The first phase of an inquiry into the handling of the coronavirus outbreak in the United Kingdom has found that the government and civil services “failed their citizens” during the pandemic, according to a report made public on Thursday.

Heather Hallett, chair of the independent COVID-19 inquiry on the resilience and preparedness of the U.K., wrote in the report that the U.K. “suffered from several significant flaws” in dealing with the pandemic.

The COVID-19 pandemic has been attributed to over 235,000 deaths in the U.K. by the end of 2023, marking one of the highest death tolls globally. The United States had the highest recorded deaths, with nearly 1.2 million people dead according to the most recent data from the Centers for Disease Control and Prevention.

Hallett acknowledged in the report that while it was widely believed the U.K., which is comprised of England, Scotland, Wales and Northern Ireland, was “one of the best-prepared countries in the world to respond to a pandemic,” the findings indicated it was “ill prepared” for any “catastrophic emergency, let alone the coronavirus pandemic.”

Newsweek reached out to the U.K. COVID-19 Inquiry press office via email on Thursday for further comment.

The report said flaws in U.K.’s response to the pandemic included the approach to risk assessment, an outdated pandemic strategy, a lack of consideration for existing health conditions and a lack of diverse perspectives, among others.

The inquiry added that the U.K. “prepared for the wrong pandemic.” While the risks of an influenza pandemic was considered and planned for, “that preparedness was inadequate for a global pandemic of the kind that struck.” Additionally, the report criticized the pandemic strategy, noting that it formulated in 2011 and was “outdated and lacked adaptability.”

The report, spanning over 200 pages, recommends “fundamental reforms” of the U.K. government to prepare for “whole-system civil emergencies.”

It calls upon the governments comprising the U.K. to “simplify and reduce the number of structures with responsibility for preparing for and building resilience to whole-system civil emergencies.” The report also recommends that a U.K.-wide pandemic response exercise should be held at least every three years.

Hallett urged of the gravity of the report and its recommendations, writing, “unless the lessons are learned, and fundamental change is implemented, that effort and cost will have been in vain when it comes to the next pandemic.”

“There must be radical reform. Never again can a disease be allowed to lead to so many deaths and so much suffering,” she said.

This first report, of which there are eight more expected ones, was based on hearings that began in June 2023. The other reports will delve into questions surrounding vaccines, testing, health care systems and economic response to the pandemic, among other topics.