Examining post-incident processes
March 2022: CRJ Advisory Panel Member Phil Trendall offers his insights into the quality and depth of evidence and questioning when organisations conduct post-incident reviews
I have been reading through the evidence from corporate bodies in the ongoing Grenfell and Manchester Arena Inquiry. I do recommend this as an activity for emergency managers who have time on their hands (I say this with tongue firmly in cheek). Reading, or even watching, the evidence unfold is not an entertainment, but it does provide a professional insight into how the nuts and bolts of corporate planning can become loose.
There is general learning here for organisations; learning about the strengths and weaknesses of internal processes. The evidence provides an insight into how organisations deal with priority setting and governance. It gives a hint about corporate perceptions of risk and it shows that it has become routine for important functions to become under resourced, leaving individuals struggling to provide services to the standard that they regard as the minimum.
Austerity and the pursuit of profit untrammelled by conscience have taken their toll.
Many organisations clearly feel that meeting the minimum regulatory standards or the recommendations of their professional bodies is enough. Indeed, listening to some of the witnesses one gets the impression that there is often a view is that ‘doing the minimum’ or blindly following recommendations offers some form of immunity to future scrutiny. In discussing this with members of the emergency services I have repeatedly heard the phrase: “If you follow policy you can’t be criticised.” This is a fiction for all but the most junior members of an organisation.
Following a recommendation of, say, the College of Policing, does not free a commander from their responsibility to do the right thing. Modern, agile organisations see regulatory requirements and guidance as a starting point, not as the final word. In the same way that embedding ‘lessons’ is not a cut and paste activity, the best organisations ask themselves the corporate questions: What does this mean to us, and what does this guidance look like in the context of our operation?’
One thing that has surprised me is that many organisations appear astonished at the evidence given by their own employees. There are examples of this in both the Grenfell and Manchester Arena Inquiries. This begs the question as to what these organisations have done to learn from the events themselves? How thoroughly did they examine what happened on the nights in question?
This has made me think about the post-incident process. I spoke to several people I know in the emergency services and in local authorities and asked them what their post-incident reviews looked like. The universal response was that they carry out debriefing sessions and use the results to change policy and/or training. That’s it. No poking around asking difficult questions. No internal investigation. No going back to people to ask them to clarify what they did or didn’t do. Statements were only taken if required for a criminal investigation or a formal inquiry. Just a debrief report and a database of comments.
Now, a couple of phone calls, a few cups of coffee and a pint or two does not make for proper research and I am sure that there are plenty of organisations out there that have a more sophisticated approach, but I am worried that, in some places, the debriefing process has assumed a status that is greater than its utility.
Of course, debriefing is an absolutely vital part of the post-incident review, especially if well constructed and conducted. But a debrief cannot provide the full picture. People generally don’t see debriefs as an opportunity to confess their shortcomings. Somebody has to be given the responsibility of frankly addressing the question: How did we do?
Organisations can, it seems, become seduced by their own media releases. In an effort to recognise staff who may done brave things or who, at the least, have worked very hard, there is often a justifiable feeling of pride in what has been achieved. It is a good and proper thing for staff to be recognised, but there also has to be a period of sober self examination. Just because everybody did their very best does not mean that the organisation did well. The public or external inquiry process should create no surprises for a mature organisation. Such bodies will have started to correct their mistakes long before the first public hearing. However, they will not seek to hide behind the recurring platitudes of ‘things are different now’ or the ‘lessons will be learned’. These phrases are hollow when heard by victims, their families and the general public.
It is good to see organisations seeking to defend their staff from unfair and improper attacks in the media or even in inquiries themselves. Staff who have been honest and have had to make difficult decisions in short timeframes deserve support. This, however, is different from the slightly trickier world of reputation management. Reputation counts, but what is said in its defence needs to be holistically true. If public bodies beyond the UK’s National Health Service (NHS), which has some of the most sophisticated incident review systems in the world, ever adopt a full duty of candour they will need to allow the facts to speak for themselves. There is no reason why this should not also apply to commercial concerns. In the aftermath of disaster there is only one legitimate interest and that is the public interest.
There was a lot of talk after the Manchester Arena outrage that non-statutory inquiries such as that conducted by Lord Kerslake offered a speedy route to the truth compared with the cumbersome structures required by a Public Inquiry. The Kerslake Report remains a useful document, especially in the context of its terms of reference, and its utility was increased by the speed of its production. Such inquiries have an important place, but they do not have the power to demand the unvarnished truth from witnesses. For the full truth to emerge, organisations have first to understand what happened and then for that information to be shared and examined publicly.
We cannot talk about learning lessons until we have a culture of openness and frank self examination. The next time I am asked to look at an organisation’s emergency plans, I will ask a few more questions about their post-incident arrangements.