I could probably supply the answers without a multimillion pound inquiry.
There were fuckups.
Why were there fuckups ?
Because a decision was made to treat this as a political situation rather than a medical one.
Why was this ?
Because ultimately we elect and trust politicians to run our lives in accordance with our proclivities. If we wanted an evidence based society then we'd act like it.
So what can we do next time ?
Who knows ? Even if we prescribed a plan now, it will be in tatters within months. Let alone a couple of years.