Why does quality and improvement matter to me?

I'd like to share with you a personal story to articulate one of the many reasons I am passionate about quality and improvement.

I met my father in law before I met my husband, which is a fun story for another time, he was a very interesting character. I would often be the family member that would assist him with his health, take him to appointments etc and field questions about things as they arose. Post Traumatic Stress was often raised during health assessments but I never knew what was behind it. He was a very private and fiercely independent man. During the pandemic it was discovered that he had Dementia, and as a family we worked with health professionals to support him remotely as he lived in Tasmania, Australia. In time it become clear living at home independently would not offer him the support he needed so he moved closer to us into residential care. We could walk there, we could see him regularly and although the visits were often short I got to know more about him and we had many laughs. As a retired Aeronautical Engineer he enjoyed sitting outside and identifying aeroplanes flying overhead or pats with our dog, which he took great joy in. Mostly our conversations were light, having a laugh and about making him feel safe.

It was sad to experience someone becoming more dependent and less able to hold some of the long and interesting dialogues with us and others, but there there were many positive memories too. One was the realisation that he came to that his family would always be there for him, that's what families do. It felt like it was only in his final year or so that he truly believed that his family would keep him safe. His nature softened, he submitted partly to receiving care but was always greatful and polite. He was never frustrated, angry or difficult with the people providing support to him which I had thought he might be as he had always liked to have things a particular way = his own way. Living on your own for 30+ years can certainly make allowing others in pretty difficult.

There had been things that we had found difficult, sad or sometimes just a bit wierd with him. He was never enthusiastic about Christmas, I remember us making the effort to visit once on Christmas day, arriving at night with young children and not a scrap was prepared. I had offered to organise it remotely before we flew in but he said it was sorted. Sometimes he appeared to have harsh opinions about some cultures and races and he was over the top nervous about things sometimes. His nervousness or jumpy behaviour was almost to the point of being beyond pedantic but unnerving and, in my mind, not logical.

Anyway as the dementia progressed my husband, James, and I started talking about his dad, his background and the fact that we knew very little. We knew that he had been on a boat, I thought it was in the Greek Islands, with his dad and the boat had sunk, with him losing his dad. He was an only child and at that time they had just recently lost his mum. As we spoke about it, we wanted to know more about this event, no one really ever spoke about it and my husband said he never felt comfortable asking his dad.

And so the journey of discovery began. Firstly we looked on the internet and found a list of shipping disasters and lined up the TSMS Lakonia, a Christmas Cruise in 1963. The dates lined up, the story lined up and we immediately felt the enormity of the tragedy. This does sound silly when I have already mentioned the death of my husbands grandfather, but remember we knew very little and no one ever talked about it.

Described as one of the "smartest" boats at sea, promising a sunny cruise to the Canary Islands heading into Christmas and the New Year - what a way to celebrate the incoming year. There were a little over 1, 000 people on the boat comprising of crew and passengers. Unfortunately a fire broke out whilst most people were in celebrating in the ball room. The alarm system did not alert passengers or crew in time, crew were slow to respond and by that time it was too late. The Lakonia was in real trouble and everyone needed to evacuate.

She reportedly held lifeboats able to hold 1, 455 people. It's shame that they had not been safety checked and there were a range of issues that lead to injury and loss of life - factors included the chains were painted onto the ship, the releasing of boats didn't work, evacuation drills had not been adequately conducted and the crew panicked and put themselves before passengers.

The Captain was reportedly the last person to leave the Lakonia alive. He was found pacing the decks of the still burning ship. At the time there was very little knowledge or support for trauma, people were just expected to get on with their lives. I learnt of siblings that only spoke of it to each other at the 50 year anniversary, they had been asked if they were happy to be interviewed so they chatted about the horrific event only the night before they went on air.

Survivors stories of the 1963 TSMS Lakonia Disaster, hosted by the wonderful Chris Chaplow and his team at the Andalucia website www.andalucia.com gave us many different perspectives of that terrible night. We became immersed in stories and a full dialogue between survivors and family members trying to put the puzzle together. There were also stories from people involved in the rescue and retrieval mission. There were tales of heroism and tales of scavengers, but mostly of the sheer chaos that people endured trying to get themselves, those they loved and those they'd just met to safety.

So after some research on line and connecting with Chris, some survivors, their families, an amazing gentleman Gordon who was involved in the rescue and retrieval and some history enthusiasts we decided we still wanted to know more. We had an inkling from family that James Grandfather was perhaps buried in Tangiers, however only one body had been buried in Tangiers and records couldn't confirm who. We decided a few months before Christmas that we would travel to Gibraltar and Morocco to see if we could definitively find where he had been laid to rest. We were also keen to learn more about the whole event and it seemed talking with people directly and being in the geographical area would bring us more answers.

To keep it short and sweet the experience was full of mixed emotions. Complete sadness and empathy for everyone involved, but in the end great hope. We had the privilege of meeting Chris and Michelle Chaplow, John the historian, Gordon Holmes, amazing groundskeepers and managers in Gibraltar, Spain and Morocco - their stories and kindness had such an impact. We learnt so much and mostly we learnt why it is likely that James dad never wanted to share or recall that fateful day, the experience had been horrific and not only had he lost his dad that day but the chaos and the witnessing of countless tragedies as people tried to evacuate without the right assistance is likely to have had a huge impact on him. It's ironic that professionally he ended up working in safety and not surprising that he was so passionate about it. He knew first hand that things can go terribly wrong and it is avoidable.

When I say sadness - the complete negligence that occurred led to the loss of almost 130 innocent lives who had put their trust in the Cruise liner and its staff. There were so many missed opportunities, if managed differently I wouldn't be writing this story today. The hope comes from the humanity that we experienced, the story telling and generosity of people and most of all the lessons that were learnt from this shipping disaster that should never have happened. James father was remembered at his funeral by friends, family and colleagues as leading in his profession. He was a highly intelligent man and the fact he was able to have a leading role in the safety of aircraft after such a horrific personal experience is fantastic.

When people ask me why I love quality and improvement - this is an example on a massive scale of where things can go wrong and the horrific impact of poor systems, processes and leadership. The impact has effected me personally, those who perished as well as the survivors and their families, those involved in the rescue and retrieval were changed forever due to a series of poor decisions and actions. This was completely avoidable. Quality and improvement matter.

If you want to know more about this shipping disaster here's a link to a succinct video https://youtu.be/VFqtjlVvxSU?si=Gmt8fwJ1GnBhlLx7