All four UK governments failed to appreciate the scale of the threat posed by COVID-19 or the urgency of the response the pandemic required, a damning report published on Thursday has claimed.
Baroness Heather Hallett, the chair of the inquiry, described the response to the pandemic as "too little, too late".
Tens of thousands of lives could have been saved during the first wave of COVID-19 had a mandatory lockdown been introduced a week earlier, the inquiry also found.
Noting how a "lack of urgency" made a mandatory lockdown "inevitable", the report references modelling data to claim there could have been 23,000 fewer deaths during the first wave in England had it been introduced a week earlier.
The UK government first introduced advisory restrictions on 16 March 2020, including self-isolation, household quarantine and social distancing.
Had these measures been introduced sooner, the report states, the mandatory lockdown which followed from 23 March might not have been necessary at all.
COVID-19 first emerged in the Chinese city of Wuhan at the end of 2019, and as it developed into a worldwide pandemic, the UK went in and out of unprecedented lockdown measures for two years starting from March 2020.
Lady Hallett admitted in her summary that politicians in the government and devolved administrations were forced to make decisions where "there was often no right answer or good outcome".
"Nonetheless," she said, "I can summarise my findings of the response as 'too little, too late'".
'Toxic culture' at the heart of UK government
The report said there was "a toxic and chaotic culture" at the heart of the UK government during the pandemic.
The inquiry heard evidence about the "destabilising behaviour of a number of individuals" - including former No 10 adviser Dominic Cummings.
It said that by failing to tackle this chaotic culture - "and, at times, actively encouraging it" - former PM Boris Johnson "reinforced a culture in which the loudest voices prevailed and the views of other colleagues, particularly women, often went ignored, to the detriment of good decision-making".
'Misleading assurances'
The inquiry found all four governments in England, Scotland, Wales and Northern Ireland failed to understand the urgency of response the pandemic demanded in the early part of 2020.
The report reads: "This was compounded, in part, by misleading assurances from the Department of Health and Social Care and the widely held view that the UK was well prepared for a pandemic."
The report notes how the UK government took a "high risk" when it significantly eased restrictions in England in July 2020 - "despite scientific advisers' concerns about the public health risks of doing so".
Lady Hallett has made 19 key recommendations which, if followed, she believes will better protect the UK in any future pandemic and improve decision-making in a crisis.
Repeated failings 'inexcusable'
In a statement following the publication of Thursday's report, Lady Hallett said there was a "serious failure" by all four governments to appreciate the level of "risk and calamity" facing the UK.
She said: "The tempo of the response should have been increased. It was not. February 2020 was a lost month."
Read more:
A timeline of the UK's response to the pandemic
Lady Hallett said the inquiry does not advocate for national lockdowns, which she said should have been avoided if at all possible.
She said: "But to avoid them, governments must take timely and decisive action to control a spreading virus. The four governments of the UK did not."
Lady Hallett said none of the governments were adequately prepared for the challenges and risks that a lockdown presented, and that many of the same failings were repeated later in 2020, which she said was "inexcusable".
She added: "Each government had ample warning that the prevalence of the virus was increasing and would continue to do so into the winter months. Yet again, there was a failure to take timely and effective action."
(c) Sky News 2025: All four UK governments 'failed to appreciate' scale of COVID pandemic threat - inquiry finds
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