What is the Point of Lessons if we don’t learn?

As well as being upset, along with the rest of the nation, as to the recent tragedy unfolding with the Grenfell fire I have also been deeply aggravated by the governments’ response of setting up a public inquiry into what happened and what were the causes.

Every time a major public tragedy occurs this is their stock response. However, as I personally discovered and as I fear we will see again, what is the point of holding public inquiries, finding out the ‘why’ when little tangible action is then taken to implement recommendations that are made?

Everyone wants to learn the same thing from painful situations: how to avoid repeating them.

Gary Zukav

Learn lessons from the past, then apply them.

They pour time, effort and public money into these types of inquiries but to what purpose?

By their very nature inquiries take a great deal of time, often years to conclude and by the time they do come out with findings and recommendations the immediate furore tied to the incident has died down and the will to make the necessary changes seems to have evaporated.

I can think of numerous examples where the time delay has led to exactly this happening and the authorities then shelve the findings as the things that need to be put right are inconvenient or too costly in their opinion. Lessons are clearly given but the will to learn from them melts away.

The only times I can think of when inquiry recommendations have been enforced and put into action have been where survivors or those affected by the incident have had the patience and energy to keep campaigning for them to be done.  I know this first hand as if I had not set up the Paddington Survivors Group and we had not then spent 5 years of our lives pushing, insisting and generally being a nuisance to the establishment our inquiry findings would have been ignored just as they had been from Clapham and Southall before us.

Cutting through red tape, learn lessons, take action.

It is simply not right.  The will should be there and remain there to make the improvements necessary and action should follow. There must be a better way to apply the lessons learned from tragedy in a timely fashion so that we prevent further tragedies occurring.

Business can be guilty of this too. When faced with disquiet amongst employees for example, they conduct internal surveys to identify the concerns. Then, they ignore the findings!

When something is going wrong; people affected naturally want to know why. Business leaders, governments, councils and those in authority have a duty to explore and investigate. However, investigating is only appropriate if you are then committed to actioning the results. All too often, the results are unpalatable; someone is to blame, mistakes have been made. The ostrich reaction is to ignore the results, bury them, delay action, argue the cost implications and do nothing.

Leadership is about accountability, responsibility and action. When something goes wrong, be it accidental, negligence, cost cutting, poor decision making or outright fraud; leaders step up and act. When disaster strikes and people’s lives are affected, responsible leaders find a way to cut through the red tape and fix it. Watch how fast a business will change course in the face of competition or a government will pass a bill that affects the immediate economy when it is needed. It can be done, it just takes the will and smart thinking.

An alternative to a public inquiry is an independent review.

In some cases, there may well be alternatives. The recent – highly revealing and highly cathartic – report on Hillsborough was handled not by a public inquiry but by an independent panel. Lawyer free, much cheaper and quicker, and, in that case, chaired by a bishop.

https://www.instituteforgovernment.org.uk/blog/are-public-inquiries-worth-time-money-and-resources

One of the problems with public inquiries is the heavy involvement of lawyers who slow down the process, add costs and whose legalese recommendations are too obscure for many of the public to understand. Public inquiries may be prompted by a need to feel something is being done- and will therefore disappoint if no action is taken. They can provide a catharsis for those affected by tragedy, but frustration when they drag on too long. They may demand accountability, but actual prosecution and/or blame may be a long time coming.

Ultimately, when tragedy strikes, we all want to know, why? Could this have been prevented? However, the process for discovering this should be as swift as possible, outcomes focused and recommendations succinct or no lessons will be learned.

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