I was very interested - but somewhat depressed - to read Gill Kernick's latest blog comparing the Post Office and Grenfell Tower scandals. Put shortly, they both raise very similar systemic issues. Here is a summary of Gill’s blog:-
Both tragedies involve misplaced trust in expertise. Expertise can (intentionally or not) lead to failure to question or demand information from experts.
General practitioner and serial killer Harold Shipman is an extreme example of misplaced trust. Shipman targeted elderly patients who trusted him as their doctor. Killing them either by a fatal dose of drugs or prescribing abnormal amounts. He is thought to have killed in the region of 250 patients.
Regarding misplaced trust, the obvious issue was that the Horizon accounting system was trusted over the subpostmasters. This creates challenging questions for the digital and AI age where we are already seeing algorithms taking on management functions such as the hiring and firing of employees.
And Grenfell residents were told by the London Fire Brigades (LFB) Control Room Operators to stay put. Someone would come and rescue them when this was not the case. Many died after listening to their advice to stay, over the pleas from friends and family to leave. This advice to stay put was made despite recommendations from the 2009 Lakanal House Fire. Six people died, and the Inquest recommended that the LFB not give people false hope that someone was coming to rescue them when it was not known if this was the case.
Then there was the dismissal by those in power of other non-expert ways of knowing (tacit knowledge). In every major disaster that Gill has studied, somebody has raised a concern. If it had been listened and responded to it could have prevented the disaster. In most of these cases, power and knowledge play a critical role in this silencing of voices. Typically it is those with less power such as front line workers or non-experts’ views such as residents or the public that are not heard or taken seriously.
For example, on Saturday 5 October 1999, 31 people were killed in the Ladbroke Grove rail crash. Michael Hodder, the train driver, who died in the crash, passed a red signal and collided with another train. The subsequent Inquiry revealed that since 1993, train crews had warned about the “inadequate sighting of certain signals,” including SN109, the one missed by Mr Hodder. In the preceding six years, seven train drivers had failed to see the red light and stop. No action had been taken.
It is hard to fathom how experts and investigators and lawyers from the Post Office and Fujitsu (and ministers and civil servants) dismissed the tacit knowledge of so many subpostmasters. Why did they not listen to the protestations of innocence or respond to a growing pattern of prosecutions instead of proceeding with false prosecutions.
Residents repeatedly raised concerns about safety before the Grenfell Tower Fire and these were dismissed. In a now (in)famous blog, written just 7 months before the fire, resident Ed Daffarn and Francis O’Connor said:
It is a truly terrifying thought but the Grenfell Action Group firmly believe that only a catastrophic event will expose the ineptitude and incompetence of our landlord and bring an end to the dangerous living conditions and neglect of health and safety legislation that they inflict upon their tenants and leaseholders …
And yet the Public Inquiry process seems far from fit for purpose.
The government recently rejected the Hillsborough Law that would have made a duty of candour legally enforceable. The law was proposed by victims and families of the Hillsborough Stadium disaster that killed 87 people in 1989. The families have campaigned for truth and justice for 25 years, after police lied about and blamed the victims for the stadium crush.
The government also rejected a proposal by the families, to extend public funding for bereaved families at inquests. This lack of equity in access to legal counsel is a key imbalance of power.
Public inquiries are slow, complex, costly and rarely satisfy everybody. Concurrent criminal investigations and court proceedings complicate matters and can extend timelines for corrective actions and prosecutions. A 2017 Institute for Government report estimated that £638.9m had been spent on 68 public inquiries alone since 1990. By June 2023 the Grenfell Inquiry had cost £170 million.
Perhaps most worryingly of all, there is no process for ensuring that recommendations are either implemented or effective. Ministers are free to either accept or reject recommendations. Once accepted there is no process for following up on progress. According to the Institute for Government, of the 68 inquiries that have taken place since 1990, only six have received a full follow-up by a select committee to ensure that government has acted.
There are very few young MPs or civil servants (or Post Office staff) who enter public service imagining that they will one day not be able to hear or see obvious evil, or that they will one day feel able to stay silent if they do perceive it. Maybe, just maybe, society’s response to the current Grenfell, Post Office and Covid Inquiries will enable today’s young recruits to behave rather better than their elders.
Martin Stanley - Author - Speaking Truth to Power
Thanks Simon - Very good points.
I wonder whether it is helpful to characterise all these affairs under the single heading of "mistrust in expertise". If we are to prevent more cases, I think we need to distinguish between experts who are lying and experts who are mistaken. It is important because different antennae are needed to detect each type.
In the Post Office scandal, there is a fair deal of evidence that some of those who were defending the Horizon system knew perfectly well that what they were saying was not supportable. Some people, it has been suggested, were outright lying.
And some - such as the investigator who signed a witness statement relating to Horizon - were making statements about matters in which which they had no expertise at all. As we learned from the hearing on Thursday, a key passage in the witness statement was written by lawyers taking instruction from the Post Office PR team - in other words, without any relevant IT expertise at all.
Contrast that with the Fire Control Operators advising Grenfell residents in the depths of a fire who (unless there is something I have missed) genuinely believed that it was safer to stay put than to step out into the flames.
As for those in authority over Grenfell Tower (landlord, local Council) who ignored the warnings in the months preceding the fire, did they "know" the truth in the way that some people at the Post Office "knew"? (I am not sure what the evidence from Grenfell has brought out on this point.) I think this question highlights that we also need to distinguish between experts advising the lay consumer on the action they need to take in real time (Shipman, LFB Control Room on the phone during a fire) and experts advising those in authority (Post Office talking to government and giving evidence to the courts) in circumstances where the recipient of the advice has the time and the resources to ask much more probing questions and debate the answers.
"Expertise" may be a theme. But I think it is much more complicated than that.