Lessons Digest blog hero

UK Resilience Lessons Digest Webinar: Learning to Read Risks

The third edition of the new UK Resilience Lessons Digest presents an analysis of lessons arising from more than a decade of emergency exercises.

Mark Birrell, Deputy Head National Risks, Cabinet Office Resilience Directorate, gives the keynote, followed by a review of the central analysis on Issue 3 'Learning to Read Risks' from Head of Thought Leadership at the EPC, Lianna Roast.

During the session you will also hear from an exciting line of guest authors and speakers including:

  • Dr Alexandra Smyth, Senior Policy Advisor, Royal Academy of Engineering
    ‘Building resilience’: Lessons from the Royal Academy of Engineering’s review of the National Security Risk Assessment methodology 
  •  Lisa Jackson, Director of Operational Reform, Emergency Management Victoria
    ‘Moving from lessons identified to lessons learned: Victoria’s path towards effective lessons management’ 
  • Dr Sarah Robertson, Highly Specialist Clinical Psychologist, Alder Hey Children’s Hospital
    ‘Organisational Learning for Workforce Wellbeing: Developing and Delivering the Ground TRUTH Tool at Alder Hey Children’s Hospital’ 
  • Dr Claudia Van Den Heuvel, Director, Crisis Leadership, PWC 
    ‘Rethinking personal resilience: Navigating an age of perma- and poly-crisis' 

> Learn more about Lessons Digest series 

Learning to Read Risks Webinar Transcript

Lianna Jane Roast

Thank you to everyone for joining us and to our guest speakers as well. To start us off, I'm really pleased to introduce Mark Birrell, Deputy Head National Risks in the Resilience Directorate, Cabinet Office, Central Government. Mark, thank you so much for being here and over to you.

Mark Birrell
Thank you, Lianna, for that introduction and thank you to the EPC for hosting this event today and good afternoon to everyone. Thank you to the audience for your interest in learning to read risks.

My name is Mark Burrell and I'm the Deputy Head of the National Risks Team in the Cabinet Office. My team's remit is to identify, assess and communicate the most serious risks facing the UK so that Ministers, the resilience community, and the public can take action. 

And we take the ‘communicate’ part of that very seriously. So, let me spend a few minutes talking a little bit about what we have done and some of our future plans. But firstly, a little bit about the context... 

In December 2022, the UK Government published the National Resilience Framework against a background where the risks we face are getting more complex than ever before. We're reminded of this every day in the news, with both abroad, with recent events in the Middle East and the ongoing war in Ukraine continuing, its disruption to energy markets and supply chains, among other things. And risks at home as well, including everything from the frequency of major weather events through to new frontiers such as artificial intelligence.

This context has fundamentally changed the way we think about our own national resilience, and quite rightly, it is posed more questions about whether we are ready and prepared for the risks that we face, we said in the Resilience Framework that a shared understanding of risk is fundamental and the resilience is a whole of society endeavour to be prepared –  and for our planning to be successful, we must all work together with that in mind, we can't expect to build our national resilience if government keeps its assessments of risk locked up.

And so, that's why when it came to updating the National Risk Register earlier this year, we adopted a ‘new transparent by default’ approach.

This is a major shift. Never before have we been able to classify and publish such detailed risk information for the first time, the National Risk Register now aligns directly with the National Security Risk Assessment, which is our internal and classified risk assessment.

Also, we've published the reasonable worst case scenario for each risk for the first time, which means that people can understand the scenarios and see the assumptions that underpin them.
This is in order to support more effective planning and uh work with partners across all the society. Only in a very small number of cases in the new National Risk Register has information not been included for national security or commercial reasons.

So, what does the 2023 version of the National Risk Register tell us about the risk landscape that we face?

Overall, a look at the risk matrix and the National Risk Register will tell you that there are a wide range of serious risks facing the UK. Both malicious threats from malign actors who seek to do us harm and non-malicious risks such as accidents or natural hazards.

There are a number of risks included for the first time in the 2023 edition, including specific Animal Diseases, which each require fundamentally different responses such as Foot and Mouth, African Horse Sickness and Avian Flu. We’ve also included new space-based risks, such as disruption to space-based services or loss of positioning, navigation and timing services, and we've included a malicious drone incident, for example, based on the Gatwick drone incident of 2018.

The National Risk Register focuses on so-called acute risks, which are the discrete events which may require an emergency response from government. However, we know that the landscape is also becoming more complex, with interconnected and cascading risks and the nature of these acute risks is being influenced by wider trends. So, we are further developing our understanding of these trends through what we are calling chronic risks.

What we mean by this are the continuous challenges, which left if left unchecked, would erode our security, economy or society. We added some examples of these to the National Risk Register, such as climate change risks from artificial intelligence or Anti-Microbial Resistance (AMR). These chronic risks and acute risks are intrinsically linked. For example, climate change is making severe weather are more likely and impactful. AI is changing the nature of cyber security threats and Anti-Microbial Resistance can exacerbate the risk of infectious disease.

As we set out in the integrated review refresh, the government is now establishing a new process for identifying and assessing a wide range of these chronic risks to enhance, enhance our understanding.

So where next? We hope that our more transparent approach to the National Risk Register provides organizations across society and the economy with the information they need to deepen their understanding of risk and improve resilience. But publishing the National Risk Register is just the start.

We want to build on this with more accessible and targeted information for the general public on risk and preparedness actions to do this properly, we know that we need a firm evidence base, so in addition to engaging with academia and identifying lessons from recent events, next year we will be launching a nationally representative survey of public perceptions of risk and household preparedness. This will enable us to focus our efforts where they are most needed.

So, we have big ambitions for both our assessment of risks and our communication of risks.
We want to make our risk products more dynamic, more digital and more reflective of an increasingly complex real world risk environment where risks don't happen in isolation. They compound, they cascade and they interdepend. But our risk products are only effective if they are used.

So, we want to hear feedback from people inside and outside of government from those in local resilience forums, from businesses, from voluntary and community groups and everyone else.
This is how we will progress the whole of society ambitions set out in the resilience framework and ultimately make the UK a safer and more resilient country. Thank you and back to you, Lianna.


Thank you very much, Mark, for that excellent keynote and introduction overview there of the national risk landscape.

That takes us nicely onto the topic of Digest 3, ‘Learning to Read Risks’. The reason for the title was to emphasize the fact that, along with assessment (which is absolutely critical), there is also something to be said for observing, for real-time learning and for the way that we psychologically interpret and understand and socialize and communicate the risks that we face.

I wanted to start with an overview of the Digest, as I'm aware that for some people it's still new. Although, amazingly, next week will be Lessons Digest's 1st birthday, celebrating a year since the 1st edition was published last October.

For any that are not familiar with the Digest series, or are coming to this for the first time, the UK Resilience Lessons Digest is part of a programme of work at Cabinet Office Emergency Planning College to synthesise lessons learned from all exercises and emergencies. 

Its purpose is anchored in the central government commitment as outlined in the UK Government Resilience Framework, to summarise lessons from a wide range of relevant sources, sharing learning insights consistently across the UK government and wider resilience partners. 

In order to do that, it really has three key objectives: to summarise transferable lessons and themes from that wide range of relevant sources; to share lessons across responder organisations and wider resilience partners; and to coordinate knowledge to drive continual improvements in doctrine standards.

Good practice training and exercising so everything that comes within the Digest publication will sit under one of those Core 3 objectives. In terms of principles for what we include in the Digest, there are three guiding principles: 

Firstly, that lessons must be anchored into that shared understanding of risk that also under pier underpins the national resilience endeavour.

Secondly, that lessons are time sensitive, but not time limited, meaning that lessons are not seen to expire or be null and void just because they could be a few years old.

We know that there's always a case to remember and to relearn and revisit lessons of the past, and that any less lessons analysis within it must deliver applied value in practice for resilience partners.

So that's a bit about the principles, the approach we take to the Digest is absolutely a partnership, one, in the spirit of whole-society resilience. And that is why the Digest is freely available, public facing from the EPC website Knowledge Hub.

So if you haven't downloaded your copy yet, please do visit the website, to download the series for free, along with webinar slides and recordings.

The Digest specifically exists to complement, not compete with, other important lessons and knowledge exchange work. In terms of the process of putting it together, analytically, we adopt some academic rigour to ensure we're providing evidence-based lessons and to try and make the product accessible.

We've broken the Digest down into specific articles so that you can digest the whole lot in one go should you want to or taken in bite-sized chunks depending on your areas of interest.

So now into the third edition of the Digest. Keep an eye on our website or sign up for EPC communications to hear a further work under that lessons workstream and within the organisation.
When it comes to putting the Digest into action, we've also included three icons, which can help direct you to metabolize what you've Digested in the publication.

We have some helpful sidelights which highlight key insights, academic information, or professional practice that sheds some light on the topic being discussed in the article.

The ‘make it active’ icon suggests practical application points, or things to try in your own context. 

The ‘resources icon, signposts to further reading and information.

Learning to Read Risks: An introduction

Within edition three of the Digest ‘Learning to Read Risks’, there was a focus on lessons arising on risk from COVID 19. And I'll come into more detail about that analysis shortly. But just to give a sort of feel for what was included, we had the central analysis in terms of summarizing those lessons and then we were also really fortunate to have a number of guest authors and contributors giving articles, looking at lessons from the review of the national Security Risk Assessment methodology and learning at Alder Hey Children's Hospital NHS Trust.

Also, some academic insights and a bit of overview of the national risk landscape as marks already outlined, along with an article from PwC around personal resilience, and also some practical tools for implementation from colleagues who very kindly have stayed up very late into the night from Australia and from Emergency Management Victoria, will be speaking to us later on.

So, in terms of the learning analysis within learning to read risks, I just wanted to highlight the sort of the meat of the analysis and the learning themes that came out so that we can understand where they've come from. And of course, I think COVID-19 really created a fundamental shift in our shared understanding of risk.

And whilst a lot of the lesson identification processes continue and most notably through the COVID 19 inquiry here in the UK and publication of the new National Risk Register, the approaching winter season and also the fact that there was some learning in hands already, really prompted us to take a look at what was already there, and do a sort of focused thematic review of high level lessons on risk to date.

So how did we do that and what did we find?

The rationale was to look for two things: common learning scenes, which we define as patterns in the lessons identified and recommendations as they were presented across the reports to understand where the key recurring areas for improvement or of good practice might lie.

And secondly, to highlight transferable lessons, which are those lessons identified that could be applied to drive continual improvements in multiple resilience settings or across multiple hazards and threats.

In terms of methodology, you can read more about that in the Digest, but just to say that it was qualitative in nature in that it looked to the written content as it appeared, allowing the reports to inform the themes directly, rather than our team attempting to infer meaning from them.
And the results are provided in in the following slides, with the additional side lights available in the Digest.

So which reports have we taken these from? 

Well, there was a total of 52 recommendations and the top five learning themes, and the four selected reports were published in a seven-month period between September 2021 and May 2022 –so quite a short period especially compared to the 12 years’ worth of lessons from exercises reviewed in the previous Digest. All of those lessons had a significant evidence base attached to them and represented multimodal research from the United Nations University, the National Audit Office, Review of Governments preparedness for COVID-19 pandemic, the House of Commons Committee of Public Accounts and the House of Lords Select Committee on Risk Assessment and planning.
It is important to note that some of these reports, given their proximity in terms of timeline, and do reference each other. But although the report quantity is small, the evidence based behind each of them combined, is truly vast. And we also hope you know in looking at those national learning, high level lessons of particular relevance, in some cases to government, that it really reflects that whole-society approach to learning and looking at what local resilience partners and central government can take away from these overarching learning themes.

So, the top five themes are displayed here in order of prevalence on the diagram and just to run through those quickly and with a bit of added detail.

The first, and most frequent, theme that arose was around the approach to risk. That COVID-19 had caused a very fundamental shift in the thinking about the risks we face as a society. And whilst it was clear that some people were already there, in terms of thinking about systems and holistic risk assessment, there was also a certain amount of evidence that went into those reports that demonstrated we were not all there at the same time together.  

Going forward, that assessment of risk had to move away from a siloed departmental or intra-organizational perspective, moving towards something more holistic and integrated – representative of a whole-society approach where and when more connections could be drawn and the cascading kind of impact and second or third order effects of the materialization of the risk could actually be addressed in a more holistic manner. 

This was seen in things such as in the international context and national context, such as school closures, the additional impacts on education that  extended the risks therefore to vulnerable groups that extended beyond the primary risks associated with fighting COVID-19.

The second theme that came out was around assessment of risk and so I'm really pleased that shortly I'll be handing over to Doctor Alexandra Smith from the Royal Academy of Engineering, who has actually been a leading on the review of the National Risk Assessment methodology.#

But it wasn't just the UK. It was coming out at the international level across the various different countries that were reviewed in the United Nations research, that actually there was something about our assessment of risk that hadn't moved at the pace of the evolving risk landscape and that actually there was a requirement and a call for a more adaptive, agile and responsive way of assessing risk to be developed and applied.

Moving on to the last three themes, it was not so surprising to see that risk communication was also in there. For those who've who come across communication lessons frequently in many different settings, there were similar themes that that have been in other circumstances, such as the consistency of communication, the accuracy, and the timeliness of information to support that key decision making process.

So just to finish off there, that the risk communication challenges highlighted underscored the importance for mechanisms for timely transfer and also smoother transfer. This, of course, becomes inherently difficult when we've got that uncertainty. However, there are examples of good communication, particularly at the local level through community-based mechanisms especially in the international context.

The fourth was risk leadership and management. This was interesting because risk management is something that's been talked about so much and what came out of these reports now, was more risk leadership. It’s really interesting to see that shift, which is about owning the risk as a department or as an individual with key accountabilities, proactive management and mitigation with a real senior drive behind it. And it was under this theme that there were calls for greater scrutiny of risk, leadership, reduction in variability in risk management strategies and for there to be a timeliness to that leadership interventions.

Finally, and very aptly, the fifth thing that came out was actually around lessons and learning. Not only did this serve the Digest well, but it also came up because of the inherent risks with not implementing change and embedding lessons after they've been identified, or not identifying them in the first place.

The risk that was present after exercises, where lessons had been identified but not acted on, was really clear. It seemed that whether some action had been taken and it was a learning sufficiency challenge, or whether the measurable change that had been presumed to have taken place had not been monitored or measured or evaluated, depended on the circumstance. But nonetheless, it was highlighted that wherever there was a lesson, there was a risk for the future. And that prompted the thought that actually there was something around a shift in mindset from learning when there's time, to learning while there's time ahead of the next emergency or crisis. That's the summary of the research from the central analysis. 

I'm really pleased now to hand over to Alex from the Royal Academy of Engineering, who is going to tell us about their review of the National Risk Assessment methodology.

Reviewing the National Security Risk Assemment Methodology

Alexandra Smyth
Thank you Lianna. For those of you that don't know, the Royal Academy of Engineering is the UK's National Academy for Engineering and Technology. Our fellowship stands 1600 of the country's best engineers and their expertise bands, disciplines from AI to nuclear and the built environment. And it's my job to draw on this expertise in infrastructures and resilience, to inform policymaking. 
Risk management and resilience are really strong themes across the engineering profession. So in 2021, we were asked to undertake a review of the National Security Risk Assessment methodology, which I will be calling the NSRA from here on in.  

Immediately we were presented with the complexities of the NSRA, as it went from central government out to local action. So, we chose to take a systems approach to explore and unpick the complex interactions across the process. We used the question framework that you can see here to structure our approach. 

First, we work with central government devolved administrations and the local resilience forums to understand the system – what worked well and its pitfalls. 

We then looked at good practice examples in risk assessment, understanding, interdependencies and scenario building. This drew examples in academia from industry and from government as well, and from these like very different examples, we were able to identify some common themes which have informed our principles for good practice. 

Finally, we made some practical recommendations to the Cabinet Office, outlining all the considerations for implementation of the changes to be expected to be successful.

These were identified from workshopping all of the recommendations with the different stakeholders involved and making sure that we understood the nuance and what was going to really make these transformative in practice.

In six months, we engaged with around 200 stakeholders to ensure that we really understood those implications and what effect they would have on the NSRA process as a whole. And I really hope that these have made a positive impact to UK resilience.

Our principles…
So, embedding resilience, thinking into risk management, we believe really helps increase preparedness for future events. The seven key principles are on the slide here, but firstly it's all about ensuring a joined-up approach. That means building really strong relationships across typical sectorial silos to create shared understanding of the capability that different organizations have this join up and strategy needs to cross prevention into preparedness and then into response and recovery.

So that together, all of the different actions to create resilience, are bigger than the sum of their parts. Then we've got encouraging participation and communication and Lianna talked about the importance of some of these areas.

But I think we all recognize that we're biased by our own lived experiences, and there will be aspects of how risks might manifest for different parts of society that as individuals, we may not automatically think of.

It's vital that a diversity of perspectives and are brought into our understanding of risk to both unpick what it might mean in practice, and to provide meaningful challenge to our assumptions. Building these networks will provide will prove invaluable when something does go wrong because you know who's to call on and who's able to help.

Our third principle is to focus on impact while knowing how likely something is to occur can be really helpful for prioritizing action. Decision making really must be driven by impact and preparedness.
Those with responsibility for managing risk should be incentivized to reduce that impact by increasing or preparedness. I enforce. 

Fourth, we suggest exploring the interdependencies. Having lived through COVID-19, we're all acutely aware of the cascades of consequences that can occur in an emergency. Coming together is critical to uncover those interdependencies between our infrastructures or services and the relationships. This will help us identify the compound consequences that might result from decisions made rapidly at the time. 

Relatedly, our fifth principle is to consider a range of scenarios. While the reasonable worst-case scenario has lots of value, considering multiple scenarios can really help with robust planning and identifying a range of different response capabilities that might be needed. It's not about scenarios for the sake of scenarios, it's about understanding where something different will be required and where the cascading risks and consequences might occur.

Our six principles suggests embedding new data and metrics, and I think we all know data is vital for informing likelihood and impact assessments, but also for providing early warnings and in monitoring the unfolding emergency.

But confidence in the data must be high. That means having data sharing agreements in place between organizations beforehand, so that we can really get access to the data we need at the time we need it. That also means models need to be carefully evaluated and paired with real world information so that we're not swayed by what the model says, and we know what's actually happening and on the ground.

And finally, we proposed reviewing based on need. Resource for risk assessment and preparedness is often scarce. So, it's important, it's used effectively. 

By reassessing risks based on need, by which I mean how sensitive those risks are to technological or societal changes, or maybe the change in provision of mitigations rather than the kind of Standard time interval, the most effective use of resource for people to engage in the process and give it deeper consideration. 

This might also enable longer term planning, rather than short term fixes. And finally, we recognize that many of these principles aren't easy to adopt everywhere.

We offer a set of questions to explore the barriers and enable enablers to implementing these good practice principles in your setting.

These include is the role of risk assessment, broadly understood? By which we mean, can you get buy in across the organization for this to be more than a tick box exercise? What are the stories you can tell that really buy people into the discussion. Is the wider organization aware of the risks identified in the assessment and any interdependencies that might sit within their responsibilities? Do you have that effective information exchange that increases awareness and can greater cross organisational collaboration be facilitated to better understand these risks that will help create a sense of shared responsibility and potential for shared action?

Is the organization better prepared for the risks included in the assessment as a result, and are the risks decreasing because of improvements in preparedness or reductions in impact? If not, is that acceptable or do actions need to be taken place?

Hopefully the answer to all of these questions is, yes. But if not, maybe you can start the conversation within your organization at start to move the practices forward. 

You can read more about our review in our building resilience report, and I'll hand back to Lianna now.


Thank you so much, really appreciated Alex. The report is available to download on your website.
I'm happy to move on to our next article and our presentation from Lisa Jackson and Oggie Dodson from Emergency Management Victoria all the way from Australia staying up late at night to share with us some of their tools for implementation and how they've moved from lessons identified to lessons learned in their context. So over to you both and thanks again for joining us.

Moving from lessons identified to lessons learned: EMV methodology

Lisa Jackson
Thank Lianna and hello to all. I will kick off today with an acknowledgement of country, which is a tradition in Australia, to acknowledge the lands on which we meet today, and I pay my respects to elders, past, present and emerging. And I extend that respect to any Aboriginal, Torres Strait Islander or other indigenous peoples who may be here with us today. 

So it's a pleasure to be joining you from Melbourne, Australia tonight and a huge thank you and congratulations to Lianna and your colleagues for your world class work on the Lessons Digest.
It's widely recognised in our part of the world, as best practice and we love reading it every time it comes out. So, it's a pleasure to be included. Again, I excited to run you through some key points relating to our article, but also continue the conversation after today. We both could talk about this stuff for hours, so we'll try and keep to time, but please reach out via LinkedIn email and contact details if you do want to chat further

But just for some context, we work for Emergency Management Victoria, which is in the state of Victoria in Australia. Our organization was established in 2014 after the significant black Saturday bushfires in 2009 and then subsequent flooding emergency in 2010/11. The purpose of our organization is to bring the sector together, to collaborate and coordinate effective Emergency Management and all hazards, all emergencies environment. We work with approximately 50 different agencies and that includes local government and not for profits and non government agencies. So all of our lessons management work that we're talking about today is conducted in this multi-agency environment. 

So we'll take you back to kind of where it all started in 2014 when the organization was established. We were looking at the Emergency Management sector and we're exploring different lessons management approaches that were being undertaken through an environmental scan and also research as well on how to effectively support learning within the Emergency Management sector.
So our environmental scan and research found that there was a strong culture of identifying themes and lessons, but not so much success at ensuring those lessons were learned by creating lasting behaviour change. There was no consistent model across our agencies, which was leading to poorly defined roles, responsibilities and expectations.
Blame and shame, although had diminished, was still prevalent in many parts of our sector. And there was a lack of visibility in the process of developing lessons leading to a perceived perception that people's contributions at debriefs just weren't being used, even if they were, they just weren't aware of how it was being utilized. And so, even though we had many champions of learning practice in the field, there was a risk at that point of losing some momentum because of the perceived black holes of information. Emergency Management agencies were working individually on lessons management, which was creating some silos of knowledge and disconnection around learning opportunities. And there was limited understanding around the principles and benefits of lessons. 

So using all of this information in the outcomes of the research on lessons management, we established EM learn, which is our Victoria's first multi-agency lessons management framework and has been released since 2015. And although it feels like yesterday, it has obviously been about eight years and it's been a journey of testing and refining that approach as well. And you'll hear how we've done that through case study today.

And as you probably appreciate, culture is often and intimidating part of lessons management, and it's often that the soft element and it's not something that you can easily touch or create a process around and you can have the best lessons processes in the world but without a positive and supportive culture, they will fail. 

So, the EM learn framework includes a life cycle, which includes key characteristics of what we what we've been focused on implementing as part of our culture since then. So that includes having a just fear or no blame culture, communication, accountability, leadership and being learning focused and everything that we do – so, no blame or shame – as well as outlining a process which includes the identification through the learning of lessons. 

To support the lessons management process, we utilize a national Australian Institute for Disaster Resilience Lessons Management methodology of observation and insight, to lesson identified and lessons learned. Separating those two terms is really important to us, and I'm sure all of you as well, because a lesson is not learned until you have seen that change implemented.
I won't go into all the methodology and a lot of detail, but essentially it's around pulling together data from individuals and their experiences at different events at any point in time and then using coding, triangulation and pet and recognition to bring that together.

So, you would use at least three sources of data to inform an insight, and then three insights to inform a lesson at a bare minimum. And that's really just to ensure triangulation from multiple sources, and we're not just reacting to the loudest person in the room. 

This allows us to have a trackable way and a transparent way of how we get from an observation through to a lesson. So, we're always able to go back to that data and explain why we have the lesson that we do. 

I'll hand over to Oggie and run you through the June 2021 extreme weather event.

Ognjen Dosen (DJCS)

So I'll take you through a practical example of lessons management applied to an emergency event, as was described in the Lessons Digest. 

In early June 2021, over a four day period, Victoria experienced destructive winds and heavy rainfall, which caused significant impact, including fallen trees, widespread damage to power, telecommunications and transport infrastructure, as well as major flooding which left some communities completely isolated. 

So the Victoria State Emergency Service, which is the lead agency in Victoria for flood, storm and rescue operations, received over 10,000 requests for assistance. This made it the single largest operational event in the agency's history.

There are a few factors uniquely associated with this event that separated it from other previous or similar events. Firstly, it occurred outside of Victoria's high risk, where the season meaning normal, emergency and management arrangements weren't in place. Secondly, there was great uncertainty and the prediction of the intensity and location of the weather event. Following the event, there was a public commitment made by the Minister for Emergency Services and the former Emergency Management Commissioner to conduct a review into the event.

Therefore, in September 21, the Coordinator Learning Review was established. The purpose of the review was to establish a coordinated and consistent approach for reviewing the event.

It was to ensure that lessons of state wide, multi-agency significance, and also aspects of particular interest to impacted communities, which involve areas of good practice and opportunities for improvement were identified, implemented and shared across the Emergency Management sector and importantly with the impacted communities.

So, in line with the EM Learn framework, which Lisa has spoken to, the review applied lessons management principles to capture observations, analyse for insights and to identify lessons. 
Through various components, over 2,000 observations were collected from impacted communities and Emergency Management personnel.

These were then themed, analyzed for patterns and trends, and developed into 369 insights. Through further analysis of the insights, we identified and developed 50 lessons that articulate a viable course of action that can either sustain a positive action, or address an area for improvement.

The lessons then went through a vigorous validation process with all relevant agencies and key stakeholders. This ensured that they demonstrated a collective level of sentiment across the Emergency Management sector. From there, we developed two reports. 

The Community report, which was a public facing report, was prioritized and was released 12 months after the review. It featured 11 lessons of significance to the community. To complement the release of the report, we joined the former Commissioner in senior representatives of Emergency Management agencies at several community visits across the state. These were organized to hear feedback from the communities in relation to the findings in the report, and to communicate back to them what change has been implemented since the event, which the Community really valued. 

Shortly after, we released a more comprehensive operational report that featured 44 lessons aimed at Emergency Management personnel to provide learnings back into the sector.

The report itself was formulated as a case study, which included a detailed summary of the event, contextual considerations to enable that sense making of why the event actually eventuated in the manner that it did, and a reflection of learning since the 2010/11 Victorian flooding inquiry, which is the last major flooding event prior to this event. Back to you, Lisa 

Lisa M Jackson (DJCS)

Now just give you a quick rundown on the implementation approach that we applied to the lessons from the June event that Oggie just spoke to, but also the Victorian flooding event from last year that's mentioned in the article.

Implementation of multi-agency lessons isn’t easy as you probably know or may have experienced yourself, and I'm yet to come across another jurisdictional country that has a process that we could steal or borrow and bring across to Australia. So, if you do have one, please share it. 

But in the meantime, we are testing and learning from this approach as well as implementing learnings from other agencies across Australia.
An important thing to remember is that the lessons aren't recommendations, so we don't tell our stakeholders how to fix the issue or sustain the good practice. It’s left up to the subject matter experts to consider the lessons and plan a way forward. And often work is already underway that kind of be informed by the lesson as well.

But the ultimate goal is to ensure that the right people have the right lessons at the right time so they can then use them to inform their programs and projects, operational decisions and planning processes. With the end state being that we can say hand on heart that we've learned and give our personnel and community comfort that there are experiences matter and have informed change.

So what we did with the June lessons and the Victorian flooding event lessons was each lesson was categorized as either strategic, operational, or agency specific. And that was really just a way for us to be able to say, can this lesson at the moment be tackled with the current resourcing and funding that we have available to us, or do we potentially need to go to government and seek further funding and resources to support that moving forward? Or is the lesson specifically relating to an agency in their sole responsibilities. 

That was the first kind of cut of the lessons was to be able to divide those lessons up in that way. And then do an assessment around what other work is underway? What other strategic work might be happening in response to other recommendations and lessons that have come out of maybe external enquiries and the like. The last step was in to think through who the lead agency or committee should be and this was all in consultation with our sector as well.

We don't operate as an independent authority around this work, we definitely work side by side with our partners. We also had significant engagement from our Emergency Management Commissioner and our other senior stakeholders from the agencies throughout this work and we were able to get a really high level of engagement and get letters sent from our Emergency Management Commissioner directly to lead agency chiefs to be able to say, you know, these lessons have now been finalized and approved in consultation with your agencies, and we now hope to see that you have considered those and we want to have conversations into the future about what's been done to either implement the lessons, or consider those in your pieces of work.

That really highlighted to us at that executive engagement is just so critical in terms of getting other agencies and stakeholders on board and really being able to effectively learn from lessons moving forward. 

As you can imagine, measuring change is a critical component in being able to understand if you have learned a lesson. This step focuses on confirming the success or the outcomes of lesson learning, involving measuring, reporting, and validation through either exercising training or future operational activities, where we use a function such as real time monitoring and evaluation.

So just a quick overview of what that capability is, it's a state level multi agency program that's been in existence for more than a decade in our state. Unlike traditional evaluation, often conducted post events, we conduct real time monitoring and evaluation during the response relief in early recovery phases of an emergency. It involves short deployments of a group of operational and evaluation subject matter experts who observe meetings, debrief personnel, and review documentation while the event is underway. And they capture details that could have been missed if an evaluation was done after the event.

The approach promotes a no blame just and fair culture and supports real time learning by collecting, analyzing and disseminating learnings, all within the 4-6 day deployment and provides a platform to escalate issues quickly.

The RTM programme is also used to monitor change and improvement in real time, to ensure lessons are being captured, implemented and learned from previous events – as we can focus on focus the terms of reference of the deployment on previously identified lessons or deploy multiple times during one event to check to see if things have changed or moved.
Thank you for giving us the time tonight to share our experiences, and there's so much more we could talk about, but please do reach out.


Thank you so much, Lisa and Oggie, so appreciated and so fascinating. I know you've got some fantastic publications that relate to that, so please visit their website.

Passing straight on, allow me to introduce Dr. Sarah Robertson, who is going to talk about developing and delivering the Ground Truth Tool in Alder Hey Children's Hospital.

Implementing the Ground Truth Toll to support NHS workers in a crisis

Dr. Sarah Robertson

Thank you, Lianna. I’m going to spend the next 5 minutes telling you a bit about our learning through the pandemic. 

I'm a clinical psychologist that works into the staff advice and liaison service, and one-door service for all of our staff within the organization to offer listening advice and support. My role is also split into organisational development, thinking about strategy and processes.

Today I’ll be talking about the Ground Truth Tool work that was supported by the wider team, and our service is led by Dr Joe Potier.
So a bit about why it was so important for us to think about a new approach and why we implemented the ground trees to tool. In COVID-19, just to set the scene for you, whilst Alder Hey Children's Hospital supports children, our staff were asked to respond to the national crisis around COVID-19 by caring for adults. 

There are risks inherent in healthcare work for staff, due to the nature of the work anyway. There's a unique emotional and psychological burden associated with care, but this was really exacerbated by a very unpredictable and volatile context where leaders were faced with high risk of moral injury and making decisions about what to do and how to respond best. And the amount of trauma exposure in the role was very high and people were affected by what they saw and heard. The amount of secondary and vicarious trauma, meant that our workforce were at an increased risk of trauma saturation, whilst continuing to work and respond with an uncertainty as well about COVID-19 and how it might impact. 

At the same time, there was a reduction in this protective factors in the workplace – the fact that people were separated due to infection control measures, teams were disconnected, redeployed, was more isolation and it was hard for leaders to understand the reality on the ground as people were working more digitally. There was also the aspect that staff were living the experience as well as caring for people through the experience.

So, we saw a huge rise in burnout in the NHS and there was a widening gap between demand and resources, which has continued as we've kind of out of the peak of the pandemic but are now recovering the backlog of services. So it's no wonder, really, that there's a spotlight on focusing on mental health and the need for sort of proactive preventative support. Whilst there's limited options externally, we know we need integrated systemic approaches, because actually isolated approaches for stress management with psychologists have little to no effect on stress management in the workplace and can increase turnover, whereas we need to keep people going and caring.

A novel approach really, to a worsening problem. So these things were risk pre-pandemic, but worsened throughout the pandemic. And so we reached out to the ground truth team at the University of Liverpool and deployed a digital mechanism which is focused on the cognitive and behavioural principles behind keeping going, building resilience –supporting adaptive recovery, helping people to stay well and reflect, come together and offered structured and framework through talk, review, understand, tell and heal. So looking at offloading, reviewing live responses, what had been learned, who needed to be told and feeding this back to leaders, whilst actively monitoring stress so that people could respond with solutions.

What we found with the Ground Truth Tool is that 95% of staff found it helpful and 47% of staff reported feeling better, and only 2% of staff reported feeling worse (which is less than typical therapy as well). 

And what we found critical really in this environment and become part of our service model is that we need to target interventions for wellbeing at all within the organization, to normalise distress and reduce stigma and support early intervention. And in integrating the dual responsibilities between individuals and organizations is paramount, so that everybody takes accountability for what they can do and has enhanced awareness about what difference they can make to reduce in stress as proactively as possible.

It’s also supporting leaders with a framework that enables them to respond in a helpful way in a focused way. It’s the idea that it's not your fault, but it is your responsibility. So supporting as much compassion within the organization, and doing that through networks of noticing.
So, within SALS we have SALS PALS who are trained on the ground using the ground truth tool to notice and having those local contacts help them maximise trust and minimise distress, whilst feeding back key insights to lead us so that they've got that enhanced situational awareness and can respond in a helpful way. 

I'm happy to talk about it more with anyone that's interested, please email me. But thank you so much, Lianna, for the opportunity.


Thank you Sarah, that was fascinating. 

The importance of personal resilience for leaders

I'm delighted to welcome Dr. Claudia van den Heuvel to speak to us now from a crisis leadership perspective around personal resilience.

Claudia van den Heuvel

Thanks so much, Lianna. My first slide is to set the scene of why I think crisis leadership is so essential nowadays. But I feel like all the speakers that have come before me have really set the scene really nicely. Mark, set the scene already about the state of the world outside, the fact that we are living in a perma-crisis and poly-crisis world and that is why they were the new words in the dictionary in 2022.

I don't think I need to labour this point because I feel like I'm preaching to the choir just a little bit, and it’s interesting to hear Sarah talk about the levels of burnout and specifically in the NHS. But I think this is this is pertinent to all workforces across the UK and across the world. And I think it's especially pertinent to those who are in leadership positions because they're at the heart of all emergency events. 

So the fact that we're having these situations, these unique crises that are both deeply rooted and mega trend crises, as well as those sudden onset emergencies that we're having to deal with, all at the same time, means that leaders nowadays are facing a really, really different operating environment. And what that really means is that we need to equip them with a whole new specific skill set so that they can learn to lead in these times.

I'll spend a little bit of time on the next slide actually because we all know that of course, in a crisis those day-to-day aspects of leadership become far more complex. Things like setting strategy, making decisions, managing a team – there's so much more challenging when a situation is rapidly unfolding, when information is incomplete, when we've got the internal and external pressures mounting both the micro stressors and those macros impacts that we're dealing with.

And I think lessons have recently really illustrated that if we're going to be able to manage through this new world that is typified by perma and poly-crisis, we need to equip leaders with really specific mindsets and skills to operate effectively. And at the core of that is leaders need to cultivate personal resilience.

This requires a stark rethink of what personal resilience even is, and then how it contributes to our ability to think clearly and perform effectively under prolonged periods of pressure and stress. So how do we build it? How do we maintain it sustainably during these periods of challenge and of pressure? How do we encourage others around us to build it? 

Historically, of course, resilience has been seen to be about people coping with challenge, change, adversity, keeping going, perseverance, grit. Nowadays, when I talk about personal resilience, I look at how individuals set achievable and sustainable patterns of behaviour, so that they can optimize their health, optimize their energy and their minds. Ultimately, it's all about their ability to continue to perform despite the uncertainty phase, despite the pressure they're under. 

As a sort of a metaphor, I guess we can learn a lot from professional athletes around this. I mean, it is their part of their job, to set these high-performance routines. They have very specific patterns and systems to warm up and prepare for the day ahead –physically, emotionally, cognitively, to prepare for the challenge for game. Then they have ways of working patterns to perform with focus and think clearly, think broadly, reframe problems and challenges. And then they have whole ways and patterns of systems to wind down to make sure they recover and recharge at the end of every day or after every session that they've performed.

We too can implement these dates to day routines, so we can help raise our performance, capability or resilience baselines. But I think equally for crisis leaders, we need to think about, realistically, what does this mean for maintaining high performance when in a crisis response, especially those prolonged crises response programs such as COVID-19. 

We know that due to the time pressure in a crisis, it's so hard to think strategically and set really effective long-term strategies at the beginning of a crisis or an incident. We have this innate human tendency to just jump in and give it our all, and we'll only think about the consequences to our own mental health or our wellbeing, or our performance later down the line, at which point we're borrowing energy from future days. This is why it's so much more important and critical to set that personal operational rhythm for yourselves as leaders at the beginning very early on in a crisis.
I'm sure we're all familiar with the concept of battle rhythms or operational rhythms to get the latest information, to get to inform situational awareness. This builds on that same principle, right?

Whether it's setting an A and A/B team at the start of a crisis, sending half you people home so that they're fresh when they come back in, or whether it's setting daily working rhythms and patterns that you know you can keep to which are sustainable for the long term.
So this is what I call our minimum viable product, high performance routine.

So what are those patterns for ourselves, what are the behaviours that we can stick to in order to manage your own personal resilience, even when we're under immense pressure and working long hours? What are your personal non negotiables and define those for yourself?
Clearly, at the beginning of a crisis, again, they're deeply personal, right. So whether it's a 10-minute walk per day in daylight, or whether it's making sure you eat only nutritious foods instead of eating pizza out of a box at midnight, or making sure you have 20 minutes to wind down before bed, or making sure you get 6 hours of undisturbed sleep, it's completely up to the individual.

But it's important to define them early on. What are those non negotiables? What will you prioritise in these time compressed and challenging periods, what rhythms can you can you set to meet them. And, ultimately, the most important part is to find how are you going to hold yourself accountable so that you can maintain them?

We are all in control of our own behaviours, but it's a lot easier to trust a process that's already ingrained into our daily habits then it is to trust intention when times are tough. And these routines are important not just from a physical and mental health perspective, there is a real clear correlation to all of the other aspects of crisis leadership that you see in that wheel as well, right? Because when we are feeling more resilient and more in control, we are better able to think clearly under pressure, to think strategically, to make decisions, to communicate impactful to those around us.

So, enhancing your own personal resilience will have a knock-on effect on your ability to do all these other things. 
I'll spend one minute on this last slide because I know we've already run over. I'll just sum up with two takeaways actually from this slide.

First of all, this is a big ask because also as leaders were not just having to think strategically, make decisions, set the rhythms. We're also tasked with being the emotional barometers for the team, for setting this culture that is, that is conducive to them being resilient and holding themselves accountable from a resilience perspective as well. And there's eight and very difficult skills in that wheel set. So you can't do it alone, right? And you really need to surround yourself at the support and the expertise that you need.

Cast your nets wide. Seek support from a large pool of people. Build on everyone's strengths and make sure that there is that culture of psychological safety, of empathy, of bidirectional trust, and, critically, of hope within your teams.

And finally, how can we do this? How can we get these patterns ingrained? I’m a really firm believer that muscle memory happens only through very frequent exposure. You don't learn to play the violin by practicing it once a year for three hours. So, crisis exercises are great, but doing it once a year for three hours is not enough. We have to keep building our muscle memory so the micro exercises are a great way to rehearse your crisis response processes. 

But it's also to hold yourself accountable to your daily routines. And again, that will shift you away from that like true intention piece that you have to rely on at the beginning of a crisis response to something that's already there. It's in the muscle memory and it will allow you to take that step back, to lead, to think clearly, to make decisions and then ultimately lead well through challenging times and crises. I'll end it there. Thank you so much for having me today.

Claudia, thank you. That was excellent. A really clear and thought-provoking talk and the running over is on us entirely. So, I'm so pleased that you could share that with us. We had planned for Q&A panel, but I'm aware that time has beaten us.

I noticed in the chat one question around those good practice principles for LRF's in the local setting. I would direct you to the link to the building resilience report that Alex's popped in the chat. Also in the Digest, you will find a bank of transferable lessons which pull out specific lessons and recommendations from those high-level reports that can be applied in the local setting. So some additional resources there for relevance in your own local contacts. 

But for now, I would like to thank EPC for hosting, thank Cabinet Office colleagues for joining us and supporting, and of course thank all of our guest speakers for their wisdom for their input, for their time for staying up at night and for putting their links to further information in the chat.
This has been the Digest 3 webinar Learning to Read Risks. Thank you very much for joining us. Goodbye.

> Visit the Lessons Digest Knowledge Hub