If an event has caused a public concern, such as a major disaster, accident or event which usually involves a significant loss of life, the Government can set up a public inquiry under the Inquiries Act 2005 to investigate exactly what happened, why did it happen, who is to blame and understand what must be done to prevent it happening again. Public inquiries are usually chaired by a serving or retired judge and the evidence presented will be in document form and oral testimony. Following a public inquiry, a report will be produced to identify all the key findings and in most cases suggest recommendations. This will be presented to the Government to implement change.