Finally learning the lessons from disaster.(Learning From Disasters)

Learning from disaster is not something that we have done well in recent years, with hundreds of similar fires--like the recent nursing home tragedies--occurring each year, but with small variations that prevent action being taken. The author calls for isomorphic learning to be applied to minimalise the impact of potential disasters.

When the widely anticipated inquiry on the fire at the Rosepark Nursing Home, Uddingston publishes its findings there will be some who are genuinely surprised by the conclusions. There are likely to be far more, whether in the caring profession or in the emergency services, who will be able to point to instances from their own experiences where similar problems occur. That is whether fire doors are wedged open or low levels of staffing occurs during sleeping hours, which have been identified either as a result of incidents or fire safety inspections.

Without doubt, inquests into the subsequent multi-fatality fires at homes in Peru brokeshire and Cambridgeshire will reach broadly similar conclusions.

Tombstone legislation has generally been the outcome of these tragedies with the aim of preventing a reoccurrence. Unfortunately, for every Rosepark Nursing Home, there are hundreds of similar occurrences each year but each with variations that prevent a tragedy on the same scale. …

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