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Using public inquiries to evolve 

August 2021: Phil Trendall explains why it is important to use inquiries as a learning experience and not wait until their legacies and recommendations fade into distant memory

main picPublic Inquiries have a massive positive influence for change. It is not just a question of learning lessons. Real success lies in their contribution to the evolution of the culture of emergency preparedness and response. Image: freshidea/AdobeStock

The Manchester Arena Inquiry is unusual in that, during the lifetime of the Inquiry, the Chair requires organisations to provide updates on their progress in meeting the ‘monitored’ recommendations in Volume One of his Report. This is a bold and innovative attempt to ensure that learnt lessons are embedded before the memory of the Inquiry fades. 

This reveals a basic truth: Some of the most painful lessons for organisations come not from major incidents, or the round of debriefs that follow them, but from formal legal processes such as public inquiries, inquests and fatal accident inquiries. The public knows this. The oft heard: “Call for a public inquiry,” may be a familiar refrain in the aftermath of tragedies, but it is based on the knowledge that many organisations have shown themselves incapable of examining their own performance honestly. I would not suggest that debriefs are not useful and do not provoke some significant improvements, but rather that the big ticket changes tend to come from the slower forensic processes that lumber forward in the years following a disaster. Four years after the terrorist attack in Manchester, organisations are reporting changes they have made in the last few months – in one case in only recent days. Public inquiries concentrate the corporate and the executive mind.

In a well-known quote from Boin, et al (2005), potential leaders are reminded: “After the worst has passed… one would expect a crisis to wind down. But crisis leaders often discover, to their bewilderment, that the worst for them is yet to come.” (p91)
This quote should be fixed to the wall of every executive and strategic training session.

Understanding the longevity of a crisis would help many senior executives appreciate that their rush to tell inquiries: “We were rubbish. We are sorry. We are now great.” is just not enough. If they stood back and noted that they (or their predecessors) had said the same thing at previous inquiries,  they would realise that their organisations are often just trying to get through the inquiry, rather than truly addressing the deep cultural issues that allowed their organisations to fail in the first place.  

The headlong rush to survive an inquiry can skew what goes on. In attempting to address shortcomings in planning or response organisations can find themselves effectively planning for the ‘last war’ rather than building systems, policies and plans that allow them to be agile and better able to face a range of evolving threats.

The failure to learn from inquiries has often been pointed out (Pollock, 2013). However, it is often the case that in the months and years after an inquiry, organisations do change. They invest in areas that were found wanting and provide senior leadership supervision for projects intended to correct the failings of the past. But major incidents are rare. Individuals move on, structures are subject to regular ‘transformation’ initiatives and memories fade. The corrective actions that were so important in the aftermath of a tragedy become viewed as irrelevant and overly expensive. People forget why the things that are in place were introduced in the first instance. The cult of the present sees anything that happened more than five years ago as ancient history. The loss of corporate memory is often commented on by older members of organisations. Rarely is anything done about it.  

Discarding corporate learning is a form of corporate negligence and the people that allow it to happen carry a considerable responsibility. They probably don’t see it in these terms, but they should. In looking at the response to the Manchester or other recent terrorist attacks, a relevant question might be: “What did you put in place as a result of the Hallett Report into the London Bombing of 2005?” And: “Were these arrangements (or an updated version of them) still in place at the time of the last attack?”

In working with various agencies I find that staff who have been involved in major incidents and the ones that weren’t directly involved, but were required to give evidence at an inquiry, are the ones who are most focused on being ready for the ‘next big one’. No surprise, I hear you say, but what is surprising is that their experience often counts for little in the wider organisation. Their zeal and their experience are great assets – they are attributes that are rarely valued as much as they should be. There appears to be very little research looking at the future careers of staff caught up in major incidents or inquiries. What there is concentrates on the traumatic effects of incident rather than on the use made of the experience. This is a research area that is ripe for development.

Public Inquiries have a massive positive influence for change. It is not just a question of learning lessons. Real success lies in their contribution to the evolution of the culture of emergency preparedness and response. If we don’t understand the deeper organisational issues at play we will, as Cicero predicted, forever remain in a state of (organisational) infancy .
Boin A, t’Hart P, Stern E and Sundelius B (2005): The Politics of Crisis Management: Public Leadership under Pressure. London: Cambridge University Press.
Pollock,K. (2013) Review of Persistent Lessons Identified Relating to Interoperability from Emergencies and Major Incidents since 1986. Easingwold: Emergency Planning College.

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