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Risk Governance Management Specialists

It Should Never Happen Again …

but sorry, it will!


Let us try to understand why.

Welcome to my blog


We fail to learn from the past and we wonder why. This purpose of this blog is to exchange ideas on what needs to change if we are not just to repeat our past mistakes.


I have been researching this subject for over ten years. In my first book, published in 2013, I explored the type and quality of recommendations made by public inquiries.  What became clear is the gap between the aspiration of the various recommendations and the likelihood that they will achieve their aims. Since that time, I have been examining what needs to be done if we are to learn from our practical experience.


At the time I started this blog the calls for society to learn where focused on the Sir Martin Moore-Bick's inquiry into Grenfell Tower fire, Sir John Saunders' inquiry into the Manchester Arena bombing and the COVID19 pandemic. I will use these cases to illustrate my arguments.


As the COVID19 crisis developed, I considered it to offer a valuable case study as it was developing in real time. This enabled the roles of foresight and hindsight within the learning process to be examined. Aware of the limits of my own expertise, I approached Professor Nigel Lightfoot CBE for his expertise in public health matters:   Nigel is a former Director of Emergency Response at the Health Protection Agency and now has his own private company where he continues to focus on emergency preparedness, crisis management and  the CBRN terrorism threat.

By alto42, Dec 14 2020 11:37AM

In November (2020) the Health and Social Care Committee and Science and Technology Committee announced that they were holding a joint inquiry into lessons to be learned from the response to the coronavirus pandemic so far.

The Committees stated that they would jointly conduct evidence gathering sessions examining the impact and effectiveness of action taken by government and the advice it had received. They listed eight topics that they intended to examine. One of these was the ’UK’s prior preparedness for a pandemic’. As the subjects of learning from crisis and preparedness for crisis are central to the research that Nigel and I are conducting, we decided to make a submission. (The full submission, that had to be brief, can be found here.)

We are concerned that this committee will repeat the mistakes made by other such inquiries and that they will fail to take on board lessons readily available to them from the past. Our proposition is that, if our theory of failure is valid, then we will see evidence of the following behaviours:

… We will see basic elements of crisis management and other issues (already well understood by subject specialists) taken as being new learning. This would support the proposition that the learning point was not new and that the organisation had already failed to learn from the past. The question then becomes, why should they learn the lesson this time?

… We will see little effort to understand the system as a whole and to understand how the various elements (components) interact: that is, little effort to map the interdependencies between those elements that are a key feature of these complex systems.

… We will see single point errors identified and solutions offered: that is to say, the implicit assumption will be that the process can be perfected by finding remedies that have caused it to be imperfect.

… we will see better learning around tangible technical issues that we will around less tangible social (management) issues.

… We will see hindsight and foresight conflated and therefore a poor appreciation of the quality of the information available to decision-makers. The perfect world paradigm assumed perfect knowledge whereas normal chaos assumes imperfect knowledge. To learn from the past we must learn to cope, as best we can, with imperfect knowledge.

… We will see poor appreciation of the implications for future crises of the information provided by the witnesses.

… We will see evidence of politics and blame culture that is known (and well documented) to be detrimental to the process of learning.

Over the period of these committees holding their hearing and making their report, we will be reviewing the evidence and the final analysis to see whether it supports or invalidates our propositions.

By alto42, Nov 30 2020 09:28AM

There are clamours for lessons to be learnt from the UK's experience of the COVID19 pandemic. This call for lessons to be learnt is a standard feature of all crisis management / disaster management models. Within Disaster Incubation Theory, the lesson learning process is a part of Stage 6 'full cultural readjustment'.

At the end of August 2020, Dame Mary Ney produced a lessons learnt with a focus on the experience in Leicester City and Leicestershire. We choose this example as it was the first to appear when 'lessons learnt' and 'COVID19' was typed into an internet search engine. As such, it offers a random insight into what was known about crisis management of pandemics prior to the COVID19 outbreak.

The stocktake done for Leicester City and Leicestershire was undertaken between 5 and 21 August 2020. It sought to identify the good practice and key learning in dealing with a local Covid-19 outbreak focusing on the experience of Leicester City and Leicestershire. The Ney report(1) says 'The key learning points from this stocktake, therefore, have focused on the strategic and systems messages and the signposting of good practice.' A summary of the lessons are detailed in the box below along with the 'good practice' that they then recommend.

In his response the Secretary of State for Housing, Communities and Local Government Rt Hon Robert Jenrick MP thanked(1) Dame Ney for her 'excellent and thoughtful work'. He goes on to say 'it is especially impressive that so much of the lessons learnt and good practice described in your report continue to have relevance'.

We find these two documents to be disturbing. Not because we question the thoughtfulness of the work, nor do we question the continuing relevance of the findings. What we do find disturbing is that it took such a review to identify that these issues were not already being addressed within the organisation. What we also find disturbing is that it took a crisis, the COVID19 pandemic, before the organisation identified the need to put such basic considerations in place.

Within Stage 2 of the Disaster Incubation Theory, it is recommended that the organisation in question identifies and puts in place the capacity required to manage the potential crisis. All the points listed in the lessons learnt are the types of things that should have been put in place just in case the organisation faced a crisis. Some of these measures are generic, therefore applicable to any crisis, others should be specific to a pandemic. In all cases, consideration of these issues should not have been new to the organisations.

The fact that these lessons are considered to be new should be cause for concern. This would suggest that the organisation was nowhere near ready to face any crisis let alone a pandemic. The question this raises is whether this is a one-off or is typical of the level of preparation to be found at local level. The response from the Secretary of state would suggest the latter.

If we, as a society, really are to learn from COVID19 so we are better prepared for the next one (and there will be a next one), we must learn how to learn and to not the 'free lessons' as seen here.



Learning Points

1. Review the national and local governance frameworks to clarify the interface between them, how councils will be engaged and to strengthen local political oversight.

2. Councils need to exercise local outbreaks scenarios so they are well prepared.

3. The management and effectiveness of announcements of changes in local restrictions could be im proved by the use of a checklist of requirements.

4. Ongoing work is required to improve the testing data available, in particular, data on ethnicity and workplace.

5. Councils should ensure they understand their communities and have community cohesion arrangements in place so that community and business engagement is effective.

6. In devising tactical control plans don’t underestimate the range of skills and local knowledge that councils can deploy at pace from across the organisation.

7. There is scope to further the role of local councils and to move to a more preventative whole system approach on the ground bringing together scaling up of testing, tracing and supporting self-isolation and shielding.

8. There is a need to refine the application of the new regulatory framework in achieving compliance of businesses and events.

9. In Civil Contingencies arrangements, the role of local political leaders and local elected representatives should be reviewed.

Good Practice

10. Implementation of a Local Political Oversight Board to provide a forum for local political leaders to have collective oversight of the management of the outbreak.

11. Integration of the PHE Incident Management Team into local resilience structures and establishing a joint outbreak management team.

12. Community and Business Engagement building on local knowledge and community cohesion work.

13. The local approach to scaling up testing – City Reach – used on the ground teams drawing on the local knowledge of council staff, local NHS staff and volunteers to undertake door to door visits.

14. Tracing contacts using the range of existing council data bases and systems as well as on the ground teams.

15. Bespoke Data Base built to capture activity and testing outcomes of the City Reach Teams.

By alto42, Oct 25 2020 05:05PM

When I try to raise the question "should we be trying to learn from our recent experience?", I often receive the reply: "not now, we are too busy." What I heard them say is "we are too busy repeating previous mistakes to learn from them"! So, when is the right time start learning from a crisis?

Let me set some background. When COVID19 struck I recognised that we had an excellent opportunity not only to learn from our experience of handling the COVID pandemic before the system was once again put under strain by the second wave but also it might provide a "live experimental context" for learning about crisis management.

While it may seem callous to those who have been affected by the virus to acknowledge that the Government is experimenting with the lives of the population, that is the nature of the scientific method when dealing with an unknown factor. And COVID19 presented an unknown factor. To this end, the message from the Government was clear. To me they were asking the population to accept short-term hardship in order to give them time to get an appropriate system up and running. The message was also clear that they recognised the potential for a second wave in the Autumn and their undertaking was that, given this breathing space, the Government would have the appropriate system in place by then. Was this a fair thing for the Government to do?

In my opinion, the answer to this question is "yes". Any organisation that deals with high-tempo dynamic situations (colloquially know as a "crisis"), such as the police and the fire and rescue services, has different administrative and operational configurations. Every time they respond to a major incident they have to go through a period of re-organisation as they establish their revised operational configuration. In a well drilled organisation that can take about an hour; this period has been labelled "hell hour".

In the case of COVID19, the organisation that needed to reconfigure itself to cope with this crisis was the Government. As the Government was not a well drilled organisation, "hell hour" took longer than the hour! In fact, it has taken months and it is questionable (even at the time I am writing this) whether it has established it optimal configuration. It still seems to be reacting to daily events rather than delivering its recovery strategy.

While the Government was absorbed by its own prolonged "hell hour", it is not clear whether they truly recognised the opportunities presented to them by the second "recovery window" [for explanation click on link] that had opened up. This was the period that they had to put in place the mitigation deemed necessary to minimise the disruption that a second wave might cause.

Lest we think that the Government has been particularly lacking in this area, I would suggest you might pause. Conversations I have had would suggest that many organisations "are too busy" trying to cope with the crisis to have the time to learn from the past why they were not better prepared for these events. From the media we see places of entertainment, be they theatres or professional sports, and places of learning all seemingly waiting for the crisis to pass and things getting back to normal. This suggests a major failure to learn from the past by many sectors of society.

So, what have we failed to learn?

• Firstly, our risk management system excludes from consideration the low probability, high impact events. Yet most inquiry reports will contain a statement to the effect that the event was not part of the plan as it was deemed unlikely to happen to them. And so the question is, does your organisation have pandemics (and other killer 'Black Swans') on their risk register and does your process mean that you will also miss the next one?

• Secondly, history shows that pandemics seem to have a life of three years. This is a lesson from the past. We might hope that modern medicine might find some way of preventing infection or of mitigating the effects of the infection but this is more a hope that a certainty. So the question is, can your organisation survive lockdown for up to three years or what is it doing to work out how it might continue to operate with an infectious agent in the community?

• Thirdly, history provides us warnings that infectious agents are not rare. Have we learnt false lessons from the past? Our recent experience of SARS, MERS, ZIKA, Ebola and various flu strains might suggest (driven by optimism bias) that such pandemics are never as bad as we might fear. This would suggest that, even if COVID19 does miraculously disappear, another infectious agent might not be far away. So the question now is, should we be considering the implications of "Pandemic X" and what we need to do to thrive in such an environment?

• Finally, history shows us that while we are absorbed by our day to day activity, we fail to see how the world is changing around us. While many businesses espouse the value of being "agile", how many have the capacity to learn and adapt. COVID19 has, to use the words of Patrick Lagadec, provided the system with a "brutal audit". A true test of being agile is whether your organisation had been able to adapt to the COVID environment and continues to be viable. And so the final question is, when is the time to start learning from the past?

If you did not expect a pandemic to affect your organisation then your risk management system failed. If you are struggling to operate in the current environment, then your risk management system failed. This does not make you a bad person for you will be in good company! I would suggest that the process we used is flawed. Now it is an issue of whether your organisation recognises the problem and looks to learn from it; now is the time to ask whether we could or should do things differently in the future.

So, in answer to the question "when is the right time to start learning from a Crisis?", the ideal answer is "from the moment it starts". The aim of such learning is to determine how organisations might use the past to help them develop better foresight. Therefore every organisation needs to be organised in such a way that prevents them from becoming so absorbed by their day to day activity that they miss how the world is changing outside of their front door.

By guest, Sep 30 2020 09:56AM

Welcome to my website.

As I point out elsewhere on my website, the aim of my work is to find ways of preventing organisational failures. The cases that I examine mainly focus on the delivery of services by public bodies. To be more precise, it is the delivery of services in the context of complex, high tempo environments. My interest is how we extract lessons from the past that help us to deliver these services more effectively in the future.

A key mechanism for learning lessons is the public inquiry. While I have no doubt that these inquiries serve many useful purposes, I would question the value of their recommendations when it comes to managing complex, high tempo operations. I would go further; my concern, based on 10 years of research, is that some recommendations are positively dangerous and lead to a subsequent failure.

I recognise that this is a challenging, multi-faceted subject for which there are no easy answers. However, before we can resolve an issue we must understand it. The question that I would therefore like to explore is:

How best, at the organisational level, can we extract lessons from past experience to ensure we reduce the possibility and impact of similar future failures?

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