Learning from incidents

Introduction

This guidance is to help Groups, Districts or other bodies with safety responsibilities to conduct a safety learning review into the circumstances relating to an incident. The ultimate aim of this is to help inform others and reduce the chance of it happening again.

A learning review seeks to:

• be a reflective look at the event and what should or could have avoided the incident.
• understand any individual’s actions and the underlying reasons for those actions and decisions if they led to and/or created this incident
• make use of relevant research/previous Learning Review recommendations to inform findings.

The review process

1. Identify why the review is necessary and what it’s aims are.
2. Identify who will undertake the review and who may contribute to the review.
3. Aim to complete the review within two weeks.
4. Clarify the details of the incident, You will need to ask more than one person. Gather as much information about the incident as possible. How/when and why were key decisions made? Was POR and Guidance referred to and followed?
5. Identify the key causes – what went wrong and/or how things went wrong,
6. Remember to consider the impact of the incident, on both individuals and the group. Eg: Will there be ongoing medical needs? Will funds need to be raised for new equipment?
7. Clarify the conclusions drawn into some key learning points. Be specific to the actual incident. Eg: Supervision – additional adults are needed for this activity. The camp kitchen – this needs to be set up with gas stoves well away from the side of the tent.
8. As part of the learning review the Group/Reviewer should identify if any further support is required for the family, other young people, staff, volunteers and the wider Scouting family.
9. Scout Groups may need to consider reaching out to their District/County for additional support, both in the review process and following the review.

Sharing Learning

Any conclusions and lessons learned by the review will need to be shared across the local team. Details how this will be done and by whom.

Agreement

The review team will need to agree that they are happy with the review, that any relevant lessons have been learned and that this learning has been effectively shared.

Summary

It is helpful to reflect on how the review has gone, as well as take an opportunity to thank those involved and express any sympathies for those involved in the incident.