all of the facts relevant to Horizon
already established. But there are several critical
facts which are worth clear emphasis from the outset, in
terms of providing the basis upon which this Inquiry
builds.
Firstly, the Post Office can no longer deny the
existence of a great many bugs in Horizon. Legacy
Horizon was not remotely robust and Horizon Online stil
had a significant number of bugs, errors and defects,
and its robustness was questionable, and did not justify
the confidence routinely stated by the Post Office was
how it was summed up in the Horizon Issues judgment.
There were numerous bugs, errors or defects in
Horizon capable of causing, and which did, in fact,
cause, shortfalls in Post Office branches. There were
problems experienced with Horizon almost from the
outset, as was observed in paragraph 39 of the judgment
in Hamilton and Others from the Court of Appeal Criminal
Division.
The Post Office knew that there were problems with
Horizon and Post Office knew that different bugs,
defects and errors had been detected well beyond
anything which might be regarded as a period of initial
teething problems. In short, they knew that there were
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been, others may be mentally and physically broken by
the impact of their conviction and what followed.
So our clients ask the Inquiry to remember that, for
those who may never come forward, the Inquiry will be
‘a genuinely important public statement, capable of
reiterating the truth, and that the scale of the scandal
and its wider impact beyond the Core Participants
represented in these hearings should not be forgotten.
The Inquiry is to build on what we now know. The
Inquiry does not start with a blank page and, as Mr Beer
said and indeed Mr Stein said, we welcome — and we
welcome Mr Beers acknowledgement that the judgments of
Mr Justice Fraser and the Criminal Appeal Courts form
the building blocks for this Inquiry's work.
The Inquiry's terms of reference provide that to
establish a clear account of the implementation and
failings of Horizon and the Post Office's actions in
respect of alleged shortfalls, it must build upon the
findings in the civil and criminal courts. What we know
already is substantial from the Common Issues judgment,
the Horizon Issues judgment and the judgment in
Hamilton. Since then, more information even has come to
light, both in the extensive disclosure to this Inquiry
and through research and Freedom of Information Act
requests by others.
70
serious issues about the reliability of Horizon.
Perhaps the question for you, sir, is who knew, when.
The persistence of reports also made it impossible
to assume that all the initial problems and any
subsequent teething problems had been resolved and
Horizon itself did not alert subpostmasters to the
existence of any such bugs.
Fujitsu had the ability, as has been mentioned
a number of times already during these openings to you
sit, and facility to inject, insert, edit or delete
transaction data or data in branch accounts.
Those concerned with the prosecution of
subpostmasters clearly wished to be able to maintain the
assertion that Horizon data was accurate and effectively
steamrolled, said the Court of Appeal, over any
subpostmaster who sought to challenge its accuracy,
astonishingly using the number of convictions that were
secured to demonstrate how reliable Horizon was and how
there should be no concems.
The human impact aspect of this Inquiry is very
important. The Core Participants we represent
appreciate the Chair's message, your message, sir, of
30 September 2022, which acknowledged both the
significance of Phase 1 and its deep impression.
Our clients were genuinely grateful, sir, for the
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opportunity to speak about their experiences and to be
heard. The human pain and suffering which was laid bear
for the Inquiry by their testimony is the true tragedy
of the last two decades of the Post Office's conduct in
respect of Horizon
Many lives were destroyed -- were destroyed for no
good reason ~- and this pain and suffering, despite the
question of the convictions, despite whatever
compensation might come, continues for many
subpostmasters and their families.
Things have happened which can't just go away and
the evidence as to human impact, we say, sir, must
remain at the heart of each phase of this Inquiry. We
ask that it sit behind the exploration of every issue,
and it's that continuing human impact which must inform
the Inquiry's work to ensure that every avenue to secure
true transparency and accountability is now explored.
That's the opportunity we wish to take on behalf of
our Core Participants during the course of this Inquiry,
sir.
Some of these convictions of the people that we
represent were decades old when they were overturned.
Horizon had been the subject of controversy for many
years and yet the Post Office continued to publicly and
vocally defend its integrity, often at the expense of
73
evidence poor judgment or was there another explanation
for them?
Sir, just to reiterate the attacks that had been
made on the Core Participants that we represent, the
Inquiry will recall that the Post Office expressly made
submissions to Mr Justice Fraser on the credibility of
subpostmasters, alleging at least one had lied
frequently and brazenly. You, sir, will have in mind
the remarks of Mr Justice Fraser in terms of the
attitude that was taken by Post Office through the GLO.
On the wider impact of the Inquiry, sir, while the
detailed and forensic judgments of Mr Justice Fraser in
the GLO marked a departure from the past, those
judgments were based necessarily on evidence which was
limited. They could not consider of necessity material
later disclosed to the criminal appeals, and now
available to this Inquiry, so that, for example,
Mr Justice Fraser was unaware of the Clarke Advices
explained by Mr Beer during the course of his opening
and the consideration of our clients’ criminal appeals
was limited to the evidence addressing the safety of
their convictions.
So in both the GLO litigation and the criminal
appeals, there was limited opportunity to look at all of
the relevant parties in play, or the relevant evidence
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the Core Participants that we represent. It was not
before December 2019 that the course of the litigation
in Bates and Others forced the Post Office to face
reality. But that didn't happen without the most heroic
of struggles. Time and again, the Post Office took
steps to repeatedly reiterate their indefensible
position that Horizon was robust, our clients’
convictions were safe: they were dishonest, they were
criminals.
This was the stance which had been taken
consistently by the Post Office over many years, as.
recognised by Mr Justice Fraser and by the Court of
Appeal. We don't repeat the examples here, sir, the
Inquiry will hear them all repeatedly as we come to the
later phases. But the Post Office's defence of Horizon
extended to statements to the press and to Parliament.
Perhaps the important work for the Inquiry now is to
consider that position, the statements made and the
motivation behind those statements, when and how and why
did the preserving of the integrity of the Horizon
System become more important than the Post Office's
integrity as a prosecutor and its commitment to its
subpostmasters?
Were the statements that were made to Parliament, to
the press, were they made in good faith and did they
74
they might hold. There was essentially no role for
Fujitsu, other than to either be praised in the GLO by
Post Office Limited or blamed in the criminal appeal
process by Post Office Limited, or for Central
Government, despite the key roles that both played.
But, as has been made abundantly clear in the
introduction by Mr Beer, there are no such limits placed
on this Inquiry and our Core Participants genuinely
welcome that.
The wider public significance of this Inquiry,
therefore, cannot be understated. The full financial
and human cost of this public scandal is as yet unknown
and, importantly, no individual or institution has been
truly been held accountable for what happened to those
we represent or the damage which resulted to them and
their families -- who must not be forgotten at any point
during the course of this Inquiry -- or for the harm to
the Post Office as an institution or for the cost to the
public purse
The key commercial players in Horizon continue to
play an important and, on one view, expensive role in
public life in the UK. In recent months, the Government
has reportedly concluded new multimillion-pound
commitments to Fujitsu in respect of a range of crucial
public services. On 24 September, the Daily Mirror
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reported that the Home Office has concluded a four-year,
£48 million contract for the police national computer:
His Majesty's Revenue and Customs, HMRC, has reportedly
concluded a five-year deal worth £500 million and the
Foreign and Commonwealth Office has reportedly awarded
a £44 million telecommunications project to Fujitsu
Those deals follow on the heels of a £6.1 million
bill for services provided during the Commonwealth
Games, a deal has also reportedly been reach with
Northern Irish Libraries, reportedly worth £27 million,
and, in the last 5 years, Computer Weekly reports that
Fujitsu has signed deals worth £673 milion with HMRC,
£456 million with the Home Office and £572 milion with
the Ministry of Defence.
So, whilst it may be entirely justified, sir
that's for your Inquiry to establish — the
understanding that Horizon was not remotely robust has.
so far seemingly had little or no impact on the
commercial relationship between the Government and
architects of that program.
The true impact of these events on the Post Office
can only be determined after the conclusion of this
Inquiry and the full and fair compensation of all
affected. The Post Office, whatever it may have done,
continues to provide a vital public service in
7
we represent welcome the commitment of all Core
Participants to the Inquiry. We have welcomed the
decision by the Post Office to waive legal privilege,
a taster of the importance of which was provided
yesterday afternoon during the opening by Mr Beer,
King's Counsel and we note the commitment to now bring
to light the full history of the scandal.
After decades of apparent obfuscation and denial,
our clients remain understandably cautious and would
resist any attempt on the part of any Core Participants
to undermine the ability of the Inquiry to finally
uncover the truth by becoming defensive in their
approach to this Inquiry.
Sir, that's our overall submissions as to the scope
of the Inquiry. In the time that remains to me, may
I just spend a short time on identifying priorities for
Phase 2, as that is what is to come over the next few
weeks, as well as then move on to some important
questions for the remainder of the Inquiry before
turning to redress.
So turning to what are our priorities for Phase 2,
sir, which is the development, rollout and the early
days of the Horizon System. As has been recognised,
this necessarily begins with technical evidence from the
Inquiry expert, Mr Cipione, designed to support public
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communities across the United Kingdom, important to
people of all ages, of all occupations, of all classes,
of all races, supported by the energies and commitment
of a network of branches operated by subpostmasters. It
remains an entity essentially owned by the public and
so, as citizens and taxpayers, we all have an interest
in the outcome of this Inquiry, sir.
Sir, we also, in considering the overall direction
of the Inquiry, we note, sir, the overriding duty you've
referred to. You recently made a statement that you
hoped to complete the evidence gathering in 2023 but our
clients welcome your recognition, sir, that any desire
to provide answers quickly must be tempered by
an overriding duty to lay bare who knew what, when did
they know it and what did they do with the knowledge
they acquired.
Sir, those we represent appreciate fully that there
must be a balance to be struck between speed and
efficiency, on the one hand, and effective searching
scrutiny, on the other.
They appreciate that your task, sir, is considerable
and would not favour speed over a full and fearless
examination of the events of the last two decades.
In that vein, sir, that's one of full and fearless
examination of the events in the last two decades, those
78
understanding of the operation of Horizon and later
evidence yet to come.
We now briefly focus on two themes which go beyond
the technology. Firstly, why was it that Horizon became
areality?
Mr Cipione includes in his written statement
reminder of how very different the world was in the
mid-1990s, something Mr Beer alighted upon yesterday
and, in order to appreciate and effectively scrutinise
the evidence in Phase 2, we will all have to be reminded
of the state of the world almost two decades ago.
We're not going to repeat the detailed introduction
by Mr Beer to the inception of Horizon, but it's well
known that Horizon did not start its life only as
an accounting system for the Post Office but that is
what it ended up as. After all you've heard in opening
and it may be that you'll hear more, sir, an obviously
important question for the Inquiry may be why the
decision was taken to proceed with Horizon at all
Also of great importance in this phase of the
Inquiry, sir, is what was known when and by whom,
because we say, sir, that that then colours decisions
that were taken later that directly affected the Core
Participants that we represent.
It's clear from the early stage that concerns were
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expressed over the technical aspects of the ICL bid.
The National Audit Office noted, reflecting the
documents referred to by Mr Beer in opening over the
last two days, that:
"Pathway submitted, narrowly, the cheapest of the
three bid but the purchasers ranked their proposal third
on 8 of 11 technical and management criteria."
Then the Inquiry may wish to consider whether there
were adequate systems in place throughout the life of
the project to ensure that the technical performance of
Horizon was adequately and consistently scrutinised,
both by the Post Office Counters Limited and by
Government.
The Inquiry, as an important part of that, may also
wish to consider whether there is evidence to support
the proposition that the highest levels of Post Office
Counters Limited were well aware of bugs, errors or
defects, even in the late development of Horizon, and
that these were bugs and flaws which were capable of
affecting accounting integrity, and which did directly
impact upon the integrity of branch accounts.
The Inquiry might consider whether there's evidence
that these were apparent before the decision taken on
24 May 1999 that Post Office Counters Limited would
continue its work on the Horizon contract with ICL and
81
what action was taken by ICL or POCL to address those
continuing incidents, indicative of bugs, errors and
defects and whether or not there were systems in place
which could effectively address those issues.
In that context, we'd ask the Inquiry to consider
whether there was ever any evidential basis for the
mantra of POL that Horizon could be considered robust.
If the Inquiry is satisfied that there was evidence
of bugs, errors and defects from the outset, what reason
or motivation there might be for Horizon to be viewed
with such confidence by the key players.
The Inquiry is likely to hear, and we hope it will
hear, pertinent evidence on the commercial motivation
for the original Horizon project. It may hear evidence
from ministers and officials and from Fujitsu on why the
project was continued in the summer of 1999, rather than
terminated. In particular, the impact of the withdrawal
of the Benefits Agency and the termination of plans for
the Benefit Payment Card is something that the Inquiry,
we hope, will consider for the business strategy and
future plans of POCL.
The Inquiry is likely to hear that POCL had
estimated that if all Benefits Agency income were lost,
up to half of the then current network of 19,000 offices
could close and the remaining offices would need
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whether, indeed, those were apparent after the decision
taken on 24 May 1999 and things were continued with.
The Inquiry may want to pay particular attention to
what was being communicated to decision-makers in Post
Office Counters Limited, at ICL and within Government
If we could just alight on one aspect of there is,
sir: the question of acceptance issues, of which POCL
and ICL were aware before contractual acceptance of
Horizon, and the start of the national rollout. As
Mr Beer explained, these included concerns both about
the support available to subpostmasters and the
operation of the helpdesk, as well as specific concerns
about the integrity of accounting data, including
incidents arising as a result of receipts and payments
failing to balance on the cash account, fundamental to
the prosecution of our Core Participants in the years
that followed, in the decades that followed.
As the Horizon Issues judgment found, these bugs,
errors and defects went beyond teething problems.
Obviously, the Inquiry will wish to consider the extent
to which these Acceptance Incidents were known to POCL,
in particular those incidents relating to accounting
integrity, and will wish to consider whether they were
ever resolved satisfactorily before or during rollout,
After rollout, we would ask the Inquiry to consider
82
a subsidy to stay open, and we give the reference to
that, without turning it up at this stage, which is
HMT00000034 at page 5, and at bullet point 1.5.
At the same time that those concerns were being
expressed in 1999, the Government was consulting on the
future of the Post Office, a White Paper "Post Office
Reform: A World Class Service for the 2st century”, was
published by the Blair Government in July 1999. That's
two months, sir, after Post Office Counters Limited had
agreed to continue its relationship with ICL. In the
introduction, the responsible manager, Mr Stephen Byers,
focused squarely on a Post Office building its future in
technology.
Then in March 1999, the Government published its
White Paper "Modernising Government", which focused on
the Government's commitment to deliver just that,
including a commitment to Information Age Government, or
the digitisation of Government services. It read:
"We must modemise the business of government
itself, achieving joined-up working between different
parts of government and providing new, efficient and
convenient ways for citizens and businesses to
communicate with government and to receive services.”
That White Paper expressly included a commitment to:
"... Information Age services for Post Office
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customers: the Post Office will be equipped with
a modem, online, IT platform to facilitate electronic
provision of government services across Post Office
counters.”
That is in March 1999.
The Inquiry hopefully will hear evidence as well
that Post Office Counters Limited and ICL had been
exploring commercial opportunities which could be built
on the back of a successful Horizon rollout from
an early stage. For example, disclosure to the Inquiry
refers to work done preparatory to participation in
tenders for Goverment gateway work or work in
partnership, what came to be known as Golden Cloud work,
sir. For example, an ICL document includes a Post
Office client director's monthly report, prepared in
December 1998 which provides:
"Work has started with government division on
planning, how Gateway/Golden Cloud should fit with ICL’s
Government market plans."
The reference for that is FUJ00058198, page 47.
It appears from the disclosure received, sir, that
there may be at least some evidence that this intention
for further commercial partnership formed part of the
negotiations in spring of 1999, which led to the
continuation of the ICL and POCL relationship.
85
Was Horizon considered simply too important to the
Post Office and others to accept that it continued to be
plagued by bugs, errors and defects? The Inquiry may
wish to consider the relevance of this bigger picture to
decisions which were taken on the rollout of Horizon,
and the seriousness attributed to continuing technical
problems with Horizon.
We ask whether or not Post Office Board members and
ministers were appropriately informed of risks, and were
known and continuing technical difficulties overlooked
or were they obfuscated?
Finally, sir, the extent to which knowledge of those
flaws and errors in the development of Horizon did or
ought to have informed the later actions of Post Office
prosecutors, and the actions of the sponsoring
department should be a question for further exploration
with witnesses, both in Phase 2 and beyond, because we
know that people were sued and prosecuted; an utterly
central question is: with what knowledge?
Briefly, sir, questions for Phase 3 and beyond
before going briefly to redress. We don't propose to
rehearse in full the crucial issues for the Inquiry.
Instead, we provisionally highlight just a few matters
which the Inquiry may wish to explore in the evidence
yet to come. Those are matters, just to highlight the
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In April '99, that's just before the Prime Minister,
Mr Blair, met with Fujitsu, sir, the director of posts
‘commented on good progress in negotiations, including
the revised version of the Golden Cloud.
Indeed, the Inquiry will also hear that, at the time
that Post Office Counters Limited was being asked to
scrutinise whether known faults in Horizon had been
successful resolved, POCL and the Post Office Board were
invested in the development of options for the further
commercial exploitation of the Horizon platform,
They were considering network banking and the
further exploitation of Horizon for potential government
Gateway contracts. The Inquiry may wish to consider
whether, on all the evidence, this kind of expansive
consideration was premature and the Inquiry may wish to
explore the knowledge, understanding and motivation of
the key players.
We ask a number of questions arising out of this,
sir. Firstly, whether the Post Office Board was on
notice of problems with accounting integrity and whether
it took any adequate steps to satisfy itself as to the
future management and integrity of Horizon, and whether
or not commercial considerations, dependent on the
success of Horizon, had an impact on decision making by
the key parties.
86
importance of Phase 2, sir, which we say will
necessarily be informed by the evidence heard in
Phase 2
Firstly, reliance on professional reports advice and
reviews.
The reliance on such reports and advice and reviews
will be a repeated theme for consideration by the
Inquiry and the engagement of Second Sight to the role
of legal advice from legal practitioners, who have been
named already a number of times during the course of the
openings.
The core Participants we represent consider that
there will be repeated questions for the Inquiry to
consider over the role of professional advisers and
reviewers engaged by the Post Office or others to inform
their position on Horizon.
In the consideration of expert or independent input,
the Inquiry may wish to subject the substance of any
advice given to close scrutiny, such as what were the
instructions given and the scope of any adviser's role?
Were they given a full and accurate picture by those
instructing them and were they constrained in their
task, whether by resources, time, access, skill? If so,
were those constraints due to the actions of Post
Office, Fujitsu or any other actor?
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What happened to their reports when they were
completed? To whom were they communicated or
circulated? Were they secret? By whom were they read,
for example, ministers? Were advisers able to operate
in a way which was truly independent, and did they
exercise apparent and de facto independence from the
parties? Were there any conflicts of interest, and did
they have the relevant skills?
The Inquiry may ultimately wish to consider whether
advice supportive of Horizon was too heavily or readily
relied upon, and the advice critical of Horizon ignored
or diminished.
Secondly, sir, why there was such delay in Post
Office Limited and Fujitsu accepting the irresistible
truth about Horizon. It should be without a doubt that
this is one of the most significant concerns for our
clients: the missed opportunity for the Post Office to
accept, at an earlier stage, that the treatment of our
clients was wrong,
The Inquiry will of course revisit these issues in
later stages, including the work of Second Sight and the
Mediation Scheme led by Sir Anthony Hooper, as well as
the Post Office's conduct of the GLO tigation. It
will be a repeated theme for the Core Participants we
represent.
89
sir, and the Inquiry team, to the question of
compensation for all -- including, importantly, those
whose convictions have been quashed but have not yet
received an interim payment, members of the GLO, and
those who have applied the Historical Shortfall Scheme.
Again, we welcome on their behalf, sir, the decision
to revisit the matter of compensation in a further
hearing on 8 December this year. We are able to say at
this stage, sir - perhaps as some encouragement -- that
whilst matters are ongoing and confidential, we have
made progress in relation to issues affecting our
clients in the months since you first heard submissions
in relation to compensation, sir.
Now while full and fair compensation for every
person affected remains an urgent priority for our
clients, it's by no means the only priority. This
Inquiry serves an undeniable public service in seeking
answers to questions our clients have relentlessly
pursued for decades in the face to defensiveness,
dismissiveness, aggression and personal condemnation.
Every review for report which previously failed to look
behind the fiction that Horizon was robust, compounded
the trauma of our clients and their families. Failures
in accountability and transparency cemented in the
public record and in the public eye that they'd been
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There were many occasions when the Post Office
refused to accept that the bugs, errors and defects in
Horizon were known and relevant to its treatment of our
clients. We hope it will be an important exercise for
the Inquiry to consider the reasons why the Post Office
took the actions it did, and who took them, against the
background of what was known about Horizon.
The importance of Phase 2 again. For those we
represent, this may be one of the most critical
exercises for this Inquiry. As the Inquiry has heard,
each of the years that they had to wait were
exceptionally hard years, financially and emotionally,
for them and their families. Many did lose loved ones
during that time. They died without knowing that the
subpostmaster in question would be vindicated. As the
Inquiry knows, not all subpostmasters have been able to
survive to see the all-important decisions of 2019, or
the apparent sea change in approach by the Post Office.
So the question of why it took so long has many
implications.
Finally, sir, recovery, redress and responsibility.
The Inquiry has, from the outset, recognised the
importance of prompt and tangible compensation for
affected subpostmasters. Those we represent, sir, have
repeatedly welcomed the proactive approach taken by you,
90
judged both dishonest and criminal. That they were
offenders, not only against the public good, but against
the most trusted and respected public institution, the
Post Office. Yet they were not criminals, and they were
not dishonest. And together, they were mothers,
fathers, sons, daughters and grandparents. They were
former policemen, bankers, and accountants, and many
others of good character committed to building a strong
business serving their local communities. They were
community volunteers and local counsellors. They were
parents starting out in life, building on hope for their
young families, and those preparing for an enjoyable and
well-planned retirement. Retirements that have, in many
cases, have been awiully denied them. They were first
and second-generation immigrant families. They were
first and second-generation Post Office families
committed to public service in the institution over
a number of generations. They were all committed to the
Post Office and what they thought it stood for. They
all trusted the Post Office. They were all broken by
their experience. And ultimately, they and their
families all want to know why the Post Office,
ministers, and so many others, appeared to have failed
them.
In considering how this most unprecedented of
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miscarriages of justice came to pass, there may be, sir,
in a broader sense, important learning on the role of
trust, good faith and candour in the provision of public
services. And it's only in seeking now to understand
why these prosecutions were allowed to happen, and why
it took over two decades for the Post Office to
acknowledge it was wrong, that lessons might be learned.
{tis only in gaining an understanding of why they were
made to suffer as they did, that many of our clients
will genuinely be able to start to truly recover and
start to rebuild their lives; and itis only in finding
those answers that damage done to the public trust might
begin to be repaired
Our clients are fully involved in this Inquiry, sir.
They will be represented in the hearing room, and they
will be online watching the proceedings, as well as here
in the room at various points.
They hope that lessons will be leamed, and that
individuals and organisations accept accountability and
responsibility where such is due. They hope that no
other person or family is failed again, nor indeed
jailed again, like they were absolutely failed, and in
some cases jailed, by publicly-owned systems, public
agencies, and public officials. And they do place their
trust in you, sir, and in the Inquiry team. They are
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(1.03 pm)
(Luncheon Adjournment)
(2.05 pm)
MR BEER: I see that you're on the screen but I'm not sure
that Mr Henry has noticed.
MRHENRY: Good afternoon sir, can you hear me?
SIR WYN WILLIAMS: I can.
MRHENRY: May I begin?
SIR WYN WILLIAMS: II was about to tell you that you weren't
yet on my screen but now you are.
MRHENRY: Ah.
SIR WYN WILLIAMS: But before you begin, can I just say,
Mr Henry, that it is possible that this aftemoon's
session won't take until 4.30. I would just like to
reassure those who are scheduled for tomorrow that
I will stick to the timetable so that if we do finish
earlier than 4.30, so be it,
Opening statement by MR HENRY
MRHENRY: Thank you, sir
Sir, can I outline from the very beginning that I'm
going to be, as it were, responding not in any legal
sense, but reflecting upon the magisterial opening that
Mr Beer, King's Counsel, delivered. 1'd like to thank
him for the immense care, detail and effort he and his
team have so obviously demonstrated in that opening as
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committed to this Inquiry. They intend to work with the
Inquiry team and other Core Participants to ensure that
the full story of Horizon and its key players is finally
told.
Thank you, sir.
SIR WYN WILLIAMS: Thank you, Mr Moloney. If I may say so,
that is a masterful compression of your opening
statement, between the time you started and lunchtime.
So well done.
MR MOLONEY: Thank you, sir
SIR WYN WILLIAMS: Thanks again for your submissions. And
we will be ready to start again at, say, 2.05. Is that
all right with everyone?
MR HENRY: Yes, thank you very much, sir.
Sir, would you mind if I addressed you sitting down,
or would that compromise the visuals?
SIR WYN WILLIAMS: Mr Henry, I'm very happy for you to do
that, because I'm conscious, from having seen you both
on Tuesday, that you may be slightly taller than
Mr Stein, and he was having difficulty directing himself
into the microphone. And so I'd be very grateful to
hear you from a sitting position.
MRHENRY: Well, 'm very, very grateful to you, sir. Thank
you
SIR WYN WILLIAMS: Right. See you all at 2.05.
94
Counsel to the Inquiry.
Itwas rendered more powerful by Mr Beer's
restrained and sober delivery and yet, in spite of that,
sir, the more one listened, ever and ever more
disquieting became the matters he addressed.
The United Kingdom is a nation of laws. The quality
before the law, indeed in our very conception of
ourselves as a just society, is founded upon that
premise. But as Mr Beer's told his tale, it almost
began to seem as if he'd made it up.
It was if we'd become a Ruritanian dukedom or
principality, where undue respect for hierarchy and
judicial deference towards an institution had reduced
people to serfdom and economic servitude, in which that
trusted institution, the Post Office, had taken every
advantage, just and unjust, when exercising almost
totalitarian control over those it pursued to custody
and beyond, destined, as Tracy Felstead was, to be sent
to an adult women's prison even though she was but
19 years old or, as Seema Misra and Janet Skinner were,
to incarceration in adult prisons where Seema was only
kept alive by the knowledge that she was pregnant and
where Janet refused to see her children because she
could not bear to let them have a memory, that indelible
image of seeing her across a formica-topped table
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wearing prison scrubs.
But the injustice did not end there. It went beyond
that, reducing its victims to destitution by bankruptcy
or criminal confiscation.
For those in the dock and also for society itself,
the depressing truth which, sir, you will not find
difficult to establish, was that the Post Office
strictly controlled the flow of information and denied
exculpatory material to those it had accused. In civil
matters, it deprived those it pursued of the means to
bring counterclaims or defend unmeritorious claims that
had been brought against them. That it was enabled to.
do so, lay in part in the naive belief that computer
evidence is reliable and that the Post Office could
itself be trusted, that a multinational household name,
Fujitsu, was also acting with integrity
How wrong those assumptions were. The Post Office
scandal reveals that, notwithstanding the legal burden
of proof that lay upon it, again and again, it
successfully shifted the evidential or tactical burden
upon its innocent victims, that they were to establish,
as it were, that the computer was not working reliably
at the relevant time. A defendant is utterly unable to
discharge that burden unless they coalesce and act as
a concerted group. I refer, of course, to the Horizon
97
alleged by Mr Castleton in 2006 and Mrs Misra in 2010.
You'll be familiar, I'm sure, sir, with that extract
from Mr Marshall's statement
One never expected or imagined that POL could act in
this way. One had a right to expect far more, much,
much more from a state institution. If its brutal
policy of raw claw civil litigation wasn't bad enough,
how on earth had an agent of the state, a government
dominion, as it were, decide to prosecute hundreds of
subpostmasters after it had realised — indeed knew --
that Horizon wasn't safe? Why, apparently not content
with aggressive, old school civil litigation tactics,
had it deliberately chosen to harrow, indeed terrorise,
loyal subpostmasters, criminalising hundreds of innocent
people? How could it have countenanced exposing so many
of these loyal, blameless, already broken victims to the
risk of being put behind bars?
Such callousness reveals a corporate mentality that
branded subpostmasters as a liability rather than POL's
biggest asset. The subpostmasters were no more than
a number, equivalent to the phantom balance they
supposedly owed: a disposable commodity, a debt to be
pursued, an example to be made of.
So itis, sir, and you know this already, but it is
your imperative duty to examine POL's conduct of
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litigation before Mr Justice Fraser.
But in criminal courts up and down the country,
there was a huge disparity of resources and obviously
a disparity of information. This is starkly revealed by
the cases of Lee Castleton -- one of the Core
Participants that together with Ms Page, I am honoured
to represent — and Mrs Misra.
In both cases, as Paul Marshall has said in his
evidence to the House of Commons back in July 2020,
civil and criminal respectively, both Mr Castleton and
Mrs Misra positively averred that they believed the
problems they had experienced, accounting shortfalls at
their Horizon terminals, might lie with the computer
system. In neither case was the Post Office required by
Judge Havery Queen's Counsel, as was, or Judge Stewart,
to prove affirmatively that the Horizon System was.
working properly, reliably, at the relevant time.
Had the Post Office, in either case, been required
to prove that the Horizon System was working reliably,
it could not have done so. That is so, as a necessary
consequence of the factual findings of Mr Justice
Fraser. He found that from its introduction, the
Horizon System was: (a) unreliable; and (b) apt to
generate accounting errors and shortfalls of the kind
alleged in the Bates Group Litigation, and as had been
98
litigation from the County Court to the High Court, and
the Magistrates Court to the Court of Appeal Criminal
Division.
This requires the investigation to discern not
simply the unjustified faith in Horizon and the origin
of that false belief but to establish when that hardened
into brutal realpolitik, the ends justifying the means,
that that crumbling, corrupt IT system had to be
defended at all costs.
The question of the Post Office as a private
prosecutor will no doubt, of course, be central to your
considerations. The Post Office failed, except in one
instance, in all its responsibilities as a private
prosecutor. First, as an investigator, it failed to
investigate. It boorishly and oppressively went all out
for a confession. Witness how it treated, sir, Nichola
Arch, Tracy Felstead, Seema Misra and Janet Skinner.
Each one was hectored, bullied, stigmatised as a thief.
This wasn't investigative and impartial interviewing but
an interrogation and when it couldn't brow beat
a confession it then, from the very beginning,
negligently failed, indeed refused, to investigate the
defence raised by those subpostmasters that Horizon was
to blame
But negligence, at some point, went further into
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active, unforgivable misfeasance and in this it was
aided and enabled by Fujitsu. Witness the shameful
conduct, as related by Ms Felstead in her evidence
before you, sir, and Mr Turner, her then expert, who was
told at court that it required a payment of £20,000 in
order for the disclosure to be produced. You will
remember Counsel to the Inquiry, Mr Beer, King's,
Counsel, asking her those questions earlier, I think it
was, in February this year or March, when that was
revealed
Subsequently, we had tried to contact Mr Turner but
unfortunately we believe that he has died but he did
submit a note when he became aware of this and he was
struck at the time at the injustice she suffered. It
remains a mystery why he was not called at her trial but
we shall endeavour to ensure that you have
an appropriate answer where that is concerned.
But it brings me now to the second role that POL
had, as a litigator and, as a litigator, it behaved
atrociously. It did not simply fail to discharge its
duty of disclosure but deliberately disregarded it and
suppressed it, playing hazard with the lives of those it
prosecuted.
It therefore connived at securing wrongful
convictions. Worse than that, it adhered to a practice
101
Well, as stated, sir, of course, that is obiter, and
thus the reference to adding an account to redress
a temporary gain is likewise obiter. But, in this case,
there was no temporary gain. In this case, this was the
subpostmasters being tormented by false results provided
by a defective system, Horizon, and subpostmasters
accepting balances, simply in order to continue to
trade
In those circumstances, sir, which prosecuting
authority would really wish to proceed against them?
Would it really be necessary if evidentially, as we now
know, the evidential test was clearly suspect with this
nascent and evolving system subject to so many bugs,
errors and defects. In any event, these people having
candidly explained their difficulties, and had sometimes
been advised, as you learnt from my learned friend's
opening statement as Counsel to the Inquiry, to just
balance the books, advice given by the helpline: how
could it possibly be right to prosecute them?
The Post Office, however, was not looking at this as
an independent prosecutor. That brings me to the third
point: the Post Office as witness, aided by Fujitsu. It
was guilty of the most egregious wrongdoing, aided and
abetted by Fujitsu, of course, in relation to expert
evidence.
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that the Court of Appeal deprecated as long ago as 1971
when the Court of Appeal had obdured the Post Office to
abandon charging both theft and false accounting. Even
though that guidance was obiter, it was plainly not
followed and, sir, you will no doubt recall the case of
Rv Eden, 55 Criminal Appeal Reports, 193, (1971), in
which the practice of the Post Office charging both
theft and false accounting received the following
observations’, ifI can put that in inverted commas, by
Lord Justice Sachs. He stated:
"It seems to this court to be rather odd that two
counts, theft and false accounting, should be put in
parallel setting if itis the object of the prosecution
to secure a conviction on the first, only if the second
is proved, or on the second, only if the first is
proved. There would seem, in those circumstances, but
little point in putting two separate counts. It would
be better in future that the prosecution should make up
its mind as to whether or not it really wants
a conviction on account for false accounting, only if
theft is proved. If so, reliance should be placed on
‘one count only. On the other hand there may be cases
when it is wise to have account for false accounting
where, for instance, a temporary gain could be the
object of the dishonest act."
102
You, sir, will remember the decision of Mr Justice
Cresswell in The Ikarian Reefer, the concerns over
abuses in both civil and criminal courts as to expert
evidence, the civil and criminal procedure rules which
were drafted in response to that and, in particular, so
far as the criminal domain is concerned, formerly
Part 33 but now Criminal Procedure Rule 19.
It's a very serious business. In the late
1980s/early 1990s, in a series of landmark appeals, the
case of Judith Ward, the Birmingham Six, the disgraceful
misconduct of experts came to light. The idea that the
expert was somehow independent and impartial was, in
fact, shown to be a lie, hence the necessity of the
Royal Commission and hence the very real importance that
our system of justice is not corrupted by false
evidence.
But, unfortunately, sir, because of the desire to
defend Horizon at whatever cost, with the raw material
for that being human misery, expert evidence was abused,
time and again, and you will see that in Lee Castleton
in the evidence of Ms Hobbs, and you will see that in
the case of Mrs Misra in the evidence of Dr Jenkins,
which brings me to the fourth point.
POL as a minister of justice. It could not be
trusted to act in accordance with those duties that fell
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upon it, as a minister of justice. In particular,
objectivity, impartiality, and restraint, as opposed to
what Mr Justice Avery described in the case of Banks as
"acting as an avenging angel”.
So, ultimately, POL only excelled in its role as
a querulous, slightly paranoid and vengeful victim. But
that was entirely performative. It was never a victim,
just as its prey were never criminals.
Inquiry, sir, however must consider more than POL's
role as a private prosecutor. Professor Richard
Moorhead, who gave evidence before you on
8 November 2021 as an interested party, cogently
described the manner in which the law in whatever
jurisdiction, was abused as central, indeed fundamental,
to this Inquiry, he argued, even more important than the
software itself. This was because the law created,
indeed sanitised, these myriad injustices. He stated
and I quote
"We don't think that there can be any argument that
Horizon harms directly arose from the way legal work was
managed and conducted. People were threatened, sued,
fired and prosecuted via partly or wholly legal work.
When Post Office and Horizon in particular came under
scrutiny, denials, non-disclosure and harm visited on
the subpostmasters and the legal work supported" —
105
oppression and unconscionable approaches were put in
place. I said, in essence, Horizon is not solely or
even mainly a computing scandal; itis also a lawyering
scandal but itis, above all, a corporate governance
scandal."
I return to the individual cases now. The Core
Participants we represent are paradigms of the evil that
was done. Tracy Felstead and Nichola Arch, right at the
beginning of this disastrous era in criminal justice,
right at the beginning
Lee Castleton, the civil case heard in December 2006
and January 2007. The precedent, the illustrious scalp
that was brandished before anybody else who wanted to
challenge the Post Office. They took him to the High
Court in London, having failed to appear at the
Scarborough County Court and then having had the matter
successfully transferred from the High Court Registry in
Leeds to the Royal Courts of Justice, pursuing a £25,000
claim, and the costs in connection with it came to
£321,000.
Itis staggering. They bankrupted him. They very
nearly destroyed him. He told you, sir, that if he had
been a braver man, he would have killed himself.
Seema Misra: her case demonstrates every conceivable
mischief of non-disclosure, perjury and oppression.
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Forgive me, sir, 'm going to start that again.
"People were threatened, sued, fired and prosecuted
via partly or wholly legal work. When Post Office and
Horizon in particular came under scrutiny, denials,
non-disclosure and harm visited on the subpostmasters
and the legal work supported or failed to challenge the
corporate governance failures that marked this scandal
so profoundly."
You will be aware that we say some of that work was
probably done incompetently or unethically, in our view.
Certainly, there are serious questions that need to be
looked at.
Professor Moorhead opined and was correct in
submitting to you, we submit, that you could not get at
the truth without analysis, sir, of the individual
cases. We pay tribute to the fact that you have heard
and encouraged so many of the victims to come before you
and speak, where they are able to, as to the profound
suffering they experienced
But Professor Moorhead continued:
"We know from the Hamilton and Bates judgments that
shortfalls were pursued oppressively, prosecutions were
pursued unconscionably and the safety of those
convictions was considered or reviewed, it seems,
inadequately. But we do not know how and by whom
106
Then, finally, Janet Skinner, a paradigm case of
an honest woman broken by this discreditable charging
practice, particularly since they could not under any
circumstances have proven theft, owing to the defects in
the system. She enters a plea, an unequivocal,
I suppose, but false plea, because she had been crushed.
There must be and there are, sir, hundreds just like
her. So therefore, she is vitally important as well,
her story, to the issues that you are required to
determine.
Serious criminal charges emerged from this scandal,
we submit. Perjury is one; perverting the course of
justice, the vital administration of justice is another;
contempt of Parliament, quite possibly even another. So
far as legal professional privilege being vitiated,
Professor Moorhead stated that "Evidence of iniquity was
in abundance": evidence of the iniquity in abundance.
What and how brought POL to this? What motivated
POL? Was it arrogance, hubris, paranoia that
an epidemic or endemic theft and false accounting had
suddenly, like a wildfire, burst out at branches up and
down the country?
Or was it far more sinister than that: the
narrative, the narrative of a computer-driven Utopia and
50, to serve its own ends, corporate, commercial,
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political and reputational, it had to subjugate all
those who might challenge it together with Fujitsu, and
thus condemn those innocent people into a never-ending,
dystopian nightmare.
Does it come to that?
I mentioned Fujitsu. What about its sidekick? The
naked triumph of Fujitsu's commercial interests
trampling over the innocent, seemed, and still does
seem, utterly incredible.
As Mr Beer's opening continued, it was delivered
with appropriate pathos for the victims of this tragedy,
pathos which never compromises independence or
dispassionate objectivity, and yet a staggeringly
surreal element began to emerge at times, sir, from his
almost prosaic exposition of the facts. There is no
need now to name the great and the good who Mr Beer
mentioned, the "Don't you know who I ams", who then
populated the Central Criminal Court in the east and
formerly the Supreme Court in the west with One Essex
Court almost plum in the middle? But it seems that the
establishment writ large with all its weight was brought
to bear on the little people.
‘Among the putrid story that emerges, are these
questions which we now pose for your consideration. How
had this country, the oldest democracy in the world
109
In doing so, in reaching your conclusions, the
accountability of each branch of Government that allowed
this to happen, indeed, perhaps doomed it from its
inception, must also be determined.
So I come to that aspect, a common theme of failed
public sector IT projects -- and, of course, this was
a public PFI IT project — is the lack of proper
govemance and oversight by government, and Horizon was
no exception. But what took the troubled history of
Horizon's procurement out of the commonplace, such as
the viability of the project itself, was diplomatic
pressure, expedient responses to threats of tigation,
and continuing internecine struggles between government
departments.
It now seems clear that the project had objectively
failed before it was inflicted on Post Office branches
and Crown Offices nationwide. We submit that because,
of course, it did not meet the standards agreed and the
functions specified were subject to inherent
vulnerabilities. The writing was on the wall and
predictable by the burgeoning costs, repeated delays,
and failures to meet completion deadlines.
Itis understood, and this is a matter, no doubt.
upon which Mr Page will be able to assist you, and also
other evidence that you well hear, that projects with
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failed so many, approaching somewhere between 800 and
1,000? How had its institutions not merely failed but
had become complicit in tearing up the lives of these
decent, law abiding, entirely innocent victims? Those
isolated individuals -- because they thought they were
isolated -- dare I say ordinary people who suffered so
much and still suffer to this day. They can be counted
in their hundreds.
They may be the so-called "ordinary people” but
their lives as you recognise, sir, are precious and have
value. They're not ennobled. No accolades, letters or
chivalric insignia follow their names but extraordinary
wrongs were done to them and those wrongs still
continue.
The causes of their suffering must be arrived at by
you, sir, root and branch. Your root cause analysis
will be multi-systemic and multifactorial and you will
only overcome the many obstacles you face if, in
accordance with the hope fervently expressed -- and
“fervent” was the actual word you used ~ that you might
receive cooperation from all parties. You expressed
that wish on 8 November 2021, but only by adherence to
candour and transparency by all the Core Participants
acting in good faith and with goodwill, shall you be
enabled to arrive at a sound conclusion
110
ong development time frames have a very high
probability of failure and, in faimess to Fujitsu
repeated alterations to the specification by government,
exacerbated the problem of delivering this mammoth, so
oftentimes repurposed project, on time.
There were undoubtedly system failures, the bugs,
errors and defects that meant that Horizon did not
perform as expected and was subject to unpredictable, at
times unknown, in other words latent and entirely
unforeseen, so far as the subpostmasters were concerned,
errors. In blunt terms, it didn't work properly.
‘As Hulme said, the fact that 19 matches ignite is no
proof that the 20th shall, David Hulme
‘As Mr Justice Fraser outlined, so clearly in his
judgment, the fact that it works most of the time does
not mean to say that it works all of the time.
Then, of course, from the very beginning, there was
a failure to ensure that the needs and expectations of
the subpostmasters were met, considered or even taken
into account. The arrogance is breathtaking. The
subpostmasters, the end users, were not front and centre
of the development process. How could they? If they
were to find out that they were to lose control of
balancing out their accounts, that they would have to
bow before the computer and surrender their control, no
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doubt there would have been uproar.
How can a programme, we ask, which requires a user
manual of more than 800 pages, be remotely practicable?
Doesn't that speak for itself? What budget was
allocated for training? How likely was the rollout
going to be fit for purpose, given the lack of staff to
implement so-called user awareness sessions that were
brief and inadequate? Was this euphemism for training
another ominous sign? Was it destined to fail? How
convenient; blame it all on the subpostmasters, as user
error.
We submit that rolling Horizon out in such
circumstances was the height of folly. It was an act of
political and reputational expedience, instead of
listening to its frontline staff and subpostmasters, POL
and Fujitsu decided, we suggest, at some point, sir, to
enter into a pact by which subpostmasters were to blame.
They were to be sued or prosecuted on the grounds that
Horizon was infallible. It was a policy founded on
a ruthless disregard for the facts, motivated by mutual
self-interest and political expediency.
It was easier to blame the subpostmasters than to
give the most remote credence to their concerns. The
alternative was devastating. They would have had to
have gone back to the drawing board, ripped it all up,
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Now, sir, prophecy, however honest, is generally
a poor substitute for experience. Ms Page and
I nevertheless predict that the corporates in this case,
and perhaps their former directors and officers, may
well follow a studied and studiously well rehearsed
routine that you, given your very considerable
experience, will be astute to.
Leaving aside equivocation and casuistry, because
one mustn't pre-judge, but one can easily see a line
taken upon reliance on the faults of others,
rationalisations concerning almost Byzantine lines of
command, lack of co-ordination and communication between
divisions, departments and the like, "If only we'd
known, if only we'd been told’. We trust, sir, that you
will see this for what itis, because this is the
governance issue that Professor Moorhead powerfully
alluded to
It was incumbent upon the board and senior
management of Fujitsu and POL, indeed government, to
take ownership of this burgeoning crisis to embrace
accountability, to ask the difficult questions.
Had they asked those very necessary questions, then
there would have been no need for this Inquiry to do so.
But now, sir, you must ask and answer those difficult
questions in their stead because of the appalling
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and started again.
So POL's corporate governance and how it came to
weaponise civil and criminal litigation must be examined
by you, sir, in the context of who knew what and when.
There are clues, however. Clues can be discerned
from, of course, evidence that still exists, evidence
that was destroyed, and matters that never ever existed,
because nobody put their minds to it. But, generically,
an effective business must have robust internal controls
to identify deficiencies in the IT system that it had to
work with. These management systems would necessarily
involve ensuring that problems, if unresolved, would be
escalated to the senior management committees and
ultimately the board, and senior management committees,
with the board's oversight, would then properly engage
in order to rectify these defects, supervising those
delegated to resolve such issues.
Senior management committees with the board's
oversight would also engage with the corresponding
management of the third-party IT provider, in other
words Fujitsu
Had such structures existed -- and surely they ought
to have been in place - itis difficult to imagine how
anyone at POL and Fujitsu could have been unaware of the
crisis engulfing the innocent.
114
consequences of their failure to do so, because of the
catastrophic impact upon those that were scapegoated.
Those who constituted the directing mind and will of
the corporates may rest the blame on middle management
or seek to pass responsibility to their internal legal
department and, ultimately, given what Mr Beer, King's
Counsel, has already alluded to, point the finger at
each other and goverment, in a sort of three-way "The
9004, the bad and the ugly" Mexican stand-off.
We suggest to you, sir, however, that this is
a self-defeating strategy. They had a fiduciary duty.
They had a duty to enquire and, of course, they had
a duty of care towards the subpostmasters. How POL
blithely accepted and regarded as truth that well over
700 staff had turned base after years of loyal and
honest service, founded largely or mainly upon
a defective computer system, Horizon, ought to have been
documented and explained. It ought, sir, to have been
ared flag
Were any concerns or warnings expressed at any
stage, citing the manifest improbability of all these
worthy individuals becoming criminal? What about the
helpdesk? Then, returning to head legal office, why was
there no central file of those who had maintained that
Horizon was the cause of the shortfall or deficiency?
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Would that not have been assiduously kept,
a register of each dispute with the litany of complaints
against Horizon? But apparently not so. Again, one has
to ask whether this may have been a deliberate policy so
that the picture emerging, the mosaic we allude to in
our opening statement, with each little shard or
fragment being a broken life wrongly prosecuted or sued,
that they didn't want that; they simply wanted chaos,
without an index.
It all comes to their own management of data and, if
you do not wish to be briefed and if you do not ensure
that there are systems in place that you can be properly
briefed, then you have to wonder whether that is by
accident or design.
What we submit to you, sir, is that the more these
responsibilities or duties of accountability are evaded,
the more untenable POL's and Fujitsu's position will
become. If there were hermetically sealed boxes, if
left did know what right was doing, if a need-to-know,
divide-and-conquer culture existed in those
institutions, this is no excuse. The tone and
structure, the apparatus of governance and
accountability is set by the senior management and comes
from the top not the bottom
If there were rigidly hierarchical or labyrinthine
7
utmost sincerity, the advice they had once received,
whether to strictly control information being provided
to Mrs Seema Misra, removing her eligibility, along with
Ms Felstead, from the mediation process, with the
intention of depriving her of information which was
critical not only to her appeal but everyone else's, or,
in the civil proceedings, so absurd as the effrontery
now seems, to seek to recuse the one judge who seemed
determined to demand answers from their counsel, trial
counsel, who himself, it appears, seemed to be oblivious
of the recusal application that was about to take place,
sir, when Lord Grabiner entered the court.
So it could be this position, and again, this has
been alluded to by Professor Moorhead, that the
executives will blame the lawyers and, no doubt, the
lawyers will blame the executives. So you are
confronted, I respectfully submit, with that classic
problem that was identified so long ago by the then.
Mr Justice Leggatt in Gestmin v Credit Suisse, which is
that legal proceedings - and although this not a legal
proceeding, the same inherent biases will exist -- tend
to distort the memory and so, therefore, you're forced
to go to the contemporaneous documents.
But beware, because you will have already noted from
what was put up on the screen yesterday, that some of
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structures impeding communications that, being left
uncorrected, may reveal a desire to exploit the ulterior
advantages that always come with such overcomplex and
ineffective corporate architecture, the means by which
those in authority are enabled to say, "We did not,
know", to make plausible denials. Ultimately, however,
the buck should stop with those at the top
To the cynical, however, the best form of
reassurance is to retain the service of the most eminent
silks, even a retired justice of the Supreme Court.
Their once privileged position, pun intended, may become
distinctly uncomfortable given the tight corner in which
POL now finds itself, together with its former senior
management. The legal advice POL happily once received
may now fall within the crosshairs.
One cannot say for sure, especially after so many
years have passed and especially with the expression of
contrition at the beginning of POL's opening statement.
that POL might now choose to blame those who were
prepared professionally to stand on their heads and
perform cartwheels for them, ranging from panel firms
who prosecuted, to those august persons Mr Beer, King's
Counsel, mentioned.
The Post Office, of course, may double down but it
would not be surprising were they to repudiate, with the
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those contemporaneous documents are Janus faced. They
make a statement of principle and then derogate from the
statement of principle thereafter.
So, as libel lawyers or defamation specialists
frequently say: don't just look at the headline. The
headline may sound the right tone, whereas the rest of
the advice or review may not. And that brings me, sir,
to three matters before I will very briefly go through
the submissions that we have submitted already.
Disclosure. Your disclosure protocol of
28 July 2021 is, I respectfully submit, inextricably
bound up with the fervent hope you expressed in November
of last year. The disclosure protocol, which you're
very familiar with, sir, stated:
"Wherever possible the chair intents to rely on
voluntary cooperation for production to the Inquiry of
the documents he considers necessary to fulfil his terms
of reference. The Chair will normally make a request
for voluntary production of documents by means of
aletter [et cetera, et cetera]. The chair expects that
all parties to whom a request of this kind is addressed
will cooperate with the Inquiry and will provide all
relevant material without the need for him to exercise
his powers of compulsion of documents or evidence."
Then I omit words:
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providers of documents including legal
representatives should provide documents requested by
the chair together with any other documents they
consider to be relevant to the Inquiry's terms of
reference without delay and within the time limits
specified by the Inquiry in any relevant request. PODs
are expected to undertake comprehensive, thorough and
rigorous searches in response to the request of
documents", and I need not say anything further.
Well, unfortunately, sir, that was a bit of a dead
letter, and we respect the decision you made on Tuesday
of this week and I dor't seek in any way to go behind
it. I fully understand the fact that you did not wish
to lose momentum. But the fact of the matter is,
without disclosure, justice is smothered and, when there
is non-disclosure, injustice flourishes
Now, none of Mr Altman's documents, advices or
reviews were disclosed in the criminal appeals. The
existence of his 2013 review was known, but not
disclosed. It is jaw dropping, when one considers.
POL00006485 ~ and I will not ask for any document to be
put up on screen, sir-- Mr Altman's consultation which
took place on 9 September 2013. Jaw dropping.
That is, I regret to submit, one of those
Janus-faced documents. Six years later, his advice on
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27 September 2022, because we - perhaps out of
an abundance of caution, and perhaps unnecessarily, for
which I ask your forgiveness -- had written to the
solicitor of the Inquiry expressing concerns about the
terms of reference. The solicitor to the Inquiry wrote
back in these terms, and it states:
“In relation to the matters set out in paragraphs
4(a) and 1(b) of your submissions, ‘Was evidence as to
the unreliability of Horizon hidden from public scrutiny
and, if so, who was responsible for doing so?" I would
draw your attention to the following issues:
"Issue 49..."
Your issue 49, sir:
"What information and knowledge did Post Office
Limited, Royal Mail Group Limited, Fujitsu Services
Limited, the National Federation of SubPostmasters, the
Communication Workers Union, UK Government Investments
and the Government have about the following facts and
matters during the relevant period? Read with (a) the
existence and extent of bugs, errors and defects in the
Horizon IT System; (b) the ability of such bugs, errors
and defects to cause apparent discrepancies or
shortfalls in branch accounts; (c) the ability of such
bugs, errors and defects to undermine the reliability of
the Horizon IT System accurately to process and to
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settlement, POL00006401. Again, hair raising,
paragraphs 19 to 22, 25, 27, paragraph 31, 17 June 2019
Utterly inimical to the very grave and onerous
responsibility on the Post Office as prosecutor that, by
that time it knew, or at the very, very least suspected,
that innocent people had either gone to prison or had
been criminalised for nothing.
In fact, really, that ought to have been clear as
far as back the Clarke Advice and the shredding advice.
It ought to have been clear. What the Post Office ought
to have done was to have self-reported to the CCRC and,
for good measure, it probably ought to have written to
every court in which it had brought a prosecution, and
it ought to have perhaps even self-referred to the DPP.
But it did not. There was raw claw litigation in both
the civil and the criminal litigation, at appellate
level.
The ineluctable conclusion, we submit, is it was
because they were wanted to suppress. They wanted to
smother the truth from ever getting out; they wanted to
manage things.
Now, we have to return to the issue of knowledge,
and I would now be very grateful, sir, if you could just
note that the solicitor for the Inquiry wrote to those
who instruct Ms Page and myself on the
122
record transactions; (d) the extent to which apparent
discrepancies or shortfalls arose in branch accounts as
a result of bugs, errors and defects in the Horizon IT
System."
Then continuing with our point:
*... the non-disclosure by Royal Mail Group Limited
and Post Office Limited of the existence of problems
with and/or concems about the reliability of Horizon
when bringing criminal proceedings against persons
alleged to be responsible for those shortfalls.”
We were then directed to issues 50, 51, 52 and 59,
namely at what level within the organisations named at
question 49 and the Government, were these known? When
and in what circumstances had they first become aware of
these matters? How did their knowledge develop over
time? What, if any, steps were taken by the
organisations named at question 49 and the Government to
bring these matters to the attention of subpostmasters,
managers and assistants?
Well, we submit that knowledge, of course, is
central. We can start out, of course, with the obvious
statement that Fujitsu knew. They knew. They must have
known and if those in senior management did not, there
must have been an active policy of Nelsonian blindness,
which is, of course, dishonest.
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We submit from the very beginning the Post Office
knew enough at the outset, to exercise caution and
restraint and not proceed as it did against the innocent
Nichola Arch and Tracy Felstead. Whilst they may not
have known the full picture at the start, they knew
enough that it wasn't working.
Why do we say that? Because of the difficulties in,
procurement, delivery, rollout and training.
The rollout, as we submit, was a premature rollout.
The defective advice that Mr Beer took you to, where
subpostmasters were advised to proceed to balance,
a sort of force majeure forced upon them by the inherent
instability of the system, the advice to sign off
an inaccurate account from the helpline beggars belief.
What about the training? The training. How on
earth, on top of everything else, to get on top of the
819-page training manual and also the fact that there
was no continuity in the training? We know again and
again that somebody comes and trains, a glitch, a defect
is noticed and then they never come back. It's almost
as if they're not sent back so that there is no
continuity of care and, if anybody did take up arms on
behalf of a subpostmaster, they would seem to have been
moved on
Sir, we respectfully submit that the helpline, as
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concentrate carefully on two matters, sir: the first is
the removal of the suspense account and the second is
the pitiless destruction of Lee Castleton and his
witness statement is, of course, WITNO3730100. These
matters arose, of course, long before the Computer
Weekly document in 2009.
Let us deal first of all with the removal of the
suspense account, the way in which subpostmasters could
park the discrepancy and, as it were, be allowed to
continue to trade so they wouldn't have to accept the
balance and it could remain, as it were, in abeyance.
The document upon which we rely for this is POL
000 ~ and if 'm wrong about that, forgive me; it might
be 000 ~ but 38870.
We know from the properties that it was composed on
46 September 2003. Mr Nick Wallis, in his book on this
scandal, addresses the terrible dilemma that confronted
subpostmasters when it was withdrawn, where they would
have to accept Horizon, accept the balances, the
shortfalls or be dismissed.
We respectfully submit that that was a result of the
fact that Horizon was unfit for purpose, that debts were
building up and that cupidity, rapacity, call it what
you like, on behalf of the Post Office, triumphed over
justice to its loyal subpostmasters.
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well, all of this must have been fed back. So the Post
Office must have realised, at a relatively early stage,
that the innocent were being put in jeopardy, that the
innocent were being potentially broken on a wheel just
so that they could pursue what they believed to be
adebt.
But the Post Office knew subsequently, and we
respectfully submit they knew at a deep level, that
Horizon was subject to these bugs, errors and defects.
But did they reverse their policy of prosecution? No
Did they remediate this appalling injustice? No.
They stopped at the beginning of 2014 because they
received an advice from Mr Altman, King’s Counsel, which
reveals that Mr Altman cannot have been in the know,
because he was advising them that they had to have
proper protocols in relation to prosecution and also the
reliability of Horizon and, as we put in our opening,
that could not be done without blowing the lid off what
they already knew. So it was far easier for them, far,
far easier for them, to simply stop prosecuting, because
the terms upon which Mr Altman said they could only
continue to prosecute satisfactorily and in safety, were
obviously toxic, so far as they were concerned.
But that, of course, is far down the line. When did
the Post Office know? We will submit that you must
126
The second thing, of course, is Mr Lee Castleton.
Mr Lee Castleton: his story is unutterably tragic.
This is far more than a legal injustice. This
destroys people's mental, physical health; takes away
their good name; they're branded as a thief; their
daughter gets gobbed atin the street: mucus, phlegm,
saliva. Mr Castleton told me she had beautiful long
hair and she would come back, having been abused that
her father was a thief, with spit and phlegm in her
hair.
The Post Office needed a precedent and, as I've
said, they brandished his story, his fate, before
others, to deter. He was, as I've already submitted
an illustrious scalp.
Awitness called in the case to give evidence of the
Horizon System was Ms Anne Chambers, a system specialist
employed by Fujitsu. Her evidence was that she found no
evidence of any problem. Judge Havery, Queen's Counsel,
was impressed by her; he described her as "clear,
knowledgeable and a reliable witness". That was not,
however, Mr Justice Fraser's conclusion. This is what
Mr Justice Fraser stated:
“At least Anne Chambers, in early 2006, and all
those with whom she was corresponding, knew that this
problem, now admitted to be a software bug, had been
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around ‘for years’. Horizon support were telling the
subpostmasters, whose branch accounts were affected by
discrepancies, that they cannot find any problem. The
SMC, the part within Fujitsu responsible for providing
corrective action for event storms, would not always
notice these had occurred in time, and by then, the
damage may have been done. I find by the damage’ that
this can only mean impact upon branch accounts."
Well, none of that, of course, was before His Honour
Judge Havery. They pursued Mr Castleton and they
pursued him as a precedent. It is absolutely clear that
the expenditure of 321,000 to pursue a debt of about
25,000 is utterly ludicrous, as a commercial case. It
ought to have been dealt with by financial controls. It
ought to, we suggest, have been escalated. Itis a mark
of the oppressive culture and it is unconscionable that
such costs were generated.
Mr Castleton, a litigant in person, did not even
know that he could require their bill to be taxed and
so, therefore, he was saddled with that and remained
saddled by that in bankruptcy. He did not even know -
nobody informed him -- that the bill could be assessed.
Itis an appalling, a most discreditable episode and it
ought never to have been countenanced,
I now come, if I may, to compensation. I want to
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sits in school and, you know, he hears people talking.
He sees stuff in his school. They have TVs that project
the news. He's happy that he doesn't have the same
surname as me. I'd like for somebody to be held
accountable. It's not just one person. There's not
just one person that knew what was going on here.
Somebody needs to be held accountable. I want them to
sit here and feel what we feel. We're having to do this
again, we're having to tell our stories over and over.
We just need answers so that we can move on with our
lives."
You know, sir, that she is now, as she has
expressed, unable to take any further part in the
provision of evidence.
Mrs Misra
"The Post Office scandal made me feel this is a land
of two law. There is a separate law for the rich and in
authority and then there's a separate law for people
in -- the common people. And another thing, you know,
like I'm really thankful for the Inquiry, you know, so
we can put a point forward but, at the same time,
I don't want Post Office to hide behind the Inquiry and
saying that ‘Okay, we'll make a decision when the
Inquiry is done’. Inquiry are going to find out who
know what, and what punishment they like, but they
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briefly deal, if I may, sir, with some of the thoughts
that have been expressed and given in evidence before
you about this. I will not refer to Mr Castleton's
evidence. He was nearly destroyed but with tremendous
courage he now tells you that he is happy, but he is
only happy because he is a person of profound faith and
stoicism, and it is humbling that a man who has been
subjected to so much, together with his wife and
children, can reach that level of acceptance.
I suppose, basically, it was submission. He was
powerless to do anything in front of this juggernaut
that crushed him.
Nichola Arch, mentally, physically, emotionally
broken, unending pain. She and her husband even
considered committing suicide together. They now have
a child but, after their child was born, she had
a massive operative procedure and she is beset with
health problems, emotional and physical.
Ms Felstead, who had to go somewhere else out of the
bosom of her close-knit family, leaving the area in
which she'd grown up because of the shame, she asked in
front of you:
"Do they have children? What ifit was their
daughter? My 15-year old son said to me last week that
he's glad he doesn't have the same surname as me. He
130
don't -- for whatever decision they need to, whatever
caution they need to answer, they should still carry on.
Every time we go to court, we find a new evidence where
there'll be a Clarke Advice shredding document and there
will probably, like, some more coming up as well."
Well, I've already referred this afternoon to the
Altman documents.
"Can they be sincere for once", Mrs Misra said, "and
say the truth, and accept it and to be honest? I say it
for myself and probably the same for everybody: not just
physically. We are mentally tired. We are mentally
tired. We want to enjoy life, whatever we got left.
Can't just like ~ i's not easy thing but that doesn't
mean we're going to give up. We do want the answer.
I just say please get this sorted."
Mrs Skinner, Janet Skinner:
"There's too many people involved in what's gone
wrong. Either itll be within the Government, the
Royal Mail, the Post Office, the legal system, the
defences, the legal teams. So many people that have
wronged all these people and destroyed so many people's
lives. We need answers from it. People think that
we're here because of money, and people automatically
think that all we're bothered about is compensation.
The only thing that compensation will ever change is our
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financial stability. We've got a life sentence for
What's been done. We will never erase the memories of
what's happened over these past 20 years, and it won't.
We've got to live with that, but yet you get the people
at the top who just basically say 'm sorry, we made
a mistake’. You made a mistake by destroying people.
Do you know, Seema was right in what she said. There's
a split between them and us. So why is it that the
people at the top think they have more power? What
makes them above the law, above anybody else? If we
break the law, we get penalised. They're breaking the
law, and nothing comes of it."
So, sir, I'm going to ask you to take the opening
statement as read.
SIR WYN WILLIAMS: I should tell you that it has been read.
MRHENRY: Yes. Well, thank you. There is no point
repeating that which has been so ably addressed by all
counsel who preceded me. You have our opening
statement. But, sir, you know your august
responsibility. You know it well.
The best expression of sorrow or contrition is not
a legally rehearsed and trite expression. It is not the
tight body language of somebody sitting by their lawyer.
It actually comes from acts, from deeds, from actually
complying with disclosure deadlines so that we do not
133
SIR WYN WILLIAMS: Thank you.
MS WATT: Thank you very much for allowing us to make this
opening statement which has been provided to you, sir,
in advance and I intend to substantially read from it
and comment and add as I go along. I also may call up
some documents.
SIR WYN WILLIAMS: Certainly.
MS WATT: First of all, in making the opening statement the
National Federation of SubPostmasters welcomes the
opportunity to assist the Inquiry and its chair in any
way it can in order that the failings of the Horizon IT
System at the Post Office and the miscarriages of
justice in the prosecutions of postmasters and other
Post Office staff which followed can be fully addressed.
I would just want to acknowledge, as counsel who spoke
before me did, the detailed and sometimes shocking
information provided in the opening statement of Counsel
to the Inquiry, so clearly given.
The NFSP appreciates that the chair has had the
benefit of already having its Core Participant status
submission, also its statement on issues and evidence of
the hearing on that in November 2021, when Calum
Greenhow appeared before you. But, notwithstanding
this, the NESP seeks to encompass the key issues for it
by making this opening statement. The NFSP recognises
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have ~ it would be trivial to call it a rigmarole,
given the destruction it has caused, but the same
monotonous, repetitive, non-compliance, wrongdoing, that
has dogged this appalling episode in British history,
British legal history, from the outset.
These broken people trust in you, but they confide
in you, that you will go therough, and root out the
truth. That you will not entertain any further excuses
or rationalisations that were advanced before you on
Tuesday of this week. And we respectfully submit, sir
that you are more than able, and very well able, to
achieve justice for those we collectively — Mr Stein,
Mr Moloney and myseif ~ represent.
SIR WYN WILLIAMS: Thank you very much, Mr Henry.
We will now have our afternoon break, and then
I think we will hear the opening submission on behalf of
the Federation. So I will see you all in 15 minutes.
(3.22 pm)
(A short break)
(3.37 pm)
Opening statement by MS WATT
MS WATT: Good afternoon, sir.
SIR WYN WILLIAMS: Good afternoon.
MS WATT: I'm Catriona Watt and I appear on behalf of the
National Federation of SubPostmasters this afternoon.
134
the scale and importance of the work of the Inquiry and
in particular, the care and time taken by it to give
voice to those affected through the human impact
testimony sessions and, of course, here, with the
statements that have been given by counsel on behalf of
those Core Participants.
The devastating effect on those individuals and
their families of what happened to them as a result of
the Horizon IT System and the operation of it by Post
Office Limited, was laid bare in those sessions.
While the NFSP has no direct involvement in the
setting up or delivery in respect of the compensation
scheme, in its written contribution to the Inquiry's,
compensation hearings, the NFSP urged the Government and
the Post Office to make interim payments to those
affected without further delay. In this regard, it is
the strongest possible hope of the NFSP that all of
those who suffered as a result of Horizon and were
wrongfully prosecuted and/or dismissed will have their
reputations restored -- although, as we've heard, how
difficult, if at all possible, that may be -- and all of
their financial losses including consequential losses,
refunded.
In applying for and being granted Core Participant
status, the NFSP is able to participate in and hopefully
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contribute to the proceedings in a way in which they
could not, for instance, in the litigations which gave
rise to the issued judgments of Mr Justice Fraser. In
particular, Bates and Others v Post Office Limited
[2019] EWHC 606 (QB) judgment number 3 (Common Issues)
which discussed and commented on the role of the NFSP,
and I will say a little bit more on that later. But
this was because neither the NFSP nor any of its
officers were asked by any of the parties to give
evidence to the court, leaving Mr Justice Fraser without
the benefit of direct evidence on matters involving the
NFSP and on which he went on to comment, such as those
discussed by him in part F of his judgment number 3.
The NFSP recognises it is one of only a number of
representative organisations, such as trade bodies —
which the NESP is ~ unions and others, whose members
were affected by the Horizon IT System and the actions
of Post Office Limited in relation to it.
Now I think what I go on to say next is important
because we have heard, of course, about many victims but
there are also a number of organisations of which they
may have been members.
Only postmasters can be members of the NFSP. As
a result of information obtained from a Freedom of
Information request -- and I understand that was from
137
this period.
This is because what happened as a result of the
introduction and consequences of the Horizon IT System
is not a postmasters-only issue; it is one which
affected a wider set of employees of the Post Office.
In addition, it is understood by the NFSP that many
of those prosecuted were likely to have been members of
other unions or trade bodies, such as the Communication
Workers Union, the CWU. The NFSP understands and
appreciates that the Inquiry is aware of these different
representative bodies and will be considering the roles,
opportunities, actions in respect of involvement, for
instance in the working group, highlighting issues with
Horizon and supporting their members
As well as assisting with giving evidence at the
forthcoming Phase 2 of the Inquiry's work, where two
former senior officers of the NFSP will be giving
evidence before you, sir, the Phase 2 of the Inquiry’s
work on the Horizon IT System itself, the procurement,
design, pilot rollout and modifications, the NFSP
sincerely hopes to contribute by way of giving evidence
at the following phases.
While the NFSP's role in the area covered by Phase 2
was more limited, itis true to say that it had more
involvement in the areas covered by Phases 3 and 4, as
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the journalist, Nick Wallis, who has shone a light on so
much that has gone wrong here -- itis understood by the
NFSP that of the 766 who were prosecuted, approximately
56 per cent were postmasters leaving the other
44 per cent of those prosecuted as assistants and Post
Office employees.
This means a sizeable number of prosecutions were
bought against people who were not postmasters and
therefore did not come within the ambit of membership of
the NFSP or another trade body, such as the National
Federation of Retail Newsagents, the NFRN. I understand
that at least one of the Core Participants discussed in
earlier submissions, for instance, was a member of that
organisation.
This, of course, actually makes it even more
difficult, as I'l go on to say, to put the whole
picture together by these organisations. There are
several different representative bodies whose members
were affected here.
The NFSP considers it is important for the inquiry
to encompass this wider group within its work and its
ultimate findings. In order to ensure that the public
understands the reality of the risk which was faced and,
in many cases, one which came to pass, for anyone, not
only postmasters, who worked in a post office during
138
well as also 5 and 6, and more will be said by the
officers of the NFSP should they be called to give
evidence in those phases before you, sir.
Asa representative body representing postmasters
across the UK ~ and just to be clear, in terms of
‘comments made this morning in submissions by counsel
postmasters are self-employed. They are not employees
of the Post Office and, therefore, it's incorrect, as
I'l go on to say, that the NFSP was on the side of or
sided with the employer; postmasters were
self-employed -- are self-employed.
The NFSP considers it has a genuine contribution to
make to the Inquiry also in terms of Phase 7 on current
practice, procedure and recommendations for the future.
In particular, the NFSP remains concerned about the
extent to which Post Office Limited is open to dealing
with change which the NFSP believes is required. That
includes governance issues, such as, for instance,
whistleblowing, the concems of postmasters and dealings
with the NFSP itself.
Il say a litle bit more about that later on.
In other words, as said by Calum Greenhow, the
current chief executive of the NFSP, when he appeared at
the hearing on issues on the 8 November 2021:
"Can a leopard change its spots?"
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As he said on that day, if any of those responsible
for the GLO strategy remain in post, is it possible for
the relationship between those who own and operate (and
work in) the Post Office Network to be reset? Through
the work and ultimate reporting of the Inquiry, the NFSP
wants to finally understand what went wrong and why.
Although, as mentioned in the opening of Counsel to
the Inquiry, that has already now been laid bare in its
detail.
The NFSP both hopes and believes the fullness of the
present Inquiry and the commitment of the Chair to it
will have a significant impact on the change which is
necessary for all those in charge, from government
departments to Post Office Limited. This will include
action to right the wrongs of the past and
recommendations to ensure such a devastating scandal
cannot happen again.
In dealing with the various chapters for the NFSP,
these will firstly set out the history and the
relationship of the NFSP with the Post Office because,
if nothing else, some comment has been made, sir, in
these last few days about that, and the NFSP wants to
make it clear to you, sir, that itis, in fact,
independent of the Post Office.
Thereafter, the opening statement will consider the
141
known it, we could have done something”.
Much of what took place for the NFSP was done at
local level, and as with other organisations, it’s
really only when it moves up the way and becomes.
collective that it's clear what the picture is, but that
wasn't possible here and we say that's because of how
the Post Office was conducting itself.
But the NFSP sincerely regrets that its belief in
the Post Office Limited, the Government, Fujitsu and the
justice system, was so misplaced, and we've heard
comment on that from others as well today. The current
chief executive and board of the NFSP have expressed and
continue to express considerable regret that more
assertive action was not taken by its past leadership to
challenge the Post Office in a way which may have
prevented some postmasters from falling victim to
miscarriages of justice.
It continues to be a source of regret to the current
leadership of the NFSP that for some of those
postmasters who came to them for help in the past, they
have had to wait many years to successfully defend their
names through the general litigation. In participating
fully in this Inquiry, and in seeking answers to
pertinent questions from the Post Office, IT businesses
and contractors, government departments and the criminal
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involvement and position of the NFSP in relation to the
Horizon IT System, what it could do and what it did do
in relation to it. That's in the earlier days with
which Phase 2 is concerned.
There will also be reference to the issues and the
evidence it can give on the further phases of the
Inquiry and, it's hoped, to provide recommendations to
the Inquiry which will create trust in the systems of
working and the relationships between postmaster,
employees, Government and the Post Office, for the
future
In closing these introductory remarks, the NFSP
wants to make it clear that, while it has supported many
members over the years in disputes with the Post Office,
and noting some of what was said by counsel who spoke
this morning, where there were any of the NFSP members
who did not receive the help that they considered
necessary, that will always be a matter of regret for
the NFSP.
But as I will go on to say, without the knowledge
that, it turns out, Post Office and Fujitsu had, the
NFSP was limited in what it could do and itis, of
course, with hindsight, with all of the information that
is now available to it, that the NFSP and others can
look and say "Well, why did we not know this? If we'd
142
justice system, the NFSP can represent the interests of
subpostmasters to full effect.
Looking at the NFSP as an organisation in order to
understand what it is and where it comes from, it is
an independent, professional, not for profit trade
association representing Post Office operators,
postmasters. The board of the NFSP is made up of
serving postmasters who are nominated by their peers,
bringing with them the understanding of the operation
and running of Post Offices with all that entails.
The history of the NFSP shows that it is
a long-established body, established on Easter Monday
1897 by a group of around 90 subpostmasters who wanted
to improve the conditions for all subpostmasters in the
UK. This was perhaps indicative of a historically
strained relationship with the Post Office and one might
ask how much has, in fact, changed since then.
The letter of invitation to subpostmasters read:
“The importance of forming a national association is
evident from the fact that, whilst our conditions of
labour have so little improved, the head postmasters,
the clerks and the postmen have each obtained important
concessions through their respective associations.”
The new Federation secured official recognition in
1906 and, in its early years, the Federation was able to
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achieve some minor successes for subpostmasters. It
started organising an annual conference and the
production of a monthly newspaper called
The SubPostmaster.
Itis from there that today's NFSP represent
members -- that's postmasters, self-employed
postmasters -- who own and operate around 8,500 post
offices across the UK, from inner cities to the remotest
corners of the countryside. Notwithstanding this
though, the NFSP is actually a small organisation with
just 26 employees.
The current objects of the NFSP include but are not
limited to, regulating relations between subpostmasters
and the Post Office, by negotiating rates of pay and
conditions of service, variations to subpostmaster
contracts; participating in any form of consultation or
negotiation relating to conditions of service for
subpostmasters; and endeavouring to settle collective or
individual disputes between members and Post Office
Limited, promoting such settlement through joint
participation, conciliation or arbitration.
Now, the status of the NFSP and its funding
arrangements have changed over time. We say this is
relevant in respect of both the litigation that followed
and how the organisation developed. Until January 2014,
145
Mr Justice Fraser was considering the evidence of the
Post Office in support of its position in the
litigations. In particular, the evidence of Mr Nicholas
Beal, that the NFSP allegedly did not support the
ligation. No evidence was offered for that.
In this passage of his judgment, apparently on the
basis of Mr Beal's evidence, Mr Justice Fraser described
the NFSP as "not remotely independent of the Post
Office", and then went on to focus on the GFA and the
funding arrangements.
Within the litigation itself and what was provided
to him by the Post Office -- or not provided, as the
case may be -- he was concerned by the failure of Post
Office Limited to make the GFA available in full to the
court.
In addition, Mr Justice Fraser also discussed
changes to the NFSP's website during the course of the
court hearings, finding this to be suspicious because he
had received no evidence from the Post Office as to why
this had happened.
As already mentioned, the NFSP were not party to any
of this, and it must be said that Post Office Limited
has no control over at all, or say in, the NFSP's
website. All that had happened during this period was
that the NFSP's communication officer was updating the
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the NFSP was a trade union but this status was removed
when the trade union certification officer advised that
the organisation did not meet the legal requirements
necessary to be a designated trade union.
In 2015 the change of status meant member
subscriptions had to come to an end and, instead, the
Federation then received its funding from Post Office
Limited, which consisted of a 15-year Grant Framework
‘Agreement, known as the GFA, paid annually, which is
currently being renegotiated to ensure it is clear and
that the NFSP can challenge the Post Office and that the
GFA is made open and transparent and, of course, that
all arises from what I'm going on to say next.
As a result of all of this, it was in October 2016
that the NFSP changed to trade association status
following a membership vote
Just before I go on to look at the Common Issue
judgment, I want to be clear that the NFSP is not
beholden to the Post Office nor is it afraid to speak
out about the Post Office and, as I will show, the NFSP
has at times, in its review, been misrepresented by the
Post Office, and perhaps therefore others have come to
the view that it is somehow siding with the Post Office
on matters.
In 2021 Judgment Number 3, Common Issues,
146
website as to tone of voice, colour and location of
content and it had been decided that the GFA should be
moved from the "About Us" section to another section
where it appeared to fit better.
The NFSP was entirely unaware of the way in which
this would end up being interpreted in the ongoing court
action, as it did not know this was an issue.
As already mentioned, the NFSP was not a party to or
called to give evidence in this case.
It had no opportunity to correct the record, or the
way in which the Post Office put forward its position on
the litigation or the GFA, or how some of these other
comments that were made about it ended up being
interpreted.
‘As can be seen from the explanation of the
development of the NFSP from trade union to trade
association, it was funded by its members until 2015
when its trade union status was withdrawn. The Freedom
of Information request I mentioned earlier showed that
around 80 per cent of the prosecutions with which this
Inquiry is concerned took place between 1999 and 2010,
with around 20 per cent from then until 2015 and, as we
have heard this afternoon, with none after 2015, and
counsel who spoke before me set out why that was.
The GFA was therefore not in place during the time
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of those prosecutions with which that litigation was
concemed. There was no evidence produced by Post
Office Limited about the position of the NFSP on the
litigations.
The NFSP has been, and remains, concerned about the
reputational damage done to it by the way in which this
was presented to the court by Post Office Limited and,
as a consequence, discussed in the judgment without
evidence from it. The NFSP seeks to correct this at the
Inquiry, in particular in evidence at Phase 4
All of that being said, the NFSP wishes to make
clear that it otherwise fully supports the judgment and
the outcome from these cases and the way in which
Mr Justice Fraser dealt with those.
It is concerned at the way in which certain evidence
and material about it were presented to the court by
Post Office Limited without an opportunity to correct
the record, which resulted in the comments about it.
Turning to Horizon, in the period with which this
Inquiry is concerned, there was a combination of a
decline in footfall and income, changes to technology,
changes in the way customers dealt with their money. In
summary, this saw several cost cutting exercises
resulting in Post Office closures through what's called,
or is termed "network reinvention” in 2003, "network
149
So this really concentrates on Phase 2.
In 1995 the NFSP's records show the number of system
providers, as we heard earlier from Counsel to the
Inquiry, down to three companies, one of which was
ICL Pathway, which that then goes on to become Fujitsu
in due course.
Each of those attended an NFSP exhibition in
Manchester where members were able to see the potential
options available.
So the NFSP were taking an active role on behatf of
their members to find out about what was going to be
coming forward.
In February 1996, in a letter to the Executive
Committee, the negotiating committee of the NFSP met
with three companies and asked questions about certain
matters: the ease of use of equipment; the impact on
transaction times; acceptability to customers; the
extent to which the design will help postmasters to
prevent fraud; the extent to which suppliers’ proposals
guide the postmasters through transactions; proposals
for training; the timescale for rollout; the extent to
which the design is foolproof; what plans do they have
for ongoing marketing; what plans for distant office
transactions; agent encashment; and change of office
procedure.
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change" in 2007, and "network transformation” from 2012.
But before all of this came, the need to introduce
a network-wide IT system was clear and the NFSP.
supported this, recognising it was necessary to secure
the future of the Post Office businesses in the digital
age.
Can I add, the NFSP wanted to ensure a proper and
fully functioning network of post offices was kept open
across the UK. That was a major issue for the NFSP.
As part of the research into Phase 2 of the Inquiry,
what has struck the current NFSP personnel is the number
of prominent MPs from the last 25 years of British
politics who, it transpires, were involved in the
procurement, rollout and working group in relation to
Horizon. The NFSP considers it is therefore important
that the Inquiry is able to establish their roles and
responsibilities in how this whole affair led to so many
postmasters, assistants and employees of the Post Office
Limited, having their reputations destroyed, suffer such
financial hardship and, in some cases, endure
a custodial sentence.
In setting out some of the information which
follows, the NFSP refers to events, meetings and, in
some cases, documents which are recordings of meetings
and issues arising from the procurement and rollout
150
The NFSP did not express any preference in which
systems should be chosen and, indeed, it was not
technically equipped to do so. But it did have
an interest in how such a system would work for their
members.
In May 1999, the NFSP were made aware that the DSS
and the Treasury were considering pulling out of the
Horizon project. Again, we heard about that in some
detail from Counsel to the Inquiry in his opening.
It's understood the DTI wanted the project to
continue and, after intervention by Stephen Byers, the
then Secretary of State for Trade and Industry, it
remained on the table.
The NFSP asks the Inquiry if this suggests that
there was discord between government departments which
led to mismanagement of the project, and/or a lack of
oversight, or that some departments may not have been
working together.
Can I add that, in light of all that has been said
by Counsel to the Inquiry over these last couple of
days, what is clear now is that from the outset, there
were doubts and difficulties, and the NFSP has listened
with concern to all of that.
On 14 June 1999 the DTI report on the Horizon
project stated:
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"We understand that the Benefits Agency failed to
prepare itself and its system sufficiently in order to
be compatible with Horizon."
The NFSP asks the Inquiry if incompetence at
Government and departmental level contributed to the
failure in procurement from the start.
In June 1999 the DTI Horizon project report says —
and I should say, sir, that some of these documents have
been provided recently to the Inquiry by the NFSP and
therefore do not, as yet, have Relativity reference
numbers and that may come in due course. I simply wish
to let you know that.
SIR WYN WILLIAMS: Yes, thank you very much.
Ms WATT: Itsays:
"While it makes evident sense for ICL to continue
with the work it has already begun, the impression
remains of an essentially political deal to ensure that
ICL has a substantial contract with the Post Office at
a price which seems to have been largely determined in
advance of contractual renegotiations as a means,
however inadequate, of making up some of the 180 million
written off by ICL in their 1998/1999 accounts."
Notwithstanding the documents referred to and
available to the Inquiry for the procurement exercise,
the NFSP has found little to no evidence of its direct
153
Union, while others were independent offices under the
responsibility of the NFSP.
On 29 April 1999, 113 post offices completed their
first cash account via Horizon, and these offices were
split into two groups: those who were supported during
the balance and those who were not. Of those who were
supported, 47 completed their cash accounts while 23 did
not, a figure that the NFSP found concerning.
The NFSP was watching this pilot carefully in order
to challenge the Post Office Limited, where ongoing
results of the pilot showed that issues needed to be
challenged and also to support its members where needed
On 30 April 1999 Pam Jervis, the late executive
officer for the Midlands region, raised concerns about
training and installation of Horizon. Now, this I'm
going to, sir, at least attempt to call up document
NFSP0000340 on the screen.
We move to the second page of this document, beyond
the fax cover. Thank you.
It's noted at section 1:
"The first day of training is okay but the second
day is bad because it is rushed. They are not finishing
on time, but they are rushing to finish before 3.30 pm
because otherwise they have to buy lunch. Why did they
use the most expensive hotels?"
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involvement in the procurement of Horizon
In terms of the rollout, the NFSP understands that
the automation project can be traced back to around
1992, when the DSS began a trial of a new benefit
entitled claim form, which omitted the use of post
offices
Following extensive campaigning by the NFSP at that
time, the claim forms were withdrawn.
The concern from Government was around the drawbacks
of the paper-based methods of payment, namely cost,
fraud, liability and lack of customer level accounting
information.
According to the September 1999 DT! committee
report, slippage of the rollout programme began to occur
and it was delayed. Similarly, the Montague report
suggested that in 1997, a formal default letter was sent
to ICL Pathway, who rejected it. That report went on to
highlight that the rollout was unlikely to begin by the
end of 2001 without improved management and uncertain
costs.
What happened next was the pilot scheme and the
pilot began on 12 April 1999 with 200 offices in the
northeast and southwest of England being involved.
These offices were a mixture of both Crown Offices,
under the responsibility of the Communication Workers
154
It goes on to say:
"Many subpostmasters have not received assessment or
certificates on completion of the course.
“In every training session, nobody had done a main
balance. Nobody had been trained to do a full balance
The trainers are people who have only received the same
training that they are giving out. It's too narrow
a field and no one can answer questions.”
Continue on to the page that follows, scrolling down
the way, and the paragraph just below the bullet points,
she reports:
"In general, subpostmasters are extremely happy.
They think it's a great, sophisticated system, but it is
being pushed out too quickly and the people doing the
training know no more than the subpostmasters. There is
no managerial back-up, no definitive answers are given
what is needed is a system helpline."
So that's back in 1999, with the comments coming as
part of this initial pilot. So things are being picked
up and commented on and then being fed back by the NFSP
to the Post Office.
You can take that document down now, thank you
In June 1999 the NFSP prepared questions for Stephen
Byers, the Secretary of State for the Department of
Trade and Industry, and Stuart Sweetman, the managing
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director of Post Office at that time, about training
modification, migration, operations, balancing, the
helpdesk and bar coding, all due to the issues that had
been raised from the pilot, some of which were
highlighted in the document just shown there.
On 14 June the NFSP appeared before the DTI Select
Committee. The Chair asked if the NFSP was being
alarmist in suggesting that thousands of post offices
were threatened by closure. At question 6, Colin Baker,
then General Secretary of the NFSP -- and I appreciate,
sir, that you'll be hearing from him later in this
phase -- was asked: "Do you really think that there had
been anything more than lip service being paid to the
concept of sustenance to the network of sub post offices
being kept going by the Horizon project?"
Mr Baker replied
"I think it is easy for successive governments to
make a commitment to a nationwide network of post
offices and yet not be in any way specific about what is
meant by that."
The NFSP says that is as true today as it was in
1999.
At this DTI Select Committee, the Communication
Workers Union and the CMA explained they had a valuable
role to play, not only in protecting members’ incomes
157
put in place as a result of the NFSP’s points to him.
There's a set of bullet points there setting out the
system changes that are going to be made, major changes
in the managers’ training course, major work being
undertaken to ensure that all documents are at the same
level as the system, and the taskforce in place to
identify the specific nature of the printing problems.
Now, from the NFSP's perspective, what is happening
in theory is that the points that it is putting to those
in charge of Horizon from its members are being taken on
board. That's what it thinks is happening.
We go on to the next page, please. Mr Foley then.
goes on to tell Colin Baker:
"You may be interested in some specific feedback
from one of the offices visited last week. The
postmistress commented that this was the second week in
succession we had balanced more quickly than we would
have done using the old method, even allowing for the
minor glitches. Whilst they were commenting openly on
how difficult they had found balancing and that they had
raised many objections, they freely admitted that it
might be easier for them if they had followed the quick
guides and manuals. They now have little fear of the
system and are standing thing to better appreciate its
benefits.”
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and security but also in protecting public interest.
They highlighted that the Crown network represents
15 per cent of the total volume of the transactions in
the network. They emphasise that the Post Office could
deliver the project but raised concems about the
commitment of the Government to the network. They
explained that without commitment from the Government,
the business would be in a downward spiral.
On 30 June 1999, there is a briefing to Colin Baker
of the NFSP, and I'll call up another document, sir:
NFSP00000027. I hope I've got that correct. Again,
we'll go beyond the fax cover page to the next page.
Now this is a personal briefing to Colin Baker of
the NFSP and it is from Liam Foley who was the business
development director and you see that at the top of the
page, ICL Pathway.
Now, that's third paragraph down. It begins
“Officers:
“Officers have experienced problems with the
balancing process both in stock unit balancing and the
cash account. There have also been printing problems.
We have taken these problems very seriously and are
making significant effort to improve the situation for
the subpostmaster."
Then he goes on to talk about what actions he has
158
He then goes on further down the page, in the final
paragraph:
"I believe it is very important that a positive,
constructive perspective is maintained by us all.
I know I can count on your support to achieve that.
I will, as ever, be happy to listen to any specific
feedback from the executive council."
Thank you, you can take that document down now.
As I said, what the NFSP was thinking was that
Pathway and others were taking on its feedback, hearing
that changes were being made and that the system was
being improved and would be fit for purpose.
On 10 August 1999, the NFSP held a special Horizon
meeting in Newcastle with over 150 postmasters in
attendance. This is all part of the early days of the
introduction, the pilot of Horizon.
David Miller of the Post Office was in attendance
along with Jean Kendall, the national president, and
Colin Baker of the NFSP
David Miller and Colin Baker highlighted that
automation was the future for postmasters. The concerns
from colleagues who were part of the pilot were
highlighted and these included the stress on the
workforce, the strain on people's lives and marriages,
there was enforced cancellation of planned holidays,
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there was low additional income provided by the Post
Office to post masters who were on the trial
On this point, these rates had not been agreed with
the NFSP but brought in by the Post Office and the NFSP
were able to ensure that those payments were doubled.
Those on the pilot also raised concems that the
installation project lacked management at every stage
and highlighted the number of reboots of the system that
was required, especially on balance day.
Now, here I'll call up NFSP00000237, please. If we
can scroll down just to the bottom half of that page,
please, you'll see the general points that I have just
mentioned were being made, agreed by all on the trial:
the stress on the workforce; strain on people's lives
and marriages; lost holidays; the small amounts paid by
Post Office Counters Limited, as it was:
“Of the 44 Horizon officers present, in a vote
30 officers said they suffered stress.”
If we can go on past the next two pages, to the
final page. if we scroll down -- I'm sorry, that's me
If we can scroll back up to the bottom part of the
previous page, the last two paragraphs of that page.
At the end of the questions, David Miller summed up
the evening and asked one question: should he authorise
the national rollout?
161
of areas during the rollout. That's prior to the full
implementation and all that happened subsequently.
The NFSP would ask the Inquiry to consider where the
losses occurred in the cases, and the figures that I go
on to give are a breakdown of examples as submitted by
the NFSP to the Inquiry. I simply have them there for
illustrative purposes.
But what those figures show is that where members
were contacting the NFSP at a national level for help,
internally, the Post Office was being challenged.
However, that does not mean that in every case, the
outcome that the postmaster wanted was achieved. It
also shows that not all issues were software or branch
accounts related. For example, the 200 cases of REMs,
counterfeit and fraud, in the main, focused on a number
of fraudulent giro cheques that were being cashed at
post offices in the mid-2000s.
This resulted in many transaction corrections being
issued to postmasters by the Post Office, which were
subsequently overturned after intervention by the NFSP.
Others involved hardware such as computer screens,
printers or base units not working,
Moving on to touch on the working group, the NFSP.
considers that it is important to note that the working
group which had been set up by the Government to seek to
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“All officers agreed there was nothing fundamentally
wrong with the system however they did not want to
rollout until further improvements had been made."
On the final page, I don't need to turn to it, its
there, simply that there was a request for urgent
training, "urgent provision must be made for training
reliefs", that’s relief workers, because without
training for those relief workers, the post masters
themselves could never be away from the Post Office.
Now, I highlight all of that to show simply that in
the pilot and the rollout phase, there were points
regularly being made by the NFSP to Post Office and to
ICL. Of course, it could not have been known at that
time what was to come.
From the NFSP's perspective, what is clear is that
throughout the rollout of the Horizon programme, the
NFSP supported colleagues where they could and
challenged the Post Office on behalf of the network to
improve. In June 1999, after concerns were raised by
the NFSP over the quality of training, the Post Office
invested a further £8 million to improve the training
programme. These improvements arose from the points
raised by the NFSP, as outlined in my earlier paragraph.
For the NFSP, this all provides clear evidence of
their headquarters helping colleagues across a multitude
162
involve interested parties on the decision-making
process consisted of the Government, the Post Office,
the CMA, the CWU and the NFSP. The NFSP considers,
therefore, it will be important for the Inquiry — which
you already just heard from counsel who spoke before me
regarding the terms of reference -- what the involvement
of each of the three representative bodies did on the
working group.
Throughout June 1999 there were issues arising with
Horizon which the NFSP were aware of. For instance,
a fax from Fujitsu to NFSP outlined software changes due
to postmasters finding the balancing process difficult
to follow, unnecessarily restrictive, and time
consuming. This was discussed at a balancing workshop
between the Post Office and Fujitsu on 11 May 1999.
One particular issue was data entry errors during
migration. There was a recognition that incorrect
figures were used at migration to Horizon, resulting in
a mismatch between payments and receipts. As a result,
a change in the MiMan software was proposed at migration
to ensure the correct figures were transferred over.
Any mismatch would be highlighted with a warning at
migration.
On 8 June 1999 the first working group meeting
between Government, the Post Office, CWU, CMA and NFSP
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The Post Office Horizon IT Inquiry
was chaired by lan McCartney MP, Minister of State at
the DTI. At this meeting, terms of reference were
circulated, and these included -- and I set that out -
overseeing negotiations between Post Office and ICL,
facilitating solutions to the development stage of the
Horizon project, maximising the commercial potential of
Horizon, concerns by the group the Government did not
come out of recent developments in a good light.
Payment for Horizon would be about 550 million, paid
with an initial 68 million and then four payments of
120 million, and 480 million would come from the Post
Office liquidated assets, with the remaining coming from
its working budget. And there would be potentially
a further 400 million of costs to ICL Pathway, which
would be part of the Post Office's future commercial
challenge.
There's then a second meeting of the working group
on 22 June, and we can see, from that, that there is
attendance from lan McCartney, the Minister of State, as
mentioned; representatives from the Post Office; Derek
Hodgson of the CWU; Tony Kearns, CWU; Terry Deegan, CMA;
Tony Harris, CMA; and Colin Baker and John Peberdy of
the NFSP, and others,
As can be seen from the minutes of that meeting,
there was discussion around the removal of the benefits
165
pace and tone, and I wonder if I'm correct in that
assumption. It's 4.30 now, and I interject to give you
the opportunity to give some direction as to the way
forwards.
SIR WYN WILLIAMS: Well, I've been following the
submissions, and unless there is to be substantial
additions to the written statement, in fact we are about
three or four paragraphs from the end. But maybe
I could be enlightened.
MS WATT: That's correct, sir. I am literally almost at the
end. I do apologise for the overrun. I'm grateful.
MRBEER: An unnecessary intervention, then. I'm sorry.
SIR WYN WILLIAMS: I No, that's fine, Mr Beer. It's always
good to be rigorous about these things, but I did
presume that you were reaching the end.
MS WATT: That is correct, sir
Just by way of going slightly off script, I do want
to touch on comments made by Counsel to the Inquiry
yesterday, where he picked out comments of George
Thompson of the NFSP at the BEIS Select Committee of
2015, regarding the system being robust, and simply
wanted to add, although I don't have the document
reference for the BEIS 2015 Select Committee with me to
hand, but simply to note that elsewhere at that same
Select Committee, the CWU's representative had said that
167
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INQ00001046
INQ00001046
13 October 2022
card from the process, and from the NFSP's perspective,
it appeared that ICL were preventing the Post Office
from seeing exactly what they were buying.
The NFSP notes from the time was that there was
a general discussion from all parties in relation to
costs, around 80 million per year, and the Post Office's
ability to afford the system. With the loss of the
Benefit Payment Card was a question if there was
sufficient business to make the whole system financially
Viable, with negotiations between the Post Office and
the Benefits Agency apparently not going well, as it
appeared there was a financial gap of around
£400 million.
On 11 October 1999 the fifth meeting of the working
group took place, and this had representatives from the
DSS, the DTI, the NFSP, the CMA, and the CWU. And at
that meeting, the NFSP was raising concerns about the
Benefits Agency trying to encourage benefit claimants to
move to the bank, despite the NFSP having understood
there was a commitment not to do that before 2003
MR BEER: I hesitate to interrupt whilst Ms Watt takes
a pause in her submissions. The Federation submitted a
time estimate of 30 minutes for their submissions, and
we've been going for just under an hour. It didn't feel
as if we were reaching a point of winding up from the
166
the Horizon System had served the community and the
wider electorate well
"By definition, there will always be bad apples in
the barrel, and it's a robust system."
I simply wanted to draw that to your attention, sir.
In conclusion, on the forthcoming Phase 2, the NFSP
has reviewed a series of meeting minutes and DTI
reports, and has concluded that at the early stages
there were concerns about the finances of the project,
the rollout, and the issues identified throughout the
pilot, and matters underpinning the whole operation, for
instance the changes in relation to benefits payments.
The NFSP recognises that itis for the Inquiry to
review documents, hear evidence, and reach its own
conclusions. However, the NFSP considers that from the
outset, from the procurement stage to the rollout, there
were identifiable issues. It had a role in raising
these issues and seeking resolution of them, and did
achieve extra funding for training and other changes, as
outlined.
Alllof that said, it is clear that what is known now
is that there were significant issues and failings, and
ultimately of the Post Office chose to prosecute
postmasters and others, rather than face what was
clearly a problem following the actual introduction of
168
(42) Pages 165 - 168
INQ00001046
sincerely hopes that the Inquiry can illuminate in full
all that happened, what went wrong, how and why it
happened, and to ensure that it can never happen again.
INQ00001046
The Post Office Horizon IT Inquiry 13 October 2022
1 Horizon throughout the network. INDEX
2 In closing, the NFSP repeats something said at th
3 be " ooo nat i" , Tepes " sri ty a atine Opening statement by MR STEIN........ 1
inning: that it regrets sincerely that its trust in
: 3 ginning im te om id tn Opening statement by MR MOLONEY 67
rt it .
5 Caiminl Juste System was so misplaced, The NFSP Opening statement by MR. HENRY... 9
i
y P Opening statement by MS WATT ..... 134
7
8
9 Thank you, sir, for your time this afternoon.
10 SIR WYN WILLIAMS: And thank you for your submissions.
" So Mr Beer, can I just check with you that we're due
12 to start again at 10.00 tomorrow morning, and that
13 unless I am very liberal in my approach to overrunning,
14 we are due to finish at about lunchtime?
15 MRBEER: Both of those things are correct, sir, yes.
16 SIRWYN WILLIAMS: All right, then we'll meet again at 10.00
17 tomorrow morning, and thank you all very much
18 MRBEER: Thank you very much indeed.
19 (4.37 pm)
20 (The hearing adjourned until 10.00 am the following day)
169 170
(43) Pages 169 - 170
INQ00001046
INQ00001046
MR BEER: [10] 65/18
66/5 66/15 66/20 66/24
95/4 166/21 167/12
169/15 169/18
MR HENRY: [7] 94/14
94/23 95/6 95/8 95/11
95/19 133/16
MR MOLONEY: [5]
65/3 65/10 65/12 67/3
94/10
MR STEIN: [11] 1/3
1/8 1/13 21120 36/20
37/2 38/18 38/21 38/25
39/2 65/1
MS WATT: [7] 134/22
134/24 135/2 135/8
153/14 167/10 167/16
SIR WYN WILLIAMS:
[33] 1/5 1/9 36/17 37/4
38/16 38/19 39/1 64/17
65/2 65/5 65/11 65/14
66/3 66/8 66/17 67/1
94/6 94/11 94/17 94/25
95/7 95/9 95/12 133/15
134/14 134/23 135/1
135/7 153/13 167/5
167/13 169/10 169/16
THE CHAIRMAN: [1]
247
‘98 [1] 39/16
'98/'99 [1] 39/16
'99 [2] 39/16 86/1
‘for [1] 129/41
Ym [1] 133/5
"My [1] 11/12
‘Okay [1] 131/23
‘the [1] 129/7
‘Was [1] 123/8
0
000 [2] 127/13 127/14
1
4,000 [1] 110/2
1.00 [1] 65/13
1.03 [1] 95/1
14.9 [2] 41/6 44/11
1.5 [1] 84/3
10 August 1999 [1]
160/13
40 March 2015 [4]
55/10
10.00 [4] 1/2 169/12
169/16 169/20
100,000 [1] 56/5
101 subpostmasters
[1] 6/7
105 [1] 25/5
106 [2] 25/5 26/14
11 [3] 31/20 81/7
166/14
14 May 1999 [1]
164/15
11 o'clock [1] 38/14
41 October [1] 8/7
11.01 [1] 38/22
41.10 [2] 38/19 38/24
411.53 [1] 65/15
4113 [1] 155/3
414.1 [1] 33/17
41th [1] 39/17
12 [2] 31/20 37/20
12 April 1999 [1]
164/22
12 years [2] 8/14 8/20
12.00 [3] 65/12 65/17
65/20
12.08 [1] 66/21
12.17 [1] 66/23
120 million [4] 165/11
13 [1] 24/8
13 October 2022 [1]
1/1
14 [5] 23/13 23/13
23/14 23/15 37/20
14 February [2] 67/12
68/13
14 June [1] 157/6
14 June 1999 [1]
162/24
144 [1] 33/13
45 [1] 57/19
15 August [2] 4/25 5/5
15 February [1] 69/2
15 July [3] 21/7 21/9
23/12
45 March 2019 [4]
12/6
15 minutes [3] 65/22
65/23 134/17
415 minutes’ [1] 66/11
15 per cent [1] 158/3
15-year [1] 130/24
150 postmasters [1]
160/14
16 December 2019 [1]
10/21
16 September 2003 [1]
127/16
47 [4] 39/23
17 June 2019 [4]
122/2
17,500 [4] 4/6
180 million [2] 39/15
153/21
1897 [1] 144/13
19 [3] 57/19 104/7
122/2
19 matches [1] 112/12
19 years [1] 96/20
19,000 [1] 83/24
1906 [1] 144/25
193 [1] 102/6
1971 [2] 102/1 102/6
1973 [1] 23/22
1980s/early [1] 104/9
1990s [2] 80/8 104/9
1992 [1] 154/4
1995 [1] 1541/2
1996 [2] 23/24 151/13
1997 [4] 154/16
1998 [1] 85/46
1998/1999 [1] 153/22
1999 [29] 2/25 39/6
81/24 82/2 83/16 84/5
84/8 84/14 85/5 85/24
148/21 152/6 152/24
153/7 153/22 154/13
154/22 155/3 155/13
156/18 156/23 157/22
158/9 160/13 162/19
164/9 164/15 164/24
166/14
nN
2,000 [1] 56/6
2.05 [3] 94/12 94/25
95/3
20 [1] 148/22
20 million [1] 36/19
20 years [3] 2/24 5/20
133/3
20,000 [1] 1041/5
200 [2] 154/22 163/14
2000 [5] 35/1 41/13
41/18 51/8 56/3
2000s [1] 163/17
2004 [4] 154/19
2003 [3] 127/16 149/25)
166/20
2006 [5] 47/21 56/6
99/1 107/11 128/23
2007 [2] 107/12 150/1
2009 [2] 3/11 127/6
2010 [4] 35/10 35/22
99/1 148/21
2012 [3] 52/25 53/20
150/1
2013 [12] 10/25 11/23
12/5 24/24 25/3 25/6
26/1 49/24 54/2 54/14
121/19 121/23
2014 [3] 55/5 126/12
145/25
2015 [9] 51/8 55/10
55/10 146/5 148/17
148/22 148/23 167/21
167/23
2016 [4] 146/14
2018 [1] 49/24
2019 [10] 3/1 10/21
12/6 12/8 34/6 56/9
74/2 90/17 122/2 137/5
2020 [1] 98/9
2020/21 [1] 36/15
2021 [7] 17/17 105/12
110/22 120/11 135/22
140/24 146/25
2022 [5] 1/1 31/14 61/9
72/23 123/41
2023 [1] 78/11
20th [4] 112/13
24 [1] 36/15
217 [1] 10/22
218 [2] 10/22 11/7
219 [2] 10/22 11/15
21st [2] 42/11 84/7
22 [2] 35/8 122/2
22 June [1] 165/18
23 [1] 155/7
23 April 2021 [1] 17/17I
24 May 1999 [2] 81/24
82/2
24 September [1]
76/25
25 [1] 122/2
25 years [1] 150/12
25,000 [2] 107/18
129/13
26 [1] 145/11
26 years [1] 5/14
27 [4] 122/2
27 million [1] 77/10
27 per cent [1] 6/25
27 September 2022 [1]
123/
28 July 2024 [1]
120/11
29 April 1999 [1] 155/3
o
3.22 [1] 134/18
3.30 pm [1] 155/23
3.37 [4] 134/20
3.7 per cent [1] 6/21
30 [2] 17/24 166/23
30 April 1999 [1]
155/13
30 June 1999 [1]
158/9
30 officers [1] 161/18
30 September [1]
72/23
34 [4] 122/2
31 October 2043 [1]
25/3
31,000 [1] 5/17
321,000 [2] 107/20
129/12
33 [4] 104/7
36 [4] 4/12
368 [1] 46/11
38 [1] 24/9
38870 [1] 127/14
39 [2] 25/4 71/18
4 October [1] 31/19
4,30 [3] 95/14 95/17
167/2
4.37 [1] 169/19
4.8 [1] 6/20
400 million [2] 165/14
166/13
44 [1] 161/17
44 million [1] 77/6
44 per cent [1] 138/5
456 million [1] 77/13
(44) MR BEER: - 456 million
INQ00001046
INQ00001046
4 105/12 110/22 140/24 I 148/3 148/13 149/3 I accountability [7] 38/6 83/1 129/5 141/15
a7 (2 85120 1657 (8.500 [1] 14817 149/5 149/16 149/18 I 73/17 91/24 93/19 143/14 148/7
48 million [1] 77/2 804) 148/20 151/11 151/15 152/8 I 111/2 115/21 117/16 actions [20] 1/14 10/4
40 million [1] 165/11 I89 convictions [1] I 185/14 157/1 157/19 I 117/23 17/3 36/4 49/19 49/21
49 [3] 35/24 12312 I 89/15 158/5 158/25 165/9 —Iaccountable [5] 9/15 I 50/19 51/15 51/18
123/13 124/13 124/17 [80 million [1] 166/6 I 166/17 167/7 167/14 I 9/25 76/14 131/5 1341/7) 51/20 51/22 52/2 70/17
Se I800 1) 10/1 168/9 169/14 accountants [2] 53/4 I 87/14 87/15 88/24 90/6.
5 800 pages [1] 113/3 Iabove [6] 22/11 22/18 I 92/7 137/17 139/12 158/25
5 years [1] 77/11 819-page [1] 125/17 I 46/14 107/4 133/10 _ Iaccounting [18] 12/11 Iactive [4] 37/23 101/1
5,000 [1] 56/8 844 prosecutions [1] I 133/10 12/18 22/10 44/10 124/24 151/10
50 [1] 124/11 51/9 absence [1] 14/21 I 80/15 81/2082/13 _Iactively [1] 56/18
500 million [1] 77/4 Ig [Absolutely [4] 18/12 I 82/22 86/20.98/12 activity [1] 61/12
509 [1] 28/41 Yd 35/23 93/22 120/11 I 98/24 102/3 102/8 actor [1] 88/25
54 [1] 124/14 9 September 2013 [1] /absurd [2] 37/8 119/7 I 102/12 102/20 102/23 Iacts [1] 133/24
512 [2] 33/6 33/10 121/23 abundance [3] 108/17 I 108/20 154/11 actual [3] 12/17
52 [4] 124/11 90 subpostmasters [1]} 408/17 123/2 accounts [17] 15/17 I 110/20 168/25
55 [1] 102/6 144/13 abundantly [1] 76/6 I 15/18 18/19 34/22 _ {actually [7] 49/5 49/16
550 million [1] 165/9 IA abuse [7] 9/18 16/1 I 39/16 42/14 49/4 72/11] 66/1 133/24 133/24
555 [2] 13/16 34/20 [aoa aap g I 16l4 1614 18/8 18/10 I 81/21 112/24 129/23. I 138/15 145/10
558 [1] 44/22 ban gon I y 4) 40/8 63/21 124/2 129/2 129/8 Iadd [4] 135/5 150/7
56 per cent [1] 1386/4 Abd iat Me abused [3] 104/19 I 153/22 155/7 163/14 I 152/19 167/22
572 million [1] 7713. {ap te i " joane I 05/4 12818 accuracy [1] 72/16 Iadding [2] 19/4 103/2
59 [1] 124/11 abetted [1] abuses [1] 104/3 accurate [3] 48/5 addition [4] 31/21 51/5
i ___ abeyance [1] 127/11 Iaccept [10] 30/19 ‘I 72/14 88/21 13916 147/16
6 abiding [1] 1104 I 6gio4 87/2 89/18 90/2 \accurately [1] 123/25 Iadditional [1] 1641/1
6.1 million [1] 77/7 oa [5] 72/8 79/11 I 93/49 127/10 127/19 accused [4] 3/23 4/5 Iadditions [1] 167/7
606 [1] 137/5 121 123/23 1667 I 497/49 132/9 5/17 97/9 address [4] 15/22
626 [1] 49/25 ae Po tear acceptability [1] achieve [4] 134/12 I 59/20 83/1 83/4
64 [1] 67/4 154/17 145/1 160/5 168/19 Iaddressed [8] 33/18
65 pages [1] 2/11 62/10 72/13 89/4 90/16 I acceptance [4] 82/7 achieved [2] 61/5 _I 61/4 64/11 94/15 96/5
67.3 [1] 6/11 91/8 93/10 106/18 I 918 82/24 130/9 163/12 420/21 133/17 135/14
111/24 134/11 134/11
873 million [1] 7/12 I 16/05 144/25 150/16
6798 [2] 23/12 24/8
accepted [5] 35/3 achieving [1] 84/20 Iaddresses [1] 127/17
35/12 50/21 68/23 acknowledge [3] 2/19 Iaddressing [2] 68/4
68 million [1] 165/10 I 1918 161/5 116/14 93/7 135/15 75/21
>= ably [1] 133/17 accepting [2] 89/14 acknowledged [2] adduced [1] 15/17
7 about [88] 1/3 1/25 216) 4193/7 63/18 72/23 adequate [2] 81/9
7 October [1] 8/25 I 2/22 3/25 8/24 12/2 I access [4] 48/19 50/11Iacknowledgement [1] I 86/21
70 million [1] 36/13 I 19/4 20/1 21/17 21122 I 64/04 gg/03, 70/12 adequately [1] 81/11
700 staff [1] 116/15 I 24/21 24/22 26/2 26/24I accident [3] 40/9 Iacquired [1] 78/16 adhered [1] 101/25
705 convictions [1] I 27/16 28/8 28/17 29/8 I agyyo q47/14 acquitted [2] 4/23 5/7 Iadherence [1] 110/22
51/10 29/14 29/15 30/1 30/2 Iaccolades [1] 110/11 Iacross [8] 5/19 78/1 adjourned [1] 169/20
723 [4] 57/23 30/14 31/14 32/15 accordance [2] 104/25I 85/3 96/25 140/5 145/8I Adjournment [1] 95/2
766 [4] 138/3 32/20 33/9 37/7 40/19 I 449/49 4150/9 162/25 administration [1]
3. Soo oe eae aeree According [1] 154/13 lact [14] 40/1 48/1 I 108/13
——— accordingly [3] 23/25 I 50/17 55/13 5715 Iadmirably [1] 68/25
8 December [2] 7/25 I 58/9 64/20 65/22 69/24) o4/44 94/16 57/22 57/25 60/21 —_Iadmitted [2] 128/25
91/8 72/1 73/1 82/10 82/13 account [17] 10/4 —_I 70/24 97/24 99/4 459/21
8 December 2022 [1] I 89/15 90/7 95/9 109/6 I 59144 gig 33/17 47/2 I 102/25 104/25 113/13 Iadmitting [1] 22/10
61/9 116/22 119/11 123/4 I g9749 70/16 82/15 _Iacted [1] 33/2 adopted [2] 44/20 55/1
8 June 1999 [1] 123/18 124/8 125/15 I 499/99 102/23 103/2 acting [3] 97/16 105/4 Iadult [2] 96/19 96/21
164/24 127/13 129/12 130/3 I 449/90 125/14 127/2 I 110/24 advance [4] 39/13
8 million [1] 162/21 I 132/24 137/20 14015 I so779 15514 158/21 tion [8] 31/21 38/3. I 40/4 135/4 153/20
8 November 2024 [3] I 140/21 141/22 146/20 action [8]
(45) 47 - advance
INQ00001046
INQ00001046
A 99/10 116/15 118/16 alarming [1] 51/7 allocated [1] 1135 I 126/14 126/21 132/7
ao I 130/16 148/23 152/11 lalarmist [1] 157/8 allow [4] 57/6 59/19 IAltman’s [2] 121/17
sventeae tt eve 462/19 163/20 albeit [1] 8/12 62/20 65/23 421/22
advantages [2] 62/14 afternoon [10] 65/18 Ialert [1] 72/6 allowed [7] 29/19 always [9] 33/7 41/21
i188 79/5 95/6 132/6 134/15Ialight [1] 82/6 50/13 51/13 64/14 93/5 48/3 62/22 118/3 12915
advice 37) 20129 2177I 134/22 134128 134/25 Ialighted [1] 8018 41112 12719 142/18 167/13 168/3
m1993;14 24/7 2616. I 148123 16919 alive [1] 96/22 allowing [5] 14/16 lam [14] 1/2 1/5 8/20
37100 2912 30/7 20/10 [afternoon's [1] 95/13 fall [114] 3/6 4/14 10/16] 60/3 62/19 1352 I 21/5 38/22 38/24 65/15
soit 30/tg zone again [36] 7/25 9/4 9/5] 12/5 12/9 15/15 17/4 I 159/18 98/6 167/10 169/13
50105 33/3 3719 4a I 2301 29/22 30/23 I 49/18 19/20 19/24 20/6] allude [1] 117/5 169/20
alts a9rn4 83708 gaiaI 36/24 40/23.41/11 I 22/18 22/22 24/20 alluded [3] 115/17 ambit [1] 138/9
B8/6 8/9 8/19 garg I S2l11 GAT 66/14 74/5 I 26/23 29/12 20/14 31/7) 116)7 119/14 ambitious [3] 4/14
89/11 103/18 119/14 I 90/8 91/6 93/21 93/22 I 32/6 34/16 36/3 38/19 Ialmost [10] 1/24 71/17) 39/4 41/23
1419/1 120/7 121/25 94/11 94/12 97/19 45/6 47/25 48/5 50/23 I 80/11 96/9 96/16 Among [1] 109/23
1422/9 122/9 125/10 97/19 104/20 106/1 50/25 53/13 58/9 58/20) 109/15 109/20 115/11 Iamongst [4] 50/2
425/13 126/13 13214 I 1414/1 117/3 119/13 59/10 59/23 61/25 125/20 167/10 amount [2] 12/20 31/2
advices [7] 20/19 122/14 125/18 125/19 I 62/10 62/17 69/9 71/2 alone [1] 26/12 amounts [3] 12/18
20/20 20/22 28/23 1341/9 141/17 152/8 72/4 74/14 75/24 77/23] along [4] 47/25 119/3 I 56/6 161/15
28/25 75/18 121/17 158/11 169/8 169/12 I 78/2 78/2 78/2 78/3 135/5 160/18 ams [1] 109/17
advised [6] 24/24 34/4 169/16 78/6 79/1 80/10 80/16 Ialongside [1] 32/10 Ian abundance [1]
55/1 103/16 125/11 against [21] 3/3 6/10 I 80/19 83/23 86/14 already [24] 2/11 123/2
4146/2 17/4 31/22 32/15 49/19] 90/16 90/17 91/2 92/18) 32/24 62/11 70/20 71/3Ian account [4] 103/2
adviser [1] 54/15 49/21 50/12 51/12 92/20 92/20 92/22 72/9 88/10 99/16 99/24] an accounting [1]
adviser's [1] 88/20 51/21 52/3 52/8 90/6 I 94/13 94/25 100/9 116/7 119/24 120/9 80/15
advisers [7] 25/21 92/2 92/2 97/12 103/10) 100/13 100/15 107/4 I 126/19 128/13 132/6 jan act [1] 113/13
26/18 43/13 43/21 44/1I 17/3 124/9 125/3 109/14 109/21 110/21 I 135/20 141/8 147/21 Ian active [2] 124/24
88/14 89/4 138/8 110/23 112/16 113/10 I 148/8 153/16 164/5 151/10
advising [1] 126/15 age [3] 84/17 84/25 113/25 116/21 117/10 Ialso [51] 6/13 7/24 an adult [1] 96/19
150/6 120/21 120/22 126/1 I 10/15 11/12 14/24 15/6) an advice [1] 126/13
afar 1] 46/16 agencies [1] 93/24 127/7 128/23 132/21 I 15/8 16/16 18/5 19/8 Ian affront [1] 18/7
affected [15] 37/18 Agency [10] 39/8 132/24 133/17 134/17 I 20/20 24/24 26/14 27/7Ian agent [1] 99/8
44/2 59/7 63/13 68/25 I 30/25 40/5 40/8 41/24 I 135/8 136/17 136/21 I 29/13 29/23 30/19 35/6) an alarming [1] 51/7
77/24 80/23 90/24 83/18 83/23 153/1 136/21 141/13 142/23 I 49/1 50/6 50/24 56/25 IAn alternative [1]
91/15 129/2 136/3 166/11 166/18 144/10 144/14 146/13 I 61/4 65/25 69/8 72/3 I 12/20
436/16 137/17 138/19 Iagent [2] 99/8 151/24 I 146/14 147/23 147/24 I 77/9 78/8 80/20 81/14 Ian annual [1] 145/2
4139/5 agents [1] 35/18 149/11 150/2 152/19 I 86/5 97/5 97/16 107/3 Ian answer [1] 9/1
affecting [2] 81/20 {ges [1] 78/2 152/23 157/3 159/5 111/4 111/24 114/19 Ian appalling [2] 46/16
91/11 aggression [1] 91/20 I 160/4 160/15 161/13 I 125/17 126/16 135/5 I 129/23
affects [1] 47/22 aggressive [1] 99/12 I 162/1 162/10 162/24 I 135/21 137/21 140/1 Ian appellant [1] 46/1
affirmatively [1] 98/16 aggrieved [1] 54/5 163/2 163/13 166/5 140/13 142/5 147/16 _Ian application [2] 37/4)
afford [2] 10/5 166/7 ago [6] 8/7 13/6 33/9 I 168/21 169/7 169/16 I 155/12 158/1 158/21 I 37/7
80/1 1024 119/18 I 169/17 46116 163/13 an appropriate [1]
Stront (1 ia agree [1] 68/17 all-important [1] 90/17Ialterations [1] 112/3 I 101/17
afraid [3] 3/14 57/7 agreed [10] 3/19 11/16Iallegation [1] 3/25 alternative [2] 12/20 Ian assistant [1] 49/6
1468 53/3 53/7 53/22 84/10 [allegations [3] 31/22 I 113/24 an audit [1] 48/7
after 34) sagen I 111/18 16118 161/13 I 50/12 595 although [6] 23/7 _Ian early [1] 85/10
sO bart arts zortaI 162! alleged [8] 11/4321 I 28/14 119/20 136/20 Ian effective [1] 114/9
F018 40/8 Ait? eiing [Agreement [1] 1469 I 46/7 50/8 70/18 98126 I 141/7 167/22 an effort [1] 13/17
SHDS 49/1 AsI7 aang (AR 95/11 99/1 124/10 Altman [16] 2021 an email [1] 8/6
Bi eiitt seroeot (ahead [1] 4/13 allegedly [1] 147/4 I 24/23 25/6 26/1 26/15 Ian employee [1] 23/21
Proc sate y7i5p royelaided [3] 104/2 103/22Ialleging [1] 7517 I 27/16 27/21 26/9 28/18) an end [2] 55/11 146/6
80/16 82/1 82/25 gag I 193/23 Alliance [2] 8/19 54/8 I 29/2 33/3 34/4 126/13 Ian enhanced [1] 5/7
(46) advanced - an enhance
INQ00001046
INQ00001046
A an organisation [2] 61/16 64/20 66/12 72/4) 140/23 148/4 157/6 —_ architects [1] 77/20
anentity [1] 705 I 46/24 144/3 72/7 72/15 76/16 78/12) 166/2 166/12 architecture [1] 118/4
an epidemic [1] an overriding [2] 79/10 79/10 83/6 86/21Iappears [11] 8/1 16/20Iare [104] 1/3 1/4 1/24
108/20 16/21 78/14 88/18 88/20 88/25 89/7I 31/15 46/24 47/2 47/23) 5/22 5/23 6/19 6/24
an essentially [2] an unequivocal [4] 95/21 103/14 105/19 I 50/10 50/18 57/1 85/21) 7/23 10/3 10/9 13/4
39/10 153/17 108/5 108/3 116/20 116/20 I 119/10 13/19 13/23 14/11 16/4
an example [4] 99/23 An unusual [1] 56/7 I 121/3 121/6 121/12 _Iappellant [1] 46/1 18/10 18/15 19/25 22/3
an excellent [1] 67/23 an utterly [1] 87/18 121/21 124/16 128/18 Iappellants [3] 17/12 I 24/20 26/20 26/24 29/1
an exceptional [1] anachronistic [1] 25/9I 129/3 131/13 134/8 17/17 18/7 32/14 32/19 34/2 34/4
18/9 analysis [3] 31/7 135/10 137/8 137/9 appellate [1] 122/16 I 34/5 35/18 37/18 38/1
an excuse [1] 33/24 106/15 110/16 141/14 142/16 145/16 Iapples [1] 168/3 38/1 38/5 47/14 51/11
an expert [3] 24/14 Andrew [1] 11/8 147/21 152/1 157/19 Iapplication [3] 37/4 I 52/8 52/12 55/1 58/20
24/16 27/22 angel [1] 105/4 160/6 164/22 37/7 119/11 59/7 59/13 60/8 61/19
an extent [1] 37/15 Angela [2] 14/9 58/22 janybody [3] 107/13 applied [2] 51/22 91/5 I 63/20 63/23 64/5 64/5
an extremely [1] 34/12 anguish [1] 9/3 125/22 133/10 apply [1] 58/3 66/6 66/24 67/4 67/18
an honest [1] 108/2 Anne [3] 47/20 128/16 Ianyone [5] 26/11 49/8 Iapplying [1] 136/24 I 71/3 71/4 76/7 79/21
an illustrious [1] 128/23 59/7 114/24 138/24 jappointed [2] 38/2 87/25 91/8 91/10 93/14
128/14 announcement [1] anything [7] 26/9 53/5 93/25 95/10 95/15
an impact [1] 86/24 7124 40/18 61/11 71/24 appointment [1] 50/24) 106/11 106/18 107/7
an important [3] 25/13 announcements [2] I 121/9 130/11 157/13 Iappreciate [7] 69/22 I 108/7 108/9 109/23
76/21 81/14 61/12 63/22 apart [1] 34/15 72/22 78/17 78/21 80/9) 110/10 114/5 117/12
an inaccurate [1] annual [3] 36/14 36/22/apologies [1] 63/20 I 157/10 159/24 117/16 118/5 119/16
125/14 145/2 apologise [1] 167/11 Iappreciated [2] 30/21 I 120/41 121/7 131/24
an inadequate [1] annually [1] 146/9 apologising [1] 7/3 I 30/25 132/14 132/11 134/41
14/47 annulled [1] 8/24 apology [1] 63/18 appreciates [2] 135/19) 137/21 138/17 140/7
an incentive [1] 48/23 another [18] 9/2 20/15] appalling [6] 36/7 139/10 140/7 140/11 144/8
an independent [5] 43/5 46/6 48/2 49/11 I 46/16 115/25 126/11 Iapproach [8] 12/21 145/12 150/24 155/22
23/40 53/4 53/6 103/21 59/3 61/8 65/22 66/11 I 129/23 134/4 45/24 54/19 69/17 155/23 156/6 156/7
4144/5 75/1 108/13 108/14 japparatus [1] 117/22 I 79/13 90/18 90/25 156/12 156/16 156/19
an index [1] 117/9 113/9 131/19 138/10 apparent [11] 37/6 169/13 158/22 159/3 159/5
an individual [4] 12/25 148/3 158/10 48/21 50/5 51/16 79/8 Iapproached [2] 35/25 I 159/10 159/24 163/5
an Inquiry [1] 62/12 {answer [8] 9/1 20/4 I 81/23 82/1 89/6 90/18 I 36/1 4167/7 169/14 169/15
an institution [1] 26/8 101/17 115/24 123/22 124/1 approaches [1] 107/1 Iarea [5] 3/11 43/14
96/13 132/2 132/14 156/8 apparently [5] 35/3 approaching [1] 110/1I 43/15 130/20 139/23
an interest [2] 78/6 answerable [2] 53/13 I 99/11 117/3 147/6 appropriate [5] 1/10 Iareas [3] 23/23 139/25
15214 55/14 166/11 22/17 60/14 101/17 163/41
an interested [1] answers [10] 43/22 appeal [20] 5/21 10/17I 109/11 argued [1] 105/15
105/12 43/22 78/13 91/18 ATIN2 17/16 17/19 appropriately [2] argument [1] 105/19
an interim [1] 8/12 93/12 119/9 131/10 17/22 18/5 24/25 37/5 I 25/25 87/9 arise [2] 20/10 59/3
an interrogation [1] 132/22 143/23 156/16 I 54/11 70/13 71/19 approximately [1] arises [2] 42/17
100/20 Anthony [3] 15/5 72/15 74/13 76/3 100/2I 138/3 146/13
an investigator [1] 54/11 89/22 102/4 102/2 102/6 April [7] 17/17 49/24 I arising [5] 29/13 82/14
100/14 anticipate [1] 52/9 11916 55/9 86/1 154/22 155/3I 86/18 150/25 164/9
an issue [2] 10/24 anticipated [1] 37/24 Iappealed [1] 13/24 155/13 arms [1] 125/22
4148/7 anticipates [1] 32/3 appeals [10] 17/13 {April 2013 [1] 49/24 arose [7] 17/13 47/8
an IT [1] 59/5 any [69] 1/9 8/21 11/5 I 25/1 28/24 29/4 45/25 Iapt [1] 98/23 48/2 105/20 124/2
an NFSP [1] 151/7 14/2 24/18 26/2 26/7 I 75/16 75/20 75/24 arbiter [1] 58/12 127/5 162/22
an obstructive [1] 28/1 28/3 28/3 29/13 I 104/9 121/18 arbitration [1] 145/21 Iaround [12] 47/21
55/2 33/5 37/23 37/23 43/1 Iappear [5] 46/14 49/6 IArbuthnot [2] 15/3 54/23 129/1 144/13
an obviously [1] 80/17; 43/2 46/16 48/15 50/14] 55/16 107/15 134/24 I 53/2 145/7 148/20 148/22
an opportunity [2] 51/2 52/15 55/22 57/2 Iappeared [9] 14/7 Arch [4] 100/17 107/8 I 154/3 154/9 165/25
60/17 149/17 57/19 58/4 59/21 60/24} 53/21 92/23 135/23 125/4 130/13 166/6 166/12
(47) an entity - aroun
INQ00001046
INQ00001046
A 135/10 75/17 82/11 142/24 —_Ibankrupt [3] 51/13 54/24 55/6 74/21 96/11
ARQ [3] 48/7 48/9 assistant [2] 48/6 49/6] 147/14 151/9 153/24 I 51/15 51/17 110/3 117/18 118/11
48/12 assistants [6] 42/20 Iavenging [1] 105/4 Ibankruptcy [4] 8/24 I 124/14 151/5
arrangements [2] 42/22 54/5 124/19 avenue [1] 73/16 9/1 97/3 129/21 becomes [1] 143/4
145/23 147/10 138/5 150/18 averred [1] 98/11 bankrupted [1] 107/21Ibecoming [3] 52/23
arrive [1] 110/25 assisting [1] 139/15 Avery [1] 105/3 banks [2] 3/9 1105/3 I 79/12 116/22
arrived [1] 110/15 _I@8S0ciation [4] 144/6 avoid [2] 10/20 48/23 Ibar [1] 157/3 been [138] 2/18 3/13
arrogance [2] 108/19 144/19 146/15 148/17 Iawarded [1] 77/5 bar coding [1] 157/3 I 5/25 8/9 8/13 8/25 9/15
142/20 associations [1] aware [23] 5/24 14/24 Ibare [4] 29/13 78/14 I 9/25 10/2 11/18 13/22
as [279] 144/23 20/1 21/4 24/20 24/22 I 136/10 141/8 13/24 16/12 17/2 17/5
ascertains [1] 57/3 assume [2] 25/12 72/4] 29/1 35/24 37/25 45/17Ibarrel [1] 168/4 18/3 18/21 21/4 21/23
aside [3] 9/15 38/4 assumption [1] 167/2 I 49/1 55/6 56/22 56/23 Ibars [1] 99/17 24/21 24/22 26/5 26/6
115/8 assumptions [1] 97/17I 56/25 81/17 82/8 base [3] 30/18 116/15 I 28/25 29/10 30/24 31/5
ask [37] 14/6 25/3 astonishingly [1] 101/13 106/9 124/14 I 163/22 35/6 37/10 37/10 37/17
31/10 34/17 32/10 7217 139/10 152/6 164/10 Ibased [4] 25/10 68/24 I 37/25 38/8 39/7 39/12
32/13 32/17 39/22 astute [1] 115/7 awareness [1] 113/7 I 75/14 154/10 40/8 42/2 45/11 45/23
40123 49/11 52/3 55/18 I@tTociously [1] 101/20] away [4] 4/17 73/11 Ibasically [2] 130/10 I 45/25 47/21 48/3 49/9
58/2 59/12 59/17 59/18 attacked [1] 64/1 128/4 162/9 133/5 49/13 49/15 50/12 51/1
60/15 62/1 62/16 63/2 attacking [2] 21/14 {awfully [1] 92/14 basis [9] 13/25 17/3 I 56/20 56/22 56/25 57/5
63/6 64/4 70/3 73/14 22/1 B 17/5 27/19 51/23 67/7 I 58/22 58/24 60/11 61/4'
82/25 83/5 86/18 87/8 attacks [1] 75/3 7115 83/6 147/7 61/5 62/25 64/11 65/21
4143/2 115/21 115/24 attempt [5] 14/2 55/17 back [18] 30/24 62/22 IBates [6] 10/1154/9 I 67/22 68/25 69/14 70/1
4147/4 121/21 123/3__ I 87/19: 79/10 155/16 62/24 66/13 85/9 98/9 I 74/3 98/25 106/21 71/23 7215 72/8 73/23
attendance [3] 160/15 I 113/25 122/9 1236 I 137/4 74/10 75/3 76/6 76/13
aekattl sore I 190/17 105/19 125/20 125/21 1261 IpBc's ty 1113 I 76/14 77/0 79128 8517
asked [15] 3/11 10/23 attended [3] 17/21 128/8 154/3 156/16 I be [244] 86/7 88/9 90/16 91/3
14/24 24/17 27/25 I 90/14 154/7 156/18 156/20 161/21 IBeal [4] 147/4 91/25 92/14 97/12
38/11 53/11 86/6 attention [7] 10/14 /back-up[1] 156/16 [Beal's [1] 147/7 98/18 98/25 103/16
415/22 130/21 13719 I 11/3 36/23 82/3 123/11]background [2] 21/18 Ibear [7] 7/2 7/17 14/15] 107/23 108/6 113/1
451/15 157/7 187/12 I 124/18 168/5 90/7 34/3 73/2 96/24 109/22) 114/23 114/24 115/14
161/24 attitude [5] 12/7 13/6 [backwards [1] 26/22 Ibeat [1] 100/20 115/23 116/17 116/18
i 53/24 55/2 75/10 bad [5] 58/16 99/7 I beautiful [1] 128/7 I 117/14 117/4 119/14
seks DL tale 1536 attributed [1] 87/6 I 116/9 155/22 1683 I became [4] 49/2 80/4 I 122/7 122/8 122/10
aspect [5] 17/8 34/15 Audit [5] 48/3 48/7 badly [1] 37/18 96/5 101/13 124/24 125/23 126/41
72/20 82/6 111/5 48/18 55/24 81/2 Baker [8] 157/9 157/16I because [52] 8/19 I 126/14 128/8 128/25
aspects [2] 15/25 64/1 Auditors [5] 4/5 16/17 158/9 158/13 159/13 I 18/3 19/2 20/6 20/23 I 129/7 129/14 129/15
assertion [2] 22/8 I 40/15 51/3 66/21 160/19 160/20 165/22 I 22/6 31/8 32/17 36/4 I 129/24 130/2 130/7
7214 august [8] 4/25 5/5 8/3Ibalance [13] 19/5 36/24 48/5 48/18 48/22I 133/2 133/15 133/17
assertive [1] 143/14 I 94/2 61/20 118/22 19/13 23/1 78/18 82/15I 50/10 55/6 59/23 62/24] 135/3 136/5 137/22
asserts [3] 22/6 25120 I 139/19 160/13 99/21 103/18 125/11 I 65/6 67/21 80/22 87/17I 139/7 141/8 141/21
26/18 August 2013 [1] 54/2 I 127/11 155/6 1586/5 I 94/18 96/23 104/17 I 146/21 148/2 149/5
assessed [1] 120/22 IAuiard [3] 15/1 54/20 156/5 161/9 105/16 108/6 110/5 I 152/17 152/19 153/9
assessing [1] 58/18 I 54/25 balanced [1] 159/17 I 141/17 114/8 115/8 I 153/19 156/5 157/4
assessment [2] 53/6 [@uthorise [1] 161/24 balances [3] 43/11 I 115/15 115/25 116/1 I 157/13 158/21 161/3
156/2 authority [3] 103/10 I 103/7 127/19 119/24 122/19 123/1 I 162/3 162/13 163/25
assessments [1] 118/5 131/18 balancing [10] 19/16 I 1425/7 126/12 12615 I 166/24 167/5
53/18 Automated [1] 40/2 I 41/8 42/23 112/24 126/20 130/6 130/21 I Beer [28] 5/3 23/4 24/4
asset [1] 99/20 automatically [1] 187/2 158/20 158/20 I 432/23 137/8 137/20 I 30/6 37/7 44/9 47/13
assets [3] 25/15 54/13) 19223 159/20 164/12 164/14 I 4390/2 141/20 143/6 I 51/7 66/4 67/13 67/22
465/12 automation [2] 154/3 Ibank [1] 166/19 147/18 155/22 155/24 I 68/12 70/10 75/19 76/7
160/21 bankers [1] 92/7 162/7 79/5 80/8 80/13 81/3
eit DB) date available [8] 31/2 39/4 Ibanking [2] 53/9 86/11)phecome [10] 33/21 I 82/10 95/23 101/7
(48) ARQ - Beer
INQ00001046
INQ00001046
B beholden [1] 146/19 I 141/3 142/9 145/13 I 58/22 412/20
Beer..[6] 109716 IPeing [55] 4/10 15/5 I 145/19 148/21 152/18 Ibook [1] 127/16 brief [2] 59/13 113/8
tare 118/22 125110 I21/1022/12 22/16 I 164/16 164/19 164/25 Ibooks [1] 103/18 [briefed [2] 117/11
467/13 460/14 22/23 23/8 28/9 20/21 I 165/4 166/10 boorishly [1] 100/15 I 117/13
Beer's [3] 96/2 96/9 I 30/4 30/7 33123 36/16 Ibeware 1] 119/24 bordering [1] 11/25 briefing [2] 188/9
109/10 50/1 52/2 53/11 56/11 Ibeyond [12] 41/13 [born [1] 130/16 158/13
Beers [1] 70/12 62/10 64/14 66/1 66/2 I 68/9 70/7 71/23 80/3 Iborrow [1] 19/6 briefly [9] 7/6 10/20
before [65] 2/11 2/12 I 82/4 84/4 86/6 99/17 I 82/1987/17 87/20 bosom] 130/20 I 56/19 68/6 80/3 87/20
409 4/17 A/t@ Sita 614 I 10315 104/19 108/15 I 96/18 97/2 155/18 —_Iboth [25] 12/15 13/10 I 87/21 120/8 130/1
oit9 11/16 14/5 147 I 17/7 (18/1 119/2 I 458/12 23/17 35/11 65/8 70/23] bring [3] 79/6 97/11
‘7949/15 tore I 1263-1264 136/24 bias [1] 37/6 7223 75/23 76/5 81/12) 124/18
1923 28/5 28/10 2a/19I 146/10 148/6 148/13 Ibiases [4] 119/21 I 82/10 87/17 92/1 94/18I bringing [3] 7/22
29/7 3aina aorta aai2 I 129/11 154/23 156/14 bid [2] 81/1 81/6 98/8 98/10 102/3 102/7) 124/9 144/9
“a6 42/04 43/7 44/17I 156/19 156/20 187/7 big [1] 2012 104/3 122/15 141/10 Ibrings [6] 46/23 64/13
44/24 65105 65/25 I 197/13 187/15 159/4 I bigger [1] 87/4 445/24 154/24 158/20 I 101/18 103/21 104/23
59/01 62/18 62/28 74/2) 109/10 160/11 160/12 Ibiggest [1] 99/20 I 169/15 120/7
79/19 81/23 Bo/8 82/24) 161/13 162/12 163/10 bill [3] 77/8 129/19 [bothered [1] 132/24 IBritish [5] 18/16 68/16
86/1 87/21 95/12 96/7 I 163/16 163/18 167/21 I 129122 bottom [3] 117/24 I 134/4 134/5 150/12
gait 104/4 105/11. (BEIS [18] 7/1077 Birmingham [2] 54/17 I 164/11 161/21 broadcast [1] 65/25
40a/t7 107113 111/16 I 8/1 8/5 8/22 9/14 13/14] 104/10 bought [2] 55/10 138/8I broader [2] 31/25 93/2
412/25 12018 127/5 I 16/6 30/1 37/25 52/14 Ibit [3] 12110 137/7 [bound [1] 120/12 I broke [2] 1/22 1/22
428/12 12919 13012 I 95/2286/2460/21 I 140/21 bow [1] 112/25 broken [8] 70/1 92/20
434/9 135/16 135123 I 61/2064/21 167/20 bitterly [1] 34/18 I box [1] 31/2 99/16 108/2 117/7
439/18 14013 14617 I 197/23 Bizarrely [1] 50/15 Iboxes [1] 117/18 126/4 130/14 134/6
148/04 1802 155/23. IBEIS's [1] 37/23 Blair [2] 84/8 86/2 —_Iboys [1] 4/6 brought [11] 1/15 7/16
45716 1064/5 100720 _IPelief [4] 97/13 1006 I blame [9] 26/21 branch [16] 11/19 I 9/19 18/21 51/9 54/10
began [5] 96/10 125/14 143/8 400/24 113/10 113/17 I 42/22 43/2 49/4 49/10 I 97/12 108/18 109/21
toorté 154/4 154/14 [believe [6] 1/24 7115 I 119/22 116/4 118/19 I 49/18 s0/23 72/11 I 122/13 16114
454/02 34/2 52/17 101/12 I 119/18 119/16 81/21 110/16 11/2 Ibrow [1] 100/20
beggars [1] 125114 I 1808 blamed [1] 76/3 123/23 124/2 129/2 I brutal [2] 99/6 100/7
begin [] “V8 917 gartaIPelieved [2] 98/11 blameless [1] 99/16 I 12918 163/13 buck [1] 118/7
95/8 95/12 154/18 I 1265 blank [1] 70/10 branches [8] 16/18 Ibudget [2] 113/4
beginning [9] 95/20 IPelieves [2] 140/17 I blighted [1] 3913 19/14 35/1340/16 I 165/13
100/21 107/9 107110 I 141/10 blindness [1] 124/24 I 74/16 78/4 108/21 I bug [2] 35/10 128/25
412/17 118/18 12/1 [Pelieving [1] 10/25 Iblithely [1] 116/14 I 111/16 buggy [1] 27/11
426/12 16913 below [1] 156/10 blocks [1] 70/14 I brand [1] 3/4 bugs [31] 17/24 19/1
begins (2) 79124 _[Penefit[6] 83/19 blowing [1] 126/18 branded [2] 99/19 I 19/2 49/18 19/21 19124
158/17 135/20 137/11 154/4 I blue [1] 8/17 128/5 22/25 27/17 29/19 35/8
begun [1] 153/16 I 166/8 166/18 blunt [1] 112/41 brandished [2] 107/13I 35/9 56/23 71/8 74/10
behalf [16] 15/10 2913 IPenefits [13] 39/8 I board [9] 8618 86/19 I 128/12 71/14 74122 7217 81/17
3002.34/16 31/19 I 39/25-40/5 40/8 41/24 I 87/8 113/25 114/14 [braver [1] 107/23 I 81/19 82/18 83/2 83/9
59/13 67/4 73/18 91/6 I 89/18 83123 1631 I 115/18 143/12 144/7 I bravery [1] 2/19 87/3 90/2 103/13 112/6
125/23 127/24 134/16 I 159/25 165/25 166/11 I 159/11 brazenly [1] 75/8 I 123/20 123/21 123/24
134104 19615 151/10 I 106/18 168/12 board's [2] 114/15 —_Ibreach [2] 24/13 57/21I 124/3 126/9
162/18 beset [1] 130/17 114/18 break [11] 1/11 13/15 Ibuild [3] 15/20 70/9
behaved [1] 01/19 [best [2] 11818 133/21 bodies [5] 137/15 I 38/14 38,28 65/4 65/6 I 70/18
behaviour [2} 16/5 [Petter [4] 9/20 102/18 I 138/18 130/8 139/11 I 65/16 66122 133/11 I building [5] 70/14
3H/10 148/4 159/24 164/7 434/15 134/19 84/12 92/8 92/11
behind [9] 44/2 15/10 [Petween [23] 46123 I body [6] 36/5 46/17 [breakdown [2] 52/17 I 127/23
2303 Tait4 Ta19_ I 51/8-54/4 62/21 77/19 I 133/23 138/10 14014 I 163/5 builds [1] 71/6
91/22 99/17 121/12. I 78/18 84/20 94/8 10/1] 144/12 breaking [1] 133/11 Ibuilt [2] 40/13 85/8
134/02 111/13 115/12 33/8 IBogerd [3] 11/16 14/9 Ibreathtaking [1] bullet [4] 24/9 84/3
(43) Beer... - bullet
INQ00001046
INQ00001046
B 137/20 142/20 143/5 I 131/21 132/8 135/11 Icash [5] 35/18 82/15 I 120/20 121/3 135/10
bullet..[2] 156/10 I 1435/8 145/12 14671 I 136/14 137/23 140/26 I 155/4 185/7 188/21 I 135/19 141/11 157/7
159/2 150/2 152/3 155/21 I 142/6 142/24 144/1 cashed [1] 163/16 I Chair's [1] 72/22
bullied [1] 100/18 155/23 156/13 158/1 I 146/11 148/15 150/7 Icasting [1] 26/21 chaired [1] 165/1
bully [1] 4/6 158/5 161/4 163/8 152/19 154/3 156/8 ICastleton [11] 98/5 I challenge [9] 44/14
bullying [1] 16/5 167/8 167/14 167/24 I 156/22 160/5 160/8 I 98/10 99/1 104/20 72/16 106/6 107/14
burden [4] 40/10 97/18{ button [1] 40/12 161/11 161/19 161/21 I 107/11 127/3 128/1 I 109/2 143/15 146/11
97/20 97124 buy [1] 155/24 165/18 165/24 169/6 I 128/2 128/7 129/10 I 155/10 165/16
burgeoning [2] 111/21 buying [1] 166/3 169/8 169/11 129/18 challenged [4] 46/7
115/20 by [252] can't [6] 6/15 9/7 23/14ICastleton's [1] 130/3 I 155/12 162/18 163/10
burst [1] 108/21 Byers [3] 84/11 152/11] 27/11 73/11 132/13 Icasuistry [1] 115/8 IChambers [3] 47/20
bury [1] 10/20 156/24 cancellation [1] catastrophic [1] 116/2I 128/16 128/23
business [13] 1/15 Byzantine [1] 115/11 I 160/25 category [1] 18/8 chance [2] 19/20
anit 424 5it1 35/22 IC candidly [1] 103/15 Icathartic [1] 63/23 I 54/17
83/20 84/19 92/9 104/8I <> candour [2] 93/3 Catriona [1] 134/24 Ichange [11] 54/4
114/9 158/8 158/14 Cairngorms [1] 4/5 I 110/23 cause [5] 42/24 71/16 I 58/25 90/18 132/25
4166/9 calamity [1] 26/4 cannot [10] 14/3 37/15] 110/16 116/25 123/22 I 140/17 140/25 141/12
call [9] 11/11 33/10 I 61/18 61/18 64/2 76/11Icaused [6] 22/25 35/8 I 146/5 150/1 151/24
businesses [4] 84/22 I g9/99 427/23 134/1
118/16 126/14 129/3 I 48/22 49/23 64/2 134/2) 164/20
143/24 150/5 169/4 I 135/65 155/16 158/10
144/17 causes [1] 110/15 changed [6] 49/17
ir ioc aspen ted 161/10 capable [3] 70/5 74/15 I causing [3] 10/24 53/25 58/21 144/17
49/22 20/6 20/16 21/17Icaled [17] 9/15 14/5 I gti19 48/24 74/15 145/23 146/15
24/18 22/10 24/7 24/12I 14/21 26/13 26/19 capacity [1] 31/8 caution [5] 3/21 4/7 Ichanges [9] 147/17
32/19 33/1 33/25 64/22I card [3] 83/19 166/1 I 129/2 125/2 132/2 I 149/21 149/22 159/3
24/20 2719 28/4 28/25 I toute 1410/9 113/7 [3]
166/8 cautious [1] 79/9 159/3 160/11 164/11
en rib sano niagI (28151402 14513 Ieare 7] 103626 lecRC Ia] 174 I 168/12 teart9
42/10 42/23 43/11 148/9 149/24 63/4 95/24 116/13 122/11 chaos [1] 117/8
44i15.45/15.47105 calling [3] 15/9 15/14 I 426/22 1386/2 CE [1] 39/20 chapters [1] 141/18
15/19 d [1] 29/15 cede [1] 64/15 character [3] 16/13
50/13 54/22 56/9 56/17 cared [1] tt] 83]
58/9 59/17 64/8 64/24 [callousness [1] 99/18 Icareful [1] 32/14 cemented [1] 91/24 I 17/4.92/8
calls [1] 14/6 carefully [4] 9/10 censured [1] 10/1 —_Icharge [2] 141/13
65/25 66/12 69/21 71/3
Calum [2] 135/22 30/14 127/1 155/9 cent [9] 6/20 6/21 6/24I 159/10
ots eore ong enrs I 140/22 carried [1] 31/23 I 6/25 138/4 138/5 charged [4] 40/15
92/2 95/4 95/10 95/12 [Came L14]. 12/12 44/6 Icarry [3] 26/953/19 I 148/20 148/22 158/3_ Icharges [3] 4/22 48/18
95/22 96/9 96/19 97/2 52/25 69/6 85/13 93/1 I 1432/2 central [7] 76/4 87/19 I 108/11
bidentate 104/11 105/23 106/4 I carrying [2] 31/23 32/9] 100/11 105/14 109/18 Icharging [3] 102/3
400/19 100/25 101/11 I 107/19 114/2 138/24 I cartwheels [1] 118/21 I 116/24 124/21 4102/7 108/2
401/42 101/15 101/18 143/20 150/2 case [26] 8/209/23 I centrally [4] 44/8 chased [1] 45/8
401/21 102/16 10373 [Camera [2] 66/5 66/14 I 18/9 19/25 21/18 27/19I 44/10 45/7 45/24 cheapest [2] 41/22
4104/7 104/17 1056 [Campaign [1] 17/1 I 33/25 44/23 46/9 98/14Icentre [2] 60/6 112/24 I 81/5
106/20 106/25 1074 [Campaigning [1] 154/7) 98/18 102/5 103/3 I century [2] 42/11 84/7 Icheck [2] 48/4 169/11
408/6 109/20 110/2 [Can {641 1/8 1/9 14/17 I 10374 104/10 104/22 Icertain [2] 149/15 —_I checked [1] 36/21
4109 140/12 110/22 I 18/22 24/7 32/17 35/13) t05/3 107/14 107/24 I 151/15 cheques [1] 163/16
tt1/9 114/8 11519 _I 20/14.44/1 46/4 47/4 I 408/1 115/3 128/15 I certainly [6] 25/10 Ichief [3] 39/20 140/23
115/24 11713 118/24 I 20/19 Se/tt Sorte 129/13 147/13 148/9 I 38/16 50/11 51/22 143/12
41976 119724 121114 I 81/10 81/11 63/9 65/7 I 163/11 106/11 135/7 child [3] 4/8 130/16
421119 129/15 126/7 I 09/24 86/9 66/14 71/7 Icases [18] 2/21 5/22 certificates [1] 156/3 I 130/16
426/10 126/24 to7/14 I 11/22 9516 95/7 95/12 I 33/22 45/5 69/9 92/14 Icertification [1] 146/2 Ichildren [3] 96/23
430/4 13015 130/16 I 22/20 102/9 105/19 I 93723 98/5 98/8 102/22Icetera [2] 120/20 130/9 130/23
434/21 134/28 13213 I LO? 11312 14/5 106/16 107/6 138/24 I 120/20 chivalric [1] 110/12
1145/9 117/12 124/21 I 149/13 150/20 150/24 Ichair [11] 2/8 17/21 Ichoose [1] 118/19
133/4 133/19 134/2
4134/6 135/23 137/7 129/8 130/9 131/10 — I 163/4 163/14 54/10 120/15 120/18 Ichose [2] 28/5 168/23
(60) bullet... - chose
INQ00001046
INQ00001046
Cc 122/10 128/19 129/11 Icognitions [1] 6/14 108/25 109/7 129/13 Icomparison [1] 18/11
chosen [2] 99/13. 140/5 141/23 142/13 Icohesive [1] 51/20 165/6 165/15 compatible [4] 153/3
4152/2 143/5 146/10 146/18 Icohort [1] 27/12 Commission [2] 69/9 Icompel [1] 3/17
Chris [4] 4/3 4/10 149/12 150/3 152/21 Icoincidence [1] 54/22 I 104/14 compensated [1] 7/20
414/25 54/20 162/15 162/24 168/21 IColin [7] 157/9 158/9 Icommissioned [1] compensation [29]
Cipione [6] 40/21 cleared [1] 17/20 158/13 159/13 160/19 I 53/14 5/8 7/6 7/8 7/13 8/4 9/9
40/24 41/4 45/13 79/25Icearly [8] 7/14 37/13 I 160/20 165/22 commitment [12] 9/16 36/11 58/13 60/19
80/6 64/21 72/13 103/12 I collaborative [1] 54/18) 74/22 78/3 79/1 79/6 I 60/23 61/1 61/8 61/17
circulated [2] 89/3 112/14 135/18 168/25 Icolleagues [3] 160/22 I 84/16 84/17 84/24 61/24 62/2 63/11 73/9
165/3 clerks [1] 144/22 162/17 162/25 141/11 157/18 158/6 I 77/23 90/23 91/2 91/7
circumstances [9] client [2] 46/18 85/15 Icollective [2] 143/5 158/7 166/20 91/13 91/14 129/25
25/20 26/17 37/9 59/3 clients [48] 2/12 3/2 I 145/18 commitments [1] 132/24 132/25 136/12
102/16 103/9 108/4 7/1 7/10 7/15 7/22 9/21 I collectively [2] 18/24 I 76/24 136/14
113/13 124/14 14/14 14/18 15/14 134/12 committed [5] 53/22 Icomplacency [1]
cities [1] 145/8 18/24 19/8 19/10 19/23}colour [1] 148/1 92/8 92/17 92/18 94/1 I 11/24
citing [1] 116/21 30/22 31/4 41/4 47/1 Icolours [1] 80/22 committee [9] 39/6 Icomplained [2] 33/14
citizens [2] 78/6 84/22 52/16 58/20 59/13 60/8I combination [1] 151/14 151/14 154/13 I 54/6
civil [17] 29/18 35/25 60/20 60/24 61/19 63/9} 149/20 157/7 157/23 167/20 Icomplains [1] 22/19
49/16 51/14 51/18 63/24 64/4 64/8 67/11 Icome [31] 30/19 57/7 I 167/23 167/25 Complaint [1] 54/3
58/12 70/19 97/9 98/10 68/2 68/4 68/15 69/24 I 62/22 62/23 63/8 63/24I committees [3] 114/13)complaints [4] 29/8
99/7 99/12 104/3 104/4 69/25 70/3 72/25 78/12I 66/13 68/3 69/1 69/20 114/44 114/18 36/1 48/16 117/2
407/11 114/3 119/7 79/9 89/17 89/19 90/4 I 70/4 70/22 73/9 74/14 Icommitting [1] 130/15Icomplete [2] 48/5
422/16 91/12 91/16 91/18 79/17 80/2 87/25 commodity [1] 99/22 I 78/11
claim [4] 11/9 107/19 91/23 93/9 93/14 106/17 109/5 111/5 Icommon [14] 10/14 Icompleted [3] 89/2
154/5 154/8 clients’ [7] 9/16 10/1 I 118/3 125/20 128/8 12/11 15/16 19/1 43/6 I 155/3 155/7
claimant [1] 43/5 20/10 47/24 60/1 74/7 I 129/25 138/9 146/6 44/4 44/22 57/14 70/20I completely [1] 8/17
claimants [9] 12/9 75/20 146/22 153/11 162/14 I 111/5 131/19 137/5 Icompletion [2] 111/22
12/14 12/16 15/16 clinical [1] 6/12 165/8 165/11 146/17 146/25 156/3
33/13 33/13 34/20 close [6] 60/5 60/13 Icomes [6] 117/10 commonplace [2] complex [1] 8/20
44/25 166/18 64/13 83/25 88/19 117/23 125/19 133/12 I 18/11 111/10 compliance [1] 134/3
claimants' [1] 12/18 130/20 133/24 144/4 Commons [2] 39/16 Icomplicit [1] 110/3
claimed [1] 51/3 close-knit [1] 130/20 Icoming [6] 19/18 66/5 I 98/9 comply [4] 52/44
claims [3] 36/10 51/12 closer [1] 55/7 132/5 151/12 156/18 ICommonwealth [2] _ Icomplying [1] 133/25
a7 closing [5] 59/14 165/12 77/5 77/8 composed [1] 127/15
clarity [1] 60/15 60/15 60/17 142/12 Icommand [1] 115/12 Icommunicate [2] 15/4 Icompounded [1]
Clarke [23] 20/19 169/2 commas [1] 102/9 84/23 91/22
20/22 21/7 21/9 21/20 closure [3] 10/6 63/23 Icommence [1] 68/11 Icommunicated [2] comprehensive [3]
23/11 23/16 24/8 24/14 157/9 comment [4] 135/5 82/4 89/2 13/24 67/15 121/7
24/14 24/22 26/1 27/15 closures [1] 149/24 I 137/12 141/21 143/11 Icommunication [10] Icompression [1] 94/7
27/20 27/23 28/9 28/18 cloud [4] 18/22 85/13 Icommented [6] 11/21 I 25/14 46/19 57/19 comprised [1] 54/8
28/25 30/25 34/3 75/18 85/18 86/4 14/22 86/3 137/6 57/21 115/12 123/17 Icompromise [1] 94/16
12219 132/4 clues [2] 114/5 114/5 I 156/20 159/16 139/8 147/25 154/25 I compromises [1]
class [2] 18/9 84/7 CMA [6] 157/24 164/3 Icommenting [1] 157/23 109/12
classes [1] 78/2 164/25 165/21 165/22 I 159/19 communications [2] Icompulsion [1] 120/24I
classic [1] 119/17 166/16 comments [8] 47/19 I 46/22 118/1 computer [11] 2/5
clause [1] 57/19 co [4] 5/25 8/8 61/7 60/1 140/6 148/13 communities [4] 3/13 I 77/2 77/11 97/13 97/22
clause 19 [1] 57/19 115/12 149/18 156/18 167/18 I 17/11 78/1 92/9 98/13 108/24 112/25
claw [2] 99/7 122/15 co-ordination [1] 167/19 community [3] 2/1 416/17 127/5 163/21
clear [29] 1/4 1/6 2/23 115/12 commerce [1] 25/14 I 92/10 168/1 computing [1] 107/3
28/2 28/18 35/23 49/2 coalesce [1] 97/24 commercial [13] 46/15Icompanies [2] 151/4 Iconcealed [1] 29/25
69/20 70/16 71/4 76/6 coding [1] 157/3 76/20 77/19 83/13 85/8) 151/15 conceded [3] 7/18
80/25 111/15 12078 cogently [1] 105/12 I 85/23 86/10 86/23 [company [1] 23/22 I 17/23 18/2
(61) chosen - concede
INQ00001046
INQ00001046
Cc conducting [1] 143/7 I 83/7 87/1 106/24 152/11 153/15 156/9 I cooperative [1] 53/21
conceivable[1] conference [1] 145/2 I 112/19 130/15 142/17 Icontinued [10] 2/25 I coordinated [1] 45/24
107/24 confession [2] 100/16 Iconsidering [10] 14/15 12/19 13/7 73/24Icope [1] 19/4
concentrate [1] 127/1 100/21 10/16 13/12 15/2 49/19] 82/2 83/16 87/2 106/20Icore [25] 13/21 23/10
concentrates [1] confide [1] 134/6 78/8 86/11 92/25 109/10 58/10 67/4 67/18 70/7
154/1 confidence [3] 64/10 I 139/11 147/41 152/7 I continues [5] 4/24 72/21 73/19 74/4 75/4
concept [1] 157/14 I 71/1283/11 considers [9] 15/14 I 63/10 73/9 77/25 76/8 79/1 79/10 80/23
conception [1] 96/7 [Confidential [1] 94/10 I 120/17 121/20 138/20 I 149/18 82/16 88/12 89/24 94/2
concern [2] 15223 {confirm [2] 5/11 40/22] 140/12 150/16 163/24 continuing [7] 31/9 I 98/5 10716 110/23
4154/9 confirmed [1] 12/7 164/3 168/15 73/15 83/2 87/6 87/10 I 135/20 136/6 136/24
concerned [17] 33/20 confiscation [1] 97/4 Iconsisted [2] 146/8 111/13 124/5 138/12
58/20 61/18 64/19 conflicting [1] 40/25 I 164/2 continuity [2] 125/18 Icorner [1] 118/12
7212 101/47 104/6 conflicts [1] 89/7 consistently [3] 22/22 I 125/22 corners [2] 3/6 145/9
112/10 126/23 140/15 IConfronted [2] 119/17 I 74/11 81/11 contract [6] 39/11 corporate [6] 99/18
4142/4 147113 148/21 I 127/47 consolidated [2] 36/14] 51/25 56/20 77/2 81/25I 106/7 107/4 108/25
149/2 149/5 149/15 connection [2] 50/8 I 36/22 153/18 114/2 118/4
149/20 107/19 conspired [1] 34/10 Icontractors [1] 143/25Icorporates [2] 115/3
concerning [7] 12/3 connived [1] 101/24 constitute [1] 57/21 {contracts [3] 57/18 116/4
24/23 36/1 50/11 57/20 Connolly [2] 3/7 8/6 Iconstituted [1] 116/3 I 86/13 145/16 correct [11] 36/24
145/11 155/8 conquer [3] 16/20 constrained [1] 88/22 Icontractual [3] 39/13 I 106/13 148/10 149/9
concerns [21] 48/3 16/25 117/20 constraints [1] 88/24 I 82/8 153/20 149/17 158/11 164/21
72/19 80/25 82/10 conscience [1] 18/7 Iconstructive [1] 160/4Icontrast [1] 46/23 167/14 167/10 167/16
82/12 84/4 89/16 104/2 conscious [1] 94/18 I constructively [1] contribute [2] 137/1 I 169/15
consequence [4] 13/11 139/21 correction [1] 43/17
toe adore lesna 34/22 51/17 98/21 consult [1] 48/9 contributed [1] 153/5 Icorrections [3] 48/15
158/5 160/21 1641/6 149/8 consultation [2] contribution [2] 56/5 163/18
462/19 165/7 166/17 Iconsequences [4] 121/22 145/16 136/13 140/12 corrective [1] 129/5
4168/9 13/3 53/23 116/1 139/3/ consulting [1] 84/5 I contrition [2] 118/18 I correspondence [2]
concerted [2] 55/17 consequential [1] consuming [1] 164/14 I 133/21 5/9 9/2
97/25 136/22 contact [4] 43/1 43/8 Icontrol [5] 96/17 corresponding [3]
concessions [1] Consequently [4] 53/2] 66/16 101/11 112/23 112/25 119/2 I 6/23 114/19 128/24
144/23 consider [39] 15/2 contacted [1] 11/19 I 147/23 corrupt [1] 100/8
an 15/8 22/16 23/8 27/4 Icontacting [1] 163/9 I controlled [1] 97/8 corrupted [1] 104/15
conclude ata 34/11 31/13 32/22 contain [1] 43/22 [controls [2] 114/9 _Icost [6] 8/16 76/12
ota 34/13 37/8 42/13 47/6 Icontemporaneous [3] I 129/14 76/18 104/18 149123
concluded [5] 67 I 48/10.82/3 82/19 55/6 I 31/24 119123 1201 Ieontroversy {1] 73/28 I 154/10
76103 7/1 771d 168/8, I 59/16 62/16 63/3 74/18Icontempt [1] 108/14 Iconvenient [2] 84/22 Icosts [8] 29/13 100/9
r 75/15 81/8 81/15 81/22Icontemptuous [1] I 113/10 407/19 111/21 129/17
ooo eel erie. I 82/20 82/23 82/26 8315I 31/10 convey [1] 60/13 I 154/20 165/14 166/6
1981 168/6 83/20 86/13 87/4 88/12Icontended [1] 44/25 Iconvicted [4] 5118 Icouched [1] 25/14
conclusions {4] 25:2 I 8814 89/9 90/5 105/9 Icontent [3] 69/3 9rtt I 51/12 6716 604 could [61] 1/6 4/18
rela I 12ti4 141/25 16373 I 14872 conviction [7] 61/4 I 8/15 11/9 23/2 25/24
condemn {1} 109/3 (considerable [4] 68/1 contested [1] 34/18 I 67/8 68/14 69/12 7072 I 30/17 34/8 3315 30721
78/21 115/6 143/13 context [4] 25/19 32/7 I 102/14 102/20 35/12 30/25 42/25
condemnation (1 Iconsiderably [1] 69/4 I 83/5 114/4 convictions [16] 17/42] 43/11 43/15 44/5 45/15
conditions [4] 144/14 consideration [6] continual [1] 10/19 18/2 18/13 51/10 68/23) 45/19 46/6 49/3 49/7
444/20 145/15 145/17 18/23 75/20 86/15 88/7I continuation [1] 85/25} 69/3 69/14 69/15 72/17I 49/17 57/25 59/3 59/10
88/17 109/24 continue [17] 3/14 I 73/8 73/21 74/8 75/22 I 75/15 8216 83/4 83/7
olan ara considerations [2] _ I 14/16 29/19 62/9 67/17I 91/3 101/25 106/24 I 83/25 85/8 96/24 97/14
30103. 99708 1013, I 86123 100/12 69/11 76/20 81/25 —_Icooperate [1] 120/22 I 98/20 99/4 99/15
conducted 3} 16/17 [Considered [11] 15/18 84/10 109/7 110/14 I cooperation [2 102/24 103/19 104/24
20/20 105/24 15/23 43/25 47/9 52/41] 126/22 127/10 143/13 I 110/21 120/16 106/14 108/3 112/22
(62) conceivable - coul
INQ00001046
INQ00001046
Cc 103/1 103/24 108/12 I 27/22 34/2 34/5 75/6 Icurrent [11] 11/2 Dawson [1] 4/3
could... [19] 114/24 111/6 111/18 112/17 ICredit [2] 40/2 119/19 I 24/18 28/1 58/6 83/24 IDawson's [1] 4/16
119/13 122/23 126/5 I 114/6 116/12 118/24 I Credit Suisse [1] 140/13 140/23 143/11 Iday [10] 4/16 4/22
426/18 126/21 12718 I 124/20 124/21 124/26 I 119/19 143/18 145/12 150/11 I 42/20 42/22 110/7
427/11 129/19 129/22 I 126/24 127/4 127/5 Cresswell [1] 104/2 I currently [3] 32/14 141/1 155/21 155/22
4137/2 142/2 142/22 __I 128/1 129/9 136/4 Crichton [6] 14/25 37/25 146/10 161/9 169/20
4143/1 158/4 162/9 137/20 138/15 142/23 I 54/14 54/18 54/20 custodial [1] 150/21 Iday's [1] 1/4
462/13 162/17 16719 I 146/12 147/17 151/6 I 54/21 54/25 custody [1] 96/17 days [9] 8/7 43/10
couldn't [1] 100/20 153/11 156/3 159/4 —_Ierime [1] 17/6 customer [2] 22/20 I 67/14 79/23 81/4
162/13 criminal [41] 2/3 9/19 I 154/11 141/22 142/3 152/21
Coulson [1] 37/8
council [1] 160/7
counsel [42] 20/21
23/4 24/24 25/7 26/1
27/16 27/21 29/2 30/6
court [62] 3/1 5/21 10/17 17/9 25/1 28/24 Icustomers [4] 16/18 I 160/15
72 7/18 10/7 10/16 I 29/4 29/18 33/22 45/25I 85/4 149/22 151/17 Ide [1] 89/6
14/17 13/5 14/10 14/12] 49/13 49/15 58/12 69/8I Customs [1] 77/3 de facto [1] 89/6
14/22 17/12 17/16 18/4I 70/13 70/19 71/19 cut [1] 6/12 dead [1] 121/10
33/1 34/8 51/7 55/1 19/20 24/25 26/10 75/16 75/20 75/23 76/3I cut-off [1] 6/12 deadlines [2] 111/22
67/11 67/13 67/14 79/6 27/19 28/6 28/24 29/4 I 92/1 97/4 98/2 98/10 cutting [1] 149/23 133/25
95/23 96/1 98/15 101/7 33/2 33/25 34/24 36/16) 100/2 102/6 104/3 CWU [7] 46/22 139/9 Ideal [14] 14/4 15/22
4101/8 103/17 116/7 37/4 38/2 38/6 42/19 I 104/4 104/6 104/7 164/3 164/25 165/21 I 15/25 25/24 28/17
418/23 11919 119/10 I 49/7 45/2 47/9 48/1 4107/9 108/11 109/18 I 165/21 166/16 39/10 44/3 48/14 59/11
426/13 128/18 133/18 I 94/11 61/2 71/19 72/15] 114/3 116/22 121/18 ICWU's [1] 167/25 77/4 77/9 127/7 130/1
435/15 135/17 136/5 I 74/12 100/1 100/4 122/16 124/9 143/25 Icycle [1] 29/21 153/17
140/6 1441/7 142/45 100/2 100/2 101/5 169/5 cynical [1] 118/8 dealing [3] 59/22
148/24 1541/3 152/9 102/1 102/2 102/11 —_Icriminalisation [2] cynically [1] 13/15 140/16 141/18
452/20 164/5 167/18 I 107/15 107/16 107/17 I 16/2 17/7 >-.UO~™” dealings [1] 140/19
109/18 109/19 109/20 Icriminalise [1] 17/10 deals [2] 77/7 77/12
counsellors [1] 92/10
count [2] 102/22 160/5
counted [1] 110/7
countenanced [2]
118/10 119/12 122/13 Icriminalised [1] 122/7 IDaily [1] 76/25 dealt [3] 129/14
132/3 137/10 147/15 _Icriminalising [1] 99/14Idamage [7] 6/25 7/7 I 149/14 149/22
147/18 148/6 149/7 _I criminals [3] 74/9 92/4I 13/18 76/15 93/12 I death [1] 4/2
99/15 129/24 149/16 105/8 12977 14916 debt [6] 44/11 44/12
counter [2] 49/4 49/5 [Sourts [10] 9/20 29/19 Jorisis (2] 114/25 damage' [1] 129/7 I 45/9 99/22 126/6
counterclaims [1] 29/25 61/23 62/18 115/20 damaged [1] 34/3 429/12
o7/11 70/13 70/19 98/2 104/3I criteria [1] 84/7 damaging [1] 52/11 Idebts [1] 127/22
counterfeit [1] 163/15 I 107/18 critical [4] 74/3 89/11 Idancing [1] 47/3 decades [12] 67/16
counters [9] 81/12 Iover [10] 14/17 50/18] 90/9 119/6 danger [1] 62/19 68/20 69/23 73/4 73/22
81/17 81/24 82/5 gaig I 92/19 52/20 55/17 criticism [1] 14/10 Idangers [1] 26/2 78/23 78/25 79/8 80/14
85/4 85/7 86/6 161/16 I 99/19 56/23 67/19 criticisms [1] 58/19 IDar[1] 15/15 82/17 91/19 93/6
country [3] 98/2 155/19 158/12 crosshairs [1] 118/15 Idare [1] 110/6 December [8] 7/25
408/22 109/25 cover-up [4] 52/19 ICrown [3] 111/17 Darlington [1] 18/14 I 40/21 61/9 61/13 74/2
countryside [1] 14519 I 52/20 85/19 56/23 154/24 158/2 data [15] 18/1 35/13 I 85/16 91/8 107/11
counts [2] 102/12 covered [2] 139/23 jerucial [2] 76/24 87/22 48/3 48/7 48/9 48/12 I December 2006 [1]
402/17 139/25 crumbling [1] 100/8 I 48/18 49/16 68/24 407/14
County [2] 10/1 covering [1] 22/12 Icrushed [2] 108/6 72/11 72/11 72/14 I December 2019 [1]
107/16 covering-up [1] 22/12 I 130/12 82/13 117/10 164/16 I 742
couple [3] 8/7 13/6 ICOvid [1] 6/24 culpability [2] 27 I date [1] 8/25 decent [1] 110/4
152/20 cowering [1] 4/8 22/12 dated [4] 8/6 17/16 I decide [2] 20/14 99/9
courage [1] 130/5 ICPSIt] 20/24 culprits [1] 52/9 25/2 31/19 decided [7] 17/6 37/3
course [49] 1/9 2/4 [cranny [1] 34/4 cultural [1] 58/24 dates [1] 33/8 AAIT 44/10 49/2 113/16
46/11 29/3 30/21 32/5 [oreate [1] 142/8 culture [4] 57/10 64/10Idaughter [2] 128/6 I 148/2
34/11 41/12 46/6 47/8 (created [1] 105/16 117/20 129/16 130/24 deciding [1] 48/14
52/9 59/1 68/13 73/19 Icreating [1] 52/6 cupidity [1] 127/23 Idaughters [1] 92/6 decision [14] 36/12
credence [1] 113/23 Icure [4] 65/22 David [5] 8/9 112/13 I 64/20 79/3 80/19 81/23
74/2 75/19 76/17 88/10
39/20 97/25 100/11 [credibility [5] 24/16 [currency [1] 21/22 I 160/17 160/20 161/23 I g2/4 82/4 86/24 91/6
(63) could... - decision
INQ00001046
INQ00001046
D degraded [1] 41/9 75/13 deteriorated [1] 55/5 Idifficult [9] 54/24 97/7
decision... [5] 1041 degree [2] 10/6 13/10 Idependent [1] 86/23 Idetermine [1] 108/10 I 114/23 115/21 115/24
424/11 131/23 432/1 [Deirdre [4] 3/7 3/19 deprecated [1] 102/1 Idetermined [5] 39/13 I 136/21 138/16 159/20
464/41 3/25 8/6 depressing [1] 97/6 I 77/22 111/4 119/9 164/12
decision-makers [1] delay [7] 21/17 62/8 Idepressive [3] 6/13 I 153/19 difficulties [4] 87/10
82/4 65/19 66/13 89/13 6/18 6/21 determining [4] 22/17 I 103/15 125/7 152/22
decision-making [1] 121/5 136/16 deprived [1] 97/10 devastating [3] 113/24I difficulty [2] 69/24
4164/4 delayed [1] 154/15 — Idepriving [1] 119/5 I 136/7 141/16 94/20
decisions [9] 2/7 delays [2] 9/13 111/21 IDerek [4] 165/20 develop [1] 124/15 _Idigital [1] 150/5
20/14 26/24 38/6 38/8 delegated [1] 114/17 Iderogate [1] 120/2 developed [1] 145/25 Idigitisation [1] 84/18
40/19 80/22 87/5 90/17 delete [1] 72/10 describe [1] 5/3 development [9] 79/22Idilemma [1] 127/17
decline [1] 149/21 deliberate [1] 117/4 Idescribed [11] 3/3 81/18 86/9 87/13 112/1I diminished [1] 89/12
dedicated [1] 17/10 deliberately [8] 13/14 I 14/17 21/20 23/3 34/17I 112/22 148/16 158/15 Idiplomatic [1] 111/11
deeds [1] 133/24 16/8 16/23 29/24 45/11} 37/8 51/24 105/3 165/5 direct [3] 136/11
Deegan [1] 165/21 50/25 99/13 101/21 105/13 128/19 147/7 _ Idevelopments [1] 137/11 153/25
deemed [1] 8/20 deliver [3] 55/9 84/16 Idescribes [1] 23/20 I 165/8 directed [2] 52/2
deep [2] 72/24 126/8 158/5 description [1] 21/10 Idid [92] 1/48 1/20 1/23I 124/11
deeper [1] 9/6 delivered [2] 95/23 Ideserves [1] 7/14 3/5 5/3 9/21 11/11 directing [2] 94/20
deeply [4] 41/21 109/10 design [5] 29/12 14/12 17/18 18/4 19/16] 116/3
defamation [1] 120/4 delivering [1] 112/4 I 117/14 139/20 151/18 I 20/1 20/2 20/5 20/23 I direction [2] 78/8
default [1] 154/16 delivery [4] 32/15 96/3] 151/22 22/6 26/10 26/23 27/8 I 167/3
defeating [1] 116/11 125/8 136/12 designated [1] 146/4 I 29/9 29/9 30/1 30/2 —_I directions [1] 43/24
defect [1] 125/19 delves [1] 58/23 designed [2] 20/6 36/20 38/9 39/25 40/15/directly [4] 41/9 80/23
defective [3] 103/6 demand [1] 119/9 79/25 40/17 42/23 42/23 81/20 105/20
116/17 125/10 demanding [1] 50/4 _Idesire [3] 78/12 43/21 43/22 44/15 director [3] 86/2 157/1
defects [23] 17/25 democracy [1] 109/25 I 104/17 118/2 44/24 48/9 49/18 56/16] 158/15
42/2 52/22 56/18 56/22 demonstrate [3] 56/12Idesperately [1] 52/23 I 56/17 56/17 66/7 68/7 Idirector's [1] 85/15
TA10 74/14 71123 61/14 72/18 despite [7] 3/19 4/23 I 71/11 71/15 72/6 74/20I directors [5] 38/1 38/5
81/18 82/19 83/3 83/9 demonstrated [4] 27/20 73/7 73/8 76/5 I 74/25 78/14 78/15 38/7 38/10 115/4
87/3 90/2 103/14 108/4 47/16 57/14 61/14 166/19 80/14 81/20 87/13 89/5) disastrous [1] 107/9
4427 114/16 123/20 95/25 destined [2] 96/18 89/7 90/6 90/13 93/9 discern [1] 100/4
423/22 123/24 124/3 demonstrates [3] 113/9 97/2 101/12 101/20 discerned [1] 114/5
4126/9 11/23 39/2 107/24 destitution [1] 97/3 I 111/18 112/7 117/19 Idischarge [2] 97/24
defence [3] 74/15 den [3] 11/16 14/9 destroy [3] 1/20 16/8 I 118/5 121/13 122/15 I 101/20
77/14 100/23 58/22 50/23 123/14 124/15 124/23 Idisclosable [2] 25/22
defences [1] 132/20 denial [1] 79/8 destroyed [10] 50/25 I 125/3 125/22 126/10 I 26/19
defend [5] 36/5 73/25 denials [3] 105/24 69/16 69/17 73/6 73/6 I 126/11 126/24 129/18 Idisclose [3] 17/23
97/11 104/18 143/21 I 1064 118/6 107/22 114/7 130/4 129/21 135/16 138/9 I 24/12 57/8
defendant [5] 21/14 denied [3] 50/9 92/14 I 132/21 150/19 142/2 142/17 142/25 I disclosed [5] 49/12
20/1 22/5 22/19 97/23 I 97/8 destroying [1] 133/6 I 146/3 147/4 148/7 56/8 75/16 121/18
defended [1] 100/9 dented [1] 34/3 destroys [1] 128/4 152/1 152/3 155/7 121/20
defending [1] 36/2 deny [1] 71/7 destruction [2] 127/3 I 155/24 162/2 164/7 —_I disclosing [3] 32/6
defensive [1] 79/12 denying [2] 26/9 36/10] 134/2 165/7 167/14 168/18 I 37/14 52/10
defensiveness [1] department [6] 1/15 Idetail [7] 2/10 15/18 I didn't [8] 19/21 64/19 Idisclosure [24] 25/19
91/19 5/11 8/23 87/16 116/6 I 37/13 37/16 95/24 65/18 65/20 74/4 26/16 28/25 29/1 31/5
deference [1] 96/13 156/24 141/9 152/9 112/11 117/8 166/24 I 31/12 52/5 59/22 62/6
deficiencies [1] departmental [1] detailed [6] 13/23 24/5Idied [4] 16/1117/19 I 70/23 85/10 85/21
144/10 153/5 37/11 75/12 80/12 90/14 101/12 101/6 101/21 105/24
deficiency [1] 116/25 departments [6] 135/16 difference [1] 8/15 106/5 107/25 120/10
defined Fs 21/45 22/2 111/14 115/13 141/14 details [2] 11/10 11/19] different [9] 12/9 12/9 I 120/10 120/13 121/15
definition [1] 168/3 143/25 152/15 152/17 Idetected [1] 71/23 12/10 40/6 71/22 80/7 I 121/16 124/6 133/25
definitive [1] 156/16 departure [2] 54/23 Ideter [1] 128/13 84/20 138/18 139/10 Idisclosures [1] 58/4
(64) decision... - disclosures
INQ00001046
INQ00001046
D division [4] 10/17 Idon't [23] 2/10 27/13 drawbacks [1] 154/9 lease [1] 151/16
discord (] 15215 I 71/2085/17 1003 34/47 32/20 33/5 39122Idrawing [2] 36/23 easier [4] 113/22
discover [2] 29123 [divisions [1] 116/13 I 40/23 S421 59722 I 119/25 126/19 126/20 159/22
38/7 do [49] 1/11 7/5 11/3 I 60/15 65/5 67/20 71/1 Idrawn [1] 13/22 easily [1] 115/9
discreditable [2] 10812] 21/16 21/17 21/19 2617/74/13 87/21 105/19 Idraws [1] 9/6 east [1] 109/18
199/03 27/3 30/10 30/22 37/46] 109/17 120/5 121/12 Idreadful [1] 11/23 I Easter [1] 144/12
discrepancies [7] _I 44/24 82/5 59/19 60/10] 131/22 13211 162/4 driven [2] 4/14 108/24 /easy [3] 11/18 132/13
34/01 46/7 Aart 4/2) 02/8 62/21 63123 67/19] 167/22 dropping [2] 121/20 I 157/17
123/22 124/2 12913 I 67/19 74/1 78/15 93/24Idone [24] 8/6 11/20 I 121/28 economic [1] 96/14
discrepancy [2] 44's I 94/179516.97/13 I 2615 26/11 26/12 33/19IDSS [3] 152/6 154/4 I Eden [1] 10216
O79 106/25 115/23 116/1 I 48/4 77/24 85/11 93/12) 166/16 edit [1] 72/10
discussed 9] 315 I (17/11 117/11 12617 I a4/9 98120 106/10 [DTI [9] 152/10 152/24 Ieffect [10] 9/12 812
47/12 6216 13716 130/11 130/23 131/8 I 107/8 110/13 122/11 I 153/7 154/13 157/6 I 20/9 21/2 29/10 29/16
137/13 138/12 147/16 I 132/14 139/7 133/25 I 126/18 129/7 133/2 I 157/23 165/2 166/16 I 42/15 49/14 136/7
44978 16414 4142/2 142/2 142/22 I 143/1 143/2 1490/6 ‘I 168/7 4144/2
discussion [3] 62/21 I 151/22 182/3 153/10 I 156/4 150/18 due [12] 3/14 35/18 effective [2] 78/19
165/25 16/5 4156/5 157/12 166/20 done’ [1] 134/24 55/9 68/13 88/24 93/20I 114/9
disgrace [1] 1/16 I 167/11 167/17 doomed [1] 111/3 I 154/6 153/11 157/3 effectively [4] 39/7
disgraceful 1] 104/10 [40ck [1] 97/5 door [2} 18/21 30/20 I 164/11 169/11 169/14 I 72/14 80/9 83/4
dishonest [5] 74/8 document [13] 31/19 Idouble [1] 118/24 dukedom [1] 96/11 [efficiency [1] 78/19
92/1 92/5 102/25 85/14 121/21 127/6 Idoubled [1] 161/5 during [21] 1/10 3/22 Iefficient [1] 84/21
124/98 12712 132/4 155116 Idoubt [14] 10/13 26/15] 6/24 29/16 72/9 73/19 effort [3] 13/17 95/24
dismissed [2] 127/20 I 195/18 156/22 15715. I 26/22 40722 60124 I 75/19 76/17 7718 7915 I 158123
136/19 158/10 160/8 167/22 I 89/15 100/11 102/5 I 82/24 88/1090/14 efforts [1] 10/19
dismissiveness [1] documentation [1] 111/23 113/1 119/15 I 123/19 138/25 147/17 Ieffrontery [1] 119/7
91/20 5073 a doubts saga I 4724 148725 1551 egregious 10923
. A locumente: lown 4 163/1 164/1 either 13/1 4
disparity [2] 98/5 98/4 I 16/4, 45/25 94/15 98/2 duties [2] 104/25 I 76/2 98/18 12216
dispassionate [1] documents [24] 31/25I 108/22 118/24 126/24 I 117/16 132/18
. 51/1 1/2 52/7 57/16 I 1541/4 156/9 156/22 I duty [8] 24/14 78/9 electorate [1] 168/2
disposable [1] 99/22 I 54 449/23 12011 I 188/17 160/1 1608 I 78/14 99/25 101/21 electronic [1] 85/2
Gsproportionate ['] I spor17 120119 120024 I 161/11 161/20 116/11 116/12 116/13 Ielement [1] 109/14
‘ 121/1 121/2121/3 _ Idownward [1] 158/8 Idystopian [1] 109/4 eligibility [1] 119/3
alepute (a) aor “895 9419 124/17 121128 [DPR [1] 122/14 E ____[Blizabeth [3] 15/15
disputed [3] 42/25 I 192/7 136/6 150/24 I Dr [18] 1419297 =I =_____ ait 50/25
44/10 44/19 153/8 153/23 159/5 I 23/18 23/20 24/2 24/11Jeach [18] 7/3 42/22 else [6] 26/11 107/13
disputes [4] 45/3 168/14 24/16 24/23 26/3 27/21) 56/5 58/14 59/15 63/12) 425/16 130/19 133/10
48/13 142/14 145/19 [does [10] 22/5 26/19 I 27/22 27/24 28/3 32/25) 67/5 67/7 73/13 90/11 I 444/21
disquieting [1] 96/5 I 29/5316 46/13 70110 I 33/10 33/24 34/5 100/18 111/2 116/8 else's [1] 119/6
disregard [1] 113/20 I 1095 1098 112115 I 104/22 117/2 117/6 144/22 I elsewhere [1] 167/24
disregarded [1] 163/11 Dr Gareth [2] 14/19 I 151/7 164/7 email [2] 8/6 66/16
401/91 Does it [1] 109/5 23/18 earlier [13] 2/13 20/11 emanated [4] 51/24
nan doesn't [7] 20/13 Dr Jenkins [13] 23/7 I 30/21 31/5 61/10 89/18] embrace [1] 115/20
disruptions tH tog I 20/14 62/23 11314 I 23/20 24/2 24/11 24/26I 95/17 10118 138/13 emerge [1] 109/14
distant [1] 191123, I 19025 1319 132/13 I 26 27/24 28/3 3226 I 1426 148/19 151/3 emerged [3] 36/1 44/4
oa dogged [1] 134/4 33/10 33/24 34/5 162/23 108/11
Sictinguonea ty doing [9] 1/20 30/11 I 104/22 early [10] 35/1 79/22 emerges [2] 60/2
23123 30/14 40/17 65/7 111/4)Dr Jenkins's [3] 24/16 I 80/25 85/10 104/9 109/23
distort [1] 119/22 117/19 123/10 156/14 I 27/21 27/22 126/2 128/23 144/25 I emerging [1] 117/5
distrust [1] 34/1 domain [2] 56/15 drafted [1] 104/5 160/15 168/8 eminent [2] 30/8 118/9
104/6 draw [4] 10/10 36/13 jearth [3] 42/12.99/8 Iemotional [1] 130/18
aiice (31 16720 16725 Jdominion [1] 99/9 I 129/11 16805 125/16 emotionally [2] 90/12
(68) discord - emotionally
INQ00001046
INQ00001046
E energies [1] 78/3 equipment [2] 57/16 I 108/14 112/19 118/10 I 101/3 103/25 104/4
emotionally... [1] energy [1] 36/16 151/16 122/14 129/18 129/21 I 104/16 104/19 104/21
130/13 enforced [1] 160/25 equipped [2] 85/1 130/14 138/15 159/18 I 104/22 105/11 108/16
emphasis [1] 71/4 enforcement [1] 51/18] 152/3 evening [2] 5/20 108/17 111/25 114/6
emphasise [1] 158/4 engage [2] 114/15 equivalent [2] 42/11 I 161/24 114/6 120/24 123/8
employed [6] 16/5 114/19 99/21 event [2] 103/14 129/5I 128/15 128/17 128/18
128/17 140/7 140/14 engaged [1] 88/15 equivocation [1] 115/8)events [10] 12/2 25/10I 130/2 130/4 131/14
140/11 145/6 engagement [1] 88/8 jera[1] 107/9 25/18 55/16 67/11 132/3 135/21 137/10
employee [2] 23/21 engaging [1] 14/16 erase [1] 133/2 67/15 77/21 78/23 137/11 139/15 139/18
47/20 engineers [1] 35/2 error [7] 20/14 20/16 I 78/25 150/23 139/21 140/3 142/6
employees [7] 58/4 England [2] 4/19 20/18 21/5 35/5 47/15 Iever [11] 9/21 29/7 1447/4 147/3 147/5
138/6 139/5 140/7 154/23 113/41 52/23 82/24 83/6 96/4 I 147/7 147/19 148/9
142/40 145/11 150/18 engulfing [1] 114/25 errors [32] 17/24 19/1 I 96/4 114/7 122/20 149/2 149/9 149/10
employer [3] 46/25 enhanced [1] 5/7 19/3 19/16 19/18 19/24I 132/25 160/6 149/15 153/25 162/24
58/11 140/10 enjoy [1] 132/12 20/12 20/13 42/2 47/5 Ievery [18] 7/4 31/2 168/14
employer's [1] 47/3 enjoyable [1] 92/12 I 47/7 48/24 71/10 71/14] 31/2 34/1 58/15 63/12 Ievident [2] 144/20
employers [1] 46/10 enlightened [1] 167/9 I 71/23 81/17 82/19 83/2I 67/19 73/14 73/16 153/15
empt [1] 11/5 ennobled [1] 110/11 I 83/9 87/3 87/13 90/2 I 91/14 91/21 96/15 evidential [3] 83/6
empty [1] 13/16 enormity [1] 9/24 98/24 103/14 112/7 107/24 122/13 132/3 I 97/20 103/12
enable [1] 64/9 enormous [1] 46/19 I 112/11 123/20 123/21 I 156/4 161/7 163/11 _Ievidentially [2] 31/13
enabled [5] 44/16 enough [7] 11/13 123/24 124/3 126/9 _ Ieverybody [2] 5/3 103/14
97/12 101/2 110/25 I 20/16 38/16 65/14 99/7) 164/16 132/10 evil [1] 107/7
118/5 125/2 125/6 escalated [2] 114/13 Ieveryone [3] 38/19 {evolving [1] 103/13
encashment [1] enquire [1] 116/12 129/15 94/13 119/6 EWHC [1] 137/5
151/24 enquiries [1] 11/5 especially [4] 8/15 — Ieverything [3] 1/18 exacerbated [1] 112/4
encompass [2] 135/24 Enright [2] 2/16 8/8 I 118/16 118/17 161/9 I 1/20 125/16 exactly [4] 1/5 12/13
138/21 ensure [18] 32/11 essence [1] 107/2 evidence [136] 2/12 I 13/11 166/3
encountered [2] 19/1 39/11 65/25 73/16 essential [2] 61/15 2/15 2/17 2/23 4/18 Iexamination [3] 13/4
241 81/10 94/2 101/16 61/24 41/16 12/3 13/5 14/6 I 78/23 78/25
encourage [2] 69/19 I 112/18 117/11 138/22 Jessentially [5] 39/10 I 14/12 14/18 14/18 examine [2 58/2
166/18 141/16 146/10 150/7 I 68/2 76/1 78/5 153/17 I 14/19 14/25 15/6 15/12) 99/25
encouraged [3] 68/25 153/17 159/5 161/5 Essex [2] 4/20 109/19 I 15/16 15/17 15/21 examined [1] 114/3
69/5 106/17 164/21 169/8 establish [9] 19/20 I 16/16 16/21 18/5 18/23Iexample [13] 6/14
encouragement [1] ensuring [2] 52/14 31/12 32/14 70/16 18/24 19/2 19/5 19/8 I 10/18 32/1 34/25 42/17
91/9 114/12 77/16 97/7 97/21 100/6} 19/23 19/24 20/10 50/20 69/2 75/17 85/10
end [14] 8/13 9/7 18/4 entails [1] 144/10 150/16 23/19 24/18 27/22 85/14 89/4 99/23
55/11 60/2 97/2 112/24 /enter [2] 56/14 113/17 jestablished [4] 48/8 I 27/25 28/5 28/5 28/13 I 163/14
14616 148/6 154/19 [entered [1] 119/12 7413 144/12 144/12 28/23 30/24 33/16 examples [2] 74/13
461/23 167/8 167/11 \enters [1] 108/5 establishment [1] 33/18 39/2 39/19 41/15I 163/5
167/15 entertain [1] 134/8 109/21 41/16 42/4 42/6 42/18 Iexcelled [1] 105/5
endeavour [2] 9/12 entirely [8] 34/9 36/10 jestimate [1] 166/23 I 43/6 43/6 44/1 44/17 Iexcellent [1] 67/23
101/46 40/6 77/15 105/7 110/4/estimated [1] 83/23 I 44/23 45/10 45/16 except [2] 45/17
endeavouring [1] 112/9 148/5 et [2] 120/20 120/20 I 45/21 46/21 47/16 48/8) 100/12
145/18 entirety [1] 67/20 et cetera [2] 120/20 I 48/12 49/12 50/21 exception [2] 30/22
ended [3] 56/10 80/16 entitled [4] 36/6 37/19 I 120/20 55/24 57/13 59/20 60/1} 111/9
148/13 55/13 154/5 euphemism [1] 113/8 I 60/2 62/19 62/25 67/7 Iexceptional [1] 18/9
endemic [1] 108/20 entity [4] 78/5 evaded [1] 117/16 67/16 69/6 73/12 75/1 Iexceptionally [1]
ending [3] 23/12 24/8 entry [1] 164/16 even [26] 12/8 23/10 I 75/14 75/21 75/25 90/12
4109/3 epidemic [1] 108/20 I 24/3 43/14 45/6 46/20 I 78/11 79/24 80/2 80/10I excessive [1] 57/12
ends [2] 100/7 108/25 episode [2] 129/23 50/19 51/2 59/8 64/20 I 81/15 81/22 83/8 83/13) exculpatory [1] 97/9
endure [1] 150/20 134/4 66/7 70/22 81/18 96/19] 83/14 85/6 85/22 86/14I excuse [2] 33/24
equates [1] 50/1 102/3 105/15 107/3 87/24 88/2 97/14 98/9 I 117/21
endured [1] 68/5
(66) emotionally... - excuse
INQ00001046
INQ00001046
E experiencing [1] 16/24]extract [1] 99/2 fairly [1] 7/20 123/16 134/17 134/25
excuses [1] 1348 expert [17] 21/12 extraordinarily [1] fairness [1] 112/2 135/9 138/11 144/24
executive [6] 39/20 I 23/10 28/19 23125 57/13 faith [6] 58/16 74/25 I 144/25 146/7 166/22
140/23 143/12 151/13 I 24/13 24/14 24/16 extraordinary [2] 93/3 100/5 110/24 I feedback [3] 159/14
455/13 16017 24/18 27/22 27/25 58/14 110/12 130/6 4160/7 160/10
executives {2} 119/15 I 792588/17 101/4 — Jextremely [2] 34/12 fal [1] 118/15 feeds [1] 7/7
HONG 103/24 104/3 104/12 I 156/12 falling [1] 143/16 _Ifeel (5] 18/20 131/8
exercise [6] 63/10 I 104/19 eye [1] 91/25 false [12] 22/10 59/4 I 131/8 131/16 166/24
89/6 90/4 120/23 125/2IexPerts [4] 21/4 22/22 F...t™~O 100/6 102/3 102/8 feet [1] 60/22
153/24 27/3 104/11 Fo! 402/12 102/20 102/23 Ifell [1] 104/25
exercises [2] 90/10 IEXPG0000001 [1] face [9] 5/18 13/3 18/8] 103/5 104/15 108/6 _I Felstead [7] 96/18
tel, explain familar
Exeter (2) OT O88 ort4 face-to-face [1] 63/14 I 120/14 felt [2] 2/13.4/1
exhibition [1] 1541/7 [explained [7] 41/17 faced [3] 120/1 121/25Ifamilies [11] 2/22 36/8Ifervent [2] 110/20
exist [4] 43/24.52/4 I 75/19 82/10 103/15 138/23 73/10 76/16 90/13 120/12
52/5 119/24 116/18 157/24 158/7 facilitate [1] 85/2 91/23 92/12 92/15 _Ifervently [1] 110/19
existed [3] 114/7 explanation [5] 33/11 Ifacilitating [1] 165/5 I 92/16 92/22 136/8 —_Ifew [3] 79/17 87/23
114/22 147/20 35/4 47/2 75/1 148/15 facility [1] 72/10 family [6] 3/16 8/10 I 141/22
existence [7] 17/24 [exploit [1] 118/2 fact [23] 10/24 24/11 I 19/7 63/17 93/21 fiction [1] 91/22
95/24 71/8 72/7 121/19IexPloitation [2] 86/10 I 28/13 29/14 30/23 130/20 fiduciary [1] 116/11
423/20 124/7 86/12 36/23 39/24 40/4 53/10Ifar [18] 5/105/10 _Ifield [1] 156/8
exists [1] 114/6 exploration [2] 73/14 I 71/15 104/13 106/16 I 2¢/25 66/17 69/15 _Ififth [1] 166/14
expansive [1] 86/14 I 87/16 142/12 112/15 121/13 I 7/48 99/5 104/6 fight [1] 36/15
expect [4] 61/12 63/9 explore [2] 86/16 121/14 122/8 125/17 I 108/15 108/23 112/10 Ifigure [4] 36/13 36/19
65/18 99/5 87/24 127122 141123 144/17 I 22/9 126/19 126/19 I 36/25 155/8
expectations [4] explored [1] 73/17 I 144/20 167/7 126/20 126/23 126/24 Ifigures [5] 6/23 163/4
142/18 exploring [1] 85/8 facto [1] 89/6 128/3 163/8 164/18 164/21
expected [4] 67/18 [exposed [2] 3/1 9/19 facts [5] 71/271/4 I fatally [3] 23/9 24/17 Ifile [1] 116/24
99/4 112/8 121/7 exposing [1] 99/15 I 109/15 113/20 123/18 I 27/23 final [5] 19/22 60/15
expecting [1] 60/8 [@xPosition [1] 109/15 factual [1] 98/21 fate [1] 128/12 4160/1 161/20 162/4
expects [1] 120/20 [express [3] 22/8 factually [1] 4/11 father [1] 128/9 finally [12] 3/1 5/21
143/13 152/1 fail [2] 101/20 113/9 I fathers [1] 92/6 717 8/11 9/3 68/9
expedience [1] 113/14
expediency [1] 113/21
expedient [1] 111/12
expenditure [1]
expressed [9] 81/1 _Ifailed [19] 17/23 22/8 I fault [7] 2/7 4/15 19/12] 79/11 87/12 90/21 94/3
84/5 110/19 110/21 I 24/11 47/25 48/17 20/7 22/7 30/19 35/4 I 108/1 141/6
116/20 120/12 130/2 I 91/21 92/23 93/21 faults [4] 2/6 58/9 86/7Ifinances [1] 168/9
129/12 131/13 143/12 93/22 100/12 100/14 I 415/10 financial [11] 29/11
expense [2] 50/6 [expressing [1] 123/4 100/22 106/6 107/15 Ifavour [2] 43/18 78/22 I 36/14 36/22 39/7 40/10
73/5 expression [3] 118/17 I 110/1 110/2 1115 fax [3] 155/19 158/12 I 76/11 129/14 133/1
expensive [2] 76/21 I 139/21 133/22 111/16 153/1 164/11 136/22 150/20 166/12
155/25 expressly [3] 13/11 _ failing [3] 12/24 22/5 Ifear [1] 159/23 financially [2] 90/12
experience [9] 18/17 I 75/5 84/24 82/15 fearfulness [1] 11/25 I 166/9
44/17 43/10 62/18 (extended [1] 74/16 failings [4] 35/24 fearless [2] 78/22 _Ifind [8] 31/12 97/6
63/19 69/23 92/24 extensive [2] 70/23 I 70/17 135/11 168/22 I 7e/24 412/23 129/3 129/7
4145/2 115/7 154/7 failure [9] 24/13 33/10 Ifeature [2] 45/20 56/7 I 131/24 132/3 151/11
, extent [13] 29/7 37/15 I 44/18 52/21 112/2 I February [7] 47/21 _Ifinding [4] 2/2 93/11
experienced 0 37/16 4219 55/12 I 112/18 116/1 147/13 I 51/8 67/12 68/13 69/2 I 147/18 164/12
45/23 TANT 98/12 82/20 87/12 123/20 I 153/6 101/9 151/13 findings [14] 10/7
406/19 158/19 124/1 140/16 151/18 Ifailures [8] 2/6 31/5 I February 1996 [1] 10/11 13/19 13/23
experiences [8] 2/14 I 151/19 181/21 34/14 34/11 91/23 151/13 15/20 17/14 18/6 18/9
2/00 12/9 61/10 61/22 \external [1] 55/24 106/7 111/22 11216 Ifed [2] 126/1 156/20 I 34/23 48/1 56/12 70/19)
63/16 63/17 73/1 extra [1] 168/19 fair [2] 77/2391/14 I Federation [10] 46/5 I 98/21 138/22
(67) excuses - findings
INQ00001046
INQ00001046
F following [13] 17/14 Ifounded [4] 25/12 96/8IFUJ00058198 [1] 85/23 86/9 86/12 87/16
finds [1] 118/13 33/12 61/6 67/6 102/8 I 113/19 116/16 85/20 91/7 100/25 121/9
fine [7] 19/11 27/18 123/11 123/18 139/22 Ifour [5] 3/6 68/7 77/1 IFujitsu [67] 1/15 11/10) 131/13 134/8 136/16
37/1 39/1 65/14 66/12 I 146/16 154/7 167/5 165/10 167/8 13/10 14/1 14/8 19/25 I 142/6 160/1 162/3
167/13 168/25 169/20 four paragraphs [1] I 21/12 21/21 22/22 23/9] 162/21 165/14
finger [1] 116/7 follows [4] 11/21 68/6 I 167/8 23/21 24/2 26/21 26/22I Furthermore [1] 57/18
finish [4] 65/13 95/16 150/23 156/9 fourth [1] 104/23 27/3 29/9 29/13 29/13 Ifuture [17] 6/16 24/18
155/23 169/14 folly [4] 113/13 Foyle [1] 3/9 32/2 32/25 35/11 40/10) 28/1 28/4 58/7 59/2
foolproof [1] 151/22 Ifraction [1] 69/15 42/9 47/17 47/20 47/25) 59/4 83/21 84/6 84/12
finishing [1] 195/22 footfall [1] 149/21 fragment [1] 117/7 48/5 48/18 48/24 49/3 I 86/22 102/18 140/14
fire [1] 60/22
: force [1] 125/12 frames [1] 112/1 52/14 55/21 56/1 56/3 I 142/11 150/5 160/21
fim (i sone 10612 force majeure [1] framework [2] 37/21 I 56/8 56/25 57/2 57/6 I 165/15
firmly [1] 715 125/12 146/8 7218 7612 76124 77168 I
firms [1] 118/21 forced [5] 4/10 61/22 Ifrankly [1] 60/8 77/12 83/15 86/2 88/25, > —__
first [21] 6/4 30125 I 74/3.119/22 125/12 [Fraser [53] 10/8 10/11 I 89/14 97/16 1014/2 Igain [4] 35/18 102/24
40/21 4514 45/17 61/13Iforces [1] 6/20 40/18 11/7 11/15 11/21] 103/22 103/24 109/2 I 103/3 103/4
62/25 6a/1891/12 \Foreign [1] 77/5 12/2 12/7 12/19 13/9 I 109/6 112/2 113/16 I gaining [1] 93/8
92/14. 92/16 100/14 {forensic [2] 53/4 75/12] 13/19 13/23 14/7 15/19] 114/21 114/24 115/19 IGames [1] 77/9
102/14 102/15 124/14 Iforever [1] 3/10 15/24 17/15 28/7 28/12I 123/15 124/22 128/17 Igap [1] 166/12
127/4 127/7 1358 (forgive [2] 106/1 29/6 33/9 34/17 35/6 I 129/4 142/21 143/9 Igaps [1] 63/4
455/4 155/21 164/24 I 127/43 35/14 37/5 42/11 44/18I 151/5 164/11 164/15 IGareth [2] 14/19 23/18
firsthand [1] 33/16 forgiveness [1] 123/3 I 44/21 46/11 47/19 49/2I Fujitsu's [4] 22/22 gateway [3] 85/12
firstly [8] 16/4 59/12 forgotten [3] 69/9 70/8} 50/2 50/20 50/24 55/25) 35/3 109/7 117/17
76/16 56/4 57/23 58/19 70/13Ifulfil [1] 120/17 Gateway/Golden [1]
ot ee 86/19 form [6] 41/15 43/25 I 74/12 75/6 75/9 75/12 Ifull [17] 16/18.63/15 I 85/18
fit [6] 42/5 53/10 a5/1eI 70/13 118/6 145/16 I 75/18 98/1 9/22 76/11 77/23 78/22 —_Igathering [1] 78/11
113/6 148/4 160/12 I 194/5 112/14 128/22 137/3 I 78/24 79/7 87/22 88/21I gave [13] 2/12 4/17
five [2] 65/11 7/4 formal [3] 20/25 54/4 I 137/10 147/1 147/7 I 91/14 94/3 12516 14/2 15/15 33/3 42/18 43/5
five minutes {1} 65/11 I 154/16 147/16 149/14 147/14 156/5 163/1 I 43/6 44/17 55/11 64/10
fixated [1] 36/9 formed [1] 85/23 Fraser's [2] 18/6 169/6 69/6 105/11 137/2
former [5] 16/10 92/7 I 128/21 fullness [1] 141/10 _ Igeneral [9] 6/10 21/15
flag [1] 116/19
flat [1] 42/12 115/4 118/13 139/17 Ifraud [7] 4/21 5/17 fully [8] 68/4 78/17 22/2 55/1 143/22
formerly [2] 104/6 I 22/10 53/10 154/19 I 93/14 121/13 135/14 I 156/12 157/10 161/12
famed A121 109/19 154/11 163/15 143/23 149/12 150/8 I 166/5
flaws [2] 81/19 87/13 [formica [1] 96/25 fraudulent [1] 163/16 Ifunction [1] 40/13 {generality [1] 21/10
flexible [1] 62/13 forming [1] 144/19 /Freedom [3] 70/24 I functionality [1] 40/11Igenerally [1] 115/1
floundered [1] 54/13 [forms [2] 16/9 154/8 I 137/24 148/18 functioning [1] 150/8 Igenerate [1] 98/24
i forth [1] 66/10 freely [1] 159/21 functions [1] 111/19 Igenerated [1] 129/17
flow [i] one 121/16 forthcoming [4] 32/4 Ifrequently [3] 50/3 I fund [1] 53/7 generation [3] 3/5
flurry [4] 61/12 52/10 139/16 168/6 I 75/8 120/5 fundamental [3] 61/3 I 92/15 92/16
focus [4] 2/1 68/2 80/3 forward [11] 7/22 Friday [1] 8/25 82/15 105/14 generations [1] 92/48
44719 33/23 34/9 57/7 61/16 Ifriend [5] 5/3 23/3 24/4Ifundamentally [1] I generically [1] 114/8
focused [3] 84/12 69/1 69/20 70/4 134/21) 47/13 50/14 162/ genuine [5] 22/14
84/15 163/15 148/11 151/12 friend's [1] 103/16 Ifunded [2] 53/14 46/23 47/23 63/18
focuses [1] 55/18 [forwards [1] 167/4 [friends [3] 19/7 50/13 I 148/17 140/12
Foley [2] 158/14 fought [2] 4/22 27/18 I 64/16 funders [1] 13/17 _Igenuinely [6] 32/8
459/12 found [18] 6/11 6/18 I from [198] funding [4] 145/22 I 63/18 70/5 72/25 76/8
follow [5] 65/8 7/7 I 12/1 18/5 3516 39/6 front [4] 5/19 112/21 I 146/7 147/10 168/19 93/10
110/12 115/5 164/13. I 44/1 50/2 50/24 56/4 I 130/11 130/22 funds [1] 61/21 George [1] 167/19
followed [8] 17/21 57/23 58/23 82/18 _Ifrontline [2] 6/23 further [24] 9/13 11/10IGestmin [1] 119/19
70/2 82/17 82/17 102/5I 99/22 128/17 153/25 I 113/15 44/19 55/5 61/23 62/1 Iget [11] 9/1 20/2 37/14
155/8 159/20 frustrating [1] 8/10 I 66/13 67/14 69/19 37/15 42/24 43/11
135/14 145/24 159/22
(68) finds - get
INQ00001046
INQ00001046
G Godeseth's [1] 33/15 I 84/16 17/25 18/3 19/3 19/6 I 32/18 45/7 65/24 74/4
get.. [5] 106714 (998 [5] 151/5 1561 I governments [1] 19/14 19/20 21/4 22/22I 93/5 111/3 144/17
105/16 132/15 133/4 I 158/25 159/13 160/1 I 187/17 24/22 27/16 28/24 4169/8
433/11 going [39] 8/169/10 IGrabiner [1] 119/12 I 28/25 30/17 34/1 34/20Ihappened [23] 2/22
gets [1] 128/6 19/19 21/6 22/24 26/20Igrandmother's [1] 2/3 I 35/2 35/6 35/8 37/10 I 4/13 18/20 21/1 21/22
getting (71 8/12/21 I 27/13 3219 32/12 32/18] grandparents [1] 9216 I 38/7 30/7 40/3 42/2 I 40/3 42/6 55/19 5918
B49 915 58/7 I 38/1240/11 40/21 Grange [1] 4/20 42/20 42/20 42/22 44/3} 68/18 69/25 73/11
1990 51/11 59/21 62/7 62/24IGrant [1] 146/83 45/14 45/22 45/25 I 76/14 89/1 133/3 136/8
GFA IT] 14619 146/12 I 65/6 65/21 6616 66/10 granted [1] 136/24 I 47/21 47/25 48/4 48/23) 130/2 147/20 147/24
14719 147/14 148i2_ I 06/12.80/12 87/21 grateful [15] 7/24 I 49/9 49/15 60/12 50/25] 154/21 163/2 16917
148/12 148/05 95/21 106/1 113/6 I 24/20 25/5 36/23 37/2 I 51/1 52/1 53/13 54/6 I 169/8
giro [1] 163/16 1341/6 131/24 132/14 I 38/15 38/21 64/14 I 54/15 54/24 55/6 56/8 Ihappening [2] 159/8
give [23] sii igri I 193/13 146113 154/11 I 64/17 65/1 72126 9421] 56/9 67/5 63/16 67/8 I 159/11
4/6 39124 40123 43/13) 105/16 157/15 159/3 I 94/23 122/23 167/11 I 69/3 69/22 71/10 71/23Ihappens [1] 21/2
51/2 59125 62/19 64/24} 106/11 166/24 167/17 I gratefully [1] 67/25 I 72/5 72/8 73/23 74/10 Ihappily [2] 66/18
85/23 84/1 113/23 (G0!den [3] 85/13 [gratitude [1] 7/21 I 75/3 75/7 77/18 83/22 I 118/14
428/15 132/14 136/2 I 85/18 86/4 grave [1] 122/3 84/9 85/7 86/7 86/24 Ihappy [7] 48/20 94/17
137/9 140/2 142/6 gone [4] 113/25 122/6 Igreat [9] 28/17 62/16 I 90/11 96/13 96/15 97/9 130/5 130/6 131/3
148/9 163/5 167/2 132/17 138/2 63/3 68/23 69/24 71/8 I 97/12 98/12 98/18 156/12 160/6
4167/3 good [29] 1/3 1/22 80/20 109/16 156/13 I 98/25 99/5 99/8 99/10 Ihard [3] 16/9 36/7
given [26] 8/25 11/2 5/20 16/9 16/13 17/4 /greater [1] 52/20 99/13 100/8 101/11 90/12
16/10 18/19 19/23 30/7I 34/1 37/4 48/20 53/10 Igreatest [1] 9/16 101/19 102/2 103/15 Ihardened [1] 100/6
33/15 34/7 42/16 49/14 59/24 59/24 65/18 73/7I greatly [1] 60/20 107/16 107/22 108/6 Ihardship [1] 150/20
55/13 59/21 62/16 74/25 86/3 92/2 92/8 IGreenhow [2] 135/23 I 108/20 109/1 109/25 I hardware [1] 163/21
88/19 88/20 88/21 93/3 95/6 109/16 140/22 110/2 110/3 111/15 I hardworking [1] 17/10
103/18 113/6 115/6 110/24 116/9 122/12 I grounds [2] 37/5 113/24 114/10 114/22 Iharm [4] 36/7 76/17
116/6 118/12 130/2 128/5 134/22 134/23 I 113/18 115/22 116/11 116/12 I 105/24 106/5
4134/2 135/18 136/5 165/8 167/14 group [34] 10/12 13/8 I 116/12 116/15 116/24 Iharms [1] 105/20
156/16 goodwill [1] 110/24 I 17/15 34/14 34/17 36/9I 119/4 122/6 122/6 Harris [1] 165/22
got [6] 30/18 45/16 42/17 44/6 47/8 47/16 I 122/13 123/3 124/14 Iharrow [1] 99/13
gives [1] 59/1 13212 133/1 13/4 I 48/2 48/8 49/1 53/1 I 126/15 128/7 128/25 Ihas [95] 1/15 2/17 2/18
giving [10] 2/15 3/23
3/25 8/2 22/3 34/11 158/11 53/3 53/19 54/7 54/11 I 129/6 130/16 130/19 I 2/22 5/10 5/11 5/25 7/1
139/15 139/17 139/21 Igovernance [7] 106/7 I 55/14 97/25 98/25 135/19 139/24 142/21 I 8/19 9/15 9/25 11/5
4156/7 107/4 111/8 114/2 123/15 124/6 138/21 I 143/21 146/6 147/19 I 13/22 15/10 16/7 18/20
glad [1] 130/25 115/16 117/22 140/18 I 139/13 144/13 150/14 I 147/20 147/24 148/2 I 18/21 21/22 21/23 22/8
glitch [1] 125/19 government [51] 8/11 I 163/23 163/25 164/8 I 148/10 156/4 156/5 23/18 23/24 24/20 29/7
glitches [1] 159/19 8/18 8/22 41/22 68/21 I 164/24 165/7 165/17 I 157/3 157/12 157/24 I 29/10 30/23 31/8 31/22
GLO Ig] 7/12 75110 I 76/5 76/22 77/19 81/13] 166/15 159/17 159/20 159/20 I 34/4 36/12 39/11 46/18
75/13 75/23 76/2 89123) 82/5 84/5 84/8 84/14 [groups [1] 155/5 159/22 161/3 162/3 I 48/3 58/18 58/21 58/24
944 1441/2 84/15 84/17 84/18 grown [1] 130/21 163/25 166/15 167/25 I 59/8 61/5 63/13 64/11
go [28] 1/6 14/2.25/4. I 4/19 84/21 84/28 86/3I quardianship [1] 168/1 168/17 67/8 67/14 68/22 68/24
34/18 39/22 40/24 85/12 85/17 85/19 25/15 hair [3] 122/1 128/8 I 69/10 70/22 72/8 76/6
50/22 61/11 62/2 66/17I 86/12 99/8 111/2 111/8/ guidance [5] 43/25 I 128/10 76/13 76/23 7/1 77/3
73/11 80/3 119/23 141/13 112/3 115/19 I 52/7 57/5 67/17 102/4 Ihalf [3] 42/22 83/24 I 77/5 77/9 7/12 77/17
40/8 124/12 130119 I 116/8 123/17 123/18 guide [1] 154/20 161/14 79/23 85/17 90/10
4132/3 134/7 135/5 124/13 124/17 132/18 Iguides [1] 159/23 IHamilton [4] 10/17 I 90/19 90/22 95/5 98/8
437119 138/16 14019 I 136/14 141/13 142/10 Iguilty [1] 103/23 I 70/22 71/19 106/21 I 101/12 116/7 117/3
442/20 146/17 158/12 I 143/9 143/25 152/15 I hand [4] 3/17 78/19 I 119/13 130/7 134/12
459/12 161/19 163/4_ I 1535 154/9 158/6 I__I 499/22 167/24 133/15 133/17 134/2
coal [1] 53/22 158/7 163/25 164/2 Ihad [149] 2/153/13 I handed [1] 45/25 134/4 135/3 135/19
9 164/25 165/7 169/4 I 4/1 4/13 8/14 12/9 hands [4] 60/11 136/11 138/1 138/2
gobbed [1] 128/6
Godeseth [1] 14/8 [Government's [1] 16/12 17/5 17/6 17/23 Ihappen [9] 19/16 140/12 141/8 141/21
68) get... -has
INQ00001046
INQ00001046
H TINO 9/4 128/4 130/18 I 56/20 103/18 125/14 I 160/23 161/8 164/22 [homes [1] 2/2
has... [14] 142/13 hear [20] 14/18 19/21 I 125/25 156/17 highlighting [1] honest [6] 1/23 16/10
444/17 146/21 147/23 26/20 28/19 60/9 65/18) hence [2] 104/13 139/13 108/2 115/14 116/16
449/5 150/11 152/19 67/16 74/14 80/17 104/14 highly [2] 18/10 25/9 I 132/9
452/22 153/16 153/18 83/12 83/13 83/14 Henderson [2] 14/8 I him [18] 4/6 4/7 24/12 IHonour [1] 129/9
153/25 158/25 168/7 83/22 85/6 86/5 94/22 I 53/17 28/10 28/15 34/1 95/24) honoured [1] 98/6
4168/8 95/6 111/25 134/16 I Henry [6] 94/17 95/5 I 107/14 107/21 107/22 IHooper [3] 15/6 54/11
have [199] 168/14 95/13 95/18 134/14 120/23 129/11 129/22 I 89/22
haven't [1] 27/4 heard [27] 16/7 16/16 I 170/4 130/12 137/13 147/12 Ihope [12] 47/4 62/2
Havery [3] 98/15 24/4 29/7 29/9 30/6 Ihens' [1] 18/11 157/11 159/41 83/12 83/20 90/4 92/11
128/18 129/10 37/6 41/15 42/6 54/18 /her [39] 3/10 3/11 4/23Ihimself [4] 23/20 93/18 93/20 110/19
having [14] 8/2 8/24 58/5 67/9 69/20 73/2 I 4/23 4/24 4/24 5/18 94/20 107/23 119/10 I 120/12 136/17 158/11
60/11 94/18 94/20 80/16 88/2 90/10 91/12) 5/20 11/16 42/19 42/22Ihindsight [1] 142/23 Ihoped [2] 78/11 142/7
103/14 107/15 107/16 I 196/16 107/11 136/20 I 42/22 42/23 50/22 his [52] 4/7 4/8 4/17 I hopefully [3] 21/7 85/6
4128/8 131/8 1314/9 137/20 143/10 148/23 I 50/24 54/16 54/18 4/18 6/2 11/6 16/11 136/25
435/20 150/19 166/19 I 191/3 152/8 164/5 54/19 54/22 96/23 17/19 21/10 24/12 hopes [3] 139/21
hazard [1] 101/22 hearing [13] 6/4 8/11 I 96/25 101/3 101/4 24/13 25/2 26/15 28/5 I 141/10 169/6
he [75] 4/9 4/16 11/20 42/14 44/8 53/16 61/8 I 101/8 101/15 107/24 I 32/25 33/21 34/2 34/5 IHorizon [198]
46/11 21/12 22/5 23/9 I 91/8 93/15 135/22 108/8 108/9 119/3 39/21 39/24 40/22 Horizon's [4] 111/10
23/10 23/22 23/23 140/24 157/11 160/10 I 119/5 119/6 128/9 40/25 41/7 41/12 43/14) hospital [1] 4/16
169/20 128/9 128/17 128/19 I 43/15 43/17 45/13 hotels [1] 155/25
ae nbe ae ane hearings [18] 2/13 128/19 130/14 130/20 I 58/20 75/19 77/3 80/6 Ihour [1] 166/24
37/10 39/24 39/25 7/23 16/7 16/17 16/22 I 166/22 95/24 96/9 98/8 109/14I House [2] 39/16 98/9
40/22 41/8 43/7 43/10 I 20/11 42/15 45/20 here [13] 1/24 22/4 112/14 120/17 120/24 Ihousehold [1] 97/15
43/11 43/12 43/15 48/10 52/6 59/14 60/23] 22/15 74/13 93/16 121/19 121/25 127/3_Ihow [47] 9/7 16/18
43/16 53/19 55/1 55/2 I 91/6 61/14 62/2 70/8 I 1314/6 131/8 132/23 127/16 128/2 128/12 I 30/3 42/24 42/25 44/2
136/14 147/18 136/4 138/2 138/19 I 128/12 129/9 130/8 I 48/14 58/14 60/21
Sere te nie hears [2] 14/25 1314/1 I 143/6 161/10 131/2 137/13 147/6 I 61/18 63/19 64/2 69/6
101/43 104/15 102/10 heart [4] 73/13 hermetically [1] 152/9 71/13 72/18 72/18
405/15 105/17 107/22 [heartbreaking [1] 8/10] 117/18 historic [2] 5/22 61/3 I 74/19 80/7 85/18 92/25
407/22 107/23 120/17 Iheavily [1] 89/10 heroic [4] 74/4 historical [4] 13/4 I 97/17 99/8 99/15
426/15 128/13 128/19 Ihectored [1] 100/18 hesitate [1] 166/21 I 25/11 25/12 91/5 100/16 103/18 106/25
429/19 129/20 129/21 Iheels [1] 77/7 Hi [1] 8/9 historically [1] 144/15 I 108/18 109/24 110/2
130/4 130/5 1305 (height [1] 113/43 hidden [1] 123/9 history [10] 1/17 18/16] 112/22 113/2 113/5
130/5 130/6 130/10 [heightened [1] 7/10 hide [1] 131/22 68/16 68/20 79/7 111/9) 113/9 114/2 114/23
130/25 130/25 1311 [held [10] 9159/25 hierarchical [1] 117/25] 134/4 134/5 141/19 I 116/13 124/15 125/15
4341/2 1341/3 137/12 I 10/4 48/5 58/14 60/22 Ihierarchy [1] 96/12 I 144/11 136/20 143/6 144/17
140/23 144/41 147/13 I 76/14 13114 131/7 I high [28] 3/1 6/9 6/13 IHMRC [2] 77/3 77/12 I 145/25 148/12 150/17
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90/14 140/21 157/11 1428/3 132/19 132/20 Ilikewise [1] 103/3 litigator [2] 101/19
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52/23 55/22 78/15 105/16 110/4 131/17 ILeggatt [1] 119/19 {limited [41] 10/12 little [11] 1/6 61/5
86/16 87/12 87/19 131/17 131/18 133/10 Ilegislation [1] 58/3 I 22/12 23/21 37/14 77/18 102/17 109/22
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128/20 lawyering [1] 107/3 I 93/18 89/14 123/15 123/15 I 65/20 65/25 69/11
known [22] 21/20 lawyers [7] 30/16 34/7 Ilet [12] 7/6 9/3 10/7 I 123/16 124/6 124/7 133/4
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468121 leadership [2] 143/14 I 154/16 161/16 161/14
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labyrinthine [1] learned [9] 5/2 23/3 I 159/6 163/9 lines [4] 115/14 localities [1] 63/25
117105 24/4 47/12 58/18 64/15Ilevels [8] 6/106/13 [Linnell [3] 15/9 54/9 Ilocally [4] 7/3
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4115 (14/7 113/6 learning [1] 93/2 45/18 81/16 lip [1] 157/43 Lock [2] 5/13 18/14
115/12 152/16 184/11 Ilearnt [2] 62/5 103/16 liability [3] 50/4 99/19 Iliquidated [1] 165/12 ILondon [1] 107/15
lacked [1] 1641/7 least [9] 12/1152/18 I 154/11 list [1] 14/24 Londonderry [1] 3/9
laid [3] 73/2 136/10 I 67/24 75/7 86/22 122/5]liaised [1] 56/1 listen [3] 29/10 39/18 long [12] 1/16 33/9
14118 128/23 138/12 155/16 ILiam [1] 158/14 160/6 40/5 60/12 62/18 90/19
lamentable [1] 55/16 leave [1] 50/15 libel [4] 120/4 listened [4] 27/9 27/14I 1024 112/1 119/18
land [1] 131/16 leaving [5] 59/18 liberal [1] 16943 I 96/4 152/22 42715 128/7 144/12
landmark [1] 104/9 I 115/8 130/20 137/10 ILibraries [1] 77/10 listening [1] 113/15 Ilonger [2] 61/19 74/7
language [1] 133/23 I 138/4 lid [1] 126/18 litany [1] 117/2 look [9] 11/13 30/13
large [3] 23/547/9 led [8] 31/1 53/1 53/7 lie [4] 36/2 36/9 98/13 Iliterally [1] 167/10 I 49/17 6213 75/24 91/21
409/21 67/11 85/24 89/22 I 104/13 litigant [1] 12948 I 120/5 142/25 146/17
largely [3] 39/12 150/17 152/16 lied [2] 16/23 75/7 _Ilitigants [5] 7/18 13/16Ilooked [3] 10/24 36/20
116/16 153/19 Lee [6] 98/5 104/20 lies [2] 30/2041/16 I 15/13 36/16 61/2 106/12
last [20] 2/8 3/5 5/24 I 107/11 127/3 128/1 life [8] 4/13 76/22 litigation [43] 3/2 _ looking [6] 2/4 11/4
6/4 8/9 8/2567/114. I 128/2 80/14 81/9 92/11 117/7I 10/12 13/5 13/8 13/15 I 13/14 49/8 103/20,
67/15 73/4 77/11 78/23ILeeds [1] 107/18 432/12 133/41 46/3 17/15 34/14 34/17I 144/3
78/25 81/4 120/13 left [7] 24/21 41/25 light [8] 8/13 25/9 34/18 34/19 35/25 looks [1] 41/12
430/24 141/22 150/12 I 94/14 54/21 117/19 70/23 79/7 104/11 36/10 37/23 37/24 Lord [7] 15/3 30/8 37/7
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L mail [5] 25/11 35/2 54/5 56/21 124/19 matter [17] 7/13 18/4 Imean [5] 29/5 112/16
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102/10 119/12 main [2] 156/4 163/15 Imanaging [1] 156/25 I 35/25 44/9 49/11 61/21Imeans [11] 25/13
Lord Arbuthnot [2] mainly [2] 107/3 Manchester [1] 151/8 I 61/24 62/4 91/7 107/16) 39/14 62/1 62/20 91/16
15/3 53/2 116/16 manifest [1] 116/21 111/23 121/14 142/18 I 97/10 100/7 118/4
Lord Grabiner [4] mainstay [1] 15/9 manifested [1] 41/19 Imatters [31] 12/3 14/4I 120/19 138/7 153/20
119/12 maintain [4] 42/9 manner [3] 40/17 15/23 27/2 34/8 37/15 Imeant [5] 19/6 40/11
Lord Justice [1] 37/7 56/16 66/15 72/13 44/25 105/13 44/3 45/19 52/8 59/11 I 112/7 146/5 157/20
Lord Justice Sachs [1] maintained [4] 34/19 Imantra [1] 83/7 59/25 60/18 62/9 68/1 Imeantime [1] 66/15
102/10 36/6 116/24 160/4 manual [2] 113/3 87/23 87/25 91/10 96/5Imeasure [2] 64/8
Lord Neuberger [2] Iaintaining [2] 36/9 I 125/17 97/10 114/7 120/8 122/12
30/8 37/9 42/12 manuals [1] 159/23 123/7 123/19 124/15 Imedia [1] 11/2
lose [5] 35/13 40/11 maintains [2] 12/22 Imany [49] 2/21 16/6 I 124/18 127/1 127/5 mediation [8] 15/1
90/13 112/23 121/14 32/11 17/11 18/13 18/14 19/6] 137/11 146/24 151/16 I 52/17 54/3 54/4 54/7
loss [4] 10/24 19/13 Majesty's [1] 77/3 23/8 23/17 28/15 30/1 168/1 1 ; 55/11 89/22 119/4
47/23 166/7 majeure [1] 125/12 30/9 38/11 41/16 42/14I maximising [1] 165/6 Imeet [5] 63/14 111/18
losses [7] 22/13 22/16 major [4] 6/21 150/9 I 51/14 51/16 57/3 68/23Imay [67] 1/8 12/20 111/22 146/3 169/16
22/24 50/4 136/22 159/3 159/4 69/22 71/8 73/6 73/9 I 25/8 25/17 30/15 32/19I meeting [9] 35/11
136/22 163/4 majority [1] 6/11 73/23 74/11 90/1 90/13) 42/9 45/11 59/18 66/4 I 160/14 164/24 165/2
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51/12 83/23 161/15 19/5 19/12 19/13 20/13] 93/9 99/15 103/13 68/17 68/20 68/25 166/17 168/7
loud [2) 1/4415 20/14 37/4 38/12 40/19] 106/17 110/1 110/18 I 69/22 70/1 70/4 77/15 Imeetings [2] 150/23
Louise [1] 15/15 48/20 59/4 59/13 59/17) 118/16 132/17 132/20 I 77/24 79/15 80/17 I 150/24
loved [1] 90/13 59/24 60/4 60/16 60/47] 132/21 137/20 138/24 I 80/18 81/8 81/14 81/24I member [4] 3/16 46/20
iow[t} 1464/4 61/16 63/5 64/14 64/20] 139/6 142/13 143/21 I 82/2 82/3 83/14 85/22 I 138/13 146/5
loyal [4] 99114 90/16 I 64/28 85/3 86/9 102/18) 150/17 156/2 159/21 I 86/13 86/15 87/3 87/24 members [23] 6/19
teItS 127125 118/6 120/2 120/18 I 163/18 88/18 89/9 90/9 93/1 I 27/4 32/25 53/5 87/8
ludicrous [4] 129/13. I 134/23 19612 136/15 March [5] 12/6 55/10 I 94/6 94/19 9618 102/22) 94/4 137/16 137122
lunch [1]. 155/24 140/13 141/23 142/13 I 84/14 85/5 101/9 110/9 115/4 116/4 I 137/23 138/18 139/7
Luncheon [1] 95/2 I 147/14 149/11 157/18 IMarch 1999 [1] 84/14 I 11714 1148/2 118/11 I 130/14 142/14 142116
lunchtime [2} 9418 I 18809 Marion [1] 16/11 118/15 118/24 120/6 I 145/6 145/19 148/17
160/14 makers [1] 82/4 mark [1] 129/15 420/7 125/4 12977 I 11/8 154/14 152/5
—* ___Imakes [3] 133/10 marked [3] 5218 I 129/25 130/1 1356/5 I 155/12 159/10 163/8
M 138/15 153/15 75/13 108/7 136/21 137/22 143/15 Imembers' [2] 46/14
machine [1] 20/15 making [8] 26/3 39/15 Imarket [1] 85/19 147/13 152/6 152/17 I 157/25
made [50] 6/3 8/3 86/24 135/8 135/25 —_Imarketing [1] 151/23 I 153/11 159/14 164/15 Imembership [3] 46/10
10/11 13/23 15/20 153/21 158/23 164/1 Imarriage [1] 4/11 May 1999 [1] 152/6 138/9 146/16
47/15 24/22 26/25 mammoth [1] 112/4 Imarriages [2] 160/24 Imaybe [2] 66/13 167/8Imemories [1] 133/2
31/18 34/3 36/12 37/11/man [3] 4/12 107/23 I 164/15 McCartney [2] 165/1 Imemory [2] 96/24
38/6 48/6 49/17 50/12 I 130/7 Marshall [1] 98/8 165/19 119/22
51/15 52/15 58/4 58/19I/manage [1] 122/21 Marshall's [1] 99/3 IMcLachlan's [1] 33/18Imental [5] 5/22 6/9
67/4 72/3 74/18 74/24 Imanaged [1] 105/21 IMartin [1] 46/18 me [35] 4/13 4/14 7/6 I 7/10 9/4 128/4
74/25 75/4 75/5 76/6 IManagement [16] 41/2IMartin's [1] 46/21 8/22 9/6 10/7 14/4 mentality [1] 99/18
78/10 91/11 93/9 96/10I 81/7 86/22 114/11 massive [1] 130/17 15/25 20/19 36/18 43/3I mentally [4] 70/1
99/23 121/11 131/16 I 114/13 114/14 114/18 Imasterful [1] 94/7 44/24 64/13 64/19 130/13 132/11 132/11
133/5 133/6 140/6 114/20 115/19 116/4 Imatches [1] 112/12 I 65/19 66/4 79/15 95/6 Imentioned [12] 17/18
141/21 144/7 146/12 I 117/10 117/23 118/14 Imaterial [17] 24/12 101/18 103/21 104/23 I 30/8 72/8 109/6 109/17
148/13 152/6 159/3 124/23 154/19 1614/7 I 25/20 25/22 26/17 106/1 120/7 127/13 118/23 141/7 147/21
160/11 161/13 162/3 Imanager [5] 3/11 5/4 I 28/21 31/8 31/13 32/22) 128/7 130/24 130/25 I 148/8 148/19 161/13
1462/6 162/12 167/18 I 43/15 43/16 84/11 35/15 52/10 62/11 63/5I 131/4 131/16 133/18 I 165/20
magisterial [1] 95/22 managerial [1] 156/16 I 75/15 97/9 104/18 135/16 148/24 161/20 Imentioning [1] 20/20
Magistrates [1] 100/2 Imanagers [5] 5/2 23/2 I 120/23 149/16 164/5 167/23 merely [2] 22/6 110/2
(65) Lord... - merely
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M 168/7 132/23 149/22 148/3 Mr Enright [2] 2/16 8/8
ceana')) 79/99 Iminutes' [1] 66/11 monies [1] 16/14 movements [1] 61/16 IMr Foley [1] 159/12
OD [2] 72/22 I Mirror [1] 76125 monitor [3] 56/13 Imoves [1] 143/4 Mr Godeseth [1] 14/8
met [6] 6/11 53/3 miscarriage [4] 18/15 I 56/16 61/20 moving [2] 2/18 Mr Godeseth's [1]
54/16 86/2 112/19 67/10 68/15 68/19 monitored [3] 9/10 163/23 33/15
451/14 miscarriages [3] 93/1 I 56/1 56/11 MP [3] 11/6 55/14 Mr Henderson [2] 14/8)
method [1] 159/18 135/12 143/17 monitoring [1] 55/23 I 165/1 53/17
methods [1] 154/10 mischief [1] 107/25 Imonotonous [1] 134/3IMPs [8] 15/4 30/4 53/1 IMr Henry [4] 94/17
Mexican [1] 116/9 misconduct [1] 104/11]Montague [1] 154/15 I 53/3 53/13 53/19 54/6 I 95/5 95/13 134/14
° misery [1] 104/19 Imonth [2] 43/8 50/2 I 150/12 Mr Holmes [2] 17/18
revcrophone [2] 1/7 misfeasance [1] 101/1Imonth’s [1] 55/12 IMr [190] 18/14
mid [2] 80/8 163/17 mismanagement [1] _Imonthly [2] 85/15 Mr Abdulla [1] 43/5 IMr Jenkins [4] 27/16
19908 [1] 8018 I 192/16 14513 Mr Altman [15] 20/21 I 28/14 33/14 33/19
20008 [1] 163/17 Imismatch [3] 35 — Imonths 6] 4/95/16 I 24/28 2516 26/1 26/16 IMr Justice [8] 3516
middle (2) 109720 I 164/19 164/22 56/9 76/22 84/9 91/12 I 27/15 27/21 28/9 28/18) 42/10 44/17 44/21
bn misplaced [2] 143/10 IMoorhead [8] 6/2 6/3 I 29/2 33/3 34/4 126/13 I 47/19 98/21 104/1
Midlands [1] 55/14 I 1895 405/11 106/13 106/20 I 126/14 126/21 105/3
might [23] 12/1 2015 [Misra [11] 33/19 96/20) 108/16 115/16 119/14 Iafr Altman's [2 Mr Justice Fraser [47]
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50100 67121 Sol1g I 104/22 107/24 11913 more [38] 913 29/20 IMr Aujard [1] 54/25 I 11/15 14/21 12/2 1217
74104 7319 Tart g1i22 I 13115 13218 29/20 33/6 36/3 52/12 IMr Baker [1] 157/16 I 12/19 13/9 13/19 13/23
83/10 93/7 93/12 ga/1gImistepresented [2] I 56/6 57/9 62/13 70/22 IMr Bates [1] 54/9 I 14/7 15/19 15/24 1715
to9i2 110/00 118/19 I 50/3 146/21 74/21 80/17 96/2 96/4 IMr Beal's [1] 147/7 I 28/7 28/12 29/6 33/9
427/13 144/16 159/22 IMissed [1] 89/17 96/4 99/5 99/6 99/20 IMr Beer [28] 5/3 23/4 I 34/17 35/14 37/5 46/11
migration [5] 157/2 missing [3] 12/18 105/9 105/15 108/23 I 24/4 30/6 37/7 44/9 49/2 50/2 50/20 50/24
19/11 31/8 4113/3 117/15 117/17 I 47/13 51/7 66/4 67/13 I 55/25 56/4 57/23 58/19
heaps 164/16 164/20 mistake [1] 133/6 1428/3 132/5 133/9 67/22 68/12 70/10 70/13 74/12 75/6 75/9
Miller [3] 160/17 mistake’ [1] 133/6 134/11 137/7 138/15 I 75/19 76/7 79/5 80/8 I 75/12 75/18 98/1
160/20 161/23 mistaken [1] 59/5 439/24 139/24 140/1 I 80/13 81/3 82/10 95/23) 112/14 128/22 137/3
million [20] 36/13 mistakes [1] 64/12 140/21 143/13 156/15 I 101/7 109/16 116/6 137/10 147/1 147/7
36/19 39/15 77/2 77/4 mistress [2] 4/19 5/4 I 157/13 159/17 418/22 125/10 167/13 I 147/16 149/14
7716 T7I7 T710 77/12 Imistresses [1] 5/1 Imoreover [1] 67/20 I 169/11 Mr Justice Fraser's [2]
7713 77/13 153/24 mixture [1] 154/24 morning [5] 1/3 140/6 IMr Beer's [3] 96/2 18/6 128/21
162/21 165/9 165/10 model [1] 29/11 142/16 169/12 169/17 I 96/9 109/10 Mr Justice Leggatt [1]
165/11 165/11 165/14 modern [2] 68/19 85/2 Imosaic [1] 117/5 Mr Beers [1] 70/12 119/19
166/6 166/13 modernise [1] 84/19 Imost [15] 3/4 11/23 IMr Blair [1] 86/2 Mr Lee [2] 128/1 128/2
MiMan [1] 164/20 Modernising [1] 84/15) 36/7 47/22 74/4 89/16 IMr Castleton [5] 98/10IMr Marshall's [1] 99/3
mind [6] 7/2 65/5 75/8 modification [1] 157/2) 90/9 92/3 92/25 103/23I 99/4 128/7 129/10 Mr McLachlan's [4]
modifications [1] 112/15 113/23 118/9 I 129/18 33/18
oe Pe ae 139/20 429123 155/25 Mr Castleton's [1] _ IMr Moloney [4] 65/2
minister [5] 86/1 (Modified [2] 1/24 mother [1] 4/16 130/3 66/25 94/6 134/13
404/24 105/1 165/1 57/18 mothers [1] 92/5 Mr Cipione [6] 40/21 IMr Nicholas [1] 147/3
465/19 Moloney [6] 65/2 motivated [2] 108/18 I 40/24 41/4 45/13 79/25IMr Nick [1] 127/16
Ministerial 1] 63/21 I 66/25 67/2 94/6 134/13] 113/20 80/6 Mr Page [1] 111/24
ministers [5] 30/3 170/3 motivation [5] 43/23 IMr Clarke [14] 21/9 IMr Roberts [2] 39/19
a3/15 8779 a9i4 g2in3 (moment [3] 1/10 33/6 I 74/1983/10 83/13 I 21/20 23/16 24/8 24/11] 39/19
Ministry [1] 77/14. I 37/13 86/16 24/14 24/22 26/1 27/15IMr Stein [8] 1/6 36/17
momentum [1] 121/14Imount [4] 20/16 27/20 27123 28/9 28/18] 38/17 64/18 65/7 70/11
Monday [1] 144/12 Imove [7] 40/1405 I 3/3 94/20 134/12
money [12] 3/18 3/23 I 64/9 79/18 131/10 IMr Darlington [1] __IMr Stephen [1] 84/11
minutes D3} ene 3/25 12/18 19/4 19/6 I 155/18 166/19 18/14 Mr Turner [2] 101/4
434/17 165/24 166/23 I 19/11 36/5 36/15 51/12)moved [2] 125/24 Mr Dawson's [1] 4/16 I 101/11
(66) message - Mr Turner
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M 110/17 narrowly [1] 81/5 150/3 150/8 157/14 153/4 153/9 153/25
MrWinn [2] 11/11 multifactorial [1] nascent [1] 103/13 157/18 158/2 158/4 154/2 154/7 155/2
1418 110/17 nation [1] 96/6 158/6 162/18 169/1 155/8 155/9 156/20
Mrs [10] 14/16 51/4 multimillion [1] 76/23 Ination's [1] 3/4 Neuberger [2] 30/8 156/23 157/6 157/7
98/7 98/11 99/1 104/22 multimillion-pound [1] Inational [13] 4/5 46/5 I 37/9 157/10 157/21 158/10
4119/3 131/15 132/8 76/23 77/2 81/2 82/9 123/16 Inever [16] 19/20 19/22 158/14 160/9 160/13
432/16 multinational [1] 134/25 135/9 138/10 I 40/7 64/6 70/4 99/4 160/19 161/4 161/4
Mrs Misra [6] 98/7 97/15 144/19 160/18 161/25 I 105/7 105/8 109/3 162/12 162/17 162/20
98/11 99/1 104/22 multiple [1] 19/24 163/9 109/12 114/7 125/20 I 162/23 162/24 163/3
131/45 132/8 multitude [1] 162/25 Inationwide [2] 111/17 I 129/24 133/2 162/9 163/6 163/9 163/20
Mrs Seema [1] 119/3 must [35] 7/2 7/5 8/5 I 157/18 169/8 163/23 164/3 164/3
Mrs Skinner [4] 14/1 14/15 15/22 20/8 Inatural [1] 8/14 nevertheless [1] 115/3I 164/10 164/11 164/25
132/16 22/4 22/7 28/19 30/24 Inature [2] 26/4 159/7 Inew [6] 61/1 76/23 165/23 166/4 166/16
Mrs Stockdale [1] 56/19 56/25 69/9 70/18] near [4] 1/6 2/2 18/11 I 84/21 132/3 144/24 166/17 166/19 167/20
514 73/12 73/15 76/16 40/18 154/4 168/6 168/13 168/15
Mrs van den Bogerd 78/13 78/18 84/19 nearly [2] 107/22 Newcastle [1] 160/14 I 169/2 169/5
It] 11/16 105/9 108/7 110/15 130/4 news [2] 5/20 131/3 INFSP's [9] 139/23
Ms [24] 5/6 5/10 14/9 1141/4 114/3 114/9 necessarily [4] 75/14 INewsagents [1] 147/17 147/23 147/25
44/14 15/9 18/14 18/14 115/24 124/22 124/24 I 79/24 88/2 114/11 138/11 151/2 159/14 159/8
46/21 54/9 54/16 54/18 126/1 126/2 126/25 /necessary [9] 17/2 Inewspaper [1] 145/3 I 162/15 166/1
54/21 54/25 98/6 101/3 147/22 162/16 98/20 103/11 115/22 Inext [12] 21/1 60/3 INFSP00000027 [1]
404/24 115/2 119/4 mustn't [1] 115/9 120/17 141/13 142/18 I 61/20 65/2 69/18 79/17I 158/11
422/25 128/16 130/19 Imute [1] 21/18 146/4 150/4 137/19 146/13 154/21 INFSP00000237 [1]
434/24 166/21 170/5 mutual [1] 113/20 necessity [2] 75/15 158/12 159/12 161/19 I 161/10
Ms Angela [1] 14.9 I y [32] 4/11 4/14 4/14] 04/13 NERN [4] 138/14 NFSP0000340 [1]
Ms Anne [1] 128/16 4/11 4/12 4/13 4/15 5/2I need [28] 9/7 10/2 NFSP [127] 46/4 46/12I 155/17
Ms Crichton [3] 54/18 5/24 7/21 8/8 8/10 8/20) 18/23 28/19 28/23 135/19 135/24 135/25 INichola [4] 100/16
54/21 54/25 8/24 9/4 9/4 9/6 11/22 I 29/23 29/23 30/19 33/5] 136/11 136/14 136/17 I 107/8 125/4 130/13
Ms Felstead [3] 101/3 23/3 23/14 24/4 46/12 I 37/8 48/10 55/8 62/21 I 136/25 137/6 137/8 I Nichola Arch [1] 107/8)
119/4 130/19 47/12 61/7 64/13 64/15) 63/6 66/11 83/25 137/12 137/14 137/16 INicholas [1] 147/3
Ms Hobbs [1] 104/21 64/15 95/10 103/16 106/11 109/16 115/23 I 137/23 138/3 138/10 I Nick [2] 127/16 138/1
Ms Kay [1] 15/9 130/24 162/23 169/13 I 117/19 120/23 121/9 I 138/20 139/6 139/9 —_Inightmare [2] 9/6
Ms Linnell [2] 54/9 myriad [1] 105/17 131/10 132/1 132/2 139/17 139/20 140/2 I 109/4
54/16 myself [6] 2/16 8/10 I 132/22 150/2 162/4 I 140/9 140/12 140/15 I no [63] 4/15 6/15
Ms Lock [1] 19/14 I 21/18 122/25 132/10 needed [4] 128/11 I 140/17 140/20 140/23 I 10/13 20/24 20124
Ms Martin's [1] 46/21 I 14/13 155/11 155/12 156/17 I 141/5 141/10 141/18 I 20/25 26/15 26/22 27/9
Ms Page [3] 98/6 mystery [1] 101/15 Ineeds [5] 30/9 63/4 I 141/20 141/22 142/1 I 27/14 26/4 26/14 2015
4145/2 122/25 N._ I 634 112/18 131/7 142/12 142/16 142/19 I 29/6 29/7 35/4 40/9
Ms Palmer [2] 5/6 5/10I——--.-. —-Ihegative [1] 6/14 142/22 142/24 143/2 I 40/12 40/12 40/22
Ms Vennells [1] 14/14 I"ave [1] 97/13 negligence [1] 100/25 I 143/8 143/12 143/19 I 61/19 61/21 74/7 72/19
Ms Watt [1] 166/21 naked [1] 109/7 negligently [1] 100/22 I 144/1 144/3 144/7 73/6 76/1 76/7 76/13,
Ms White [1] tai4 ("ame [5] 5/18 5/20 I negotiating [2] 145/14I 144/11 145/5 145/10 I 77/18 91/16 93/20
much [24] 9/7 14/10 97/15 109/16 128/5 I 451/14 145/12 145/22 146/1 I 99/20 100/11 102/5
15/18.36/16 38/20 (named [4] 64/6 88/10 Inegotiation [1] 145/17] 146/11 146/15 146/18 I 103/4 109/15 110/14
58/14 60/3 62/13 gaia) 124/12 124/17 negotiations [6] 39/13I 146/20 147/4 147/8 I 1114/9 111/23 112/42
99/5 99/6 10/7 130/8 "namely [2] 124/12 40/4 85/24 86/3 165/4 I 147/21 148/5 148/8 I 112/25 115/23 116/24
434/14 13512 13872 I 14/10 166/10 148/16 149/3 149/5 I 117/21 119/15 125/18
443/2 144/17 153/13. AMES TA]. 17/19 69/21 neither [2] 98/14 137/8] 149/9 149/11 150/3 I 125/24 126/10 126/11
469/17 169/18 110/12 143/22 Nelsonian [1] 124/24 I 150/7 150/9 150/11 I 128/17 133/16 136/11
mucus [1] 128/6 narrative [2] 108/24 I network [16] 78/4 150/15 150/23 1514/7 I 147/5 147/19 147/23
multi [1] 110/17 108/24 83/24 86/11 141/4 151/10 151/14 152/1 I 148/10 149/2 153/25
narrow [1] 156/7 149/25 149/25 150/1 I 152/6 152/14 152/22 I 156/8 156/15 156/16
multi-systemic [1]
(67) Mr Winn - no
INQ00001046
INQ00001046
N 15/25 20/19 21/2 25/2 objectively [1] 111/15 I 137/9 139/17 140/2 90/13
no... [2] 156/16 167/13 37/12 38/4 38/12 38/14] objectivity [2] 105/2 I 158/18 158/19 161/17 Iongoing [6] 5/23 32/14!
nobody [5] 9/15 114/8 45/13 47/14 52/16 53/2} 109/13 161/18 162/4 91/10 148/6 151/23
129/22 156/4 156/5 58/12 62/5 64/15 66/5 I objects [1] 145/12 offices [21] 3/12 3/14 I 155/10
noise [1] 21/18 69/23 70/9 73/17 74/17] obliged [1] 65/10 3/20 83/24 83/25 online [3] 71/9 85/2
nominated [1] 144/8 75/16 79/6 80/3 91/14 Ioblivious [1] 119/10 I 111/17 144/10 145/8 I 93/16
non [8] 25/19 26/16 93/4 95/10 101/18 observations [1] 150/8 154/6 154/22 [only [54] 3/2 3/5 8/7
405/24 106/5 107/25 I 103/14 104/7 107/6 102/9 154/24 154/24 155/1 I 8/12 13/5 14/17 16/23
124/16 124/6 134/3 109/16 109/24 111/15 Iobserved [1] 71/18 155/3 155/4 157/8 24/9 29/15 29/17 30/10
non-compliance [1] 115/1 115/24 118/13 Iobstacles [2] 9/13 157/14 157/19 159/15 I 31/12 44/4 44/14 45/16)
4134/3 118/15 118/19 119/8 I 110/18 163/17 45/22 46/2 56/9 57/1
non-disclosure [7] 121/17 122/22 122/23 Iobstructive [2] 45/12 I official [6] 50/17 57/15) 59/19 60/24 64/7 66/5
25/19 26/16 105/24 128/25 129/25 130/5 I 55/2 57/22 57/25 63/15 66/11 69/15 77/22
106/5 107/25 121/16 I 190/15 131/12 134/15 obtain [1] 11/19 144/24 80/14 91/16 92/2 93/4
4124/6 137/19 141/8 142/24 jobtained [2] 137/24 I officials [6] 55/21 93/8 93/11 96/21
none [5] 34/20 60/24 145/22 152/21 155/15 I 144/22 55/21 56/22 63/24 102/14 102/15 102/20
42417 129/9 148/23 I 196/22 158/13 158/17 I obtaining [1] 31/7 83/15 93/24 102/22 105/5 110/18
nook [1] 31/1 159/8 159/23 160/8 — jobvious [3] 46/12 often [10] 19/9 21/15 I 110/22 115/13 115/14
nor [4] 46/13 93/21 161/10 162/10 167/2 I 68/12 124/21 22/2 22/19 28/16 40/17) 119/6 126/21 129/8
137/8 146/19 168/21 obviously [6] 28/17 I 40/17 43/10 43/13 130/6 132/25 137/14
normally [1] 120/18 number [37] 10/14 80/17 82/20 95/25 98/3) 73/25 137/23 138/25 139/4
northeast [1] 154/23 10/15 10/21 12/6 14/11] 126/23 oftentimes [1] 112/5 I 143/4 156/6 157/25
Northern [2] 3/7 77/10 23/22 24/8 28/11 32/3 Ioccasions [4] 18/22 okay [1] 155/21 onwards [2] 41/25
not [203] 38/1 42/1 47/9 47/19 I 43/12 45/18 90/1 old [6] 69/23 73/22 59/22
note [15] 35/10 35/15 47/22 49/4 49/5 49/25 Ioccupations [1] 78/2 I 96/20 99/12 130/24 —Iopen [4] 84/1 140/16
37/20 38/4 38/13 41/12I 97/21 69/3 69/16 71/10Ioccur [1] 154/14 159/18 146/12 150/8
57/2 66/1 67/17 78/9 72/9 72/17 86/18 88/10I occurred [4] 25/20 oldest [1] 109/25 opening [37] 1/12 2/8
79/6 101/13 122/24 92/18 99/21 137/5 26/17 129/6 163/4 ominous [1] 113/9 31/15 65/6 67/2 67/3
463/24 167/24 137/13 137/14 137/21 IOctober [8] 1/1 8/7 omit [1] 120/25 67/12 67/23 69/18
noted [7] 22/18 47/19 I 1389/7 146125 150/11 I 8125 25/3 25/6 31/19 omitted [1] 154/5 75/19 79/5 80/16 81/3
87/17 6912 81/2 119124I 19172 1641/8 163/15 I 146/14 166/14 once [7] 9/3 20/8 94/7 95/18 95/22 95/25
455/20 number 3[5] 10/14 I October 1999 [1] 54/17 118/11 118/14 I 103/17 109/10 117/6
notes [1] 166/4 1216 13715 137/13 I 166/14 119/1 132/8 118/18 126/17 133/13
nothing [6] 5/10 44/21 I 146/25 October 2013 [1] 25/6 Ione [57] 7/4 9/24 10/4 I 133/18 134/16 134/21
420/7 133/12 144/21 [Rumer 6 [3] 10/15 [October 2016 [1] 42/11 20/15 20/18 27/9I 135/3 135/8 135/17
4160/1 10/21 28/11 146/14 27/14 29/5 29/7 29/15 I 135/25 144/7 141/25
notice [4] 12/12 56/12 {Number 6798 [1] 24/8 Jodd [1] 102/11 34/15 42/17 42/20 46/3] 152/9 170/2 170/3
86/20 129/6 numbers [1] 153/11 off [9] 6/12 20/7 39/15 I 51/2 52/11 52/18 57/1 I 170/4 170/5
noticed [2] 95/5 numerous [1] 71/14 I 43/14 116/9 125/13 _ I 58/15 62/14 63/2 75/7 Iopenings [3] 67/18
425/20 0 126/18 153/22 167/17 I 76/21 78/19 78/24 82/6I 72/9 88/11
notified [1] 45/3 =____loffenders [1] 92/2 I 89/16 90/9 96/4 98/5 openly [1] 159/19
noting [1] 14218 o'clock [1] 38/14 offer [1] 44/15 99/4 99/5 100/12 operate [5] 44/24 54/4
notwithstanding [5] obdured [1] 102/2 offered [1] 147/5 400/18 102/22 108/12 I 89/4 1414/3 145/7
923 97/18 135/03 Ibfuscated [1] 87/11 office [343] 109/19 115/9 115/9 operated [2] 5/13 78/4
14519 153/23 obfuscation [2] 9/13 office's [13] 12/15 I 117/3 118/16 119/8 operating [4] 30/3
November [7] 6/4 79/8 17/1 32/12 34/24 52/19] 121/20 121/24 134/5 operation [10] 18/25
obiter [3] 102/4 103/1 I 69/17 70/17 73/4 74/15I 1314/6 137/14 138/12 I 20/3 23/19 23/25 29/17
54/13 105/12 110/22
420/12 135/22 140/24 I 103! 74/24 89/23 165/15 I 138/24 139/4 144/16 I 80/1 82/12 136/9 144/9
object [2] 102/13 166/6 151/4 156/8 159/15 I 168/11
November 2021 M1 I toa officer [3] 146/2 161/24 164/16 operations [1] 157/2
objections [1] 159/21 I 147/25 155/14 onerous [1] 122/3 operative [1] 130/17
now [71] 2/48/14 8/16) 17. i
one ia objective [1] 36/2 officers [9] 115/4 jones [3] 16/24 45/22 Ioperator [1] 35/5
168) no... - operator
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0 117/14 117/16 117/25 I 165/23 168/24 323 78/7 149/13 own [16] 1/21 4/7 4/15
——________.—I 11916 1204 1207 others v Post [2] I 163/12 18/1 19/4 21/3 29116
coined tI i063 420/24 121/17 12/5 I 10/42 137/4 outcomes [2] 32/6 I 29/25 46/10 46/14
spinion (t} 243 I 122/6 128/22 12412 otherwise [7] 1011 I 63/0 60/12 108/25 117/10
spportunities (3) 68/3 I 124/8 127/20 133121 I 1711 22/13 32/19 42/10loutine [1] 95120 I 14119 14617 te8rt4
Te aOrt 4134/9 136/12 136/19 I 149/12 155/24 outlined [4] 112/14 Iowned [3] 36/5 78/5
A 138/10 139/8 140/9 fought [12] 87/14 I 162/23 164/11 168/20 I 93/23
oro a eae 145/16 145/18 145/21 I 114/22 116/17 116/18 Ioutraged [1] 60/9 Iownership [1] 115/20
67/25 69/19 73/1 73/18 147/12 147/23 148/8 I 122/8 122/10 122/10 outrageous [1] 17/3
P
148/10 148/12 148/12 I 122/12 122/14 129/14 Joutreach [2] 3/12 3/14If -__
oneyiotom 149/25 152/16 152/17 I 129/15 129/24 outset [12] 35/7 39/3 Ipace [3] 62/4 62/17
opposed [1] 105/2 I 196/2 163/13 169/22 Jour [83] 2/6 2/12 3/2 I 41/20 56/1 71/4 71/18 167/1
oppression [2] 107/1 I 197/8 5/9 7/1 7/10 7/15 8/15 I 83/9 90/22 125/2 134/5Ipact [1] 113/17
407/25 oral [5] 14/1853/16 I 9/16 9/21 10/1 14/13 I 152/21 168/16 page [31] 5/19 21/8
oppressive [3] 49/22 I 59/20 60/17 65/8 14/18 15/14 18/24 19/8I outside [1] 15/23 21/24 23/13 23/14
57/24 129/16 order [11] 6/21 65/24 I 19/10 19/22 20/10 21/8I over [38] 3/17 9/8 23/14 24/8 25/4 33/13
oppressively [2] 80/9 101/6 103/7 30/22 31/4 36/23 37/12I 10/19 12/10 18/25 41/7 41/14 70/10 84/3
100/15 106/22 114/16 135/11 138/22 I 41/4 46/18 47/1 47/24 I 28/21 36/13 39/4 55/19I 85/20 98/6 111/24
option [1] 41/22 4144/3 153/2 155/9 52/16 58/20 59/13 60/1I 56/4 58/14 66/24 67/14] 115/2 122/25 125/17
options [2] 86/9 1541/9 ["dinary [2] 110/6 I 60/8 60/20 60/24 61/10] 72/46 74/11 78/22 155/18 156/9 158/12
110/9 61/19 63/9 63/23 64/4 I 79/17 81/1 81/3 88/14 I 158/12 158/16 159/12
Oat aos aaa ordination [4] 115/12 I 64/8 67/10 67/20 68/1 I 92/17 93/6 96/17 104/2I 160/1 161/11 161/20
43/10 13/11 4917 20/22 /OPGAnisation [6] 46/24I 68/4 68/6 68/7 68/14 I to9/B 116/14 124/16 I 161/22 161/22 162/4
215 22110 22/11 22/00) 138/14 144/3 145/10 I 69/23 69/24 69/25 7013] 127/24 1341/9 134/9 I Page 13 [1] 24/8
145/25 146/3 72/25 73/19 74/7 75/20I 133/3 142/14 145/23 Ipage 14 [2] 23/13
oa/8 290 9018 4133. organisations [7] 76/8 78/11 79/9 79/14 I 147/23 152/20 160/14 I 23/14
32/20 33/19 34/24 93/19 124/12 124/17 I 79/21 82/16 89/16 162/20 164/21 page 144 [1] 33/13
37/10 37/24 38/9 39/13I 137/15 137/21 138/17 I 89/18 90/3 91/11 91/15I overall [3] 37/17 78/8 Ipage 2 [1] 21/8
40/12 42/24 42/25 43/1 143/3 91/18 91/23 93/9 93/14I 79/14 page 39 [1] 25/4
43/8 43/24 43/24 48/6 ITganising [1] 145/2 I 96/7 104/15 106/10 overcome [1] 110/18 page 47 [1] 85/20
43/7 48/24 49/6 49/16 [Origin [1] 10/5 117/6 124/5 126/17 —_Iovercomplex [1] 118/3IPage 5 [3] 41/7 41/11
50/14 52/1 52/7 55/22 Original [1] 83/14 131/9 131/10 132/25 overlooked [1] 87/10 I 84/3
57/5 57/6 59/4 59/16 \Other [33] 14/11 20/10 I 133/18 134/15 144/20 Ioverly [1] 41/23 pages [3] 2/11 113/3
60/1 60/13 61/20 64/7 20/17 31/10 31/25 ourselves [3] 28/6 overly-ambitious [1] 161/19
65/4 66/11 71/14 72/10I 32/25 33/14 33/22 41/14 96/8 41/23 paid [6] 16/14 28/3
72/44 75/1 75/25 76/3 I 38/11 39194518 lout [54] 2/2 2/11 8/17 Ioverriding [3] 16/21 I 146/9 157/13 161/15
76/4 76/13 76/15 76/17I 40/22 50/2 63/19 66/6 I 9/5 16/8 21/9 21/24 I 78/9 78/14 165/9
76/18 7/18 81/17 76/2 78/20 88/25 93/21) 23/16 24/11 25/2 26/15Ioverrun [1] 167/11 Ipain [3] 73/2 73/7
32/24 83/1 83/3 83/10 I 94/2 102/22 111/25 I 27/1 27/16 31/42 31/23Ioverrunning [1] 130/14
84/17 85/12 86/23 87/8I 1129 114/20 116/8 I 31/23 30/5 42/1 42/6 I 169/13 Palmer [3] 4/19 5/6
87/11 87/13 88/15 121/3 135/13 138/4 I 44/6 46/23 53/19 58/23I overseeing [1] 165/4 I 5/10
88/17 88/25 89/2 89/10 199/8 140/22 143/3 I 63/5 66/18 69/7 86/18 Ioverseen [1] 54/7 Pam [2] 44/17 155/13
80/12 90/17 93/24 148/12 168/19 92/11 100/15 108/21 Ioversight [6] 20/24 IPamela [4] 5/13 15/14
94/16 96/11 96/20 97/4 others [34] 10/12 114/40 112/23 112/24 I 63/11 111/8 114/15 I 42/18 50/21
97/14 97/20 98/15 g9/4I 10/17 18/13 18/16 23/7) 113/12 122/20 123/1 I 114/19 152/17 pandemic [1] 6/24
4019 102/15 102/19 I 34/16 49/20 57/3 58/22] 123/7 124/21 130/19 overstate [1] 61/18 I panel [1] 118/21
405/22 106/3 106/6 I 61/7 69/19 70/1 70/26 I 131/24 134/7 141/19 overturned [3] 17/13 IPaper [4] 84/6 84/15
406/10 106/24 07/2 I 71/19 74/3 87/2 88/15 I 142/21 146/20 148/24 I 73/22 163/20 84/24 154/10
408/20 108/23 109/12 I 92/8. 92/23 115/10 150/22 151/11 152/7 Ioverview [1] 32/11 I paper-based [1]
41014 142/19 113/18 I 128/13 137/4 137/46 I 156/7 156/14 159/2 jowed [3] 16/15 44/11 I 154/10
41615 116/16 116/20 I 142/24 143/11 146/22 I 165/3 1665/8 167/19 I 99/22 paradigm [1] 108/1
116/25 11716 117/7 I 1595/1 160/10 163/21 Joutcome [5] 17/19 owing [1] 108/4 paradigms [1] 107/7
(69) operators - paradigms
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Pp 10/22 parts [3] 29/17 34/8 I 109/3 109/22 110/6 —Iphantom [3] 35/1 56/3
varaaraph{96) 14/7 Parallel [4] 102/13 84/21 110/9 122/6 131/1 99/21
Paragraph Oa ow -IParamilitaries [3] 3/16 party [6] 38/6 38/8 I 131/48 131/49 132/47 I phase [44] 2/28 15/2
24/9 26/14 26/14 28/14 3/24 4/1 105/12 114/20 147/21 I 132/20 132/21 132/22 I 15/12 16/7 39/2 40/22
33/6 33/10 33/17 35/24 paranoia [1] 108/19 I 148/8 132/23 133/4 133/6 42/13 49/19 52/5 52/16:
30/21 39/23 41/6 41/14 paranoid [1] 105/6 pass [3] 93/1 116/5 133/9 134/6 138/8 55/23 58/6 59/15 64/22
44/22 46/11 57/23 pared [1] 40/9 138/24 156/6 156/14 67/12 67/19 68/8 68/9
7418 122/2 156/10 _ Parents [1] 92/11 passage [1] 147/6 people's [4] 128/4 69/5 72/24 73/13 79/17
458/17 160/2 162/23 park [2] 4/5 127/9 passages [2] 2/15 132/21 160/24 161/14 I 79/21 80/10 80/20
paragraph 1.1.9 [2] Parliament [4] 53/5 33/12 per [12] 6/20 6/21 6/24I 87/17 87/20 88/1 88/3
41/6 41/11 TAIN6 74/24 108/14 passed [2] 4/17 6/25 50/2 56/6 138/4 I 90/8 139/16 139/18
paragraph 106 [1] Parliamentary [1] 39/6] 118/17 138/5 148/20 148/22 I 139/23 140/13 142/4
26/14 part [25] 3/8 18/15 past [9] 21/24 38/10 I 158/3 166/6 149/10 150/10 151/1
paragraph 14 [2] 20/4 21/2 29/10 45/4 I 64/12 75/13 133/3 perform [3] 43/11 157/12 162/11 168/6
23/13 23/15 51/20 52/18 55/16 58/4] 141/15 143/14 143/20 I 112/8 118/21 Phase 1 [5] 2/23 16/7
paragraph 17 [1] 59/8 79/10 81/14 85/23I 161/19 performance [1] 81/10I 67/12 69/5 72/24
39/23 97/13 104/7 129/4 —Ipathos [2] 109/11 _I performative [1] 105/7IPhase 2 [17] 39/2
Paragraph 218 [1] 131/13 137/13 150/10 I 109/12 performed [1] 49/9 40/22 68/8 79/17 79/21
4417 156/19 160/15 160/22 IPathway [10] 24/2 perhaps [15] 7/9 30/9 I 80/10 87/17 88/1 88/3
Paragraph 219 [1] 161/21 165/15 40/10 41/1 41/23 81/5 I 46/9 65/5 66/9 72/2 90/8 139/16 139/18
1445 Part 33 [1] 104/7 151/5 154/17 158/16 I 74/17 91/9 111/3 115/4I 139/23 142/4 150/10
paragraph 31 [1] Participant [2] 135/20 I 160/10 165/14 122/14 123/1 123/2 151/1 168/6
4122/2 136/24 pattern [1] 45/10 144/15 146/22 Phase 3 [3] 42/13 68/9
paragraph 368 [1] [Participants (21) Paul [4] 98/8 period [8] 42/3 45/8 I 87/20
46/11 13/22 67/5 67/18 70/7 IPaul Marshall [1] 98/8 I 49/24 71/24 123/19 IPhase 4 [3] 49/19 52/5
paragraph 38 [1] 24/9 72/21 73/19 74/1 75/4 IPaula [1] 58/21 139/1 147/24 149/19 I 149/10
paragraph 39 [1] 76/8 79/2 79/10 80/24 Ipause [2] 28/6 166/22 I periods [2] 12/10 55/3 IPhase 5 [3] 15/2 15/12
T1i18 82/16 88/12 89/24 94/2I pay [10] 4/2 4/9 10/13 Iperjury [2] 107/25 52/16
paragraph 49 [1] 98/6 107/7 110/23 13/2 20/8 43/16 45/5 I 108/12 Phase 6 [1] 55/23
35/21 136/6 138/12 82/3 106/16 145/14 permitted [5] 14/3 Phase 7 [2] 58/6
paragraph 509 [1] _IPatticipate [1] 136/25 Ipaying [1] 48/24 50/7 50/11 59/13 59/15] 140/13
28/11 participating [2] payment [10] 5/8 8/12 Ipersistence [1] 72/3 Iphase's [1] 20/11
paragraph 512 [2] 143/22 145/16 8/12 8/21 83/19 91/4 Ipersistent [1] 45/6 phases [12] 32/5
33/6 33/10 participation [2] 85/11] 101/5 154/10 165/9 I person [8] 2/21 20/15 I 37/12 37/15 38/13 60/5
paragraph 558 [1] 145/21 166/8 91/15 93/21 129/18 60/14 63/6 74/15
44/22 particular [19] 10/13 Ipayments [7] 35/9 130/6 131/5 131/6 139/22 139/25 140/3
paragraph 723 [1] 10/13 11/2 26/7 35/9 I 82/14 136/15 161/5 —_I personal [3] 63/20 142/6
57/23 63/6 82/3 82/22 83/17 I 164/19 165/10 168/12 I 91/20 158/13 Phases 2 [1] 37/12
paragraph 8 [1] 12/8 104/5 105/1 105/23 I PEAK [3] 47/9 47/10 Ipersonally [1] 7/3 Phases 3 [1] 139/25
paragraphs [141] 10/22I 16/4 136/2 1374 I 47/41 personnel [2] 6/20 I phlegm [2] 128/6
10/23 21/8 24/24 25/5 140/15 147/3 149/10 IPeberdy [1] 165/22 150/11 128/9
31/20 37/20 122/2 164/16 peers [1] 144/8 persons [3] 17/4 physical [2] 128/4
4123/7 161/22 167/8 particularly [2] 6/17 Ipenalised [1] 133/11 I 118/22 124/9 130/18
paragraphs 105 [1] 108/3 people [50] 1/18 1/22 Iperspective [5] 42/7 physically [3] 70/1
25/5 parties [9] 62/21 75/25I 1/23 2/1 3/13 6/15 159/8 160/4 162/15 130/13 132/11
paragraphs 11 [1] 86/25 89/7 110/21 11/13 16/43 17/10 166/1 picked [2] 156/19
31/20 120/21 137/9 164/1 22/23 23/8 27/10 27/12I pertinent [2] 83/13 167/19
paragraphs 12 [1] 166/5 29/18 29/24 30/10 143/24 picture [6] 87/4 88/21
37/20 partly [2] 105/22 106/3] 30/12 30/12 51/13 57/7I pervert [1] 34/10 4117/5 125/5 138/17
paragraphs 19 [1] IPartners [1] 53/9 66/6 69/3 73/21 78/2 Iperverting [1] 108/12 I 143/5
12919 partnership [2] 85/13 I 87/18.96/1499/15 _IPeter [1] 16/9 pilot [14] 41/20 42/2
paragraphs 217 [1] 85/23 103/14 105/21 106/2 IPFI [2] 29/11 111/7 139/20 154/21 154/22
(70) paragraph - pilot
INQ00001046
INQ00001046
Pp POCR [1] 54/11 23/7 24/24 25/23 27/1 I 16/4 58/14 58/15 64/7 Iprevent [2] 52/23
pilot..[9] 1559 PODS [1] 12116 28/7 34/14 34/24 40/3 I 133/9 151/19
155/11 156/19 157/4 IPOint [22] 10/9 12/21 I 42/10 46/4 47/24 47/25I powerful [4] 2/18 59/4 Iprevented [3] 13/9
4e0rte 180/22 161/6 I 19/13 26/7 33/5 39/24 I 54/24 59/16 62/28 74/7) 6719 96/2 57/10 143/16
462/11 168/11 43/7 50/19 66/14 76/16] 74/18 88/16 94/22 —_I powerfully [1] 115/16 Ipreventing [1] 166/2
Pinicis 2] 471 I 84/3 100025 402117 I 117/17 118/11 119/13 powerless [1] 130/11 I prevents [1] 57/19
a2 103/22 104/23 113/16 I 142/1 147/2 148/11 Ipowers [1] 120/24 _I previous [3] 21/23
1146/7 124/5 131/21 I 149/3 practicable [4] 113/3 I 47/10 161/22
pitiless [1] 127/3
Pitlochry [4] 4/4
place [19] 7/21 38/2
38/5 54/23 64/15 81/9
133/16 161/3 166/25 Ipositive [1] 160/3 practice [6] 45/21 58/6Ipreviously [2] 1/16
points [16] 24/5 24/10 I positively [1] 98/11 101/25 102/7 108/3 91/21
30/7 31/21 31/25 38/12I possible [16] 1/18 140/14 prey [1] 105/8
83/3 93/24 107/2 61/13 64/19 93/17 1/20 20/4 26/2 34/9 practitioners [1] 88/9 Iprice [2] 39/12 153/19
414/23 117/12 119/11 156/10 159/1 159/2 48/3 48/17 52/1 52/19 I praised [1] 76/2 primarily [1] 41/13
421/23 143/2 148/21 I 1599/9 161/12 162/11 I 62/20 95/13 120/15 I pre [2] 11/5 115/9 primary [1] 36/2
162/22 436/17 136/21 141/2 Ipre-empt [1] 11/5 IPrime [4] 86/4
teene 1596 pox (20) 25/20 31/22 I 14376 pre-judge [1] 115/9 I Prime Minister [1]
32/3 34/6 49/20 83/7 I possibly [4] 31/3 61/7 Ipreceded [1] 133/18 I 86/1
Leena ieraa 99/4 101/18 104/24 I 103/19 108/14 precedent [3] 107/12 Iprincipality [1] 96/12
plagued [1] 87/3 105/5 108/18 108/19 I post [365] 128/11 129/11 principle [2] 120/2
plain [1] 24/13 113/15 114/24 115/19 IPost Office [5] 85/3 Iprecious [1] 110/10 I 120/3
plainly [1] 102/4 116/13 118/13 118/14 I 86/8 86/19 87/8 161/16] predecessor [1] 23/22Iprinters [1] 163/22
planned [2] 92/13 118/19 127/12 post offices [1] 3/14 Ipredict [1] 115/3 printing [2] 158/21
160/25 POL's [7] 25/8 99/19 I post-traumatic [3] predictable [1] 111/21I 159/7
planning [1] 85/18 99/25 105/9 114/2 6/12 6/14 6/18 prefer [1] 65/4 prior [1] 163/4
plans [5] 83/18 83/21 117/47 118/18 posted [1] 66/4 preference [1] 152/1 I priorities [3] 68/8
85/19 151/22 151/23 POL00006358 [1] 25/4) postmaster [3] 5/4 I preferred [1] 27/17 79/16 79/21
plastered [1] 5/19 POL00006404 [1] 142/9 163/12 pregnant [1] 96/22 I priority [2] 91/45
platform [2] 85/2 122/1 postmasters [29] 20/5 Ipremature [2] 86/15 I 91/16
86/10 POL00006485 [1] 23/4 135/13 137/23 125/9 prison [3] 96/19 97/4
121/21 138/4 138/8 138/25 —_I premise [1] 96/9 122/6
plausible [1] 118/6
play [3] 75/25 76/21
157/25
POL00006798 [1] 21/8] 139/4 140/4 140/7_—_Ipreparation [1] 2/20 Iprisons [1] 96/21
police [5] 20/24 26/13 I 140/10 140/19 143/16 Ipreparatory [1] 85/11 Iprivate [4] 29/11
29/6 30/10 77/2 143/20 144/7 144/8 —_Iprepare [1] 153/2 100/10 100/13 105/10
Paved [3] 14/13 14/19 policeman [1] 16/10 I 144/21 145/6 145/7 _—I prepared [3] 85/15 privilege [2] 79/3
players [4] 76/20 policemen [1] 92/7 I 150/18 151/18 151/20 I 118/20 156/23 108/15
83/11 86/17 94/3 policies [3] 52/2 52/4 I 160/14 160/21 161/2 Ipreparing [1] 92/12 I privileged [1] 118/11
playing [1] 101/22 52/7 162/8 163/19 164/12 [present [2] 141/11 I proactive [1] 90/25
plea [2] 108/5 108/6 policy [7] 51/21 52/1 I 168/24 161/17 probability [1] 112/2
pleadings [1] 12/21 99/7 113/19 117/4 postmen [1] 144/22 presented [3] 45/2 probably [6] 33/5
please [7] 1/11 23/12 124/24 126/10 postmistress [1] 149/7 149/16 54/22 106/10 122/12
25/4 132/15 159/12 _ [Political [5] 39/10 159/16 presents [2] 68/3 132/5 132/10
161/10 161/12 109/1 113/14 113/21 Ipostmistresses [1] 69/19 problem [11] 22/14
plight [1] 4/24 163/17 23/2 preserving [1] 74/20 I 27/13 47/21 54/19
plum [1] 109/20 politics [1] 150/13 I posts [1] 86/2 president [1] 160/18 I 65/20 112/4 119/18
pm [9] 65/17 66/21 IPOor [3] 41/5 75/1 potential [6] 14/11 press [5] 16/1953/1 I 128/18 128/25 129/3
66/23 95/1 95/3 134/18. 115/2 59/1 60/4 86/12 151/8 I 63/22 74/16 74/25 168/25
134/20 155/23 169/19 poorly [1] 39/5 165/6 pressure [4] 7/16 8/5 Iproblem-solving [1]
pocket [1] 46/25 populated [1] 109/18 Ipotentially [6] 35/12 I 53/1 111/12 54/19
pockets [1] 13/17 population [1] 6/10 35/18 48/13 57/24 presume [1] 167/15 Iproblematic [1] 25/9
POCL [7] 82/7 82/21 IPose Lt] 109/24 126/4 165/13 pretend [1] 27/18 _I problems [25] 8/1
83/1 83/21 83/22 as/25I Posed [1] 11/1 pound [1] 76/23 pretty [1] 28/2 16/24 35/7 41/8 41/19
86/8 position [28] 4/23 16/2Ipower [7] 16/1 16/4 Iprevalent [1] 19/3 53/11 56/14 58/9 61/3
(71) pilot... - problems
INQ00001046
INQ00001046
Pp profound [2] 106/18 I prosecution [18] pub [1] 42/21 qualifications [1]
problems... [16] 71/17 130/6 14/20 18/8 21/21 22/3 I public [37] 1/25 10/5 I 23/23
TAID4 71/25 72/4 7215 profoundly [1] 106/8 I 22/21 24/19 25/8 25/10I 18/7 18/18 18/19 26/12I quality [2] 96/6 162/20
82/19 86/20 87/7 98/12/Program [1] 77/20 28/1 67/6 68/14 72/12 I 36/5 37/18 52/24 56/15} quantum [1] 22/16
444/12 124/7 130/18 [Programme [5] 41/23 I 82/16 102/13 102/18 I 63/19 64/9 66/9 70/5 I quarterly [1] 37/22
158/19 158/21 158/22 113/2 154/14 162/16 I 122/13 126/10 126/16 I 76/10 76/12 76/19 quashed [5] 67/8 69/3
4159/7 162/22 prosecutions [8] 76/22 76/25 77/25 78/5I 69/14 69/15 91/3
procedural [4] 59/14 progress [4] 59/24 21/23 51/9 93/5 106/22) 79/25 91/17 91/25 Queen's [2] 98/15
60/18 62/4 64/19 63/3 86/3 91/11 135/13 138/7 148/20 I 91/25 92/2 92/3 92/17 I 128/18
procedure [8] 44/20 IProgressed [1] 53/24 I 149/1 93/3 93/12 93/23 93/24I querulous [1] 105/6
57/12 58/6 104/4 104/7IProgresses [4] 9/11 Iprosecutor [8] 21/3 I 111/6 111/7 123/9 question [23] 11/1
130/17 140/14 151/25 project [24] 23/24 39/3) 58/12 74/22 100/11 138/22 158/1 13/2 38/4 43/20 50/6
procedures [4] 44/13 39/7 53/15 77/6 81/10 I 100/14 103/21 105/10 Ipublicly [4] 36/5 64/6 I 52/4 60/23 62/6 72/2
50/16 51/24 57/4 83/14 83/16 1141/7 122/4 73/24 93/23 73/8 80/18 82/7 87/16
proceed [5] 62/9 80/19 111/11 111/15 112/5 I prosecutors [4] 21/4 Ipublicly-owned [1] 87/19 90/15 90/19 91/1
103/10 125/3 125/11 131/2 152/8 152/10 21/41 27/6 87/15 93/23 400/10 124/13 124/17
proceeding [1] 119/21 152/16 152/25 153/7 Iprotect [1] 1/19 published [2] 84/8 157/9 161/24 166/8
proceedings [12] 1/4 154/3 157/15 158/5 I protecting [4] 25/13 I 84/14 question 49 [1] 124/13
28/4 49/13 49/16 51/11 161/7 165/6 168/9 29/15 157/25 158/1 I pulling [1] 152/7 question 6 [1] 157/9
51/14 67/24 93/16 projects [2] 111/6 protection [2] 25/11 [pun [1] 118/41 questionable [1] 71/11
1149/7 119/20 124/9 411/25 25/15 punishment [2] 22/17 Iquestions [21] 14/14
4371 prolonged [1] 13/15 Iprotocol [2] 120/10 I 131/25 20/5 20/10 38/11 68/9
proceeds [1] 14/1 prominent [1] 150/12 I 120/13 purchasers [1] 81/6 I 79/19 86/18 87/20
process [24] 7/19 18/3 promoting [1] 145/20 Iprotocols [1] 126/16 Ipure [1] 9/2 88/13 91/18 1041/8
18/8 31/23 52/18 53/7 [Prompt [1] 90/23 prove [3] 12/23 98/16 Ipurpose [5] 11/11 42/5) 106/11 109/24 115/21
54/16 54/19 61/1 61/15IPrOoF [3] 12/24 97/19 I 98/19 113/6 127/22 160/12 I 115/22 115/25 143/24
62/5 62/8 62/12 62/17 112/13 proved [3] 102/15 purposes [1] 163/7 151/15 156/8 156/23
63/2 64/3 76/4 112/22 [Proper [4] 25/19 1114/7) 102/16 102/21 purse [1] 76/19 161/23
4119/4 123/25 158/20 126/16 150/7 proven [1] 108/4 pursue [2] 126/5 quick [1] 159/22
164/2 164/12 166/1 properly [8] 7/19 12/1 Iprovide [13] 15/6 129/12 quickly [5] 60/21
procured [1] 41/22 27/9 32/23 98/17 15/11 24/18 27/25 pursued [10] 12/13 I 66/18 78/13 156/14
procurement [10] 2/5 112/11 114/15 117/12 I 37/22 63/23 64/8 70/15} 45/19 91/19 96/17 159/17
111/40 125/8 139/19 [Properties [1] 127/15 I 77/25 78/13 120/22 97/10 99/23 106/22 I quite [3] 42/4 66/8
150/14 150/25 153/6 IProphecy [1] 115/4 121/2 142/7 106/23 129/10 129/11 I 108/14
453/24 154/1 168/16 IProposal [1] 81/6 provided [18] 5/7 pursuing [2] 49/22 I quote [3] 23/15 50/14
produced [3] 35/10 proposals [2] 151/19 I 19/23 28/21 32/21 107/18 105/18
101/6 149/2 151/20 45/15 46/21 56/8 67/14I pushed [1] 156/14 quotes [2] 21/6 24/7
production [3] 120/16 [Propose [2] 2/10 87/21] 77/8 79/4 103/5 119/2 Iput [22] 14/14 20/7 R..
120/49 145/3 proposed [1] 164/20 I 135/3 135/17 147/11 I 28/3 29/21 33/23 34/9
I proposition [1] 81/16 I 147/12 153/9 161/1 I 46/14 47/1262/25 [Rv Eden [1] 102/6
aro ial prosaic[1] 109/15 provider [1] 114/20 I 99/17 102/9 102/12 _Iraces [1] 78/3
prosecute [4] 99/9 Iproviders [2] 12/1 I 107/4 114/8 119/25 _I raids [1] 16/17
provessionally [1] I'yoart9 126/22 168128 I 151/3 121/22 126/3 126117 Iraise [2] 21/14 2211
Professor [a] 6/1 6 IProsecuted [20] 4:21 [provides [2] 85/16 I 131/21 138/16 148/14 [raised [12] 21723
Ta oe Sein I 8169122 16/15 22123 I 162/24 4150/1 31/25 48/18 67/22
Toone Herta Horna, I 23/9 27/11 29/18 51/6 Iproviding [3] 71/5 putrid 1] 109723 I 100128 156/14 15714
Poe ene MOLI’ I 87/18 101128 105/22 I a4rat 12914 putting [5] 12/20 29/11) 158/5 159/21 164/6
106/2 113/18 117/7 provision [5] 23/19 I 38/4 102/17 159/9 162/19 162/23
16] 6/3 106/13 106/20 I J g/o9 436/19 1383 I 85/3 93/3 134/14 162/6I raising [4] 37/2 122/1
Professor Richard [2 138/5 139/7 provisional [1] 64/20 Qe 166/17 168/17
6/4 105/10 prosecuting [4] 20/23 Iprovisionally [1] 87/23IQB [1] 137/5 range [1] 76/24
29/3 103/9 126/20 I PTSD [1] 6/21 quagmire [1] 39/7 [ranging [1] 118/21
profit [1] 144/5
172) problems... - ranging
INQ00001046
INQ00001046
R recall [9] 6/3 17/22 recuse [2] 37/5 119/8 Ireinvention [1] 149/25) 127/12
ranked[1] 81/6 19/5 44/8 46/1 46/18 /red [1] 116/19 reiterate [2] 74/6 75/3 Irelying [1] 50/16
rapacity [1] 127/23 53/16 75/5 102/5 redress [5] 68/10 reiterating [1] 70/6 —Iremain [5] 51/17 73/13
rare [2] 18/10 45/18 receipts [3] 35/9 82/14] 79/20 87/21 90/21 rejected [1] 154/17 I 79/9 127/11 141/2
rarely [1] 43/11 164/19 103/2 relate [4] 10/23 12/3 remainder [1] 79/19
rate [2] 51/5 51/7 receive [7] 9/20 56/17 Ireduced [1] 96/13 14/4 52/7 remained [2] 129/20
rates [2] 145/14 1641/3 58/13 63/18 84/23 reducing [1] 97/3 related [3] 50/23 101/3I 152/13
rather [7] 22/13 46/10 110/21 142/17 Reefer [1] 104/2 163/14 remaining [2] 83/25
60/14 83/16 99/19 received [15] 2/18 refer [3] 10/1997/25 Irelates [2] 60/18 62/4 I 165/12
402/11 168/24 5/10 5/25 42/20 46/19 I 130/3 relating [4] 31/21 61/3 Iremains [8] 9/23 78/5
rationalisations [2] 85/21 91/4 102/8 reference [26] 10/9 82/22 145/17 79/15 91/15 101/15
145/11 134/9 118/14 119/14 126/13 I 23/12 24/5 24/7 25/3 I relation [18] 15/1 140/15 149/5 153/17
raw [3] 99/7 104/18 146/7 147/19 156/2 30/7 31/17 31/18 35/15) 33/19 40/3 47/7 53/17 Iremarkable [2] 16/1
122/15 156/6 39/21 39/21 39/23 55/19 59/9 91/11 91/13] 17/8
Rayleigh [1] 4/20 receiving [2] 1/4 1/5 I 40/23 58/17 70/15 84/1I 103/24 123/7 126/16 Iremarks [2] 75/9
re[1] 62/20 recent [6] 25/9 25/18 I 85/20 103/2 120/18 I 137/18 142/1 142/3 I 142/12
re-call [1] 62/20 34/41 68/15 76/22 4121/5 123/5 142/5 150/14 166/5 168/12 Iremediate [1] 126/11
reach [3] 77/9 130/9 165/8 153/10 164/6 165/2 [relations [1] 145/13 Iremember [5] 18/23
168/14 recently [3] 62/5 78/10I 167/23 relationship [7] 37/21 I 25/17 70/3 101/7 104/1
reaching [3] 111/1 153/9 references [1] 33/13 I 77/19 84/10 85/25 remembering [1] 33/8
466/25 167/15 recognise [2] 69/14 [referral [1] 17/14 141/3 141/20 144/16 Iremind [3] 16/9 28/6
reaction [1] 31/4 410/10 referred [6] 28/16 relationships [1] 41/14
read [16] 2/15 216 8/6 recognised [3] 74/12 I 78/10 81/3 122/14 142/9 reminded [1] 80/10
40/20 23/15 24/7 24/9 I 79/23 90/22 132/6 153/23 relatively [1] 126/2 Ireminder [2] 25/6 80/7
25/3 31/16 84/18 89/3 recognises [3] 135/25 Irefers [5] 33/16 39/24 IRelativity [2] 31/17 I remit [1] 15/23
123/19 133/14 133/15 I 137/14 168/13 41/4 85/11 150/23 153/10 remote [1] 113/23
4135/4 144/18 recognising [1] 150/4 Ireflecting [2] 81/2 released [1] 30/5 remotely [9] 23/10
readily [1] 89/10 recognition [3] 78/12 I 95/22 releases [1] 63/22 24/3 46/13 49/3 68/22
reading [1] 43/14 144/24 164/17 Reform [1] 84/7 relentlessly [1] 91/18 I 71/9 77/17 113/3 147/8
ready [4] 38/25 66/19 recommendation [1] _Irefunded [1] 136/23 [relevance [1] 87/4 remotest [2] 59/8
66/24 94/12 5/12 refused [6] 5/11 51/2 Irelevant [21] 6/17 145/8
real [4] 34/5 58/24 recommendations [5] I 56/13 90/2 96/23 12/14 13/2 23/23 25/19I removal [3] 127/2
64/1 104/14 8/2 58/7 140/14 141/16] 100/22 26/16 32/4 32/6 62/11 I 127/7 165/25
realised [4] 52/21 142/7 regard [3] 15/12 62/12I 71/2 75/25 75/25 89/8 Iremoved [2] 55/3
54/24 99/10 126/2 recommended [2] 5/1 I 136/16 90/3 97/23 98/17 146/1
reality [4] 58/8 74/4 5/5 regarded [2] 71/24 120/23 121/4 121/6 — Iremoving [1] 119/3
80/5 138/23 record [7] 2/16 7/21 I 116/14 123/19 145/24 REMs [1] 163/14
really [14] 9/6 19/25 48/5 91/25 124/1 regarding [5] 38/13 [reliability [4] 72/1 rendered [1] 96/2
62/21 102/19 103/10 I 148/10 149/18 39/9 55/23 164/6 123/24 124/8 126/17 Irenegotiated [1]
403/11 122/8 131/20 IFecordings [1] 150/24 I 167/21 reliable [3] 72/18 146/10
443/4 1541/4 157/12 records [3] 49/7 49/8 Iregards [2] 25/1 28/23I 97/14 128/20 renegotiations [2]
realpolitik [1] 100/7 1651/2 region [1] 155/14 reliably [3] 97/22 39/14 153/20
reason [9] 25/23 34/1 recount [1] 63/15 register [1] 117/2 98/17 98/19 renewed [1] 52/25
57/9 58/5 59/24 65/19 Irecover [1] 93/10 Registry [1] 107/17 _Ireliance [5] 26/2 88/4 Ireopen [1] 69/23
66/5 73/7 83/9 recovery [3] 44/13 regret [4] 121/24 88/6 102/21 115/10 —_Irepaired [1] 93/13
reasonably [1] 37/24 51/16 90/21 142/18 143/13 143/18 Irelied [3] 23/18 28/15 Irepeat [4] 2/10 67/20
reasons [4] 33/24 rectification [2] 47/4 Iregrets [2] 143/8 169/3I 89/11 74/13 80/12
52/12 59/18 90/5 4TIT regularly [1] 162/12 [relief [2] 162/7 162/8 Irepeated [7] 27/7
reassurance [1] 118/9 rectify [3] 35/2 48/24 Iregulating [1] 145/13 Ireliefs [1] 162/7 64/12 88/7 88/13 89/24
reassure [1] 95/15 114/16 rehearse [1] 87/22 relive [2] 2/1461/22 I 111/21 112/3
reboots [1] 161/8 recurrent [1] 41/8 rehearsed [2] 115/5 Irelived [1] 2/19 repeatedly [5] 20/8
rebuild [1] 93/41 recusal [1] 119/11 133/22 rely [3] 55/3 120/15 I 46/2 74/6 74/14 90/25
(73) ranked - repeatedly
INQ00001046
INQ00001046
R 1/21 4/12 25/16 43/19 119/17 120/11 I 118/10 39/19
repeating [1] 133/17 _ reputational [3] 109/1 I 125/25 126/8 127/21 _Iretirement [1] 92/13 Irobust [11] 34/20 40/7
repeats [1] 169/2 113/14 149/6 134/10 Retirements [1] 92/13 I 68/22 71/9 74/7 77/17
repetitive [1] 134/3 reputationally [1] respective [1] 144/23 Iretrieve [1] 65/6 83/7 91/22 114/9
replaced [3] 50/22 52/11 respectively [2] 6/22 Ireturn [2] 107/6 167/21 168/4
54/20 54/25 reputations [7] 10/1 I 98/10 122/22 robustness [2] 59/5
replied [1] 157/46 16/9 17/20 59/6 63/25 Irespondents [1] 6/11 Ireturning [1] 116/23 I 71/11
report [17] 4/25 8/3 136/20 150/19 responding [3] 29/3 Ireveal [1] 118/2 role [21] 14/13 14/20
20/5 39/17 40/23 40/25 request [11] 52/15 48/15 95/21 revealed [2] 98/4 25/8 25/10 25/14 33/21
AAIT 41/42 45/13 55/9 59/12 59/18 62/3 response [4] 11/8 101/10 69/8 76/1 76/21 88/8
85/15 91/21 152/24 120/18 120/21 121/6 I 11/47 104/5 121/8 revealing [1] 22/13 88/14 88/20 93/2
153/7 154/14 154/15 121/8 137/25 148/19 responses [2] 60/13 [reveals [3] 97/18 101/18 105/5 105/10
454/17 162/5 111/12 99/18 126/14 137/6 139/23 151/10
reported [5] 6/13 33/3 requested [2] 63/8 responsibilities [3] [revelations [1] 34/3 I 157/25 168/17
43/4 77/1 122/11 121/2 100/13 117/16 150/17 IRevenue [1] 77/3 roles [3] 76/5 139/11
requests [1] 70/25 responsibility [13] reverse [1] 126/10 150/16
ear Ae nad require [3] 48/20 59/16I 12/24 13/1 14/15 19/12I review [11] 25/2 54/3 IRoll [1] 57/2
T7N0 129/19 64/7 68/10 90/21 93/20] 61/25 64/22 64/25 69/9Irolled [2] 41/25 42/5
reporting [3] 36/22 required [9] 22/16 4116/5 122/4 133/20 I 91/21 120/7 121/19 _I rolling [4] 113/12
56/3 1441/5 37/22 50/15 98/14 154/25 155/2 146/21 168/14 rollout [25] 2/25 79/22
reports [14] 32/20 98/18 101/5 108/9 responsible [13] 9/17 Ireviewed [2] 106/24 I 82/9 82/24 82/25 85/9
34/25 47/10 47/10 140/17 1641/9 9/25 10/3 12/16 47/18 I 168/7 87/5 113/5 125/8 125/9
ATIN1 47/44 72/3 77/11 [Pequirements 1] 52/6 54/1 64/5 84/11 Ireviewers [1] 88/15 I 125/9 139/20 150/14
88/4 88/6 89/1 10216 I 146/3 123/10 124/10 129/4 Ireviews [7] 20/20 150/25 151/21 154/2
156/11 168/8 requires [3] 31/7 100/4I 141/1 28/23 29/2 31/24 88/5 I 154/14 154/18 161/25
reprehensible [1] 36/4 113/2 rest [3] 22/4 116/4 88/6 121/18 162/3 162/11 162/16
represent [22] 42/18 Ifeduisite [1] 40/18 I 120/6 revised [1] 86/4 163/1 168/10 168/16
54/16 69/13 69/15 research [2] 70/24 restart [1] 38/25 revisit [2] 89/20 91/7 Iroof [1] 8/16
69/21 72/21 73/22 74/1 150/10 resting [1] 40/10 rich [1] 131/17 room [3] 4/7 93/15
75/4 76/15 78/17 79/4 reset [1] 141/4 restoration [1] 39/9 IRichard [3] 6/157/2 I 93/17
80/24 88/12 89/25 90/9 resign [1] 4/10 restorative [1] 63/12 I 105/10 root [4] 42/24 110/16
90/24 98/7 107/7 resilience [1] 69/22 Irestored [1] 136/20 I Richard Roll [1] 57/2 I 110/16 134/7
134/13 144/1 145/5 _ Iresist [1] 79/10 restrained [1] 96/3 [right [16] 13/7 18/12 Iroute [1] 44/14
representation [2] resolution [2] 19/22 Irestraint [2] 105/2 38/19 48/11 66/8 94/13/routine [2] 45/21 115/6
50/7 50/9 168/18 125/3 94/25 99/5 103/19 routinely [2] 19/4
representations [1] resolve [3] 8/1 60/25 [restrictive [1] 164/13 I 107/8 107/10 117/19 I 71/12
37/1 114/17 result [14] 3/2 17/14 I 120/6 133/7 141/15 —_IRoyal [6] 35/2 104/14
resolved [5] 44/16 20/22 53/25 82/14 169/16 107/18 123/15 124/6
representative [8] ae
37/23 46/17 137/15 48/13 72/5 82/24 86/8 I 124/3 127/21 136/8 [rigidly [1] 117/25 132/19
138/18 139/11 14074. IFesolving [1] 13/9 I 136/18 137/24 139/2 Irigmarole [1] 134/1 IRoyal Mail [2] 123/15
464/7 167/25 resources [2] 88/23 I 146/14 159/4 164/19 I rigorous [3] 52/13 132/19
representatives [3] 98/3 resulted [3] 76/15 121/8 167/14 RPM [1] 35/9
toi 165/20 166/15 \Fespect [11] 15/21 I 149/18 163/18 ripped [1] 113/25 ruined [1] 10/2
represented [6] 12/17 45/3 58/3 70/18 73/5 Iresulting [3] 51/9 tise [4] 22/3 59/1 Rule [4] 104/7
47/11 24/25 67/5 70/8 76/24 96/12 121/11 149/24 164/18 64/11 137/3 Rule 19 [1] 104/7
93/15 136/12 139/12 145/24 Iresults [2] 103/5 risk [5] 3/19 4/2 35/16 Irules [1] 104/4
. respect of [4] 73/5 155/11 99/17 138/23 rumours [1] 16/19
representing [2] 140/4) spectable [1] 1/17 Iresume [2] 66/19 risks [1] 87/9 running [3] 3/13 29/12
represents [1] 1582 Ifespected [2] 26/12 I 66/24 riven [4] 22/25 144/10
repudiate [1] 118725 I 923 Retail [4] 138/11 River [1] 3/9 rural [2] 3/12 3/20
respectfully [11] 15/8 Iretain [1] 118/9 RMG [4] 23/17 Ruritanian [1] 96/11
repurposed [1] 112/5
reputation [4] 1/19 32/10 32/13 32/18 retired [2] 54/11 Roberts [2] 39/19 rushed [1] 155/22
(74) repeating - rushe
INQ00001046
INQ00001046
R 132/9 132/9 132/15 Iscrolling [1] 156/9 I seek [8] 14/2 42/9 56/4 96/18 125/21
rushing [1] 155/23 133/5 137/7 137/19 _Iscrubs [1] 97/1 53/22 57/25 116/5 154/16
ruthless [1] 113/20 138/16 139/24 140/9 scrutinise [2] 80/9 119/8 121/12 163/25 _Isentence [3] 22/15
I 140/21 142/20 142/25 I 86/7 seeking [5] 30/24 133/1 150/21
Ss 143/6 145/23 146/13 Iscrutinised [2] 9/11 I 91/17 93/4 143/23 separate [4] 46/15
Sachs [1] 102/10 147/23 153/8 156/41 81/11 168/18 102/17 131/17 131/18
saddled [2] 129/20 _ Isaying [12] 19/25 23/9Iscrutiny [6] 61/15 seeks [2] 135/24 149/9ISeptember [7] 56/9
129/24 26/23 27/10 27/11 78/20 88/19 105/24 Iseem [4] 96/10 102/16I 72/23 76/25 121/23
sadly [1] 61/5 27/12 32/8 33/25 34/2 I 106/4 123/9 109/9 125/23 123/1 127/16 154/13
safe [2] 74/8 99/11 34/4 46/2 131/23 sea [1] 90/18 Seema [6] 96/20 96/21Iserfdom [1] 96/14
safety [3] 75/21 says [7] 3/25 4/10 sealed [1] 117/18 100/17 107/24 119/3 I serial [2] 25/19 26/16
106/23 126/22 40/22 41/8 153/7 search [1] 31/1 133/7 series [2] 104/9 168/7
said [43] 3/10 11/18 153/14 157/21 searches [1] 121/8 seemed [3] 109/8 serious [8] 11/25
12/19 19/15 21/5 24/13/Scale [2] 70/6 136/1 searching [1] 78/19 I 119/8 119/10 18/10 24/23 34/13 72/1
28/9 32/24 33/9 33/19 Iscalp [2] 107/12 second [27] 14/8 17/7 Iseemingly [2] 45/21 I 104/8 106/11 108/11
39/9 40/5 43/7 44/21 I 128/14 29/5 53/8 53/9 53/12 I 77/18 seriously [1] 158/22
46/11 52/13 62/13 66/2/Scandal [28] 2/24 3/5 I 53/17 54/9 55/7 55/9 Iseems [14] 1/17 20/4 I seriousness [1] 87/6
68/12 69/13 70/11 5/23 6/8 9/24 10/2 55/11 55/14 55/19 34/9 39/12 45/23 48/23Iserve [1] 108/25
70/11 72/15 98/8 107/2I 14/13 14/16 16/1 17/8 I 60/18 88/8 89/21 92/15I 51/22 66/3 102/11 served [2] 28/13 168/1
412/42 126/21 128/12 I 34/15 52/20 56/24 57/1] 92/16 101/18 102/14 I 106/24 109/20 111/15 Iserves [1] 91/17
430/24 132/8 133/7 I 64/9 64/11 70/6 76/12 I 102/15 127/2 128/1 119/8 153/19 service [9] 77/25 84/7
140/1 140/22 1414/4 79/7 97/18 106/7 107/3I 155/18 155/21 159/16 Iseen [5] 25/18 52/20 I 91/17 92/17 116/16
142/15 147/22 149/41 I 107/4 107/5 108/11 165/17 94/18 148/15 165/24 I 118/9 145/15 145/17
152/19 160/9 161/18 I 127/17 131/16 141/16 ISecond Sight [1] 54/9 Isees [1] 131/2 157/13
167/25 168/21 169/2 IScapegoated [1] 116/2Isecond-generation [2] Iseize [1] 51/13 services [9] 23/21
sales [2] 35/156/3 _ IScarborough [1] 92/15 92/16 seizure [1] 57/16 76/25 77/8 84/18 84/23
saliva [1] 128/7 107/16 Secondly [2] 63/11 I Select [6] 39/6 157/6 I 84/25 85/3 93/4 123/15
same [22] 5/2 8/23 scenarios [1] 22/18 I 89/13 157/23 167/20 167/23 Iserving [3] 17/10 92/9
12/24 23/12 24/7 29/21 Iscenes [1] 15/10 secrecy [1] 57/12 167/25 144/8
35/25 49/5 54/23 58/3 Ischeduled [1] 95/15 secret [1] 89/3 selected [2] 16/12 servitude [1] 96/14
65/9 68/6 84/4 119/21 IScheme [18] 7/13 15/1 ISecretary [3] 152/12 I 17/5 session [2] 95/14
130/25 131/3 131/21 I 15/4 39/9. 40/7 41/20 I 156/24 157/10 self [9] 41/6 113/21 I 156/4
432/10 134/2 156/6 I 41/25 52/17 54/3 54/7 Isecrets [4] 50/17 116/11 122/11 122/14 Isessions [3] 113/7
1459/5 167/24 54/13 55/4 55/11 61/1 I 57/15 57/22 57/25 140/7 140/11 140/11 I 136/4 136/10
sanitised [1] 105/17 I 89/22 91/5 136/13 section [4] 57/19 145/6 set [23] 2/11 13/25
sapping [1] 9/4 154/21 148/3 148/3 155/20 _I self-employed [4] 16/8 21/9 21/24 23/16
satisfactorily [3] 48/13)Schemes [2] 61/4 sector [1] 111/6 140/7 140/11 140/11 I 24/11 25/2 26/20 27/1
82/24 126/22 63/11 secure [4] 69/11 73/16I 145/6 27/16 54/2 57/5 57/6
satisfied [1] 83/8 school [3] 99/12 131/14] 102/14 150/4 self-inflicted [1] 41/6 I 59/3 117/23 123/7
satisfy [1] 86/21 1341/2 secured [3] 68/23 _I self-interest [1] 4139/5 141/19 148/24
saw [3] 8/1360/20 _Iscope [2] 79/14 88/20 I 72/18 144/24 113/24 159/2 163/25 165/3
149/23 Scotland [1] 4/3 securing [1] 101/24 _Iself-referred [1] sets [1] 34/15
say [53] 1/9 7/4 11/7 Isereen [13] 21/8 21/16Isecurity [1] 158/1 122/14 setting [5] 26/15
14/15 16/25 18/12 24/6 25/4 31/18 39/22 Isee [23] 4/18 17/18 I self-reported [1] 102/13 136/12 150/22
24/45 27/23 35/14 42/4I 40/24 66/17 95/4 95/10] 23/14 32/18 32/22 122/11 159/2
44/2 48/19 55/5 58/17 I 119/25 121/22 155/17 I 39/25 43/17 49/8 63/24Isenior [10] 63/14 _Isettle [3] 44/7 44/10
64/21 66/4 67/23 68/17IScreens [1] 163/21 I 63/25 90/17 94/25 95/4I 63/24 114/13 114/14 I 145/18
68/24 69/8 73/12 80/22I script [3] 43/14 43/20 I 96/23 104/20 104/21 I 114/18 115/18 117/23 Isettled [1] 45/7
88/1 91/8 94/6 94/12 I 167/17 1145/9 115/15 134/17 I 118/13 124/23 139/17 I settlement [5] 7/19
95/12 106/9 110/6 scripts [1] 43/24 151/8 158/15 161/12 Isense [4] 20/25 93/2 I 13/8 13/13 122/1
412/16 118/5 118/16 [scroll [3] 161/11 165/18 95/22 153/15 145/20
4120/5 1214/9 125/7 161/20 161/21 seeing [2] 96/25 166/3I sent [7] 2/8 6/1 8/7 —Iseven [1] 43/8
(75) rushing - seven
INQ00001046
INQ00001046
Ss 37/25 38/5 38/7 38/10 I 117/8 126/20 153/11 I 63/5 65/2 65/7 66/4 59/11 60/9 61/2 62/7
several [3] 71/3. 40/7 43/1 43/16 43/25 I 162/5 162/10 163/6 66/4 66/5 66/9 66/9 64/23 73/21 79/18
138/18 149/23 83/4 54/21 58/13 62/22] 167/21 167/24 168/5 I 66/10 66/14 66/18 I 85/22 91/9 93/23
severity [1] 7/7 62/25 64/6 64/23 65/12Isince [11] 23/22 23/24 I 66/24 67/19 69/15 70/3} 100/25 106/9 113/16
shall [4] 66/18 101/16 66/13 70/8 72/19 85/18} 30/25 56/6 61/5 67/8 I 71/4 75/17 75/23 77/15) 119/25 130/1 132/5
110/24 112/13 87/16 89/15 102/12 68/23 70/22 91/12 77/18 78/6 79/21 88/23} 135/6 141/21 142/15
shame [2] 1/16 130/21 102/18 102/21 118/7 I 108/3 144/17 90/19 90/19 92/23 94/6I 143/16 143/19 145/1
shameful [1] 101/2 121/2 132/2 133/15 Isincere [1] 132/8 94/9 94/21 95/16 95/17} 148/12 150/20 150/22
shard [1] 117/6 140/2 148/2 152/2 sincerely [4] 139/21 I 95/25 97/13 98/20 150/24 152/8 152/17
share [1] 69/6 153/8 161/24 143/8 169/3 169/6 98/20 99/15 99/24 153/8 153/21 157/4
shareholder [1] 37/21 show [8] 31/8 34/24 I sincerity [1] 119/4 102/21 103/13 104/5 I 159/14 167/3
sharks [1] 19/7 45/3 48/1 146/20 151/2Isingle [1] 31/6 105/5 106/8 106/17 somebody [4] 125/19
she [46] 3/10 3/12 3/20 162/10 163/8 sinister [2] 57/9 108/8 108/14 108/25 I 131/4 1341/7 133/23
3/21 3/22 4/18 4/20 IShowed [4] 18/6 24/6 I 108/23 1140/1 110/6 110/9 somehow [2] 104/12
4/24 4/22 4/23 5/16 148/19 155/11 sir [174] 1444/1 1114/5 112/4 146/23
5/17 5/20 8/23 11/18 shown [2] 104/13 Sir Anthony [2] 15/5 I 112/10 112/14 113/7 Isomeone [2] 8/19
15/11 22/6 42/19 42/20 1857/5 54/14 1144/2 115/23 116/1 62/24 ;
42/25 43/1 46/19 46/20 shows [5] 6/25 42/4 Isit [4] 7/25 60/11 73/14 117/3 117/4 118/16 — Isomething [6] 7/4 37/6
51/1 54/14 54/17 54/21 45/11 144/11 163/13 131/8 119/7 119/13 119/16 I 80/8 83/19 143/1 169/2
96/19 96/22 96/23 shredding [2] 122/9 Isites [1] 47/22 419/18 119/22 120/4 Isometimes [5] 18/22
104/14 108/5 108/6 1321/4 sits [1] 131/4 123/10 123/10 125/21 I 20/16 51/10 103/15
4108/8 128/7 128/8 sickness [1] 58/10 sitting [3] 94/15 94/22 I 126/1 126/5 126/19 135/16
4128/17 128/24 130/14 side [1] 140/9 133/23 126/23 127/10 129/20 Isomewhat [1] 57/24
130/16 130/17 130/21 sided [2] 46/9 140/10 Isituation [2] 55/5 130/8 131/10 131/20 Isomewhere [2] 110/1
134/12 134/12 133/7 sidekick [1] 109/6 158/23 132/20 132/21 133/8 I 130/19
156/11 siding [1] 146/23 six [5] 4/9 5/16 43/8 I 133/13 133/17 133/25 Ison [1] 130/24
she'd [1] 130/21 sight [15] 14/8 29/6 104/10 121/25 134/17 135/18 138/1 Isons [1] 92/6
shifted [1] 97/20 53/8 53/9 53/12 53/17 Isix months [2] 4/9 143/10 144/21 150/17 Isophisticated [1]
shocked [1] 43/9 54/9 55/7 55/9 55/11 I 5/16 1451/4 151/10 152/3 156/13
shocking [1] 135/16 55/14 55/20 61/25 88/8I Six years [1] 121/25 I 156/18 156/19 169/5 Isorrow [1] 133/21
shone [1] 138/1 89/21 sizeable [1] 138/7 169/11 sorry [6] 18/20 21/17
short [13] 7/19 38/14 sign [2] 113/9 125/13 Iskill [1] 88/23 so-called [3] 3/15 36/17 133/5 161/20
38/23 60/17 64/23 65/4ISignal [1] 50/15 skills [1] 89/8 4110/9 113/7 167/12
85/5 65/16 65/19 66/22/Si9ned [1] 77/12 Skinner [5] 96/20 _Isober [4] 96/3 sort [3] 47/1 116/8
71125 79/16 134/19 significance [5] 68/8 I 100/17 108/1 132/16 Isociety [2] 96/8 97/5 I 125/12
shortfall [5] 4/6 45/6 68/11 68/12 72/24 132/16 software [5] 105/16 I sorted [2] 9/1 132/15
51/3 91/5 116/25 76/10 slightly [3] 94/19 128/25 163/13 164/11 Isought [5] 50/18 55/2
shortfalls [33] 3/20 significant [10] 14/13 I 105/6 167/17 164/20 57/15 58/3 72/16
12/12 12/13 12/17 14/15 14/20 41/14 slippage [1] 154/14 Isold [1] 7/18 sound [2] 110/25
42/17 12/23 12/25 22/3 69/10 71/10 89/16 small [4] 20/12 20/16 Isolely [1] 107/2 120/6
34/21 40/16 42/24 43/5 141/12 158/23 168/22 I 145/10 161/15 solicitor [4] 8/8 122/24Isource [4] 28/5 28/15
43/10 43/16 44/19 significantly [2] 6/19 ISMC [1] 129/4 123/4 123/5 33/15 143/18
45/23 46/7 47/18 48/24 18/4 smother [1] 122/20 _ Isolicitors [4] 5/25 33/2Isouth [3] 3/9 4/4 5/19
48/25 49/23 50/5 50/9 silent [2] 57/460/11 Ismothered [4] 121/15 I 61/7 67/5 South Wales [1] 5/19
51/16 70/18 74/16 silks [1] 118/10 so [127] 1/11 1/20 3/15}solid [1] 19/24 southwest [1] 154/23
98/12 98/24 106/22 similarly [2] 69/10 11/20 18/10 18/12 solutions [1] 165/5 Ispeak [5] 69/7 73/1
123/23 124/2 124/10 154/15 18/14 19/3 19/18 23/3 Isolving [1] 54/19 106/18 113/4 146/19
427/20 Simon [4] 20/19 20/22 I 23/8 23/12 25/22 29/5 Isome [51] 1/23 2/11 Ispeaking [3] 1/25 46/1
should [48] 7/19 11/20 21/6 23/11 30/9 30/21 34/8 36/8 I 8/1 14/4 17/11 18/17 I 69/24
22/6 24/17 26/5 26/6 simply [18] 31/9 42/4 I 36/9 36/16 37/17 37/24) 20/3 20/11 20/12 20/15Ispecial [1] 160/13
26/41 26/11 27/25 28/2 42/25 44/20 60/16 87/1] 40/17 41/16 44/14 21/6 21/18 22/9 33/16 I sper d [1] 53/9
28/3 31/1 33/1 34/13. 100/5 101/20 103/7 53/10 57/3 59/19 60/12I 38/12 39/15 47/4 51/23Ispecialist [1] 128/16
(76) several - specialist
INQ00001046
INQ00001046
Ss 94/12 106/1 124/21 I stigmatised [1] 100/18Isubmission [4] 68/6 I 74/23 75/7 78/4 82/11
specialists [1] 120/4 125/5 153/6 169/12 I still [8] 38/1 38/5 71/9 I 130/10 134/16 135/21 I 90/16 90/24 99/10
specific [7] 31/22 started [6] 2/24 53/20 I 109/8 110/7 110/13 I submissions [34] 1/10] 99/14 99/19 99/20
60/22 82/12 157/19 85/17 94/8 114/1 145/2) 114/6 132/2 2/9 6/3 26/25 33/12 100/23 103/5 103/6
4159/7 159/14 160/6 starting [3] 10/9 67/12 )stock [1] 158/20 36/18 37/12 53/16 105/25 106/5 112/10
specifically [1] 33/18 92/11 Stockdale [3] 15/15 I 59/14 59/17 60/4 60/15) 112/19 112/21 113/10
specification [1] 112/3 state [10] 10/10 46/16 I 44/17 51/4 60/16 60/17 64/13 113/15 113/17 113/22
specified [2] 111/19 61/18 80/11 99/6 99/8 IStockdale's [1] 51/1 I 64/15 64/18 64/24 65/8) 116/13 123/16 124/18
12416 152/12 156/24 165/1 I stoicism [1] 130/7 67/3 67/21 68/7 75/6 I 125/11 127/8 127/18
specify [1] 22/5 165/19 stood [1] 92/19 79/14 91/12 94/11 127/25 129/2 134/25
speed [2] 78/18 78/22 stated [11] 11/12 stop [3] 20/23 118/7 I 120/9 123/8 138/13 135/9 144/2 144/13
spend [2] 36/13 79/16 46/19 47/21 71/12 126/20 140/6 166/22 166/23 I 144/14 144/18 145/41
spiral [1] 158/8 102/10 103/1 105/17 Istopped [1] 126/12 167/6 169/10 145/13 145/18 156/2
spit [1] 128/9 108/16 120/14 128/22 Istories [2] 69/20 131/9/submit [19] 32/18 156/12 156/15
spite [1] 96/3 152/25 storms [1] 129/5 101/13 106/14 108/12 Isubpostmasters' [3]
statement [36] 1/12 I story [5] 94/3 108/9 I 111/17 113/12 117/15 I 37/17 42/7 50/4
split [2] 13378 158/5 2/16 4/17 28/14 31/16 I 109/23 128/2 128/12 I 119/17 120/11 121/24 Isubpostmistress [1]
spoke [4] 135/15
442/15 148/24 164/5 I 39/21.41/15 65/7 67/2 IStrabane [1] 3/8 122/18 124/20 125/1 I 3/7
sponsoring [1] 87/15 70/5 78/10 80/6 94/8 I strain [2] 160/24 125/9 125/25 126/8 I subpostmistresses [1]
95/18 99/3 103/17 164/14 126/25 127/21 134/10 I 6/7
spots [1] 140/25 .
cere th 46/19 117/6 118/18 120/2 strained [1] 144/16 Isubmitted [5] 81/5 SUBS0000005 [1]
spring [1] 85/24 120/3 124/22 127/4 —_I strategy [5] 16/20 120/9 128/13 163/5 34/7
133/14 133/19 134/21 I 16/25 83/20 116/11 166/22 subscriptions [1]
etait a aoe 4135/3 13518 13517 I 4141/2 submitting [1] 106/14 I 146/6
staff [7] 1/21 27/4 135/21 135/25 141/25 Istreet [1] 128/6 subpostmaster [34] {subsequent [1] 72/5
29/25 113/6 113/15 167/7 170/2 170/3 stress [5] 6/126/18 I 3/17 4/3 5/5 10/23 11/5I subsequently [4]
116/15 135/14 170/4 170/5 160/23 161/14 161/18 I 11/12 12/4 12/25 13/2 I 101/11 126/7 163/2
stage [17] 26/6 26/8 statements [9] 2/21 Istrictly [2] 97/8 119/2 I 31/6 44/5 44/7 44/9 163/20
29/4 59/23 62/1 67/20 33/1 36/15 36/22 74/16Istrokes [1] 48/6 44/12 45/4 45/8 45/15 I subsidy [1] 84/1
69/18 80/25 84/2 85/10 TAIN18 74/19 74124 strong [1] 92/8 48/4 48/6 49/6 49/7 substance [1] 88/18
89/18 91/9 116/21 136/5 strongest [1] 136/17 I 49/14 50/20 50/22 substantial [6] 7/1
126/2 1641/7 165/5 states [3] 40/24 45/13 Istruck [3] 78/18 51/25 57/17 57/18 39/11 66/13 70/20
168/16 123/6 101/14 150/11 63/12 72/16 90/15 153/18 167/6
stages [4] 13/13 60/16 station [1] 30/10 structure [1] 117/22 I 125/23 145/4 145/15 substantially [1] 135/4
89/21 168/8 status [7] 135/20 structures [2] 114/22 I 158/24 substitute [1] 115/2
staggering [1] 107/21 136/25 145/22 146/1 I 118/1 subpostmasters [106] Isuccess [1] 86/24
staggeringly [1] 146/5 146/15 148/18 Istruggles [2] 74/5 5/1 5/6 6/7 6/19 7/9 I successes [1] 145/1
109/13 statutory [1] 62/14 111/13 8/19 12/23 14/20 15/11Isuccessful [2] 85/9
stance [3] 11/22 12/15 stay [1] 84/1 Stuart [1] 156/25 16/2 16/6 16/12 16/22 I 86/8
74/10 stead [1] 115/25 Stubbs [4] 15/14 42/18) 17/4 17/4 17/7 17/24 Isuccessfully [3] 97/20
steamrolled [1] 72/15 I 44/17 50/21 18/13 19/3 19/10 19/14I 107/17 143/21
stand [5] 3/3 13/25 " .
59/25 ae 449/20 [Stein [10] 16 1/12 __Istudied [1] 115/5 20/12 20/17 21/5 27/8 Isuccession [1] 159/17
stand-off [1] 116/9 36/17 38/17 64/18 65/7I studiously [1] 115/5 I 27/10 29/20 36/1 36/8 Isuccessive [1] 157/17
standard [1] 43/24 70/11 94/20 134/12 I study [4] 5/25 40/13 40/16 41/9 41/16} such [41] 5/6 6/15
standards [1] 111/48 170/2 stuff [1] 131/2 42/1 42/15 43/4 45/16 I 15/7 18/13 27/1 32/22
standing [1] 159/24 step [1] 32/17 sub [2] 4/4 157/14 45/22 46/5 46/6 47/18 I 37/13 48/19 52/6 57/21
staple [1] 2/4 Stephen [3] 84/11 subject [10] 14/9 48/20 49/20 49/21 59/7 59/17 60/4 60/16
stark [1] 45/20 152/11 156/23 32/19 35/10 44/12 49/23 49/25 50/1 50/6 I 62/3 72/7 76/7 83/11
starkly [1] 98/4 steps [4] 69/10 74/6 I 73/23 88/18 103/13 51/6 51/14 51/17 51/21] 88/6 88/19 89/13 93/20
start [16] 1/3 7/11 65/3 86/21 124/16 141/19 112/8 126/9 52/3 52/8 54/5 54/8 99/18 111/10 113/12
65/12 65/20 70/10 Stewart [1] 98/15 subjected [1] 130/8 I 55/3 56/5 58/15 60/6 I 114/17 114/22 118/3
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(77) specialists - such
INQ00001046
INQ00001046
S supporting [1] 139/14 I 41/3 41/10 42/8 45/14 Itaking [7] 3/3 30/15 _Iterminated [1] 83/17
such..[10] 137/12 [Supportive [1] 89/10 I 47/5 47/7 47/14 47/18 I 33117 49/21 51/15 I termination [1] 83/18
137/15 138/10 1398 [SUPPOrts [1] 149/12 I 48/16 48/22 56/3 56/11] 151/10 160/10 terminations [1] 51/6
140/18 144/16 145/20 [SUPPOSE [2] 108/6 I 56/23 56/24 58/9 59/6 Itale [1] 96/9 terms [20] 10/9 21/15
450/19 152/4 163/21 I 130/40 63/13 74/21 79/23 I talk [1] 158/25 22/2 25/15 39/4 58/17
suddenly [2] 1716 I[SUPPosedly [1] 99/22 I 80/15 98/14.98/16 talking [4] 12/2 13/4 I 70/15 71/5 75/9 112/11
408/24 suppress [1] 122/19 I 98/1998/23 100/8 I 21/22 131/1 120/17 121/4 123/5
Sue [1] 4/19 suppressed [1] 101/22] 103/6 103/13 104/15 Italks [1] 8/22 123/6 126/21 140/5
sued [5] 87/18 105/21 (Supreme [2] 109/19 I 108/5 11216 114/10 _ taller [1] 94/19 140/13 154/2 164/6
4062 113/18 11777 I 118/10 116/17 123/21 123/25 Itangible [1] 90/23 165/2
suffer [3] 93/9 110/7 {Sure [6] 26/3 55/12 I 124/4 125/13 128/16 Itask [2] 78/21 88/23 terrible [1] 127/17
150/19 63/5 95/4 99/2 118/16 I 128/16 132/19 135/12 Itaskforce [1] 159/6 I terrified [1] 4/4
suffered [5] 67/10 {surely [1] 114/22 136/9 137/17 1309/3 Itaster [1] 79/4 terrorise [1] 99/13
101/14 110/6 136/18 ISUMame [2] 130/25 I 130/19 142/2 143/10 Itaxed [1] 120/19 Terry [1] 165/21
161/18 1341/4 144/1 150/3 51/2 _—_Itaxpayers [1] 78/6 _Itest [1] 103/12
suffering [6] 9/18 64/1 [SUrPrise [2] 31/6 60/9 I 152/4 163/2 186/13 TCs [1] 48/15 testimony [2] 73/3
73/2 73/7 106/19 surprising [1] 118/25 I 156/17 159/3 159/6 _Iteam [11] 6/2 6/6 136/4
MONS surreal [1] 109/14 I 159/24 160/11 161/8 I 22/21 32/25 34/6 34/8 Ithan [30] 6/19 9/21
sufficient [1] 16619 [SUttender [1] 112/25 I 162/2 16617 166/9 I 60112 91/1 93/26 94/2 I 19/9 22/13 46/10 52/12
sufficiently [1] 153/2 [SutTounded [1] 56/24 I 167/21 168/1 168/4 95/25 52/20 56/6 60/14 62/13
suggest [18] 7/2 16/11/SuTveved [1] 6/6 169/5 teams [1] 132/20 69/4 74/21 76/2 83/16
15/13 15/19 18/18 (Survive [2] 1/23 90/17 ISystem's [2] 18/25 tearing [1] 110/3 94/19 95/17 99/19
28/18 30/23 40/9 41/21 ISUrvivors [1] 63/21 I 29/17 tears [1] 46/2 99/20 101/25 105/9
43120 45/10 58/16 59/2I SUSAN [3] 14/25 54/14 systemic [3] 56/14 technical [8] 40/19 I 105/15 108/23 113/3
60/5 64/6 113/16 54/20 59/5 110/17 47/15 79/24 81/1 81/7 I 113/22 128/3 134/11
A160 129/15 suspect [2] 39/18 systems [10] 53/10 I 81/10 87/6 87/10 156/15 157/13 159/17
suggested [1] 154/16 I 199/12 59/7 59/10 81/9 83/3 Itechnically [1] 152/3 I 168/24
suggesting [4] 21/15 {Suspected [1] 122/5 I 93/23 114/11 117/12 Itechnology [4] 39/4 [thank [28] 1/13 37/4
20/2 51/11 15718 suspended [4] 4/9 I 142/8 1522, I 80/4 84/13 149/21 38/18 38/19 65/1 66/15
suggests [1] 152/14 I 49/25 50/1 54/1 T teeth [1] 18/11 66/20 67/1 67/3 94/5
suicide [1] 130/15 {Suspending [2] 50/19 I"______lteething [3] 71/25 72/5] 94/6 94/10 94/14 94/23
Suisse [1] 11919 I 97/16 table [2] 96/25 152/13 I g2/19 95/19 95/23 133/16
sum [4] 13/3 44/10 [Suspense [2] 127/2 tactical [1] 97/20 telecommunications I 134/14 135/1 135/2
45/7 45/9 12718 tactics [1] 99/12 [1] 7/6 153/13 155/19 156/22
summary [3] 41/20 [Suspensions [1] 51/5 take [22] 1/113/12 _Itell [7] 9/7 61/10 69/20] 160/8 169/9 169/10
67/9 149/23 suspicious [1] 147/18 I 3/19 21/6 28/8 30/22 _I 95/9 131/9 133/15 169/17 169/18
summed [2] 71/13 ISustenance [1] 157/14 32/17 50/13 62/10 63/6) 159/13 thankful [1] 134/20
161/23 Swansea [1] 5/14 65/4 65/22 67/25 73/18) telling [4] 2/21 8/11 I Thanks [1] 94/11
summer [2] 53720 [Sweetman [1] 156/25 95/14 115/20 119/11 I 45/21 1291 that [849]
83/16 sympathise [1] 18/19 I 125/22 131/13 133/13 Itells [6] 13/6 18/24 _Ithat I [1] 64/21
supervising [1] 114/16 sympathy [1] 18/22 I 156/22 160/8 19/2 19/8 31/14 130/5 Ithat is [2] 94/7 157/21
suppliers’ [1] 151/19 symptoms [4] 6/9 6/12/taken [31] 4/14 11/22 Itempered [1] 78/13 I that's [35] 3/15 4/4
support [16] 15/17 I 9/13 6/18 16/3 33/1 34/14 44/1 Itemporary [4] 50/22 I 6/10 6/11 7/12 8/18
16/6 22/20 41/5 a3iq _[S¥Stem [99] 2/5 3/21 I 51/18 51/20 52/2 52/8 I 102/24 103/3 103/4 I 27/20 28/2 30/14 34/6
45/14 4618 46/21 79/25I 5/15 16/24 17/9 17/25 I 60/8 66/1 68/20 69/10 ten [2] 38/16 50/1 35/20 37/1 39/16 41/6
81/15 82/11 129/1 19/1 19/5 19/11 19/15 I 74/10 75/10 80/19 —_Iten minutes [1] 38/16 I 50/10 65/14 66/8 66/12
44712 14714 185/12 I 19/19 20/2 20/13 21/5 I 80/23 81/23 82/2 83/1 Itend [1] 119/21 73/18 77/16 78/24
460/5 22/7 22/25 26/10 27/5 I 87/5 90/25 96/15 tendency [1] 18/18 I 79/14 84/8 86/1 142/3
supported [a] 78/3 I 27/8.27/11 27/14 27/17 112/19 115/10 124/16 Itenders [1] 85/12 143/6 145/6 156/18
105/25 106/6 142/13 I 27/18 29/8 20/12 34/20) 136/2 143/14 158/22 Iterm [4] 5/2 158/17 159/11 161/20
4150/4 155/5 155/7 35/17 35/19 35/24 40/6I 159/10 termed [1] 149/25 162/7 163/1 167/10
462/17 40/9 40/11 40/14 40/20Itakes [2] 128/4 166/21 Iterminals [4] 98/13 I 167/13
(78) such... -that's
INQ00001046
INQ00001046
T 96/24 97/12 103/10 4114/5 115/23 116/24 I 141/22 142/12 148/12 I 101/8 101/22 102/16
theft [9] 4215/17 103/19 110/13 118/24 I 117/12 117/18 117/25 I 149/13 152/20 153/8 I 103/9 104/25 106/23
22/11 102/3 102/8 125/12 126/15 126/19 I 121/15 122/15 124/23 I 154/24 155/4 158/22 I 109/2 109/3 110/4
402/12 102/21 108/4 I 126/20 131/7 133/8 125/17 125/21 131/17 I 160/23 161/3 162/22 I 110/13 114/16 115/22
108/20 133/10 136/8 143/20 I 132/4 133/16 137/21 I 165/3 167/14 168/18 I 115/24 116/2 116/3
their [124] 1/21 2/2 144/9 159/22 163/6 138/17 142/5 142/16 I they [231] 116/24 117/20 118/5
24 2/15 2/19 2/22 7/4 168/18 145/5 149/2 149/20 I they'd [1] 91/25 118/7 118/19 118/22
10/4 12/24 13/1 13/47 theme [5] 12/11 16/21 I 152/15 152/21 156/15 Ithey're [5] 5/4 110/11 I 120/4 121/24 122/24
45/17 17/41 17/19 88/7 89/24 111/5 157/5 157/12 158/9 125/21 128/5 133/11 I 124/10 124/23 128/24
18/24 18/23 19/2 19/4 Ithemes [2] 68/7 80/3 I 158/21 159/2 160/25 I thief [3] 100/18 128/5 I 134/12 136/3 136/6
19/12 19/12 19/14 20/7 themselves [2] 41/19 I 161/1 162/1 162/5 128/9 1436/7 136/10 136/15
22/11 22/14 25/18 162/9 162/5 162/11 163/6 I thing [7] 8/23 29/15 I 136/18 137/12 138/5
26/24 27/4 27/16 28/15Ithen [54] 3/3 8/17 8/22) 164/9 164/17 165/13 I 128/1 131/19 132/13 I 139/7 140/3 141/1
28/15 28/22 28/22 9/1 9/3 12/15 12/25 165/18 165/25 166/4 I 132/25 159/24 141/3 141/13 143/19
29/25 30/2 30/18 30/20I 20/24 30/18 38/19 166/8 166/12 166/20 [things [11] 22/24 149/1 149/14 151/7
34/12 34/21 35/19 36/3I 44/12 47/12 62/19 63/6) 167/6 168/3 168/9 33/18 50/3 66/18 69/25] 155/5 155/6 155/6
39/16 41/17 46/8 51/2 I 70/22 79/18 80/22 81/8) 168/16 168/22 73/11 82/2 122/21 159/9 161/5 161/6
52/4 53/20 53/23 54/6 I 89/24 84/14 100/21 there'll [1] 132/4 156/19 167/14 169/15 I 162/8 163/8 169/15
60/11 60/12 60/13 101/4 107/16 108/1 I there's [14] 18/18 things’ [4] 11/14 though [6] 45/9 49/8
60/22 61/22 63/16 109/17 112/17 114/15 I 21/18 27/13 66/12 think [22] 9/5 11/3 66/7 96/19 102/4
63/17 63/25 67/8 69/3. I 119/22 116/23 117/13 I 81/22 131/5 131/18 26/7 28/8 30/12 30/14 I 145/10
69/20 69/21 70/2 73/4 I 119/18 120/2 120/25 I 132/17 133/7 159/2 30/15 36/18 64/22 65/5I thought [7] 8/14 25/8
124/5 124/11 125/20 I 165/17 65/12 66/3 101/8 39/5 43/12 46/2 92/19
eo voat cme 129/6 131/18 134/15 I thereafter [3] 42/8 105/19 132/22 132/24 I 110/5
88/22 89/1 90/13 91/6 I 144/17 146/7 147/9 120/3 141/25 133/9 134/16 137/19 Ithoughts [1] 130/1
91/23 92/9 92/14 92/21) 148/22 151/5 152/12 I therefore [19] 13/16 I 156/13 157/12 157/17 Ithousands [3] 20/17
92/21 93/11 93/24 156/20 157/10 158/25 I 30/15 41/14 44/23 63/2I thinking [4] 160/9 20/18 157/8
98/13 103/15 110/38 159/12 160/1 165/10 I 63/8 65/23 76/11 thinks [2] 8/24 159/11 Ithreat [1] 3/15
440/10 110/12 110/15 I 189/17 167/12 169/16 I 101/24 108/8 119/22 I third [7] 34/15 61/22 Ithreatened [5] 37/24
112/24 112/25 113/23. theoretically [1] 45/14 I 129/20 138/9 140/8 62/4 81/6 103/21 56/14 105/21 106/2
4114/8 115/4 115/25 __ Itheory [1] 159/9 146/22 148/25 150/15 I 114/20 158/17 157/9
1146/1 116/5 117/10 [there [126] 12/2 12/10 I 153/10 164/4 third-party [1] 114/20 Ithreats [4] 111/12
118/11 118/20 11919 I 14/11 16/19 18/4 19/41] therein [1] 67/22 Thirdly [1] 64/4 three [13] 4/22 8/9
124/15 126/10 128/5 20/23 20/25 25/21 26/9I these [80] 3/13 3/19 I this [287] 15/25 17/17 22/18
4128/5 129/19 130/16 I 20/19 28/14 26/24 5/22 10/3 10/23 11/25 IThompson [1] 167/20 I 45/14 81/6 116/8 120/8
430/23 133/23 136/8 I 30/13 34/5 34/25 35/4 I 12/11 12/16 19/16 thorough [3] 31/1 151/4 151/15 164/7
436/19 136/22 139/14 I 39/6 35/7 35/16 35/17 I 19/18 20/4 31/3 31/11 I 121/7 134/7 167/8
443/21 144/8 144/23 I 38/1 40/12 40/25 43/20] 32/1 32/4 33/8 34/8 thoroughly [1] 49/12 Ithree weeks [1] 8/9
449/22 150/16 150/19 I 45/10 45/18 47/1 S0/6 I 36/4 37/25 38/11 43/12Ithose [107] 2/13 2/19 Ithree-way [1] 116/8
454/11 152/4 153/22 I 98/19.57/1 57/5 57/9 _I 45/5 47/14 48/10 50/16) 10/3 14/6 15/18 17/13 Ithrough [32] 2/14 2/20
155/3 155/7 162/25 57/9 57/12 58/24 62/20) 51/18 51/20 52/2 55/16] 19/2 25/17 38/7 43/22 I 4/15 7/15 8/16 8/18
166/23 63/4 63/4 71/3 71/14 I 61/13 67/3 67/24 70/8 I 43/24 47/41 49/8 51/12) 13/7 26/20 29/18 29/21
them [53] 2/22 3/17 TANG 71/21 71/25 72/9 73/21 77/21 81/19} 51/22 55/20 63/17 64/4) 31/2 43/12 44/14 45/14
9/18 9/19 10/6 15/19 I 72/19 75/1 75/24 76/1 I 81/23 82/10 82/18 64/15 68/25 69/4 69/11) 46/8 51/15 51/18 60/22
46/7 18/21 19/4 20/1 I 78/7 78/17 81/8 81/15 I 82/21 89/20 93/5 99/16] 69/21 70/4 72/12 74/19] 60/25 60/25 61/23 62/2
20/5 20/6 20/7 20/7 82/6 83/3 83/6 83/8 103/14 105/17 109/23 I 75/13 76/14 77/7 78/17I 70/24 75/10 120/8
28/20 30/13 42/25 83/10 85/22 88/13 89/7) 110/3 114/11 114/16 I 78/25 82/1 82/22 83/1 I 136/3 141/4 143/22
43/23 50/12 50/13 89/13 90/1 93/1 97/2 I 116/21 117/15 123/6 I 83/4 84/4 87/12 87/25 I 144/23 145/20 149/24
52/15 53/14 62/25 98/3 102/16 102/22 124/13 124/15 124/18 I 88/21 88/24 90/8 90/24) 151/20
63/17 63/25 69/25 103/4 105/19 106/11 I 126/9 127/4 129/6 91/2 91/5 92/12 93/12 Ithroughout [9] 34/18
74/14 75/2 76/15 88/22I 108/7 108/7 109/15 132/21 133/3 134/6 95/15 96/17 97/5 97/9 I 51/23 56/2 64/22 81/9
90/6 90/13 92/14 92/24) 112/68 112/17 113/1 138/17 139/10 141/19 I 97/10 97/17 100/23 162/16 164/9 168/10
17) theft - throughout
INQ00001046
INQ00001046
T
throughout... [1] 169/1
thuggish [4] 40/17
Thursday [4] 4/1
thus [5] 5/9 5/10 22/4
103/2 109/3
tiger [1] 3/15
tight [2] 118/12 133/23
time [64] 10/20 11/23
12/8 12/10 12/11 15/4
18/25 20/3 20/18 28/21
29/16 29/21 29/21
29/22 32/16 38/13 39/5
50/10 54/23 55/19 59/9
59/21 61/23 63/1 63/4
63/7 64/14 64/23 65/9
65/20 66/11 74/5 79/15
79/16 84/4 86/5 88/23
90/14 94/8 97/23 98/17
101/14 104/20 112/1
1142/5 112/15 112/16
1241/5 122/5 124/16
129/6 131/21 132/3
136/2 145/23 148/25
154/8 155/23 157/41
162/14 164/13 166/4
166/23 169/9
times [9] 43/8 53/13
61/25 72/9 88/10
109/14 112/9 146/21
151/17
timescale [1] 151/21
timetable [1] 95/46
timing [1] 62/17
tired [2] 132/11 132/12
tirelessly [4] 15/10
to [1164]
today [5] 25/10 25/14
51/17 143/11 157/21
today's [1] 145/5
together [10] 18/5
92/5 98/6 109/2 118/13
121/3 130/8 130/15
138/17 152/18
told [29] 8/17 8/22
15/5 16/10 16/12 16/23
19/10 20/7 20/8 28/20
30/3 30/4 30/17 37/10
37/10 38/8 42/25 43/15
45/5 50/22 51/7 53/19
65/21 94/4 96/9 1041/5
107/22 115/14 128/7
tomorrow [3] 95/15
169/12 169/17
tone [4] 117/21 120/6
148/1 167/1
Tony [2] 165/21
165/22
too [8] 3/14 32/21
40/17 87/1 89/10
132/17 156/7 156/14
took [14] 54/23 74/5
86/21 90/6 90/6 90/19
93/6 107/14 111/9
121/23 125/10 143/2
148/21 166/15
top [8] 24/9 117/24
118/7 125/16 125/16
133/5 133/9 158/15
topped [1] 96/25
tormented [1] 103/5
total [4] 11/24 51/9
69/16 158/3
‘totalitarian [4] 96/17
touch [2] 163/23
167/18
touched [2] 3/6 12/4
Touching [1] 31/15
towards [3] 16/6 96/13
116/13
town [1] 3/8
toxic [1] 126/23
traced [1] 154/3
Tracy [4] 96/18 100/17
107/8 125/4
trade [16] 39/17 103/8
127/10 137/15 138/10
139/8 144/5 146/1
146/2 146/4 146/15
148/16 148/16 148/18
152/12 156/25
tragedies [1] 10/3
tragedy [3] 64/5 73/3
109/11
tragic [1] 128/2
trained [1] 156/5
trainers [1] 156/6
training [31] 22/19
23/4 23/6 41/5 42/14
42/16 42/19 42/20
42/23 44/3 113/5 113/8
125/8 125/15 125/15
125/17 125/18 151/21
155/15 155/21 156/4
156/7 156/15 157/1
159/4 162/6 162/6
162/8 162/20 162/21
168/19
trains [1] 125/19
trampling [1] 109/8
transaction [8] 43/17
48/15 49/3 49/9 56/5
72/11 151/17 163/18
transactions [4] 124/1
151/20 151/24 158/3
transcript [1] 65/24
transcription [2] 65/21
65/25
Transfer [1] 40/2
transferred [2] 107/17
164/21
transformation [1]
1450/1
transparency [3]
73/17 91/24 110/23
transparent [1] 146/12)
transpires [1] 150/13
trauma [2] 69/23 91/23)
traumatic [4] 2/14 6/12
6/14 6/18
Treasury [1] 152/7
treat [1] 7/11
treated [2] 44/11
100/16
treatment [3] 9/21
89/18 90/3
tremendous [1] 130/4
trial [15] 4/22 15/16
18/3 33/20 33/21 43/6
44/4 56/7 56/9 57/14
101/15 119/9 154/4
161/2 161/13
tribute [1] 106/16
tried [3] 35/2 52/22
101/11
trite [1] 133/22
triumph [1] 109/7
triumphed [1] 127/24
trivial [1] 134/4
trouble [1] 63/7
troubled [1] 111/9
true [9] 9/20 22/11
24/2 47/25 73/3 73/17
77/21 139/24 157/21
truly [6] 8/9 16/1 20/1
76/14 89/5 93/10
trust [8] 30/12 93/3
93/12 93/25 115/14
134/6 142/8 169/3
trusted [8] 3/4 6/15
97/15 104/25
truth [14] 2/6 10/20
29/25 53/22 55/7 70/6
79/12 89/15 97/6
106/15 116/14 122/20
132/9 134/8
try [2] 68/2 69/10
trying [2] 23/1 166/18
Tuesday [3] 94/19
121/11 134/10
tune [1] 47/3
tunnel [2] 8/13 8/13
turn [13] 7/6 10/7
15/25 17/6 20/19 33/6
38/12 43/3 46/4 47/4
52/16 56/19 162/4
turned [1] 116/15
Turner [2] 101/4
101/11
turning [4] 79/20
79/21 84/2 149/19
turns [1] 142/21
TVs [1] 134/2
42/21 66/11 67/14
67/16 73/4 78/23 78/25
80/3 80/11 81/4 84/9
93/6 102/11 102/17
127/1 131/17 139/16
155/5 161/19 161/22
two days [2] 67/14
81/4
two decades [5] 67/16
73/4 78/23 78/25 80/11
two months [1] 84/9
two pages [1] 161/19
two paragraphs [1]
161/22
two weeks [1] 42/21
type [2] 18/10 40/6
U
ugly [1] 116/9
UK [8] 6/20 6/24 76/22
423/17 140/5 144/15
145/8 150/9
UKGI [1] 30/2
59/10 92/3 92/20 96/15] 89/9 92/21 105/5
two [23] 3/12 24/5 24/9) 71/2
ulterior [1] 118/2
ultimate [3] 11/8
138/22 141/5
ultimately [8] 13/9
114/14 116/6 118/6
168/23
unable [4] 2/14 43/4
97/23 131/13
unaware [5] 25/21
26/19 75/18 114/24
148/5
uncertain [1] 154/19
uncomfortable [1]
118/12
unconscionable [2]
107/1 129/16
unconscionably [1]
106/23
uncorrected [1] 118/2
uncover [2] 9/17 79/12
undeniable [1] 91/17
under [14] 3/21 4/7
37/20 52/25 61/2 61/25
64/21 64/24 105/23
106/4 108/3 154/25
155/1 166/24
underline [3] 33/5 68/1
underlined [1] 27/20
undermine [2] 79/11
123/24
undermined [2] 24/17
27123
undermines [1] 24/12
underpinning [1]
168/11
understand [13] 11/11
13/22 14/2 28/8 53/12
64/1 93/4 121/13
137/25 138/11 141/6
144/4 153/1
understandably [2]
33/14 79/9
understanding [5]
TTT 80/1 86/16 93/8
144/9
understands [3]
138/23 139/9 154/2
understated [1] 76/11
understood [7] 26/4
49/15 111/23 138/2
(80) throughout... - understoo
INQ00001046
INQ00001046
U unprecedented [2] 126/21 127/12 129/8 I 58/20 59/23 60/2 60/19} 143/21
understood... [3] 67/10 92/25 uproar [1] 113/1 61/5 62/9 64/14 64/17 Iwaited [1] 5/20
4139/6 152/10 166/19 unpredictable [1] upstairs [1] 4/8 65/1 72/20 80/7 94/14 Iwaive [1] 79/3
undertake [1] 121/7 112/8 urged [1] 136/14 94/17 94/21 94/23 Wales [2] 5/13 5/19
undertaken [2] 6/1 unquestionably [1] _ Iurgency [1] 7/13 94/23 95/20 96/7 wall [1] 111/20
4159/5 35/3 urgent [3] 91/15 162/5 I 100/21 104/8 104/14 I Wallis [2] 127/16
undoubtedly [2] 62/7 unreasonable [1] 9/13] 162/6 107/21 112/1 112/17 I 138/1
11216 unrelenting [1] 49/22 us [19] 1/44/1 8/11 I 115/6 115/22 120/8 I want [18] 25/17 29/9
undue [1] 96/12 unreliability [4] 123/9 I 11/13 13/6 18/24 19/2 I 120/14 122/3 122/5 29/9 40/1 56/17 60/10
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