When things go wrong – how should organisations respond?
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Steve Scown, Dimensions’ CEO, reflects on relations between providers and families when tragedy strikes, and the impact of prosecution, as we share a new guide to help bereaved families co-written with Sara Ryan and Rosie Tozer.
We live in a time of high profile inquests and prosecutions involving companies in most industries, including some major learning disability and autism support providers. I don’t plan to comment upon these. How could I reasonably offer such comment when my understanding is limited to what is in the public domain?
However, I have been reflecting on what I’ve read and listened to – it’s hard not to, knowing that not that many years ago my own organisation was prosecuted by the Health and Safety Executive (HSE.) The experience of being prosecuted is long lasting and the memory continues to shape the attitudes and decisions of everyone from Dimensions who was involved including a number of my executive team.
Emotions for everyone directly involved in such tragedies are inevitably high. For those looking in from outside our understanding is limited to whatever is in the public domain. The recent ‘live tweeting’ about some of these events has been a very welcome development. More than ever before a bright spotlight is being shone on organisational behaviours and actions.
As I mentioned above Dimensions was once prosecuted by the HSE. In brief, a colleague had to go to hospital after being kicked by a person we support. The support plan hadn’t been followed, and our colleague had knelt down (contrary to the support plan and risk assessment guidance) in front of the person. It was an incident reportable under RIDDOR, and the HSE reviewed it in depth.
The inspector wasn’t satisfied with the response she got from Dimensions. Frankly, our response was casual in the extreme – and it turned out that the processes we thought were being followed, weren’t. Our checks and balances had failed to pick this up. Some records were missing and we were unable to evidence a number of things. A relatively minor incident swiftly snowballed into an exhaustive, and exhausting, investigation into every aspect of our support processes. It led us to change very nearly everything we do. With hindsight, it was one of the best things that ever happened to us.
And yet… and yet, I’m increasingly caught between hope and fear.
My fear is not so much about Dimensions being next in line; we’re an organisation that relies on the judgement and decisions seven thousand colleagues make 24 hours a day 365 days a year. All the improved staff recruitment, training, culture and processes in the world can’t stop the laws of probability. At the end of the day we’re a collection of human beings supporting other human beings. Sooner or later, someone we employ will do something really unwise and there will be another awful incident. And Dimensions may well be in the dock and under the spotlight.
In that event I hope that we engage quickly, openly, with humility and real humanity with the person’s family. I hope that we say sorry straight away. I hope that we will investigate what happened and put measures in place so it can’t happen again. I hope that everyone will be able to agree what went wrong and why. I hope that we will be able to maintain relationships with families and friends through what will be a difficult period for so many. I hope that the phrase ‘reputation management’ does not get used.
I fear we might fall short of this. I fear that because facts are shared unequally between everyone involved, everyone has a different perspective and therefore rarely is there a single version of truth. I fear that this means it will be for a court to determine the truth. I fear that, because an organisation is restricted in what it can say publicly whilst a legal process takes place, only one version of the truth will be out there. I fear that because legal processes take so long, grief will become frustration which inevitably becomes anger.
As society becomes ever more litigious, the fear of litigation is inevitably influencing how organisations and their leaders behave. Consequently I also fear that how organisations have to behave following a tragic incident may not be the same as how we want to behave.
No organisation (or individual come to that) goes against the advice of its lawyers; such a move could have very damaging consequences for the people still reliant on the support it offers and upon its hardworking staff. Thankfully, unlike many in our sector, as a not-for-profit Dimensions does not have the added complexity of having to consider our owners and any impact upon share value.
Some law firms seem to advocate a say nothing, admit nothing, couch everything in legalese, protect your vital interests, play the long-game approach. Prompted by these reflections and fears I recently convened a meeting with some of our legal advisors and our insurers to talk through with some of my Dimensions colleagues these fears and hopes.
I was pleased to learn the strength of their appreciation of the need to be candid, the need to express regret and say sorry. So I do believe not all law firms are the same – some understand what organisations like Dimensions want to achieve and how we want to behave. But – and for some readers I fear this will come across as too big and weasely a ‘but’ – as they explained, saying sorry is not necessarily the same thing as admitting liability. Why? Because as I’ve said above and as they confirmed only a legal process can determine the truth.
If the organisation does not believe it is at fault, of course it must defend itself in court. How an organisation develops its belief as to whether it was at fault and thus should acknowledge liability is a litmus test of its leadership. Has it listened to people without already having its conclusion written? Has it considered all of the facts and the expert opinion? Are its senior players prepared to be criticised? Is it prepared to be judged as not being good enough?
This is when the principles of openness and transparency are of critical importance; anything less and it seems that the organisation has something to hide.
I fear some readers will by now be gnashing their teeth. I’m thinking of all those bereaved families who have been belittled by organisations and professionals. Who have been on the receiving end of legal questioning and who have come up against the seemingly limitless resources of big organisations. Who have fought for years for justice. Who have been ignored, misled, lied to. Who have had to fund high risk private prosecutions, and who have navigated the care and legal systems with tenacity and desperation. And what about all those families who haven’t quite made it? Who have eventually given up, their case whitewashed into history?
We cannot do anything to ease their suffering or their anger. But we can do something for families who may find themselves in such a position in the future. That is why with some external help Dimensions has developed a new guide.
It is a resource for families who may experience a loved one unexpectedly dying whilst in care, and may also be helpful for staff. It is a starting point – nothing more – for families needing some help in their darkest hour. It is a guide that, I am aware, may help a bereaved family take action against Dimensions in future.
My last thought is that if one day in the future my truth ends up differing from your truth, if we end up on opposite sides in court, if our relationship irrevocably breaks down, and despite everything you may feel, I promise that Dimensions will always do what we believe is the right thing for the people we support and their families.
The guide is being launched at a small family event today [17 May 2018].