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Preface from the Chair

In framing the work of my

Review and producing this

report, I have four key aims

• To provide a record of the

pandemic experience in the

Isle of Man

• To highlight what went well

and good practice

• To identify weaknesses in the

response

• To identify lessons to be learnt

to strengthen future response

Kate Brunner KC

Review Chair

In my report, I set out and analyse

Government’s approach to decision-

making, including decisions about

strategy, closing the borders, and

lockdowns and how specialist and

scientic advice was provided. I

describe the arrangements that

were put in place for new activities

such as testing, contact tracing,

vaccine roll out and nancial

support to businesses. I record

the extent to which the delivery

of essential services was aected,

such as education and social

care, and the way that support

services performed such as

communications, technology and

procurement.

The report sets out my ndings

of strength and weakness in the

pandemic response, and makes

practical recommendations in

a wide range of areas. Those

recommendations seek to support

this Government to improve

the Island’s resilience so that it

is stronger going into another

pandemic, as well as assisting

future governments to respond

robustly to any prolonged

emergency.

These ndings and

recommendations should be taken

seriously. Another pandemic

is thought to be inevitable:

according to the Centre for Global

Development, the annual likelihood

of a pandemic is around 2-3%.

My hope is that the Isle of Man

Government and Tynwald will

reect on the Review’s ndings and

recommendations and will agree

“These ndings and recommendations

should be taken seriously. Another

pandemic is thought to be inevitable...”

to refresh work on recovery from

Covid, to develop their planning

and preparedness and to build

resilience in public services and the

population.

The onset of the Covid pandemic

provided great challenges for

Government, for businesses and the

public and high levels of anxiety

were prevalent for everyone. The

pandemic was a terrible time for

many people on the Island. Lives

were lost and many people suered.

The Review has seen the long-

term impacts and trauma that the

pandemic had and continues to have

on all parts of the community, the

public, businesses, public servants,

civil servants and politicians alike.

There were many unknown factors

and uncertainties at the outset and

the Government needed to grapple

with complex and unfamiliar issues

and decisions to protect residents

Given the novel experience of

managing a pandemic, it is no

surprise that there were areas of

weakness in the response, and that

there is considerable scope to learn

and improve.

The Review team is grateful for the

willingness of so many people to

come forward and the willingness

of those who did come forward

to speak openly. I appreciate

how dicult that can be and I

was impressed by the motivation

of so many to assist the Review

to understand what happened,

and to make realistic and useful

recommendations for change. I have

been able to gather all the evidence

I needed to reach clear conclusions.

I have had full cooperation from

Government and from all signicant

ocials, advisers and politicians

who have left Government. I have

not been prevented from obtaining

and the economy. Ministers and civil

servants worked excessively long

hours and showed great dedication

to safeguarding the wellbeing of the

people of the Isle of Man.

Government’s approach was

largely successful. Outcomes were

comparatively good in terms

of numbers of deaths, time in

lockdown, costs per head and

economic recovery. The Island

fared much better than many other

places.

any evidence which I sought. The

Review was appreciative of the

co-operative and collaborative

approach of politicians and

Government Ocials, both current

and former, and their strong desire

to identify lessons for the future.

The Review has not written

individual letters of thanks to the

hundreds of people who assisted,

but each of those people has

contributed to the robustness of

my conclusions. It is not possible in

the report to mention every detail

that we received, but every piece

of information has been welcomed,

and it has all been considered and

taken into account.

that there are many in Government

who were there in the pandemic,

and many parts of Government are

still dealing with the eects of Covid.

“The Review Team is grateful for the

willingness of so many people to come

forward and the willingness of those who

did come forward to speak openly....”

Any review of a government’s

activity over a two and a half year

period (from December 2019 to

April 2022) could have taken an

almost unlimited time - certainly

many years. My instructions

from Tynwald were to carry out a

Review to be completed by the end

of 2023. That gave me 15 months:

roughly two months setting up, 11

months of evidence-gathering and

analysis, and two months drafting

and creating the report. That time

frame governed my approach to the

level of detail which I sought. The

Review looked at decision-making

at some points in time in great

detail to piece together exactly what

had happened, but at other points

a broader approach was taken.

Similarly, in some areas the Review

looked at the specics of operational

delivery, while in other areas the

focus has remained at a strategic

overview level. I am entirely

satised that the time frame which

Tynwald set was appropriate. I have

been able to gather and analyse

sucient information to identify

the central features of the pandemic

response, and to identify patterns

and cultural issues. The relatively

short interval between the end of

the pandemic and this report means

The Review team is aware that we

placed a burden on Government in

our requests for data, documents

and information. I am grateful for

the hard work of Ms Quayle and

her team who provided an ecient

and eective liaison point with

Government in this regard.

I also wish to place on record my

thanks to the Review team members

for their work and insight. This has

been a team eort, although any

errors are mine. When the report

speaks of ‘the Review’s ndings’, that

means my conclusions having taken

into account the advice of experts,

and building on analysis carried out

by others in the team.

The report has been written with

a wide range of readers in mind,

from members of the public to

those in Government who may

have a specialist area of interest. I

recommend that readers look at the

‘Navigation’ section to determine

which parts of the report will meet

their particular needs.

The Independent Covid Review

Isle of Man

Terms of

Reference

The Terms of Reference were expanded and claried in November 2022, at the

Chair’s request. The initial terms of reference are available here.

The initial period of the Review set by Tynwald when it commissioned the

Review was from December 2019 to the end of September 2021, which was the

end of the previous government administration. The Chair of the Review asked

that the end date be moved to April 2022 which was the end of Covid restrictions.

This change enables the entirety of the Government response to the pandemic to

be considered. The change was supported by the Council of Ministers, the Public

Accounts Committee, and approved by Tynwald in November 2022.

Further amendment and clarications were made to the Terms of Reference

in November 2022 to make explicit that, as is usual in Reviews, the Chair has

discretion as to what parts of the Review will be heard in public, and what

evidence will be published.

Terms of Reference

GD 2022/0087

UPDATE ON INDEPENDENT REVIEW INTO THE ISLE OF MAN GOVERNMENT’S HANDLING

OF THE CORONAVIRUS PANDEMIC

Background

1. The Standing Committee of Tynwald on Public Accounts Annual Report covering activity during

the session 2020-2021 recommended that a public inquiry should be held on the Isle of Man

Government’s handling of the coronavirus pandemic; and that it should cover the period

December 2019, when the first case of Covid-19 was reported in China, to the end of September

2021, the end of the term of office of the 2016-2021 administration.

2. On 16 November 2021, Tynwald approved the Chief Minister’s amendment to the PAC’s proposal,

determining that an independent review (‘the Review’) be commissioned which will be conducted

by an independent chair rather than a public inquiry, with the terms of reference for the Review

to be prepared jointly by the Public Accounts Committee and Council of Ministers and then

submitted to Tynwald for its approval.

3. Tynwald also supported the PAC’s proposal that Tynwald waive privilege in relation to any

evidence relating to the Covid-19 pandemic held by the Public Accounts Committee and Tynwald

Policy Review Committees; and resolved that such evidence may be provided on terms decided by

the relevant Committee to an independent review if requested.

4. The terms of reference for the review were approved on 26 April 2022 when Tynwald approved

the following motion:

That Tynwald approves the terms of reference for an independent review into the Isle of

Man Government’s handling of the coronavirus pandemic; covering the period December

2019, when the first case of Covid-19 was reported in China, to the end of September

2021, the end of the term of office of the 2016-2021 administration, with a report to be

published to Tynwald by the last day of December 2023. [GD 2022/0033]

5. An extensive recruitment process was undertaken in May 2022 to identify a suitably qualified and

experienced Chair for the Review and a selection panel formed jointly by Council of Ministers and

the Public Accounts Committee considered a number of candidates. The panel recommendation

that Kate Brunner KC be appointed chair of the Review was approved by Council of Ministers on

28 July 2022.

6. Subsequent to the appointment of the chair for the Review, her preliminary research and further

consideration, Ms Brunner wrote to the chair of the selection panel Hon Jane Poole-Wilson MHK

seeking two specific changes to the terms of reference: to extend the period within scope and to

clarify the presentation of evidence in the review’s final report. The Public Accounts Committee

and Council of Ministers are in agreement that it is logical to extend the period of consideration by

GD 2022/0087

the review to 1 April 2022 to allow the entirety of the major responses to the pandemic to be

considered. PAC and Council also agree to the Review chair’s proposals in respect of publication of

evidence in her final report. At the same time as seeking Tynwald approval to these two specific

changes to the terms of reference, PAC and Council have also agreed to seek Tynwald approval

for –

 a new, streamlined mechanism for further changes to the terms of reference; and

 an extension of the waiver of Tynwald privilege originally agreed in November 2021.

7. The chair additionally requested clarification in respect of the extent to which enquiries will be

undertaken in public, as referenced in the background preamble to the terms of reference agreed

in April 2022 (GD 2022/033). The Review chair noted that while there will be public evidence

sessions and public engagement, evidence gathering will largely be out of the public gaze. This

clarification has been acknowledged and agreed by the panel chair and PAC, and Ms Brunner

advised to this effect in correspondence which will be published in due course.

8. The Review is to be undertaken completely independently of the Isle of Man Government and it

will have entire independence of action and thought. It will also be afforded full access to all

records held by, and personnel employed by, the Isle of Man Government and all its agencies.

9. The Chairperson will report their conclusions and identify any recommendations for consideration

to Tynwald by 31 December 2023.

10. The Review will act with complete freedom and entirely unfettered from any obligation to Isle of

Man Government.

GD 2022/0087

Terms of reference

Objective

The objective of the Review is to scrutinise and evaluate the Isle of Man Government’s handling of

the response to the coronavirus pandemic; during the period December 2019, to 1 April 2022.

The Review will assess the decisions made by Government at the time and identify any lessons to be

learned.

Further, the Review will make recommendations, as necessary, to ensure that the lessons learned are

embedded into current working practices, and to enhance preparedness for any future emergency

response to a pandemic. It should also capture what worked well, and how or if this way of working

ought to be continued.

In forming these terms of reference regard has been given to written statements in the Standing

Committee of Tynwald on Public Accounts’ (“the Public Accounts Committee”) Annual Report, and to

remarks made during the debate on the motion in November Tynwald, to ensure the points raised are

addressed by the Review.

Governance

The Review will be led by an independent Chairperson. The Chairperson will have full editorial rights

over the final report that will be provided to Tynwald. The Chairperson has the ability to appoint

such professionals or laypersons as they see fit to support them in fulfilling the terms of reference.

In compiling the report, that person will be entitled to call for and obtain such evidence as they

require, including from Council of Ministers (both the current and previous administration), Tynwald

members, civil and public servants, business owners and the wider public.

Secretariat support for the Review will be provided by Isle of Man Government officers (outside of

Cabinet Office) appointed by the Chair. The officers will be responsible for project management, data

collection, the production and development of working documents, record keeping, facilitation of

evidence taking and other functions as required.

The secretariat and any other individuals appointed by the Chairperson to support the Review will

work under the direction of the Review’s Chairperson.

Scope

Without aiming to restrict the areas or matters which the Review may consider, it is asked to cover

the following:

Review areas

 Circumstances and decisions leading to the Proclamation of Emergency, Emergency Powers and

the use of legal restrictions under the Emergency Powers Act 1936, together with the Public

Health Act 1990, and any restrictions in the areas listed below

 Border closures and subsequent restrictions

 Education provision as a result of school closures



Government quarantine requirements imposed for returning residents

GD 2022/0087

 Loss of life as a result of Covid-19

 Benefit provision for self-employed persons and businesses, and the broader economic recovery

and support schemes provided

 Individual and household isolation in relation to positive cases and close contacts

 Testing in relation to symptomatic cases, close contacts and following travel

 Contact Tracing in relation to positive cases and how it was conducted

 Vaccination governance and roll out

 Preparedness for the outbreak of a pandemic

 Genomic sequencing for positive cases

 Communications – internally to government and Tynwald, and externally to the public

 Command structures and decision making processes

 February 2021 Covid-19 Outbreak and its relation to the Isle of Man Steam Packet Company

(IOMSPC), to the extent not already covered by the Public Accounts Committee’s 2020-21 Annual

Report (PP 2021/0166).

If at any time the Chairperson conducting the review is of the view that a specific area should be

subject to a more formal public inquiry, the Chair may make such a recommendation to Tynwald in

their report.

Reporting

A final report will be published by 31 December 2023. Progress or interim reports may be presented

as the Chairperson shall consider appropriate throughout the process of the Review.

The final report will be a public document which will summarise the evidence gathered on which any

conclusions and recommendations are based. Evidence, extracts from evidence, and summaries of

evidence will be published at the Chair’s discretion subject to considerations of confidentiality,

relevance, cost and practicality.

Review terms of reference approved by Tynwald April 2022

Revised subject to Tynwald approval, November 2022

The Independent Covid Review

Isle of Man

Navigation:

How to Use This

Report

This is a large report, running to thousands of pages. That should not put readers

o: the report has been designed so that readers with dierent areas of interest

can access the Review’s ndings in dierent ways. Chapters are designed to

stand alone, so that they can be accessed and read without reading the whole.

This section is intended to assist readers to determine how to approach the

report.

Accessibility

1. The report has been designed to be as accessible as possible to anyone who

wishes to read it. We worked to ensure:

i. Content reproduction Where possible, we have re-formatted evidence

such as emails, meeting minutes or tables, allowing for the content to be

accessible for readers and screen readers.

ii. Images tags and descriptions In some circumstances the use of original

evidence in the main content is critical or reproduction is not possible. In

these instances, we have ensured that images displaying such evidence are

tagged, and where possible web links are provided, to allow accessibility

devices to process and follow the data.

iii. Use of colour A specic group of colours were selected and tested to

ensure that contrasts in diagrams, imagery or type produced by the

Review is compliant to accessibility standards (WCAG 2.0).

iv. Fonts Also in accordance with accessibility standards, specic groups of

fonts were selected and tested to support accessibility and legibility of the

document, using a font size of 12pt and over.

v. Content construction During the content production we have been

conscious of keeping sentences and paragraphs manageable and ensured

that paragraph items are numbered and the use of ‘All Caps’ is not present.

2. Generally duplication has been avoided but each chapter is written to stand

alone, meaning that at times the ndings of the Review on a particular matter

appear in more than one chapter.

How to Use This Report

Suggestions for navigating the Review Report

3. Concise Report Readers who are interested in a summary of the pandemic

response and the Review’s ndings are directed to the ‘Concise Report’. The

Concise Report gives an overview, and tells readers the headline ndings of

the Review in each area, as well as the Recommendations. Any reader of the

Concise Report who wishes to understand more about particular ndings or

recommendations is advised to read the relevant chapter in the full report.

Any reader of the Concise Report who wishes to understand more about the

way in which Government operated during the pandemic is advised to read

the ‘Pandemic Government’ section of the main report. All material in the

Concise Report has been extracted from the full report.

4. Full Report The full report is divided into parts, and each part has a number

of chapters. Each part can be separately accessed on the Review’s website.

The report has been designed so that chapters stand alone; it is not a

sequential report which requires any one part to be read before any other

part. The parts of the report are:

Part 1: Overview (summary of the Island’s response and outcomes, the public

eorts and background information about the Island)

Part 2: Emergency Planning (the emergency plans which were in place and

the extent to which they were useful)

Part 3: The Pandemic Government (the structures and processes which

Government adopted, and how the strategy was set)

Part 4: Decision Making (detailed analysis of who was advising, who was

creating policy options, who was making decisions, and how information was

conveyed to the Council of Ministers)

Part 5: Topics (17 chapters on individual areas)

Part 6: Complete Recommendations

5. Full Report, where to start Most readers will be assisted by looking at the

Overview section, and in particular reading the chapter ‘The Pandemic

Response: An Overview’ which gives a high-level outline of the actions of

Government and the outcomes. Readers who are unfamiliar with the Island

will also be assisted by reading ‘The Isle of Man: A Pre-Pandemic Snapshot’

rst. For those who are interested in a broader overview, the Overview

section also sets out the public’s experience of living through the pandemic

(‘Living Through the Pandemic’), and the sequence of strategies adopted by

Government (‘The Island’s Pandemic Strategies’).

6. Full Report, where to go next:

i. Readers who are particularly interested in the structures and processes of

Government are directed to the ‘Pandemic Government’ section. That sets

out the Review’s ndings about the Command and Advisory structures

which were used in the pandemic (‘Command Structures’ and ‘Advisory

Structures’), and how Government operated including information

sharing, redeployment and culture (‘Ways of Working in the Pandemic’).

ii. Readers who are interested in the early pandemic decision-making will

nd details in the ‘Early Pandemic: Setting the Strategy’ chapter (in Part 3),

and further detail about the decision-making process around closing the

borders in the ‘Closing the Borders: decision-making in detail’ (in Part 4).

iii. Those who want further detail about how command and advisory groups

worked in practice will nd that detail in the ‘Pandemic Decision-Making’

section, which analyses the day-by-day operation of Government in four

dierent time periods: closing the borders in March 2020, the January

2021 lockdown, the March 2021 lockdown, and opening the borders

between May and June 2021. Those detailed analyses lie behind the

Review’s conclusions in Part 3 about how the command and advisory

structures operate.

iv. Readers who are particularly interested in emergency planning will wish

to look at the ‘Emergency Planning’ section, which includes analysis of

the pandemic plans in place during the pandemic, the extent to which

they were used, and detailed recommendations for new pandemic and

resilience plans. Although there is only one chapter in this section, it

stands alone because of its importance in the overall pandemic response.

v. Readers who are interested in a specic topic such as vaccination, or

education, can access that topic chapter separately. For those particularly

interested in health and social care, there are chapters ‘Healthcare’, ‘Social

Care’ and ‘Abbotswood’. The legal regimes and Tynwald’s involvement are

examined in ‘Emergency Powers’ and ‘Communications with Tynwald’.

Each of the 17 topic chapters sets out a summary of what happened, the

Review’s ndings, and relevant recommendations. The topics are all listed

in the Table of Contents.

6. Full Report, where to end All readers are encouraged to look at the Review’s

recommendations. The recommendations can be found in individual

chapters, but the easiest way to access them is to view them together

in the ‘Complete Recommendations’ section. Most recommendations

speak for themselves. In four areas the Review has created ‘Expanded

Recommendations’. These are essentially tool kits to assist Government with

implementation of the recommendations and provide outlines for a new

pandemic plan, a communication strategy, a ‘ways of working’ plan, and a

resilience programme.

The Independent Covid Review

Isle of Man

Review Method

General method

1. A review does not have a xed process, meaning that dierent research

methods can be used for dierent topic areas, depending on which method

is most likely to generate full, frank and reliable evidence. This Independent

Review has used many dierent methods to gather information, including

conducting interviews, obtaining reports, and holding public drop-in meetings.

2. The Review has used established research methods including:

i. Focus groups, for example with teachers, social care workers and business

leaders.

ii. Semi-structured, non-attributable conversations (referred to as ‘meetings’

in the Review process to dierentiate them from interviews).

iii. Formal interviews.

iv. Requesting written submissions about specic topics from named

individuals and bodies.

v. Receiving written submissions from the Manx public.

vi. Examining documentation from Government, Tynwald, committees.

vii. Examining documentation from non-Government sources.

viii. Analysing data

ix. Commissioning research and external advice on specic points, notably

the legality of decisions to exclude residents and quarantine them at the

Comis, and the specics of Manx law.

x. Drop-in meetings for the public and for particular groups.

xi. Desk-based research.

3. Although the Review was not carried out in public in a court setting, there has

been signicant public involvement. Members of the public were invited to

join focus groups on particular issues. The public was invited to make written

submissions through the Review’s website, and many did so. Submissions were

requested on particular issues from individuals, businesses, charities and other

groups. Those who were bereaved or otherwise particularly aected by the

pandemic spoke privately to the Review, usually face-to-face but sometimes by

telephone or video link. The Review held four drop-in meetings in locations across

the Island where many members of the public shared their views on a wide range

of issues. The views of children were gathered through school leaders.

4. Evidence-gathering has been a thorough process. The Review Team were on the

Island for ten week-long visits between September 2022 and January 2024, held

meetings in the UK with former members of Government who have moved to the

UK, and held many remote meetings. Information was obtained from 291 current

and former civil servants and politicians, and around 200 groups and individuals

outside Government. The Review has received almost 380,000 documents. A range

of research methods has been used to extract necessary information from those

documents. Some have been examined individually in great detail. Some groups

of documents have been analysed by using dip sampling and/or search terms to

target particular issues of interest.

5. Evidence was gathered from a broad range of people including civil and public

servants, previous civil and public servants, those who advised the Government,

decision-makers, members of the Council of Ministers (both the former and

current administrations), Tynwald members, self-employed people, company

directors, business leads, clinicians, teachers, parents, charities and the wider

public.

6. Many people gave evidence to the Review condentially. That was an option made

available to anybody making a written submission, and also to anybody speaking

to the Review. That means that what they have told the Review has been taken

into account, that follow-up research has been carried out where needed to look

into matters raised, but those individuals have not been quoted, and conversations

have not been published. It was apparent to the Review from an early stage in

the process that many individuals were unwilling to speak to the Review on

the record. As a result, the Review determined that the default position would

be that comments from conversations and meetings would not be attributed to

individuals, unless there was some particular need to do so, in which case the

Review reverted to them for permission.

7. Among those who gave evidence to the Review condentially were Ms Magson,

former CEO of the Department of Health and Social Care, and Dr Ranson, former

Medical Director. The Review is grateful for involvement from them both,

which has been of much assistance. The Review also has the benet of detailed

contemporaneous records relating to those witnesses and many others, including

emails, daybooks, minutes and the like. Their requests for condentiality are

respected, as are requests from anyone, and so transcripts of the detailed

conversations with both are not being published.

8. No current or former civil servant or politician has refused any request from

the Review for information, save for the refusal of Ms Malone, formerly a senior

ocer in the Department of Health and Social Care, to participate, and the Interim

Director of Social Care declining to provide the Review with a chronology of social

care service provision during the pandemic. The Review was unable to obtain

contact details for the former Chief Operating Ocer at the Department of Health

and Social Care and has not received evidence from them.

9. The Review carried out interviews, which were more formal and not

condential, with current and ex-Ministers, senior civil servants and advisers.

The Review also interviewed Dr Glover, and central gures at Abbotswood who

had made signicant criticisms of Government. The Review also interviewed

Ms Quayle at an early stage. She was a business analyst who played a role in

early research, and ordinarily the Review would not have conducted a formal

interview with someone in that role. However, Ms Quayle led the team which

coordinated the Government’s documentation for the Review. The Chair

decided to interview her on the record to ensure that any evidence she had to

give was captured in a transparent way, early on in the Review, before she

was exposed to a large volume of contemporaneous documentation which may

have aected her memory.

10. Government provided letters to ex-employees releasing them from any non-

disclosure agreements and any other legal restrictions on what they could

discuss, meaning that they were free to share all information with the Review.

11. The Review set out in correspondence with witnesses the likely areas for

that witness’s evidence. Depending on the witness, that was at times general

headings of topics, and at times lengthy lists of events. People who were being

interviewed were invited to make written submissions in advance and many

did so. Witnesses were oered the opportunity to refresh their memory by

looking at documentation. Where witnesses asked to see documentation the

Review had a process for putting documentation into a secure digital ‘reading

room’. That process was particularly used by people who had left Government

and who wished to remind themselves of forgotten details before answering

questions. Witnesses were only permitted to access material to refresh their

memories, and not to carry out their own research. That meant that witnesses

were permitted to look at their own emails, but not other people’s emails, and

were permitted to look at minutes of meetings which they attended, or which

were circulated to them, but not other meetings.

12. The Review spoke to some people repeatedly because they had a great deal of

insight into a wide range of areas. That includes individuals in Government,

who were in various dierent roles during the pandemic, or are now the last

remaining person in their area of work who was in post during the pandemic,

and also some individuals outside Government such as the CEO of the Chamber

of Commerce. Particular thanks are extended to those individuals.

13. Where necessary, the Review has made its decisions on a ‘balance of

probability’ basis. Where there are diering assertions the Review has

weighed up competing evidence, taking account of a range of factors

including the source of the dierent assertions, whether they are rst-hand

accounts or hearsay, whether the person making each assertion is otherwise

a reliable source of information, whether each assertion is supported by any

contemporaneous evidence such as emails or minutes. The report does not

set out all of the Review’s ‘workings’ for its ndings. It would be impossible

to do so given that much material has been received on a condential basis.

Setting out workings for each nding would have required many more months

of work and resulted in an unhelpfully lengthy report. All ndings have been

reached after a rigorous analysis of relevant material, taking into account

relevant expert advice.

14. Each chapter has a ‘Review Process’ section which sets out more information

about the methods adopted in relation to particular topics.

15. Standard correspondence relating to meetings, interviews, and submissions

are in Appendix 1.

Selection of material

16. The Review determined what material should be provided from Government.

Each Department and Board provided an asset register of material which may

be relevant, and the Chair identied the material which the Review required,

or requested a sample of documentation where there were large batches of

similar material, or requested a more detailed description in order to make a

determination.

17. Protocols and legal waivers were put in place to enable the Review to have

access to material which would otherwise be highly condential, such as

minutes of Council of Ministers meetings.

18. Redaction of material was carried out to remove unnecessary personal data by

the Government Coordination team at the direction of the Review team, in line

with a working protocol, in Appendix 2. Material was then indexed by topic

and subtopic to enable searching by subject matter: the topic list is in

Appendix 3.

Publication of evidence

19. The Review has published a substantial amount of evidence as Appendices to

various chapters in this report.

20. Minutes and emails have been reproduced in part in the chapters and

appendices: where those documents are not complete, such as where part of an

email is quoted, that is indicated by [...].

21. Interviews and submissions by interviewees have been published. Transcripts

were prepared by professional transcribers, with usual edits to remove

repetition, llers and the like to make the transcripts easier to follow. Some

personal data has been removed from transcripts and submissions, in line

with the Review’s data protection framework. Some other matters have

been redacted such as references to matters which may be ongoing court

proceedings. It should be noted that interviews were carried out before the

Review had completed its analysis of material, and so suggestions put in

interview should not be taken as the Review’s nal position on any issue.

22. Some interviewees submitted written material to the Review. Many of those

submissions were detailed, and they assisted the Review team to focus on

particular areas in the course of the interviews. Interviewees kindly gave

permission for all or part of those submissions to be published at the Chair’s

discretion. Either the full submission or an extract has been published. Some

interviewees provided documentation alongside their submissions, and some

has not been published; that is because the material was not suciently

relevant, duplicated material elsewhere, contained signicant amounts of

personal data or otherwise was not in line with the Review’s publication

protocols. The Review’s resources were not extended to redact personal data

from hundreds of documents, which is what would have been required in

some cases in order to publish all material submitted by interviewees. Those

interviewees are, of course, at liberty to publish their material themselves, as is

any person who has made a submission to the Review which is not published,

or not published in full.

23. The Review has been given full access to CoMin minutes and papers, with

legal restrictions lifted, in relation to material relating to the pandemic. The

Review has redacted material which does not relate to the pandemic before

publication.

24. A further selection of evidence will be published. That is at the Chair’s

discretion, as set out in the Terms of Reference, taking into account

considerations of condentiality, relevance, cost and practicality. The Review’s

purpose in publishing a further selection of evidence is to assist with the

understanding of the report, which is primarily a report for this and future

Governments. It is not the function of a Review to marshall and publish a large

database of material, and in any event that would not be possible. Much of that

material has been gathered on a condential basis. There is substantial time

and cost associated with publishing material, because each document needs to

be checked for personal data, commercially or nationally sensitive material,

condentiality, copyright, material which makes unfounded and extreme

allegations, material which may cause distress to individual members of the

public, and other factors. The public interest in publishing personal material

needs to be considered, many documents need to be redacted, and at times

due diligence means that specialist legal advice needs to be taken. The Review

is not resourced to undertake that project with the hundreds of thousands of

documents which have been received. The Review will take a proportionate

approach and intends to publish a further selection of evidence by the end of

January 2024.

Terminology

25. The Review uses the term ‘Covid’ to mean the covid-19 virus, and the disease

caused by that virus.

26. The Review uses the term ‘Government’ to mean all or any parts of the Isle of

Man Government including Cabinet Oce and departments. It is recognised

that there is no single legal entity of Government, but the word is frequently

used, including in the Review’s terms of reference.

27. Where the Review gives job titles, they relate to roles during the pandemic.

28. Given dates are generally the date that an event happened, rather than the date

when the event was announced. The dierence between the two is, at times,

not set out clearly in material provided to the Review, and the fact that many

requirements came into force at midnight creates a further complication.

29. Further central terminology and acronyms are explained in each chapter.

Independence

30. The Chair has ensured that the Review project has remained independent of

Government, Tynwald and all agencies throughout the Review process. Nobody

in Government or the wider political framework could dictate the process of the

Review, or the conclusions of the Review. The independence of the Review has

been recognised, and respected, by Government throughout the Review process.

31. In the set-up phase of the Review, the team has necessarily had various

interactions with civil servants, public servants and ministers, such as

discussing the document management platform where hundreds of thousands

of documents will be stored; discussing data-sharing agreements; setting-

up processes to obtain information from Tynwald and so on. The Review

Team occasionally used a room in Government oces, in order to avoid the

expense of permanently renting separate oce space. For the same reasons,

meetings with MHKs were held at Tynwald. Meetings with the public and

formal interviews with current and ex politicians and ocers were held in

independent venues hired by the Review team, largely on the Island, but

sometimes in the UK.

32. Throughout the Review, the formal channel of communication between the

Review and Government has been through identied ‘sponsors’. This is a

standard procedure in a Review such as this which is set up by Government.

Having sponsors is part of the way in which independence is maintained while

ensuring that the Government has appropriate administrative oversight of the

progress and cost of the Review.

33. The sponsors were Hon Jane Poole-Wilson MHK (Minister for Home Aairs)

and Interim Chief Secretary Caldric Randall. Both explicitly recognised and

welcomed the independent nature of the Review.

34. It was agreed between the Chair and sponsors that the sponsors’ role was:

i. To keep oversight of the progress of the Independent Review, which will be

achieved through progress reports from the Chair.

ii. To keep oversight of the cost of the Independent Review.

iii. To act as the point of contact between the Review and both Government and

Tynwald.

iv. To take action where necessary to assist the Independent Review to full the

Terms of Reference.

35. In communication between the Chair and the sponsors, it was acknowledged

that both sponsors were likely to also be witnesses, and, as anticipated, both

were spoken to as witnesses. In the context of a small administration that is

not unexpected. Both sponsors and the Chair of the Review were alive to the

potential conict that may have created. Matters relating to evidence were kept

separate to matters relating to the sponsor role.

36. Sponsors were called upon on a few occasions to assist where the Review was

facing signicant delays in obtaining material from Government. Sponsors also

assisted with liaising with Tynwald in relation to amendment to the Terms of

Reference in November 2022 and liaison with Tynwald about the publication

date.

37. Sponsors had an administrative role only. Information provided by witnesses

to the Review was not shared with the sponsors, nor with Government or

Tynwald. That separation of roles was entirely respected on all sides. The

Review operated at arm’s-length from all other institutions.

38. The Review was assisted by a Coordination Team in Government, led by Ms

Quayle. That team coordinated processes, such as setting up data sharing

agreements with Departments, and coordinated the collection of documents

from Government and the practicalities of uploading them onto the database.

That team was, on occasion, asked to nd specic material which the Review

needed. As an example, the Review was unable to create a chronology of

testing and isolation rules due to the Government’s chaotic record-keeping,

and so the Coordination Team was asked to create that record. In the event,

the best chronology which could be provided remains incomplete and

inaccurate. That is not the fault of the Coordination Team, which was seeking

to draw together material which had not been properly named and retained.

Ultimately, responsibility for research and for determination of what material

is accurate lies with the Review, and not with the Coordination Team.

39. The Coordination Team provided an extremely useful service to the Review.

It would not have been possible to complete the Review in this time period

without the extensive assistance of that team. Some of the work of that team,

and learnings from the process, are summarised in a report at Appendix 4. The

Coordination Team is thanked and commended for its remarkable eorts in

supporting the Review.

40. The Review entirely directed the work of the Coordination Team in evidence-

gathering. As examples, the Review determined what material was relevant,

not the Coordination team. The Review gave instructions for what material

should be redacted before it was uploaded to the database, in line with data

protection agreements; the Coordination Team did not make separate decisions

about redaction.

41. The Review’s independence extended to independence from the Coordination

Team. That Coordination Team gathered evidence from Government

departments, but was not privy to all information from individuals in

Government. There was no sharing of information the other way, from the

Review to the Coordination Team. Submissions from civil servants were

generally made via the Review’s website link, which went straight into a

secure document platform which only the Review team had access to. The

Chair did not share information with the Coordination Team about who had

been spoken to, or what other material had been gathered. The Chair did not

share provisional conclusions with anybody in Government, including the

Coordination Team.

42. Independence also meant being independent from all witnesses. That meant

that the Review did not answer the many questions which it received about

what material had been gathered and who had been spoken to and what the

Review’s provisional conclusions were. In line with the Review’s protocols,

nobody was provided with a list of material held by the Review. It follows

that nobody is in a position to accurately say what material the Review does

or does not have. Public comments by individuals about the Review not being

in possession of certain material, or certain material being withheld from the

Review are speculative. Anyone who was concerned that the Review did not

have a particular piece of material was specically invited to communicate

directly with the Review by way of email or submission which could be

anonymous. Some people did so, and that was a useful way for the Review

to check that it had all material which it should have. That process did not

indicate to the Review that any material was being withheld.

Legally privileged material

43. There was a requirement for Government to identify where material was being

withheld on the grounds that it was legally privileged, or any other grounds.

44. That material was then described. If the Chair determined that it was relevant,

then Government was asked to waive privilege, and did so. Ultimately, no

material requested by the Chair was withheld on the grounds of legal privilege

or any other grounds.

Challenges

45. The Review was hampered initially to some extent by a lack of planning for

the Review process. The Chair was appointed in August 2022 but it was not

possible to gather evidence until the end of the year; the process of setting up

the Review was far more complex than it should have been. The legal basis for

the Review was unclear which created diculties and delays in the Review

Chair’s application for registration under data protection legislation. It was

entirely unclear how the process of data-gathering was going to be managed

in Government. There was no secretariat despite reference to a secretariat in

the Terms of Reference, and it was not until November 2022 that Government

appointed a coordinator to manage Government documentation and liaise

with the Review to establish protocols for data sharing, identication of

relevant material and the like.

46. The Review has also been hampered by chaotic data and record management

systems. Some details are set out in the ‘Ways of Working’ chapter. It has not

been possible for Government to provide the Review with reliable data and

chronologies in relation to a number of signicant areas including testing

and isolation rules, incidents at the border, closure and opening of social

care services, numbers of keyworkers coming into the Island in any month,

numbers of compassionate leave exemptions coming into the Island in any

month, and meetings of key groups.

47. The initial aim was for Government to provide all material by the end of

January 2023. That was extended to the end of February, then April, then June.

Material provided after June 2023 included signicant meeting minutes and

the like. Material provided as late as November 2023 also included signicant

information.

48. The Review has been alive throughout the process to the possibility that

documents may be deliberately withheld or altered. The Review has carried

out processes of cross-checking and triangulation to identify whether material

is complete, and has examined meta data where deemed to be relevant. Much

material which is adverse to Government has been provided. The Review’s

conclusion is that the late provision of some material and the absence of other

material reects the chaotic data and record managements systems in some

departments. The Review has not found that Government has deliberately

withheld or altered material requested by the Review.

49. The eect of provision of some material late in Autumn 2023, and some witnesses

only agreeing to participate in November 2023, meant that the publication date

was in jeopardy. The Review has been nished in time by running research and

production workstreams in parallel in the latter stages of the project.

50. A further signicant challenge for the Review was that people’s memories

have, of course, faded. It was dicult for witnesses to recall in mid 2023 what

happened in meetings in early 2020. That problem was exacerbated by the lack

of logs of decisions and actions, and poor minutes.

The Dr Ranson Tribunal

51. The ndings of that tribunal stand as ndings of a court of law, which have not

been appealed.

52. The Review has not sought to reinvestigate the conclusions of the tribunal, and

the central conclusion, that Dr Ranson was unfairly dismissed, is not a matter

which the Review has addressed in any way. There are, unsurprisingly, areas of

overlap between the Review and the tribunal’s remits. The most signicant of

those is whether the advice from clinicians including Dr Ranson about border

controls reached CoMin on 16 March 2020. The tribunal found that they did not.

The Review is satised that they did.

53. No criticism is made of the tribunal. Unlike the Review, the tribunal is not

an investigatory body. It makes decisions on the basis of evidence which is

presented to it and arguments which are presented to it. The Review has seen

the tribunal material, and it appears that the tribunal did not have signicant

material, which has enabled the Review to see that the clinicians’ advice

reached CoMin. In particular, it seems that the tribunal did not have minutes

of the Council of Ministers meeting on 16 March 2020 which record that the

Department of Health and Social Care supported border closure, nor emails and

attachments which show the various iterations of material created for CoMin

over the weekend of 13 - 15 March 2020.

54. The conduct of the Ranson tribunal including issues in relation to

documentation provided to the tribunal is addressed in the separate Wright

Review. A memorandum of understanding has governed the interaction

between the two reviews.

No public inquiry recommended

55. The Chair had a specic requirement in the terms of reference to consider

whether a public inquiry was needed. The terms said: “If at any time the

Chairperson conducting the review is of the view that a specic area should

be subject to a more formal public inquiry, the Chair may make such a

recommendation to Tynwald in their report.”

56. A statutory inquiry, also called a public inquiry, is a specic type of

investigation set down under the Inquiries (Evidence) Act 2003. Reviews

and inquiries are both independent processes to investigate an event or

situation. The principal four dierences between an independent review and

a statutory inquiry are:

i. The Process of gathering evidence

• In general, a statutory inquiry sits like a court room.

• Witnesses give evidence, one-by-one.

• The procedures in a Review are not as formal, and the Chair of a Review

can use any procedures which are likely to generate useful and accurate

information such as focus groups and public drop-in meetings, as well as

formal interviews.

ii. Public access

• In general, a statutory inquiry is a process held in public, whereas a

review is not. The evidence upon which a review makes its ndings is

not laid out in the public arena and the public does not have access to the

material which a review gathers, some of which is likely to be condential,

save for limited material published in or with the report.

iii. Legal representation

• In statutory inquiries various core participants have lawyers, who make

representations to the inquiry.

• A review process is less formal, and lawyers are not required. The Review

did not permit witnesses to be accompanied by lawyers, and did not

provide funding for anyone to have a lawyer.

iv. Legal powers

• In statutory inquiries there is a power to compel people to give evidence.

The Attorney- General advised Tynwald in relation to the Wright Review

that the power to compel witnesses to attend would not extend to

witnesses who were no longer on the Island.

• A review chair does not have the power to compel people to cooperate,

but where appropriate can publicise names of those who do not accept

requests to participate.

57. The Review Chair did not consider at any time that a statutory inquiry was

required. It is acknowledged that there are some members of the public who

would have preferred the process of evidence-gathering to be carried out in

the public gaze, and to hear witnesses being questioned and challenged in

public.

58. The Chair did not, however, consider at any time that the Review was

hampered by the lack of statutory powers. The Review process has been an

eective way to investigate the pandemic response, as Tynwald intended.

Only one person refused to cooperate with the Review, and that did not

aect conclusions. Much information has been gathered through condential

discussions with civil servants at all levels, through focus groups where

people shared experiences in an informal way, and through written

submissions, which have enabled the Review to form clear conclusions on

important topics. Much of that information may not have been forthcoming

if there had been a public inquiry where only senior gures would be

examined, and where questioning in the public eye may not have generated

the same frank exchanges.

59. It ultimately remains a matter for Tynwald and Government as to whether

any separate statutory inquiry is sought. The Chair is satised that the Terms

of Reference have been met in full by the review process.

The Independent Covid Review

Isle of Man

Team Members

Ms Brunner KC’s role is to lead the Independent Covid Review. She is responsible for

appointing the Review Team, setting the Review’s methodology, commissioning and

undertaking research. The Chair is the sole decision-maker for the Review and will be

responsible for the evaluation of evidence, and drafting and presenting her report.

Ms Brunner KC is a Barrister and King’s Counsel at Albion Chambers in Bristol practising

largely in crime, healthcare and regulatory law. Ms Brunner is also an associate tenant

of the 36 Group, London.

In her work as a Barrister Ms Brunner KC has led teams of investigators and lawyers

in cases of murder, gross-negligence manslaughter and inquests, with cases sometimes

running for many months. She holds two part-time judicial positions, as a Recorder

(sitting in the Crown Court with juries) and Judge of the Upper Tribunal (Administrative

Appeals Chamber).

Ms Brunner was Leader of the Western Circuit 2019-2022. She was elected to represent

the Barristers in the South West, one of six geographical ‘circuits’ that make up the Bar

of England and Wales. She has instigated numerous research and review programmes,

and initiatives. These have included:

• A review of the Government’s closure of courtrooms in criminal courts. The

methodology sought to conduct a gap analysis of data, and ll them through liaison

with the Oce of National Statistics, an analysis of court listings, and interviews with

stakeholders, many of whom requested anonymity. The report, This doesn’t Look

Like Justice received national media interest and exposure.

• An investigation, led by Ms Brunner as Leader of the Western Circuit, into safety in

court buildings during the Covid pandemic, resulted in her Report on Court Safety.

The rst investigation of its kind to address the specic issues in court buildings

during the pandemic, it was evaluated by HM Court Service, and was the trigger for

practical changes and improvements.

Ms Brunner was selected in 2020 to be Chair of the Appeal Board of the Prescription

Medicines Code of Practice Authority, the self–regulatory arm of the Association of the

British Pharmaceutical Industry. She chairs a Board which hears appeals from rst-

instance decisions relating to alleged breaches of the Pharmaceutical Industry Code of

Conduct.

Kate Brunner KC

Review Chair

Alex West

Counsel to the Review

Counsel to the Review is Alex West. His role is to assist the

Chair in all aspects of the Review save for the evaluation

of evidence. He will carry out research and case studies,

analyse documentary material, lead focus group meetings

and provide legal support to the Chair.

Alex is an experienced Barrister whose specialisms

include Inquests and Inquiries, which look at the

circumstances leading to a person’s death and include an

assessment of whether there is any responsibility for the

death on behalf of public authorities. Alex is head of the

Inquests and Inquiries team at Albion Chambers. Alex also

has experience of independent reviews, having carried out

an independent review of over fty deaths in custody on

behalf of a private prison provider.

Alex’s experience has seen him represent the families

of deceased individuals, as well as a range of public

authorities including prisons, health trusts, regulators,

care homes and local authorities. Alex also has signicant

experience in healthcare work and regulatory law.

Dr Mike Gill

Expert Consultant

Dr Mike Gill has worked as a Director of Public Health

at District Health Authority level in the nineties in Brent

and Harrow, and for seven years within the Department

of Health as Regional Director of Public Health for the

South East Region. During that time he had lead national

responsibilities for ‘seasonal deaths’, leading to the rst

Heatwave plan for England in 2004, for the roll out of

screening programmes as a member of the National

Screening Committee, and for the commissioning of highly

specialised services across UK as chairman of the National

Specialist Commissioning Advisory Group (NSCAG).

Since then he co-founded the Climate and Health Council

and helped in the establishment of new medical and

nursing schools in Somaliland.

Recently, Dr Gill has been a frequent contributor to the

British Medical Journal through editorials and op-eds

on various aspects of management of the pandemic in

England.

Dame Mary Ney DBE

Expert Consultant

Mary Ney has a BSc and an MSc in Mathematics from

London University and a postgraduate Diploma in

Management Studies. She has pursued a career in public

services for over forty years, initially in British Telecoms

and then in local government and consultancy.

She rst worked in various roles in policy, strategic

planning and nancial management in Westminster,

Haringey and Southwark Councils. In 1992 she was

appointed Director of Social Services and Housing for the

London Borough of Harrow.

She held the post of Chief Executive of the Royal Borough

of Greenwich from 2000 to 2014. That period saw the

transformation of council services, major regeneration of

the borough and the development of the local economy. In

2012, Greenwich became a Royal Borough and successfully

hosted three venues for the Olympic and Paralympic

Games. The Royal Borough of Greenwich was awarded

‘Council of the Year 2013’ by the LGC. She has extensive

experience of resilience arrangements including as

London Local Authority Gold during live incidents.

In 2014, Mary was an inspector on the Casey Corporate

Governance Inspection of Rotherham MBC. Following

the removal of decision-making powers from the Council

in 2015, she was appointed by the Secretary of State as a

Commissioner in Rotherham to its successful conclusion at

the end of a four-year period of intervention.

From 2016 - 2022, she was a non-executive director at the

Department for Levelling Up, Housing and Communities.

She undertakes mentoring and strategic consultancy

projects and is a Senior Associate of Cratus

Communications. Mary has undertaken a number of

strategic reviews for the UK Government including

a Review of the Governance of Local Enterprise

Partnerships, an Independent Review of FE Colleges

Financial Oversight, and a Rapid Stocktake of the Lessons

Learnt and Good Practice in Management of Local Covid

outbreaks with a focus on the experience in Leicester City

and Leicestershire. She undertook a review of London

Resilience Structures for London Councils.

In the 2019 New Year’s Honours List she was made a Dame

of the British Empire for services to local government.

Rachael Geddes

Project Manager

Rachael Geddes works at Croft Consulting. Her role

as Project Manager for the Review includes witness

liaison, timetabling the Review team’s work, auditing,

collating and marshalling of Review documentation,

management of the Review’s document platform,

coordination of written submissions, and process

design. Rachael manages the Review’s external

and media communications and has overseen the

production of the Review report. Rachael also heads

up the project management team on a separate

substantial Review.

Rachael is an accomplished communications and

project manager with experience across a variety

of sectors, including retail, tourism, nance and

professional services. She has extensive experience

working with both start-ups and complex

organisations, leading projects and communicating

with diverse audiences, stakeholder groups and

remote teams.

Lana Murphy

Lead Researcher and Document Analyst

Lana Murphy is Lead Researcher and Document

Analyst to the Review. She assists the Chair by

undertaking research, analysing material, and

providing administrative support to the team.

Lana is a criminal Barrister who has experience in

both prosecution and defence work, and regularly

appears at the Crown Court. She also acts on behalf

of police forces and the probation service. Before

joining Albion Chambers, she was employed as a

Senior Crown Prosecutor at the Crown Prosecution

Service where she was responsible for making

charging decisions. Lana was also seconded to the

Attorney General’s Oce where she gained valuable

experience drafting advices for the Attorney-General

and Solicitor-General.

The Review’s Report was produced by Stefan Godier, who delivered accessibility

consultancy, brand denition, typography, design, layout and typsetting

throughout.

The Review was also supported by Paul Fletcher, Lucy Swingler, Rachael Stitt

and Joe Broadway.

The Review’s solicitors were DQ Advocates and Kingsley Napley.

The Independent Covid Review

Isle of Man

Appendices

Contents

Appendix 1: Standard letters re: meeting, invitation to interview,

and submission .....................................................38

Appendix 2: Working protocol between the Review and

Government Coordination team ......................................46

Appendix 3: Topic list ................................................52

Appendix 4: Government Coordination team report ....................60

The Independent Covid Review

Isle of Man

Appendix 1:

Standard letters re:

meeting, invitation

to interview, and

submission

Created by the Review

The Independent Covid Review

Isle of Man

Chair of the Review: Kate Brunner KC

Counsel to the Review: Alex West

Project Manager: Rachael Geddes

Website: www.covidreview.im

Name

Address

By email only:

Date

INTERVIEW INVITATION

Dear X

As you will have anticipated I would very much welcome your involvement in the Independent

Covid Review. This letter is to give you more information about the process which I would like to

follow.

Talking to the Review

I would like to speak to you towards the end of my information-gathering process, in September

2023.

I am sure that you will have a great deal to tell me, but to structure our conversation I will send

you a list of topic areas which I would like to talk about. I anticipate that I will send that list to you

by August 2023.

Please alert my administration if you no longer have access to documents or emails which are

needed to refresh your memory. Could you please let me know by the end of June what

documents or emails you think would assist you, with reference to the role you played during the

pandemic, and I will endeavour to make those available to you through the Review’s secure

online platform. It may be that on later receipt of the list of topic areas in August you realise

there are further documents you wish to review. If that is the case I will be happy to make those

further documents available to you.

If you wish to prepare a report or informal statement before our meeting then that would be

welcome, but it is not expected. Please share any such documents with the Review by submitting

them using a secure link.

I intend to record the conversation to assist me when it comes to writing my report. I will not

make the audio recording public. I may wish to publish all or part of the transcript of our

conversation as part of the materials supporting the Review. I would intend to refer in my report

to important information and opinion which you give me, and attribute that to you. Please let

me know before the interview if you do not agree to this procedure.

I will ask you at the end of our conversation whether you wish to tell me anything further in

confidence. If so then I would not identify you as the person who provided that confidential

information to me.

Page 2 of 3

About the Review

The Review is entirely independent of Government and is considering all aspects of the

Government’s handling of the pandemic: the Terms of Reference are here. I am keen to capture

what went well, as well as what could be improved upon. The website has details about the

Review’s procedures, and updates on progress.

The Review’s privacy notice is link which will give you further detail about what information the

Review is seeking and how the Review will handle information you give.

Next Steps

I will be back in touch later in the year, but in the meantime if you have any queries about the

planned process please don’t hesitate to get in touch with my project manager

Rachael.Geddes@covidreview.im.

Yours sincerely,

Kate Brunner KC

Chair of the Independent Isle of Man Covid Review

www.covidreview.im

The Independent Covid Review

Isle of Man

Chair of the Review: Kate Brunner KC

Counsel to the Review: Alex West

Project Manager: Rachael Geddes

Website: www.covidreview.im

Name

Address

By email only:

Date

MEETING INVITATION

Dear ,

I am writing as Chair of the Independent Isle of Man Covid Review to ask for your assistance. I

would be very pleased if you could take part in a meeting to provide information for the Review.

This is not a request to take part in a formal interview; the meeting is intended to be a relatively

informal discussion.

My administration team will be in touch with details. The meeting will be with you alone, rather

than in a group, because that seems to us to be the best way to capture the information you may

have without taking up too much of your time. The meeting will be chaired by a member of the

Review team.

The meeting will be recorded, simply to ensure that I have an accurate record of what was said,

which is likely to assist me when I come to write the report. The recording will not be made publicly

available. I do not intend to publish a transcript of the conversation.

I will use the information which you share with me to help me understand what happened. In the

final report I intend to list the names and roles of people who I have had meetings with. Generally,

I do not plan to attribute particular comments from meetings like this to particular people. Instead

where possible I intend in the final report to refer to information from groups of people. For

example, the report might say: ‘I understand from officers and ex-officers in the Department of X

that xyz happened’. If it seems to me that it would be helpful for readers of the report to understand

where a particular comment came from then I will ask for your permission to attribute a comment

to you.

I am taking this approach because I recognise that it may sometimes be difficult for those employed

by Government to make frank comments about decisions and processes in public, and because my

priority is to obtain the most full and accurate information possible to inform recommendations.

About the Review

The Review is entirely independent of Government and is looking at the Government’s handling

of the pandemic. The terms of reference are here. The Review will identify what was done well by

Government and what could have been done better.

Page 2 of 3

I wish to stress that I see this Review as a constructive process of gathering as wide a range of

recollections and views as possible, to assist me to evaluate Government decisions and make useful

recommendations. The focus is on learning lessons and emphatically not on apportioning any

blame. There is more information about our processes at www.covidreview.im.

A copy of the Review’s Privacy notice is included here.

I am conscious that speaking about matters relating to the pandemic may be difficult for a whole

variety of reasons, and Government has put in place support which is available to you on a

confidential basis at IOMG Staff Welfare: [contact details]

Best wishes,

Kate Brunner KC

Chair of the Independent Isle of Man Covid Review

www.covidreview.im

Isle of Man

Chair of the Review: Kate Brunner,

Counsel to the Review: Alex West

Project Manager: Rachael Geddes

The Independent Covid Review

Name

Address

Date

REQUEST FOR WRITTEN EVIDENCE

Dear X

I am writing to you in my role as Chair of the Independent Isle of Man Covid Review.

I would greatly value your input into the Independent Review.

The Review is seeking a written submission from you about the following topics:

Your views about what you think went well, and what you think could be improved would be

helpful, along with any suggestions you have for how Government could put itself in a stronger

position to deal with any similar situation. Specific examples are often very useful. You are

welcome to let me know your insights about any other aspects of the Government’s response to

the pandemic that you consider to be relevant to the Review.

I would like to have the option to publish all or part of your submission alongside my final report,

and to use comments from the report which I may attribute to you if I consider it would assist

readers to understand my conclusions. If you do not want me to take this course and want your

identity and documents to remain confidential then please indicate that when you make your

submission.

I appreciate that it will take some time to respond to this request, and am very grateful for your

assistance.

Please make your submission to the Review Team using this secure link by [date]

About the Review

Page 2

The Review is entirely independent of Government and is looking at the Government’s handling

of the pandemic, to identify what was done well by Government and what could have been done

better. The Terms of Reference are here. I see this Review as a constructive process of gathering

as wide a range of recollections and views as possible, to assist me to evaluate Government

decisions and make useful recommendations. The focus is on learning lessons and not on

apportioning any blame. There is more information about our processes at www.covidreview.im.

The Review’s privacy notice is here which will give you further detail about what information the

Review is seeking and how the Review will handle information you give. Please do not include

sensitive information about identifiable individuals, such as their health details. Any information

about identifiable individuals should only be provided if it is necessary to understand your

submission.

Please contact my administration team if you would like to discuss anything relating to the

proposed process.

Yours sincerely,

Kate Brunner KC

Chair of the Independent Isle of Man Covid Review

The Independent Covid Review

Isle of Man

Appendix 2:

Working protocol

between the Review

and Government

Coordination team

Created by the Review

The Independent Covid Review

Isle of Man

Chair of the Review: Kate Brunner KC

Counsel to the Review: Alex West

Operations Director: Paul Fletcher

REVIEW SUPPORT PROJECT TEAM/INDEPENDENT REVIEW TEAM

WORKING PROTOCOL

Draft 4, 21.03.23

1. Members of the Independent Review team and project team meet weekly. Most processes

are determined by discussion and agreement without the need for a formal protocol.

2. In relation to quality assurance, the project team will update the Independent Review team

if there are any significant concerns about accuracy or completeness of information.

3. In relation to redaction, both the project team and Review team agree the minimum

personal data should be transferred. Both the project team and Review team work within

data protection legislation and in line with their internal data protection documentation.

The following reflects the general approach to be taken:

• Special category data will be redacted.

• Personal identifying information except for names will be redacted (contact details,

date of birth etc).

• Names will be redacted where they are in a list of members of the public, where it

appears unlikely that the Review would be assisted by knowing particular names. As

examples, names should be redacted from lists of people who have been awarded

grants; lists of parents of vulnerable children; lists of passengers on a repatriation

sailing; lists of staff with health conditions.

• Names of all members of government and Tynwald, civil servants, public servants,

advisors and the like must be retained (unless they fall into the special category

data above e.g. lists of staff members with medical vulnerabilities).

• Names will be retained where they provide some context and have some relevance.

That is to be construed widely, as it is likely that the Review will be assisted by

knowing who attended meetings, or who was corresponding about public health

advice, or who was sending information about a topic or being consulted or spoken

about. As an example, it would clearly make a significant difference to the weight of

a document whether it was provided by a public health specialist in the UK, or a

member of the public. As another example, the Review will be positively helped by

being able to identify the business leads etc who were corresponding with

Government.

4. The Support Team will using the following coding system:

Special Category data

Personal Identifiable Information

Block redacted in Blue

Block redacted in Orange

• Race/Ethnicity

• Sexuality

• Political opinion

• Religious belief

• Union membership

• Physical/Mental Health

• Biometric/Genetic data

• Criminal record

• Commission/alleged

commission of an offence

• Proceedings of any offence

committed or alleged

• Other sensitive data

• Name

• Date of Birth

• Age

• Gender

• Passport number

• Contact number

• Email address

• Location

• Online identifier

• Other unique identifier

• Other personal data

5. Redactions will be replaced with a description (e.g. ‘list of patient names’ or ‘contact

details’).

6. If there is any doubt about whether to redact then the Chair or counsel of the Review

Team should be asked.

7. The Project Team will keep a log of all documents redacted by Department/Board/Office

and, once the document transfer process is complete, will reflect this information in the

final version of the IAR for each. The Project Team will also keep a record of any queries

and decisions made by the Review Team regarding redactions.

8. Information Asset Registers (IARs) will be the key document whereby

Departments/Boards/Offices identify documentation which may be of relevance to the

Review. Robust version control will be maintained in order to demonstrate where decisions

have been made and where additional information has been included.

The following method will be used in relation to the agreed coding system:-

• Red = these items, or group of items, have been indicated as required by the

Independent Review Team, and should be imported.

• Purple = the Independent Review Team require more information and/or a

summary of what this item contains. IoMG will detail on the asset register

document or provide a summary paragraph in a document referencing the line

number.

• Green = the Chair will review documents in person when on Island to determine

requirements.

• Black = these items are not required at this time, but may be requested at a later

stage.

9. The central principle of the Information Asset system is that all potentially relevant

material must be listed, and the Chair determines what documents should be provided.

There should be no withholding of documentation by any Department or Board on any

grounds including privilege: that would be against the Terms of Reference which grant the

Chair full access to government documentation.

10. In relation to high volume emails identified on IARs, the Chair has agreed to meet with key

personnel from the relevant Department/Board/Office to discuss the most pragmatic way

forward. All are conscious of the time commitment required to upload, review, redact and

transfer high volumes of emails which will often contain a large amount of personal data,

and which may contain minimal relevant material. The general approach taken is that if the

information is already contained within other types of documents, then emails are not

necessarily required. However, should emails contain any related approvals or if they

record decision making for example, not captured elsewhere, then they are of relevance.

The Project Team will organise meetings between officers central to the process and the

Chair of the Review so that the detail can be discussed and recommendations made. For

example, the Chair may ask for summary reports which still provides the Review with the

relevant information, or the Chair may ask for emails between specified dates.

11. Confidential/highly sensitive documentation, as flagged by the relevant

Department/Board/Office will be listed on a separate spreadsheet in addition to the IAR.

This will be used as a flagging system to identify documents of a highly sensitive nature

where the Chair of the Review is required by the Data Sharing Agreement clause 12.5

(replicated below) to seek permission before publishing as part of the Review.

“any confidential information expressly identified by the Cabinet Office, Government

Department or Statutory Board as being of a highly sensitive nature shall not be publicly

disclosed without first consulting”.

It is recognised that at least one member of the project team is also a witness. That is

unavoidable in a small jurisdiction and will be treated with caution. Any discussion

between the project team and Review Team about evidential matters will be dealt with in

the usual way through a meeting.

12. Large volume emails from archived individual mailboxes

Where large volumes of emails are identified from within the mailboxes of former

employees, the project team and the Review Team have agreed that a keyword search will

be performed on emails to identify those which are related to Covid. The project team will

filter out any which are not deemed relevant using this method, however those emails and

attachments will be retained in a holding folder so that should the Review team require

any additional threads or find links to emails which have not been transferred, the project

team can search and transfer at the request of the Review Team. The project team will

provide a report which will identify the titles of emails which have not been sent (redacting

any personal information as necessary). Due to the manual nature of undertaking this

process, the project team will also perform a 10% QA check as a peer review of decisions

made not to transfer emails to the Review Team.

The Independent Covid Review

Isle of Man

Appendix 3:

Topic list

Created by the Review

Topic Category Sub-topic Keyword

Borders

Border Rules

Communications at border

Comis

Police Escort

Exemptions incl. keyworkers

Quarantine and testing regime

Airbridge

Travel Notication Service

Data tracking re borders

Repatriation

Communication

111 line

Public announcements

Communication with police and other agencies

Communication between Government departments

Communication - other

Consultations and responses

Community Support Line

Are you ok?' Campaign

Education

Remote Learning

School Closure

Vulnerable Children & safeguarding in schools

Hub Schools

Essential workers

Communications

Exams

Strike action

School holiday support

Data tracking re schools

Mental health

Infection Control

Free school meals

Topic Category Sub-topic Keyword

Emergency Planning

Pandemic planning

exercising

Logs and sitreps

Infrastructure and utilities

Civil defence corps

Mass notication system

Risk register

Covid emergency command structures

Mass fatalities, coronial service

Current emergency planning

Modelling

Governance

Delegation framework

Constitution

Codes

Scrutiny incl PAC

Equalities

Complaints and whistleblowing

Vision statements, strategies,

HR policies and practice, sickness levels

IT actions re home working

Business as Usual arrangements eg planning

applications, registrars service

Covid funding programmes and allocations

Funding criteria

General

Public Health Governance

Public Health Advice

Topic Category Sub-topic Keyword

Emergency Powers

Monitoring spend

Use of Emergency Powers Act

Use of Public Health Act

Scrutiny of Emergency Powers

Rationale for using EPA/PHA

Communication of legislation to Tynwald

Publication of legislation

Civil contingencies bill

Financial Support

Earning replacement scheme incl. take up

Salary support scheme incl. take up

Other nancial support

Data sharing between Treasury/Department of

Enterprise

Communications between Departments and business

Welfare benets incl. demand data

Impact on economy

Data tracking re nancial support

Advice and support to business

Hospitals & Health

Capacity & Infrastructure

Delivery of non-Covid healthcare

Delivery of Covid healthcare in hospital

Delivery of covid healthcare in community

Long Covid

Effect on waiting lists

Data on infection and loss of life

Primary Care

Stafng

Shielding

Topic Category Sub-topic Keyword

Procurement & Supply

PPE

Medical Equipment

Supply Chains

Procurement Process

Financial regulations

Contract standing orders

Restrictions inc

lockdowns

Policing lockdowns

Modelling

Medical leadership structure

Lockdown 1 March--June 2020

Lockdown 2 Jan 2021

Lockdown 3 March-April 2021

Social distancing

Masks

Social Care

Abbotswood

Care Homes

Commmunity based services

Voluntary sector

Safeguarding

Mental Health services

Social care demand data

Nursery provision and Childcare

Social Issues

Housing and Homelessness

Domestic Abuse

Justice System

Prisons and Detention

Immigration and Asylum

Inequality of impact

Foodbank demand data

Disability and learning disability

Employment Rights

Topic Category Sub-topic Keyword

Steampacket

Isolation exemptions

Communications between Steampacket and government

Protocols

Outbreak

Testing

Testing in UK

Testing in IOM

Isolation

Outbreak management

Genomic testing

Contact tracing

Home testing

Procurement

Frontline worker testing

Vaccine

Patient Group Direction

Procurement

Indemnity

Delivery

Communication and Messaging

second dose

booster

Take up & rates

Vaccine hesitancy

Stafng/resourcing

Topic Category Sub-topic Keyword

Tracking Data re health

and testing

Infection rates, R number

Hospitalisation rates

Intensive care/ventilator rates

Hospital stay times

Hospital capacity and performance for non-covid

services

Death rates

Long covid data

Testing capacity

Positive test rates

Tracing performance

Modelling

The Independent Covid Review

Isle of Man

Appendix 4:

Government

Coordination team

report

Created by the Government

Coordination team as an internal

report, provided to the Review

Page 1 of 11

Independent Covid Review – Isle of Man Government Project Team

Reflections and Opportunities

Background

An Independent Review into the Isle of Man Government’s (IoMG) handling of the Covid pandemic was

commissioned by Tynwald with the Terms of Reference agreed in November 2021. Subsequently, upon

appointment of the Chair of the Independent Review, amendments to the Terms of Reference were

recommended and agreed in November 2022. A formal project was then created in order to coordinate

the IoMG provision of material held across the organisation and provide other forms of assistance

required by the Review.

Procurement of the electronic document records management system (EDRMS) had already begun in

October 2022, led by a Project Manager from Business Change Services, supported by the Public

Records Office (PRO) who provided specialist advice relating to specification and configuration. The

PRO then initiated the first phase in liaison with 20 Departments, Boards and Office to commence a

piece of work known as the ‘discovery phase’; the purpose of which was to identify documentation

held by the Isle of Man Government relating to the response to the pandemic.

It is important to recognise the scale of this project which touched every Government Department,

Board and Office and was, in essence, a large scale records management, information governance and

data protection project. Challenging time frames were initially set in order to deliver this Review by

December 2023, however there was a need to balance this with ensuring that each phase was given

the attention to detail it required, in order for it to be conducted thoroughly.

A Project Coordinator was appointed in December 2022 to manage the gathering of records and other

information for the purposes of the Review and to act as a point of contact for Kate Brunner KC, Chair

of the Review and her team. The immediate priority was to progress a number of key pieces of work in

relation to the legal basis for the Covid Review, complete a Data Protection Impact Assessment (DPIA),

create multiple data sharing agreements as well as working closely with the PRO and Departments,

Boards & Offices to agree processes in order to identify material. The deadline for the transfer of

documents to the Review team had originally been agreed as 31 January 2023. It was recognised very

early on that it was extremely unlikely that this would be achieved, given that in early December, the

discovery phase was in its infancy, the EDRMS (Laserfiche) had not been configured and tested, there

were no sharing agreements in place, the DPIA had not been sighted by the Information

Commissioner’s Office (ICO), and there was no project team resource in place to undertake the transfer

of any documents. The foundations of the project were being built at speed and those officers involved

were working extremely hard to ensure that the project could continue at pace. Work which would

usually take months to achieve sign off was being completed in days.

There were real concerns at this stage in the project, that the ability to deliver on schedule in order for

the Review to meet the final report deadline of 31 December 2023 was at risk. Therefore, the Project

team set actions in motion in order to work towards preserving this deadline and thanks to the

patience and understanding of the Chair and her team, the Review has remained on track. It must be

acknowledged that the Chair and team have had to review and implement alternative processes in

order to account for the fact that not all documentation had been received by the original deadline.

Page 2 of 11

The bulk of material which was originally identified via Information Asset Registers (IARs) was

transferred by the end of May 2023; the Project team worked closely with the Chair to prioritise and

reprioritise material which was required to support the methodology applied by the Review team and

that would work with their timescales for topics, interview preparation etc.

The contribution, support and engagement from all officers across the Isle of Man Government has

been instrumental in keeping the project moving forward at the pace which was required and also in

maintaining this into the transfer phase. The Project team and sponsors are extremely grateful and

recognise that the requirements of officers and Departments to provide assistance was in addition to

already pressured roles. Although in the early stages of the Project, a small number of officers in each

Department, Board or Office were involved, throughout the course of the Project, the Coordinator and

team have contacted over 200 members of staff to seek assistance, guidance, provide documentation

or answer queries.

Reflections

The purpose of this report is to record the reflections of the Project team over the course of the

project. This report documents what went well, what could have been done differently and any lessons

taken from the work over the last eleven months which present opportunities for the Isle of Man

Government to make changes and improvements.

Now in its final stages, the Review is on schedule and there is an expected underspend with regards to

the Project team budget. The Project Coordinator and Project Manager have spent time recently

reflecting on the work of the last eleven months and reviewed logs kept of highlights, challenges and

noteworthy events in order to detail in this report. It is also important for historical purposes to

document how the Review was conducted from the point of view of the IoMG. The Project will be

transferring tens of thousands of records to the Public Records Office for preservation.

Challenges

 Information Asset Registers (IARs)

It was recommended that the best approach to discovering what material was held across the

entire Isle of Man Government was for each Department, Board & Office to undertake the

process of completing an IAR. A template was created by the PRO along with supporting

guidance and advice sheets. It was determined, mainly due to time constraints and expected

volume, that a high-level register would be completed in the first instance, followed by further

detail if the Chair of the Review required it in order to understand the detail of material at a

more granular level. The challenge with this method was dealing with the broadness of the

request – the Review itself covers an extensive range of topics and spans a wide date range

(Dec 2019 – April 2022). It was difficult to provide Departments, Boards & Offices with an

indication of what was “relevant” when the request was “anything relating to Covid during the

Review period”. It was crucial that Departments, Boards and Offices were not determining the

relevance and excluding documents; this decision was the Chair’s alone and therefore

requirement placed on each Department, Board & Office was great. The deadlines for

submission of all IARs was 31 December 2022 – the time of year and already pressured officers

meant that there was a considerable amount of negotiation in terms of realistic delivery of

those IARs.

Page 3 of 11

 Resource

Given the enormity of the task for Departments, Boards & Offices, the Project Coordinator

reviewed the Project budget and offered funds to each in the form of an EO (or equivalent) for a

period of six weeks which could be used for backfill or employing agency staff. Some

Departments, who held a significant volume of documentation, utilised this funding and

backfilled existing staff to deliver the work. One of the hurdles encountered early on related to

access to the Covid pandemic records. These were restricted to certain members of staff and/or

only a small number of staff were familiar with the records themselves and the way they had

been archived, so the work rested with a small number of officers. It has to be acknowledged

that resource implications were underestimated at the outset and did play a role in the delay in

identifying records and subsequent transfer of material.

In terms of resourcing the Project team itself, there were a small number of applications for the

six month LTA roles. Short-term roles and this nature of work are not particularly attractive to

officers in substantive roles or in longer term LTAs; only one of the LTA roles was recruited to.

The Project team also found it difficult to recruit agency staff who were available at short notice

to support the programme of work with little training/introduction to IoMG. It was crucial to

have a strong background in information governance and data protection along with a good

knowledge of how the IoMG functions as an organisation. Agency staff who were employed

were extremely capable, learned very quickly and were consistently working at speed. The

Project was fortunate enough to have two staff redeployed at very short notice who were

invaluable to the success and speed of the operation once the project was in the transfer phase.

 Legal basis for the Review

A learning point for the IoMG in relation to the legal basis is that at the point of ToR being

approved or even prior to this, the legal basis should have been considered and agreed. It is

understood that discussions were taking place, however there were delays to agreements being

signed and the commencement of the transfer of documents. The AGC Office were extremely

responsive and worked at pace to ensure that the relevant drafting was undertaken and

Direction Notices were organised in order for the transfer of documents to begin in the New

Year.

 Data Protection Impact Assessment (DPIA)

Due to the nature of this Project, the drafting of the DPIA was critical in terms of considering

and identifying risks, solutions to mitigate the risks identified, and suggestions for best practice

processes to be used to ensure that all aspects of security, sharing, processing personal data

and the impact of such was included. One of the difficulties in drafting the DPIA was that the

Independent Covid Review was a new process to everyone involved. In order to conduct the

DPIA it was necessary to be clear on the legal basis and the business process that would be

adopted to capture and transfer the information to the Independent Review Team. As

mentioned above, the initial delay in clarifying the legal basis and the need to build the

appropriate ‘business process’ to support the Review Team requirements meant that a

considerable amount of research and discussion was required in order to be assured that all

things were considered as well as identifying issues which may not be obvious at first.

Page 4 of 11

 Data Sharing Agreements (DSA)

DSA’s were drafted as best practice to ensure the data sharing between the Parties occurred in

accordance with the provisions of the Data Protection Legislation. The DSA set out the

parameters of sharing, the process which would be used and the types of information to be

shared. Again, due to timeframes and the pressure to begin transferring material, it was

extremely time pressured to ensure that the DSAs were agreed, signed and in place prior to

transfer. One Department was content with the Direction which was in place so did not wish to

 Cross-Government challenges

Simply, the practical challenges of dealing with a large number of officers across all

Departments, Boards and Offices who are structured differently in terms of their information

governance set-up and leadership teams was challenging in the early part of the Project. Some

are more advanced in the IG space and others were having their own challenges in terms of

resource and available expertise. The initial expectation of having 25 Laserfiche licences soon

escalated to having 57 licences across the IoMG in order to provide Departments, Boards and

Offices with the access to upload material to the EDRMS. The DHA finance team were extremely

helpful in processing urgent purchase orders and MBS (providers of Laserfiche) were supportive

of a pragmatic approach to setting up users and providing access swiftly.

 Laserfiche Training

Online training sessions were organised with training guides created and distributed.

Fortunately, there were only a few teething problems with the configuration and crucially the

metadata form had been reduced from 3 minute completion to 50 second completion. The

system had the ability to batch upload which sped up transfer considerably. However, there

were persistent problems with the desktop application in terms of performance and ability to

transfer large volumes of documents. This issue was repeatedly raised with IoMG IT support

over the course of a number of months and unfortunately still remains unresolved.

 Organisational memory

Due to the number of senior officers who have left the IoMG and who were central to the

pandemic response, the lack of organisational memory has affected the ability to be able to

provide substantial responses and evidence to the Review across a number of key topics. This

also resulted in a small number of senior officers who are still employed by IoMG being

approached numerous times over the course of the Project to answer queries and assist with

sourcing documentation. The Project team is extremely grateful for the continued support from

those individuals.

 Staff wellbeing

The effect of “re-living” the time of the pandemic has, understandably, been difficult for a large

number of people. The Project team were conscious of this throughout and early on discussed

additional resource for Staff Welfare as an avenue for officers to seek help and support. The

Project Coordinator has been very mindful of the impact of this on people and has spent time

offering support on a 1:1 basis. Given this, the team are even more grateful for the support and

assistance of officers who have been involved in answering emails, writing submissions,

collating documents, trawling through material which was very difficult and often upsetting to

read. This should be recognised.

Page 5 of 11

 Documentation gathering

Not knowing if all Covid-related documents held by each Department, Board & Office has been

provided was something which the Project team were conscious of throughout. Some

documentation was discovered weeks or months later. For most documents discovered at the

later stages, it was as a result of the Review asking a specific question which when led officers

to look in other folders on the network and was also dependent upon how those people

identifying the material undertook the initial searches to complete the IARs. A further issue

which hindered the search for documents was that former employees saved documents in

personal folders/moved folders and documents into areas which other officers no longer had

access to. GTS provided support if this was the case. Also, for some, it was not immediately

apparent that the information would be of relevance, but may have links to the pandemic

response.

Often this uncovered more documents of relevance, which have been found in network folders

or SharePoint sites. This is not a reflection on those providing assistance to the Project and

there has never a suggestion that Departments, Boards & Offices were withholding material

intentionally. After discussion with the Chair, the Project Coordinator reached out to all those in

scope in May 2023 to advise that if further documents were identified it was not too late to

share with the Review. The Chair was always amenable to being informed of documents found

and transferred, even at the very late stages of the Review process.

It is not possible for the IoMG to be 100% confident that all material of relevance has been

identified, documented and transferred to the Review. Due to the sheer volume and

inconsistent recording/filing of documentation together with the time which has passed since

the “end” of the pandemic period, absolute assurance cannot be provided. However, the

Project team and Departments, Boards and Offices have done all they can to provide a level of

reassurance that appropriate and thorough checks have been made to identify documentation.

Although the Project team drafted and deployed robust procedures for processing and

transferring documentation, it was necessary to review almost every single document to check

for personal data/special category data. With the pressure on Departments, Boards & Offices to

upload documentation into the EDRMS, this meant that the metadata form was not always

complete or accurate. In order to keep the pace of the transfer the Project team adopted the

task of reviewing a significant proportion of the material prior to sending to the Review team.

Although this was a resource intensive task, it was a necessity to protect personal data.

There is naturally a risk of human error involved in processing substantially large volume of

documents on this scale and although robust processes and procedures were adopted to

minimise any risk of error or personal data being transferred this needs to be taken into

account.

 Due to the fact that the Review has been conducted independently and that serving officers

were directed to submit their written material via the IRT website portal, there is not a full suite

of IoMG provided documentation on the IoMG side of Laserfiche. This is understood and it may

be that the Chair decides to transfer some or all of this material to PRO at the end of the

Review; this is at the Chair’s discretion.

Page 6 of 11

 Dealing with emails

As one could imagine, the volume of emails discovered which spanned the Review period was

significant. The mailboxes of former DHSC employees totalled approximately 250,000 emails.

The Project team and Chair of the Review recognised early that there would need to be

proportionate and robust procedures for dealing with emails. Protocols were drafted and

agreed which protected personal data and special category data, likely to be voluminous in

emails, but provided the Review team with the material required to provide evidential material.

It was apparent at an early stage that emails provided a key source of evidence together with

attachments which were not stored elsewhere within network folders or SharePoint sites.

Therefore, emails became a key focus in terms of document provision.

The Chair recommended specific data ranges of interest to narrow down the request and

provided a list of key mailboxes of former and current employees. It was extremely difficult to

avoid duplication without removing emails which should have been sent. Methods were

adopted to categorise emails and remove duplicate threads, emails from members of the public

(unless they led to discussions re changes in approach/policy then personal details were

redacted), business sensitive material etc.

The Project Coordinator has provided the Review with a detailed report and multiple

appendices associated to each request for emails.

An issue was identified which related to emails and mailboxes which had been deleted. If

officers had moved Departments at any point during the pandemic and then since the

pandemic, mailboxes were not always kept open or accounts were deleted on the request of

the transferring officer or a senior officer. Therefore, there are emails of relevance and

importance which are not available for transfer to the Review. This is explained further in a

detailed email summary report.

The task of reading each document to perform the appropriate checks for personal data cannot

be underestimated. Over 59,000 emails were processed by two members of the project team in

eight weeks during the final stage of the transfer phase. Approximately 60% of the total number

of documents transferred within Laserfiche are emails with attachments.

 Minutes

Minutes, by their very nature, were crucial documents which captured discussions and decision

making. For the most part, minutes were easily identifiable across those areas in scope,

however at a late stage in the Review further minutes were sourced which were brought to the

attention of the Chair. Those minutes were only discovered by the process of providing the

Review with a schedule of all key meetings which took place during the pandemic.

A common issue was found to be the use of the previous set of minutes as a template (which is

often common practice), however unfortunately in a number of circumstances, the previous set

was overwritten and therefore no longer available. This was the case with some central Covid

Response minutes/notes.

A further factor with minutes and other material is that many were left in draft form – final

versions were not always saved as such. It is understandable that during an emergency

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situation, meticulous minute/note taking is not at the fore however there were so many

versions of draft and “final, final draft” marked documents that it caused confusion about which

was the latest version of events and which, if any, were approved.

 MS Teams chat

During the discovery phase, when identifying information which may have been recorded via

MS Teams, it was reported to the Project Team that the MS Teams chat retention policy

(applied in May 2020) meant that Teams chats between individuals were no longer available.

We understand that, at the time, there was a concern that this policy was not discussed with

the Public Records Office or Departments, Boards & Offices and was implemented with no

communication. Again, this is referenced in the email summary report which provides some

information from GTS regarding the implementation of this policy.

 Information Governance practices

Some Departments, Boards & Offices have less developed IG practices and understandably the

transition from pandemic back to BAU, plus pandemic work, back logs, changes to working

practices etc. has meant that there has not been a “tidy-up” or period of debrief, or reflection

for some officers to enable them to review and formalise their records. Departments now need

support to be able to take stock, review and organise their records. This has hampered the

process of information gathering for the Review but not delayed it.

 EDRMS

The availability of some functionality in Laserfiche was discovered at a late stage and it would

have been beneficial to have early knowledge of “add-ons” (e.g. the import agent tool) which

could have saved hours of document processing and sped up the transfer period, particularly

when it came to processing email attachments.

 Information Sharing

As each Department, Board and Office is a separate legal entity there were issues with

information sharing between areas. Appropriate and proportionate information sharing is made

extremely difficult with bureaucratic and unnecessary hurdles to overcome which delayed work

progressing.

Decisions not to share information for legitimate or not legitimate reasons were not always

shared with either the Project Team or the Review. Transparency about what documents were

withheld for understandable purposes or legal privilege was important. It may be that this

information was deemed extremely sensitive or high in volume and so a different approach

should be taken to provide this, either redacted or the provision of a summary report in place of

large volumes of sensitive documents/emails. The Project Team contacted all areas in scope in

May 2023 to ask whether information was being withheld for any reason and to disclose this so

that it could be discussed with the Chair.

 Legal Privilege

Clarity around legal privilege and the use of this as a reason not to share is something which

needs further consideration when it comes to the agreements between the IoMG and an

organisation/person commissioned to undertake a Review. It is understood that this cannot and

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should not be waived in every case but officers need to be clear when this should be used and

for what purpose, and what the impact of sharing or not sharing has.

 Sourcing data

Sourcing reliable, validated data was difficult within some topics of the Review. Data sets

crossed multiple systems, departments and people, therefore searching for the “approved” set

of reliable information caused problems. Also, teams which were created to respond to the

pandemic and are no longer in situ were not able to source data from those early

spreadsheets/documents/emails. Little consolidation activity had been undertaken since the

pandemic to provide a definitive set of Covid statistics. It is acknowledged that teams had to

revert quickly back to BAU and then run BAU alongside Covid with limited resource so it is likely

that this is “on the list to do”. However, given that much of the data available has not been

reviewed or validated, the Review has been advised that only a small number of data sets can

be used as published material. Other data sets have been provided but not with approval to

publish as the data is not reliable and can only provide an indication of trends.

 Chronologies

A number of chronologies/timelines of specific events during the pandemic were required to be

developed by the Project Team, in conjunction with the relevant authorities involved as the

document evidence did not provide the Review team with a clear pathway of what happened

when. The Review team were in receipt of conflicting information in relation to testing

pathways for example. The Project Team trawled internet archives, documentation and

involved officers across the IoMG to develop timelines such as this one.

Achievements

 As mentioned in this report, the support of Data Protection Officers, Senior Information Risk

Owners and IG Officers has been invaluable to the success and speed of the Project.

 The pace at which the EDRMS was procured, configured, tested and made live was a huge

achievement. That, together with establishing the data sharing elements, contractual terms,

DPIA and other project documentation was a period of extreme workload and pressure but was

progressed at speed.

 Approval of the DPIA by the ICO with one minor amendment should be considered an

achievement given the impact, public importance and scale of this Review. The creation of the

DPIA was greatly supported by officers from Business Change, the Office of Cyber Security &

Information Assurance (OCSIA) and the former DHA DPO.

 High level IARs were extremely useful for enabling the Chair to identify which Departments,

Boards and Offices were potentially out of scope. As a result of reviewing those registers, three

were deemed out of scope, with two providing some more detailed information along with a

small number of documents.

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 In relation to IG processes (naming conventions, registers, filing, archiving, and creation of IARs)

for some areas this was completed to a very high standard and any questions relating to

documentation were able to be answered quickly and thoroughly with supporting evidence.

 Positive, professional working relationships with the Chair and her team have significantly

supported the Project when negotiating deadlines, prioritising and reprioritising tasks. Given the

unexpected issues and hurdles encountered, the Chair has been very patient throughout the

project and amenable to adapting processes and negotiating deadlines whilst still managing to

keep on schedule. Issues were escalated accordingly to Sponsors when it was necessary to gain

traction on a particular concern or where not having significant/crucial information may have

delayed the Review.

 Throughout the entirety of the Project, the team have been very conscious of the importance of

maintaining and upholding the independence of the Review. This was at the fore when

developing processes and procedures which maintained those important boundaries.

 A central element to this Review was the need to protect and keep secure the personal and

special category data of members of the public, patients, residents, as well as special category

data relating to staff. The Project team have reviewed a significant proportion of the documents

transferred and whilst the metadata forms were helpful in identifying what groups of

documents may contain personal information, this was not always accurate during bulk upload

and therefore the project team had to read and re-read some documentation to provide the

assurance that they had all been checked and any appropriate redactions applied.

The time pressure of this project was a significant factor, however the Project team were

focussed on ensuring that a thorough review of material was undertaken when it came to

making appropriate redactions. The Project team did look into technology to support the

identification of personal data/special category data however, this was a particularly niche task

as redactions were dependent upon understanding the names within the document (e.g. names

of staff working for IoMG were retained to be able to follow through lines of enquiry etc. but

names of patients were removed) therefore there was no common factor to applying

redactions.

 Despite the extreme time pressured nature of the transfer of documents, the Project Team were

consistent in undertaking random sample checks of both redactions applied, quality of

documents transferred and a review of the IARs against what documents were in the system.

This provided reassurance to both the Chair of the Review and the organisation that, as far as

possible, the Review has received the documentation it identified as relevant and that personal

data has been protected.

 The total number of documents transferred to the Review team stands at 136,289, as of 29th

November 2023.

 Although the bulk of the work involved in the Project has focused on the document

identification, upload and transfer, the Project team have been involved in supporting the

Review in other ways. For example, scheduling focus groups with Head teachers across the

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Island, organising group sessions across health and social care, scheduling on Island visits

including planning of the open public meetings, individual informal meetings with staff,

responding to a significant number of queries to seek responses to source information or

documentation, sourcing data, creating timelines and chronologies. Throughout the Review, the

IoMG Project team has not had access to any material gathered by the Review from non-

Government sources, or material submitted by Government employees which has been sent

directly to the Review. The Project team has not been privy to any discussions about what

material the Review has gathered or who they have spoken to.

 Contribution and involvement of officers across the organisation has been remarkable; the

project would not have progressed at the pace it did without this support. Towards the last

couple of months of the Review, it was clear that the requests were taking a strain on particular

departments and responses were slower but still delivered in time to provide information to

inform the Review.

 The Project budget is projecting a significant underspend; finances and resources have been

managed closely to ensure that the funding allocation was utilised in the most efficient way.

Opportunities for changes/improvements

Records

management during

a pandemic

The directive from CoMin to not delete any records was not adhered to

across the board. A number of officers deleted material which could

therefore not be provided to the Review. There is a need to consult with the

PRO more closely when making decisions to delete material of importance or

at least have a forum established to seek advice and guidance on deleting

government material.

Guidance on IG & IA

practices

Closer working with OCSIA and the Information Commissioner in relation to

Information Governance and Information Assurance practices to seek advice

and guidance. There was a resistance in some areas to seek this support.

Guidance on IG & IA

practices

There are some basic good record keeping practices which perhaps need

revisiting and training/guidance offered. Some robust communications

around helpful and appropriate practices across government would be

beneficial (e.g. standardising naming conventions, date formatting,

electronic date stamps, use of electronic signatures, strict version control,

use of watermarks, and use of template documents and importance of

metadata). A Records & Information Policy is already in place; it is suggested

that more training and guidance could be developed and communicated to

officers across the organisation with the sponsorship of Chief Officers to

impress the importance of this work.

Utilising technology

to support good IG

practices

General IG practices and standardisation of technology applications could be

expedited. The team is aware that there is work ongoing in this space but can

often move slowly. Utilising technology to lead some small changes but with

a significant impact should be investigated and supported by senior officers.

For example, automating processes across the IoMG estate which

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standardise processes to enforce good records management practices and

utilising a single EDRMS where possible across the majority of Departments

(appreciating the need for service-specific requirements where necessary.

Post-pandemic

debrief

Some may argue that it does not feel “post pandemic” and that Covid

continues to have an impact on people and resources. However, for staff

who were central in responding to the pandemic emergency and were likely

affected by that period in their working life, a form of debrief should be

considered. Some have seen this Review as therapeutic process but also the

Review may have been a triggering process for people who would rather

have left this period behind. The IoMG need to be mindful of this and should

continue to offer support in liaison with Staff Welfare for the most

appropriate solutions/options.

Retention policies

Retention policies in relation to administering and filing documentation in

emergency situations should be reviewed and updated.

Approach to Data

Sharing

The approach to Data Sharing Agreements, the need for them and the

content of them should be reviewed to make the documents meaningful and

practical. The ability to link the DSAs back to legal basis and the DPIA is a

fundamental component of the purpose for information being shared and

therefore the rationale for the DSA. The silo way of working with regards to

data sharing is a barrier to “getting things done” and should be

proportionate and useful rather than purely a paper exercise.

Preservation of

Covid Records

The PRO will be undertaking a piece of work in relation to preservation in the

coming months and will be working closely with all areas to identify any

material which was not provided for the Review and making decisions on

whether this documentation should be preserved.

Summary

On reflection, this unique Project has encountered many challenges, balanced by a number of

achievements over the course of the last year. The Review is due to be delivered on time and the

Project budget is projected to be underspent. The volume of work which has been delivered in a very

short time frame with the support and dedication of all those involved cannot be underestimated.

There is so much good work taking place across the organisation and some innovative ideas to develop

the way people are working; Departments, Boards and Offices should be supported to harness these

initiatives with better networking providing an enabler to make improvements across the organisation.

It is hoped that this report provides the IoMG with an opportunity to review how some working

practices may be developed and rolled out across the organisation in liaison with central functions

which support Departments, Boards and Offices to deliver their services.

Independent Covid Review - IoMG Project Team, November 2023

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