Covid Inquiry Module 3, healthcare report: 'We came masked. We changed minds'
- @cv_cev
- 22 minutes ago
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Opinion | 22 March 2026
By Lara Wong, Founder and CEO, Clinically Vulnerable Families
On Thursday, the Covid Inquiry published its report on healthcare. For Clinically Vulnerable Families it is a vindication - and the beginning of a new phase of our battle.
There is an image I have carried with me since the very first day of our first UK Covid Inquiry preliminary hearing. We were seated beside a water table, next to an open door, in a large hotel reception room - packed with lawyers and members of the public, large established organisations, government departments, and one well-respected, highly experienced judge. And between oral submissions, a lady appeared from behind the dark blue Covid Inquiry temporary wall panel, working swiftly and methodically to disinfect surfaces with her cloth after each unmasked barrister had stepped away from the lectern.
The barristers, to be clear, were doing nothing wrong. This was February 2023, and they were following the guidance of the time ...or the lack of it. Many of them would, shortly afterwards, board a tightly packed tube train home. Meanwhile, the surfaces where we sat - as representatives of Clinically Vulnerable Families (people whose health conditions put them at the greatest risk from infections) - were not wiped. Not that we needed them to be! Having been scientifically trained, we knew that fomites on surfaces can be washed off hands before eating. More importantly, we knew that Covid is an airborne threat. But what nobody in that room could do was clean the air.
That experience crystallised a misconception that had become embedded across society during the preceding years. By cleaning the wrong things, a false impression of safety had been created. This came to be known as 'hygiene theatre'. It is important to say that nobody should blame the Inquiry for following flawed guidance - it was present throughout government messaging, and the vast majority of people would have considered it thorough and appropriate at that time. But the problem was real, and we were always ready to point it out.
Then it was our turn. Our barrister, Adam Wagner KC, pulled out a CO2 monitor and held it up for Baroness Hallett to see.
The reading showed her what was happening to the air in that room, in real time. CO2 can be used as a proxy for how much exhaled air - potentially infectious air - is accumulating in an enclosed space. The numbers on that monitor were, as it happened, reassuring for us - well at least where we had been seated at the edge of the room next to an open door.
Our monitors were later used to measure air quality in the, then, new hearing centre. It was not long before things started to changed. Because we had made the invisible visible, in the room, on the day, to the person who needed to see it most!
AN UNKNOWN SMALL VOICE When Clinically Vulnerable Families (CVF) arrived at that first hearing, we were not a charity with a long history and a board of trustees. We were not a professional body with a helpline and a press office. We had begun as a Facebook group - people with serious underlying health conditions and their families, finding each other in the chaos of the early pandemic, sharing scientific papers and reputable sources, and realising that no one was speaking for us.
We fought hard to be granted Core Participant status - recognition by the Inquiry Chair that allowed us to submit evidence, question witnesses, and make legal submissions. After two failed attempts, we had finally won the fight. But, on that first day, we were still largely unknown. Around us sat organisations with decades of experience and standing. I felt a huge weight of responsibility to represent this poorly understood group - so that their experiences could be properly examined and important lessons learned.
TEACHING BY DOING
Before a single expert witness had given formal evidence on infection prevention and control, CVF was already changing how the Inquiry operated. We brought our own HEPA air filters into the hearing centre. We wore FFP3 masks - a visible presence for witnesses including Boris Johnson, who had me in his line of sight as he gave evidence. We showed, simply by doing, that what we were asking for was possible.
In order to improve the air quality I prepared a detailed presentation on Covid safety measures and clean air standards. The inquiry provided me with measurements to calculate the room volume and occupancy of the hearing centre and Dr Adam Squires, our expert advisor from the University of Bath, reviewed and agreed with my calculations for the modelling of additional air changes required before we submitted them. To their considerable credit, the Inquiry's staff listened. They accommodated our needs as reasonable adjustments - making the building not just more accessible for Clinically Vulnerable people, but safer for everyone. Four HEPA filters were then purchased and added to the hearing room. Subsequently, a number of other filters were added throughout the hearing centre.
In my presentation I also challenged the fluid-resistant surgical masks being offered at the door - a gesture towards protection that the science did not support - and asked for FFP2 masks as a minimum, backing our request with scientific evidence relating to the efficacy of these masks compared to baggy surgical masks. That request was accepted. All of this was in place before the Module 3 substantive hearings began. The Inquiry had accepted our evidence and updated its Covid Policy document accordingly.
This was, in miniature, the same challenge we faced everywhere: institutions operating on the wrong assumptions, misled by misinformation into believing they were doing the right thing, but capable of changing when given the desire and the correct information. The Inquiry was a microcosm of the wider pandemic.
ANOTHER FIRST
Giving evidence at the witness desk while masked was not the done thing at the time. Boris Johnson's government had given the impression, including through parliamentary sessions, that masking and speaking were incompatible. Even though we had worn our masks throughout every session, speaking formally as witnesses was a different matter. Legal proceedings had seemingly not encountered this before.
As far as we are aware, CVF became the first witnesses to give formal evidence to a UK public inquiry while masked - possibly the first in any UK court or formal legal setting. We are proud of that, not as a point of principle but as a point of proof. Every barrister in the room heard every word. Baroness Hallett heard every word. The transcript records every word. The argument that mask-wearing impedes communication - used to justify removing masks from patients in hospitals, from children in schools, from vulnerable people in every setting where they sought protection - did not survive contact with the reality of first Dr. Cathy Finnis and then me speaking clearly and fluently from behind our FFP3s.
We didn't ask for permission to be safe. We arrived modelling safety - and insisted the Inquiry should simply accept our needs. We are pleased to say, it did.
WHAT THE MODULE 3 REPORT FOUND
On Thursday, Baroness Hallett published her report. It is just over 400 pages. CVF's members have been waiting for it for years. What follows is what it means for the people in clinically vulnerable households that CVF represents - and, in some cases, what still needs to happen.
✓ THE SCIENCE ON AIRBORNE TRANSMISSION: CONFIRMED
From our very first submissions, Clinically Vulnerable Families argued that there was a fundamental misunderstanding at the heart of infection control policy: that the belief Covid-19 spread primarily through droplets landing on surfaces - rather than through the air - was driving the wrong decisions and leaving people at the highest risk unprotected in the very settings meant to help them.
The report identifies three fundamental flaws in the UK's infection prevention and control approach. The guidance, Baroness Hallett finds, was:
"wedded to an outdated and scientifically inaccurate understanding of how the virus spread" Module 3 Report
The consequences were exactly what CVF said they would be: airborne protections were deprioritised, ventilation was neglected, and people at the highest risk were left unsafe in NHS settings. Our members who cancelled high-risk appointments, who described hospital care as 'like a game of Russian roulette', who stayed home because they did not trust the precautions in place - they were right. The science was on their side the whole time. The Inquiry has now confirmed it.
✓ CLEAN AIR IN THE NHS: NOW A RECOMMENDATION
The report recommends that HEPA air filtration be prioritised across NHS healthcare settings in the short term, and that all new NHS facilities be built with effective ventilation. The Inquiry's own expert, Professor Beggs, described HEPA filters as 'cheap', easy to install, and doing 'a similar job to ventilation.' We had brought them to the hearing centre before any expert said this. We had measured the air quality. We showed Baroness Hallett the numbers.
Now the NHS must do the same. When hospitals are safe enough for the most vulnerable, they are safe enough for everyone. I will be watching - and asking, loudly and specifically - how and when this recommendation will be implemented. A recommendation without a timetable risks all too easily being shelved.
✓ THE RIGHT TO WEAR A MASK: VINDICATED
Every Clinically Vulnerable Families member who was asked at a hospital entrance to remove their FFP3 and replace it with a surgical mask - told that their own evidence-based protection was less appropriate than a poorly fitting surgical one - has been vindicated today. The Inquiry's expert witness, Dr Ben Warne, stated it plainly, and Baroness Hallett quoted him with approval:
"There was no good reason to prevent patients from wearing face masks." Dr Ben Warne, IPC Expert Witness
The report also records that when routine masking guidance was relaxed in May and June 2022, the proportion of CVF members delaying or cancelling NHS appointments rose sharply. That data came from surveys I had been running with our members over those years - data the government had failed to collect. It tells you everything about the cost of getting this wrong.
High-grade masks are not a political statement. They are protective devices that make healthcare accessible for people who cannot afford to catch an infection. They should never have been taken from us. The Inquiry has said so. Next, we need enforceable guidance to back us up.
✓ EMPOWERING PEOPLE AT HIGH RISK: A COMMITMENT FOR THE FUTURE
The report states that advising people at high risk on how to protect themselves will be:
"vital in any future pandemic" Module 3 Report
During the height of the pandemic, our members were not given information about appropriate airborne protections. They were given a letter telling them to stay home - and then, when shielding ended, nothing. No guidance on assessing and managing personal risk. No framework for re-emerging into a world that had decided that 'Covid was over'. Some of our members have never fully re-emerged. The Inquiry has recognised this as a failure. That recognition matters.
◉ DNACPRS: ON THE RECORD - AND NOT YET RESOLVED
The report confirms what Clinically Vulnerable Families submitted: that 'Do Not Attempt Cardiopulmonary Resuscitation' notices were placed on patients' records without their knowledge or consent, based on underlying conditions rather than individual clinical assessment. The accounts of CVF members are in this report by name - including Lesley Jean Moore, who gave witness evidence on behalf of CVF and feared her severely disabled son would be deemed not worth saving because he was seen as 'a burden'. The Care Quality Commission found 'a worrying picture of poor involvement, poor record-keeping, and a lack of oversight.' All confirmed.
The report does not recommend a systematic review of all pandemic-era DNACPR decisions. The reason given is that these decisions are often not held electronically, making a comprehensive check disproportionately resource-intensive. I understand that. But my response is: if a decision of this gravity - a decision about whether to attempt to save someone's life - is not held in an accessible electronic record, then that is itself an urgent failure that must be fixed. Our members have discovered these notices on their records when attending hospital for something else entirely, years later.
Jennifer, aged 47, found one on a routine hospital discharge note, years later. She had never been asked, and it came as a real shock. Melissa was told over the phone by her GP and felt, in her own words, 'disposable.' This is what happens when a system treats the lives of people with underlying conditions as less worthy of protection. CVF will continue to press for accessible records and a clear process for every patient to see what is written about them. We would not want to see a second inquiry into this issue.
→ LEGAL RIGHTS: OUR ARGUMENT CONTINUES...
This report does not recommend legal recognition of clinical vulnerability as a protected characteristic. However, Module 3 was our first module, and our legal rights argument took time to develop throughout the inquiry via testimony and other evidence.
By the time we reached Module 10 - the Inquiry's final investigation into the impact of the pandemic on society - our argument was more fully formed. The Equality Act does not protect many people with serious underlying health conditions, who face increased health risks. They fall through the gaps in the law that the pandemic exposed this catastrophically. As a consequence their protections were switched on and switched off at the discretion of officials, with no specific recognition or rights to fall back on.
That argument is still not finished. Our final written submissions are yet to be completed. The next pandemic will come. There are millions of people with conditions like cancer, asthma, diabetes, heart disease, and weakened immune systems who deserve to have their safety guaranteed in law - not temporarily extended or withdrawn depending on the whim of the government.
I have often reflected on those early days. A small Facebook group of people learning to manage incredible risks, sharing information, that slow realisation that the most vulnerable in society were being left to work it out alone. That is where Clinically Vulnerable Families came from. That is still, in many ways, where we remain - supporting, informing, and advocating for those most at risk.
But this week something has shifted. The science that our members have lived by - the understanding of airborne transmission, the importance of clean air, the right to wear a mask - is now recognised in an important official report, confirmed by the Chair of a national public inquiry, part of the permanent record of this pandemic. The experiences that our members shared, sometime at personal cost and often with considerable courage, are in that record too.
We walked into that first hearing room carrying our own air filters, wearing our masks, with a CO2 monitor that showed Baroness Hallett in real time what was happening to the air. The cleaner was wiping the lectern. We knew then, as we know now, that the problem was never the surfaces.
So we mark today as a victory. A real one, years in the making, achieved by people who were told to stay at home - and but instead we turned up and made ourselves heard.
Now comes the next phase of this work...
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Lara Wong is Founder and CEO of Clinically Vulnerable Families. CVF was granted Core Participant status in Module 3 of the UK Covid-19 Inquiry, represented by Adam Wagner KC, Daniella Waddoup and Rosa Polaschek of Doughty Street Chambers, instructed by Kim Harrison and Shane Smith of Slater and Gordon. UK Covid Inquiry Healthcare module 3.