The Weekly Reflektion 07/2024

When changes are made, people with the necessary competence should be involved in evaluating the risks arising from the change. Competence is also an essential element indetermining measures that should be taken to mitigate these risks.

Do we ensure that people with the right competence are involved when making changes, and do we take their advice?

Coldharbour Hospital in Sherborne, Dorset, England was built early in World War 2 to be used as a hospital for rehabilitationof injured Royal Navy personnel. In 1948, the National Health Service took over the hospital which was then used for patients with ‘learning difficulties’. In 1970, the hospital was upgraded, the large dormitories partitioned into smaller units to make the building more personal and less communal. 

One of the dormitories, the Winfrith ward, still housed 36 young males, and was locked at night to prevent the patients from wandering. At 0230 am on 5th July 1972 a fire broke out on the ward, and 30 of the 36 patients were killed by smoke inhalation. An inquiry found that one of the patients in the ward had been reprimanded by the staff, and that this person had got hold of some matches and set fire to his bedding. He was one of the survivors.

The newly refurbished ward was found to have been partitioned with flammable materials, as were the decorations and furniture. Non-flammable materials had been recommended by the fire officers involved in the planning of the refurbishment, but these recommendations had been overruled ‘to retain greater homeliness’.

When the ward was locked, a member of staff should have been present at all times, among other things, so that the door could be unlocked in the event of a fire. Unfortunately, on this particular night, the nurse took a break at 0220 hrs and left the ward. The staff were alerted to the fire at 0250 hrs and the fire was estimated to have started at 0230 hrs, emitting lethal toxic smoke. As the staff rushed to help, they did not have a key to the ward, which further delayed entry and rescue. Other findings were inadequate staff firefighting and evacuation training, and the building had no sprinkler system, or smoke alarms.

A management of change process should involve people with the correct competence to evaluate risks that may arise from any change. When these people make recommendations, there should be a very good reason to ignore these. How does your process function? Do you involve the right people, and take their recommendations seriously? 

Fast forward to 2017 and Grenfell Tower, and we see that concerns voiced by fire officers were ignored by the building owners. 72 people died at Grenfell Tower, and this has been the subject of recent Reflektions. How many tragedies do we need to endure before we learn?

Reflekt AS