As we approach the third anniversary of the Grenfell Tower fire on 14th June, the Bennett Institute's new report on 'Policy Lessons from Catastrophic Events' captures the output of a workshop held in February 2020. The report focuses on why we find it difficult to learn from events such as the Grenfell Fire to bring about change, and demonstrates the importance of bringing together a range of stakeholders with a common interest in a shared problem - to help create effective policy.
Catastrophic events are so often things that happen to other people we see on the news. A plane crash; an explosion; a terror attack; a fire. Sometimes we may know someone who has been affected, but rarely does it affect us directly. After the event, there is an inquiry and then the memory gradually fades for all but those directly involved.
Yet we are all currently in the middle of what is turning out to be a catastrophic event – the Coronavirus crisis. It is affecting all of us in multiple different ways.
It is also disrupting how we often learn from these types of event. The Public Inquiry into the Grenfell Tower fire – a previous low likelihood, high impact event to affect the United Kingdom – has had to halt any further hearings because of the stringent social distancing measures put in place to help manage the current crisis.
The two crises are seemingly entirely different. At the time of writing there have been 36,914 deaths (25 May 2020) in the UK associated with COVID-19 in comparison to the 72 deaths in the Grenfell Tower fire. Despite the contrasts, though, there are underlying lessons from the Grenfell tragedy that can be seen to be playing out in real time in front of us.
For example, there is the failure to learn lessons from previous health crises or even from simulated exercises designed to ensure preparedness. There are lapses in co-ordination between different authorities responsible for different aspects of managing systemic risks. Decision-makers have a strong incentive to avoid future blame. At the time of the Grenfell Tower fire, one of the points made was that lessons had not been learnt then from previous catastrophic events. The same point is likely to be made when the government’s response to Covid19 is scrutinized in future.
While the Grenfell Tower fire deeply affected and continues to affect the people of North Kensington, people across the country are continuing to live with the consequences of the decisions that led to or contributed to the Grenfell Tower fire. It is estimated that half a million people across the country are still living in properties with illegal cladding. To compound the stress of 24-hour waking watches and the mortgage crisis affecting homeowners, people are now locked down in properties that they know are not safe.
In February this year, before the pandemic and lockdown, in partnership with Gill Kernick of JMJ Associates, we hosted an ESRC funded workshop looking at why policymakers do not learn from catastrophic events. The workshop brought together stakeholders with a shared interest in learning from the Grenfell Tower to consider this question and to propose ways in which we could improve our ability to learn.
One of the overriding conclusions of the workshop was the importance of hearing and acknowledging a wide range of different voices when considering complex problems. As one of the workshop attendees put it: “There was so much expertise in the room, each bringing different parts of the puzzle, and because we were all from different communities, there was almost no ‘siloing’ into disciplinary groups.”
To bring this breadth of voices to our report, we are delighted that Gill Kernick and four of the workshop attendees have been able to contribute short essays to our report.
In her contribution, Gill Kernick considers issues of power and accountability after a catastrophic event.
Martin Stanley, editor of the Understanding Government website and Chief Executive of the predecessors of the Better Regulation Executive and the Competition and Markets Authority, sets out some reflections on the way government Ministers learn, or fail to learn, from catastrophic events.
Dr Flora Cornish, a community psychologist working on the role of grassroots mobilisation in responding to public health crises, describes her work with the residents of North Kensington after the Grenfell Tower fire, and provides some personal reflections on the workshop.
After a distinguished career in the Fire and Rescue Service (FRS), David Wales established SharedAim, to help organisations deliver excellent services and customer experience by design. David has previously written on how a more customer focussed approach could improve the patient experience for people suffering from burns and we share an excerpt from his report written with Kristina Styles: Saving Lives is Not Enough.
Finally, David Slater asks: why can’t we learn from disasters? David is currently a Director of the regulatory strategy organisation Cambrensis. Through the 1970s and 1980s, as founder of Technica, he led the pioneering application of risk assessment techniques to the offshore and petrochemical industries. As Her Majesty’s Chief Inspector of Pollution and Director of the Environment Agency, he had a leading role, through the 1990s, in developing and implementing risk-based pollution control legislation in the UK and Europe.
The remainder of the report sets out the findings of the workshop. Amongst the reasons identified for the inability to learn from catastrophic events were:
· Too great a focus on meeting regulatory requirements rather than doing what is right for people
· The increasing complexity of how the world works and the difficulty of regulating for complexity, coupled with a reliance on simple fixes
· A lack of cognitive diversity and different voices which stifles the ability to understand risks and the impacts that they can have.
The report also identifies ways in which we can improve our ability to learn, including:
· Ensuring that there is a clarity of purpose and shared sense of endeavour amongst stakeholders
· Focussing on developing a learning culture rather than a culture of blame
· Creating safe spaces or forums where learning and effective practice can be shared and experienced
· Developing a sense of chronic unease and understanding the risks associated with low probability, high impact events.
The lessons apply to any complex system or environment involving overlapping risks, although we did not imagine in February that there would be another early and extraordinary demonstration of them.
The workshop demonstrated the importance of bringing together a range of different stakeholders with a common interest in a shared problem. To build on the momentum and connections created at the workshop, we will continue to:
· Curate the emerging network of stakeholders, including identifying how the group could contribute to the understanding of the Coronavirus crisis
· Create ‘safe spaces’ for different stakeholders to come together to discuss shared problems. We are keen in future discussions to widen the range of voices involved
· Share the knowledge that is being created in the form of this report and further blog posts.
If you are interested in getting involved, please get in contact with us.
The views and opinions expressed in this post are those of the author(s).