It goes further, reporting that this was all about 'not holding people accountable'.
So far, so very typical of the media.
To report in this way is to make a category error because you can either investigate in order to hold people accountable and find out who is to blame, or you can seek to identify lessons for the future. You can't do both - at least, not as part of the same process you can't.
In his excellent book, 'Black Box Thinking', which I reviewed here, Matthew Syed writes about the 'blame game' and the way it prevents people, teams and organisations from learning about past performance, thereby depriving them of valuable learning opportunities for the future.
"...if professionals think they are going to be blamed for honest mistakes, why would they be open about them? If they do not trust their managers to take the trouble to see what really happened, why would they report what is going wrong, and how can the system adapt?" (p. 240, Black Box Thinking)Readers may recall my review of the great Sidney Dekker's book, 'Just Culture', in which he examines the dilemma of balancing openness (and learning) with accountability (and blame).
Dekker relates a powerful story of a nurse who volunteers the information that she made a mistake which contributed towards the death of child, with the result that she loses her job and is prevented from nursing again.
In such an environment, and with such consequences, how likely is it that other healthcare professionals will volunteer insight into their own mistakes? Or is it more likely that they will seek to cover them up?
Back to the media, and the campaign groups, and the families of the deceased - such people need to ask themselves, what outcomes do they seek? Do they want to learn what happened and reduce the likelihood of recurrence? OR, do they want to hold people to account and blame them for their decisions and actions?
They can't have both - not from the same process, at any rate.
If you run lessons capture meetings, use a structured process to examine past events and identify lessons for the future, including actions that, if implemented, will help to improve performance.
You need to ask:
- What did we expect to happen?
- What actually happened?
- Is there a difference between these and if so, why?
- What have we learned?
- What will do differently next time?
- What actions do we need to take to embed this learning?
- What was the impact of this issue?
Please don't ask 'Who?' Even when examining 'what happened' and 'why', I am always very careful to ensure that no-one uses words like 'fault' or 'blame', and that we talk about 'actions taken' rather than 'he or she doing this or that'.
It may sound as though we're avoiding the hard questions and seeking an easy life, and it is certainly the case that organisations that have such processes hardwired into their projects and programmes are more comfortable with providing answers to questions that might be uncomfortable for others that are less familiar with this approach.
However, the aim of such meetings in particular, and of knowledge management (KM) in general, must be to improve performance through the sharing and re-use of knowledge. Other processes exist to 'hold people to account' and they must be kept separate from KM in order to encourage people to talk freely, without fear of consequences.
Can and should politicians and civil servants and generals be 'held to account' and 'blamed' for their decisions? Where appropriate, absolutely.
But an inquiry set up to identify lessons for the future is not the place for such motives and it is wilfully naïve of the media to expect both aims to be achieved through the same process.