![](https://emergencyservicestimes.com/wp-content/uploads/2025/05/ESS-Button-resized.png")
Having provided advice on how to give evidence at a public inquiry in our first article for Emergency Services Times, here we look at what happens to the recommendations that arise from these inquiries and question why there is no national oversight of them to ensure that they truly become lessons learned leading to improvement and not just a tick box exercise.
In our experience, the term ‘lessons learned’ is often used too loosely and in circumstances where an issue may have been defined, but some or all the steps that are necessary to address the situation haven’t been taken; in extremis, some necessary changes may not even have been considered!
For the emergency services, the scrutiny associated with significant external investigations often follows a major incident – although valuable learning is often also highlighted by smaller and less high profile incidents.
Typically there are four to six major incidents in the UK every year. Historically, 60 per cent of these have involved public transport (e.g. train crashes) and the next two largest groups have been civil disturbances and industrial accidents. More recently, trends have shown an increase in climate related incidents, such as wildfires and wide-area flooding.
Risk and planning assumptions
Risk is never just about what is most likely. Prior to June 2017, few would have predicted that one of the greatest peacetime losses of life in the UK would have occurred in a residential high rise building, although some of the residents of Grenfell certainly raised their fears about the building’s safety before this fire occurred.
The Grenfell Tower fire is a stark reminder that an incident that went significantly beyond the operational planning assumptions that were in place at the time (i.e. a fire spreading rapidly and with great intensity over the full height of a tall building) can have the most tragic and severe of impacts.
Recurring themes from inquiries
Based on our preliminary review of past inquiry findings it is apparent that there are many recurring themes that have been identified by multiple investigations, carried out over time and across a variety of incident types and services. Further research is needed to fully understand why this is happening, but we believe that the reasons outlined here are likely to form at least part of the explanation.
We hope that it is unlikely an emergency service fails to engage earnestly with investigation outcomes. However, while a genuine intent to enhance the service invariably exists and actions that it is believed at the time will deliver the necessary change(s) are implemented, our initial evidence gathering suggests that these actions don’t always translate into sufficient and/or sustained improvement.
Often inquiry recommendations are specific to one type of incident, but dealing with them in isolation can create a risk that the action taken isn’t comprehensive and therefore fails to deliver an improvement across a service’s full range of activities.
And in some circumstances, this can even have unintended and adverse consequences, when, for example, the change is applied in a different context and/or different incident type.
Learning changes over time
Inquiry processes are often measured over years and when this is combined with one inquiry’s findings feeding into another, it can be an error to treat what appear to be similar topics as a repeat of the same thing.
Communications failures were, for example, an issue during the 1987 Kings Cross fire, but these were different to those experienced in 2005 during the 7/7 London Bombings and different again to those that occurred during the Grenfell Tower fire. However, variations associated with different operational environments, changing technologies and/or developments in the built environment can make what seems like an obvious remedy wrong or unachievable.
Another common theme arising from inquiry findings is a failure to gather and assess risk information in advance and/or, when it does exist, to make effective use of pre-planning information at an incident. Training regarding specific skills – and in particular linked to decision-making for those in command roles – is also often identified as being deficient. And when this is underpinned by inadequate service protocols and policies, staff competence inevitably becomes a key focus for the investigation.
During an incident itself, many inquiries describe a failure to develop and/or share an accurate appreciation of the incident, both within an organisation (i.e. vertically) and between all the agencies involved in the response (i.e. horizontally). Inadequate situational awareness leads to poor decision-making and this can, in turn, adversely affect the timely sharing of information with the public and others affected by the incident.
Inquiries leading to improvements?
The recurrence of these and other issues shows that, despite the significant amount of time, effort and resources invested into conducting and responding to formal investigations – it is reasonable to question whether the UK’s current scrutiny processes succeed in delivering the lasting and consistent improvements.
There is also evidence to suggest that a service’s response to inquiry recommendations can sometimes be overly focused on just one aspect of preparation or response element, when what may be required is a far broader review and change programme.
Emergency services personnel are generally practical people and as such they are predisposed towards tangible solutions. This can mean that harder-to-identify cultural improvements are sometimes overlooked in favour of what might be characterised as ‘clearer cut’ and more easily measurable solutions e.g. the procurement of new vehicles and equipment.
A further common issue is that action planning does not always extend to the point where an organisation itself would be able to reliably evidence whether the changes made have delivered the intended sustained and sustainable improvement. For example, the delivery of training may be the final action in a plan, but there may not be formal mechanism by which the training’s impact on performance or behaviours can be evaluated, over time and confirm lasting change has been achieved.
An overarching question to emerge from our reflections is whether the UK currently strikes the right balance between investigating significant incidents and having a framework within which identified improvements can be resourced, managed, delivered and measured?
Currently, there are no national, inter-agency systems and processes in the UK to record and make easily accessible the full range of recommendations that are made by public inquiries and other significant investigations, including findings from Coroner’s Courts.
This also works against services that are not directly involved in an incident learning from it, even though they may share the risk and have the potential for the same or similar failings. It can also mean that a service may not be easily be able to determine whether the issues they have identified are a ‘one-off’ or form part of a wider and potentially more significant pattern within the sector.
The Grenfell Tower Inquiry considered whether lessons should have been learned from other countries. This is beyond the scope of this article, but suffice to say here that while there would be much to commend this approach, the complexity of making robust comparisons across international boundaries should not be under-estimated.
Monitoring recommendations at a national level
The absence of a national framework means the UK has no way to routinely monitor the extent to which recommendations are being implemented nor any mechanism by which to evaluate whether the required change(s) have been delivered in practice. In recent years, increasing and louder concerns have been voiced by those personally affected by a range of failures that led to inquiries and they certainly deserve better and more transparent arrangements than presently exist.
This article is not a full diagnosis nor a comprehensive prescription for change. However it seems reasonable to think that a new independent body and the establishment of new national systems that could be used to monitor and assure the delivery of recommendations might be needed, without which we will continue to see changes that fall short of what might properly be described as ‘lessons learned’.
This is the second of two articles from Rita Dexter, written in partnership with Peter Cowup and Gary Reason who also worked in senior leadership roles for the London Fire Brigade.
