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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.

Welcome - Please Comment

By guest, Sep 30 2020 09:56AM

Welcome to my website.

As I point out elsewhere on my website, the aim of my work is to find ways of preventing organisational failures. The cases that I examine mainly focus on the delivery of services by public bodies. To be more precise, it is the delivery of services in the context of complex, high tempo environments. My interest is how we extract lessons from the past that help us to deliver these services more effectively in the future.

A key mechanism for learning lessons is the public inquiry. While I have no doubt that these inquiries serve many useful purposes, I would question the value of their recommendations when it comes to managing complex, high tempo operations. I would go further; my concern, based on 10 years of research, is that some recommendations are positively dangerous and lead to a subsequent failure.

I recognise that this is a challenging, multi-faceted subject for which there are no easy answers. However, before we can resolve an issue we must understand it. The question that I would therefore like to explore is:

How best, at the organisational level, can we extract lessons from past experience to ensure we reduce the possibility and impact of similar future failures?

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