How your own development protects you when scrutiny comes at an inquiry

At The Emergency Services Show, solicitor advocate David Burrows-Sutcliffe, resilience consultant Nick Farr, and CPDme founder Andrew Ormerod explore why records and professional reflection are now central to operational practice. They identify two key issues: incomplete decision records and the gap between attending training and proving competence.

David, who works extensively in public inquiries and coroners’ courts, says commanders often fail to document not just the decisions they make, but also the options they considered and rejected. “The main problem that I come across on a regular basis is that commanders fail to annotate the decisions that they make. Not only the decisions, but the reasons for those decisions, and the decisions they considered but discounted,” he explains. Without this detail, proving that a decision was reasonable becomes difficult.

“If it’s not written down, it didn’t happen.”

David Burrows-Sutcliffe

Scrutiny extends beyond the actions themselves to whether frameworks such as JESIP influenced decision-making. David recalls the Manchester Arena Inquiry and earlier 7/7 inquests, noting that Rule 43 reports were “the acorn from which JESIP grew,” and that inquiries now expect commanders not just to know JESIP, but to show it shaped their thinking. In the courtroom, he adds, a wrong decision can be acceptable as long as it was reasonable at the time.

A second challenge is the assumption that attending a course demonstrates competence. Andrew, who has assessed CPD portfolios for fitness-to-practice cases, says organisations often focus on certificates or spreadsheets showing attendance rather than the impact on practice. “This is not about collecting certificates. This is not about Excel spreadsheets saying people attended a JESIP course,” he says. Instead, courts and regulators want to know what was learned and how it changed practice. He compared it to paramedic documentation, where clinicians record not only what they observe, but also what they rule out.

Organisations can show that training has been completed, but few can prove that individuals were prepared to make complex decisions in volatile and complex environments. “Compliance doesn’t mean competence,” Nick says, adding that “the absence of information isn’t a rationale for not making a decision. Decisions need to be made in these environments.”

The discussion emphasises that expectations have shifted, and documentation is now an active part of operational practice. David explains that training and exercise records need to be detailed enough to withstand scrutiny even years later, while Andrew notes that capturing reflections promptly ensures they accurately represent what was learned. Nick adds that organisations play a crucial role in supporting this process, providing systems that turn attendance into demonstrable competence and bridge the gap between simply completing training and being accountable in practice.

The panel reinforces that when incidents are examined years later, memory alone won’t protect anyone. Clear records of decisions, the reasoning behind them, and the professional development supporting those decisions are essential.

Listen to the full session on the For Every Response podcast below.

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