Waking on Sunday morning I imagine that many people felt the same sense of terrible shock and sadness that I did at the news of mass fatalities at a football match in Malang, Indonesia. Unsurprisingly, amidst the outpouring of grief, there have been many calls to learn lessons from the tragedy. This would seem to be a perfectly reasonable expectation but, sadly, change may not come as quickly as people would both hope and expect.
Looking at out own history of football tragedies in the UK, the deaths of 66 people at Ibrox Stadium in January 1971 led to a public inquiry and, four years later, new legislation. However, there had been very limited practical progress on spectator safety by the time of the Bradford City Fire in 1985, in which another 56 people died. Indeed, arguably, very little happened until after the Hillsborough Disaster four years later. We must hope that the Indonesian public do not have to wait 18 years and suffer further fatal incidents before they see real reform.
This call to learn from disasters is particularly topical today as the first preliminary hearing of the UK Covid-19 Inquiry takes place but, unfortunately, the track record of public inquiries is not good. Dominic Elliott, one of the leading academic experts on learning from crises addressed this in an excellent article in 2009. Focusing on the failure of Haringey Social Services to learn from the death of Victoria Climbie in 2000, he identified many barriers to learning from public inquiries and made many recommendations. For me, perhaps his most important suggestion is:
“Given the persistent failure to translate knowledge into new behaviours, those who initiate such inquiries might extend the range of experts consulted to include individuals with an understanding of how to develop and sustain a context for change…”
Sadly, as one looks at the composition of the panels for the Grenfell, Manchester Arena and now Covid-19 Inquiries, there is little evidence of Elliot’s recommendation being heeded.