Promoting a culture of learning
A new (17 July 2026) Research & Analysis Bulletin from HM Inspectorate of Probation: Serious Further Offence reviews: Promoting a culture of learning in probation acknowledges that the current SFO review process, which is designed to facilitate learning and improve practice is actually experienced by probation practitioners and managers as “an exercise of blame and shame”. The bulletin sets out the inspectorate will adopt the ‘New View’ of safety science, grounded in learning from frontline experience, and facilitating psychological safety.
The bulletin
The bulletin is based on the findings of a survey of 245 probation practitioners and managers and the views of ten SFO reviewing managers (SFO RMs) and six senior managers with SFO oversight duties through interview and focus group settings. A broad literature review of the safety science and business studies literature was also undertaken, and the inspectorate interviewed two leading senior academics with expertise in the subject area.
The overall objective of the research and analysis was to better understand the issues of blame, learning and growth following SFOs in probation, and to outline key lessons and strategies from other sectors in learning from mistakes and tragedies.
Shocking findings
The survey demonstrated just how unhappy probation staff are with the current SFO review process. Key findings included:
- 39 per cent of all respondents were not satisfied that the HMPPS SFO reviews were helpful, with 30% responding positively to this question
- 55 per cent did not believe there was sufficient support for staff involved in SFO reviews, with just 20% responding positively
- 45 per cent did not believe that there were sufficient opportunities for staff to learn from SFO reviews, with 23% responding positively
- of those with direct experience of an SFO review (as a practitioner or line manager), 58 per cent did not believe there was a sufficient learning opportunity for the team as part of the process, with less than one in six (15%) responding positively.
In their survey comments, probation professionals talked of their anger at the culture of blame which they believed characterised SFO reviews. Probation professionals were frustrated as they felt that the focus upon frontline practitioners masked the organisational and systemic drivers of SFOs.
Five principles of New View of safety
The bulletin articulates five principles which provide a coherent framework to structure thinking about improving the SFO review process.
- Error is normal. All humans make mistakes, mostly without consequence. To expect perfect performance every day is unrealistic and demoralising for employees. It should be recognised that safety-critical work, such as probation, operates within a VUCA (volatile, uncertain, complex and ambiguous) environment, and that ‘human error’ is usually the symptom of deeper organisational problems.
- Blame fixes nothing. A blame culture at work provokes defensive behaviour; workers will hide their mistakes and refrain from reporting systemic problems. A blame-free approach is not an accountability-free approach; indeed, blame reduces accountability. Professionals can be held accountable by telling their story, being frank about how things went wrong, and what all in the organisation can learn when facing the same or similar situations.
- Context influences behaviour, systems drive outcomes. The ‘Old View’ of safety looked for ‘bad apples’ who undermined otherwise safe and efficient work systems. Adopting the ‘New View’, practitioner sensemaking should always be considered and understood in the context within which events occurred, with the context being the total work environment, encompassing organisational processes, tools, goals, expectations, resources, training, values, and culture.
- Learning and improvement are vital. An organisational reframing of ‘failure’ is required where mistakes are treated as valuable learning opportunities. Relationships need to be continually nurtured to support learning and collaboration, with staff openly sharing their experiences and attempting to reconstruct their emotions, choices and actions as they appeared at the time. Beyond finding out what went wrong after an event, a learning organisation should pay attention to both: (i) safety ‘signals’ and any blind spots; and (ii) the everyday successes of its operations.
- Responses matter, especially for leaders. Constructive reactions engage with the complex realities of everyday work where many outcomes were possible in the context and the situation. Key principles include being evidence-informed, focused upon learning and improvement, and fully inclusive of all those involved in the event, respecting and recognising the value of differing views. The New View insists that investigations focus upon holistic understanding and clear, feasible, and accountable recommendations which guide the implementation of learning into changes in practice, policy, and systems.
The inspectorate have published a helpful video summarising the whole bulletin:
Conclusion & Recommendation
Rather than paraphrase the conclusions of this research & analysis bulletin, I think the issue is of such importance for just about all probation managers and practitioners, that I have reproduced the final paragraph of the Executive Summary in full below:
“Probation in 2026 finds itself in a situation of relatively inexperienced practitioners dealing with large workloads and caseloads, with some teams having high levels of vacancies and staff turnover. These systemic problems will not be overcome quickly or easily. However, reforming SFO reviews along the lines of the New View of safety, with its concomitant emphasis on trusting relationships and operational empowerment, is a potential way forward, supporting continual improvement and staff engagement, development, morale and retention. Crucially, promoting a culture of learning is beneficial to all: probation practitioners, managers and leaders, and victims and wider society through minimising the risk of future adverse events.”
Thanks to Dav Hovhannisyan for kind permission to use the header image in this post which was previously published on Unsplash
