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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.

Review the Ney Report

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.

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