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British government communication during the 2020 COVID-19 pandemic: learning from high reliability organizations

Abstract This article examines British government communication during the COVID-19 pandemic, assessing how it aligns to the communicational characteristics of high reliability organizations (HROs). The central proposition of the study is that HROs’ organizational culture enables and cultivates effective, ethical communication that, in turn, enhances the trust and engagement of stakeholders and citizens. A thematic content analysis of the UK prime minister’s public communication about the new coronavirus outbreak, examining televised statements, news briefings and prime minister’s questions from January to June 2020, shows that the British prime minister’s initial approach to communication about the virus was complacent about the country’s preparedness and capacity to control the disease’s spread. No errors were admitted in any of the government’s subsequent handling of the pandemic nor were mistakes acknowledged in the actions of those in or advising government. These approaches to communication are at odds with those adopted by HROs. The study suggests that lessons can be learnt from HRO practices for communication in high risk environments. They are also applicable to organizations that have experienced historical difficulties both in admitting errors and in fostering a transparent, responsive communicational culture.

better predictor of successful crisis communication efforts than having a crisis communication plan ' (2010, 553). This is, in part, because of the strong focus placed on continuous organizational communication directed towards detecting, recognizing and correcting errors. High reliability organizations are, by necessity, high-communication organizations, overseen by regulatory bodies that can stand apart from short-term interests and ensure that the main organizational focus is on safety.

High reliability principles
Reliability has been defined as the 'unusual capacity to produce collective outcomes of a certain minimum quality repeatedly' (Hannan and Freeman 1984, 153). However, reliability should not be conflated with invariance of performance. Schulman, for example, argues that (1993, 369), 'reliability is not the outcome of organizational invariance, but, quite the contrary, results from a continuous management of fluctuations both in job performance and in overall department interaction.' Reliability is also inherently relational (Busby and Iszatt-White 2014): there is a relied upon entity and a relying subject. Pursuing reliable performance requires, then, a extremely rich communication culture which privileges communication within and without the organization. The implementation of the following high reliability principles drives a specific type of communication culture as detailed below (Weick and Sutcliffe 2007;Lekka 2011): 1. Commitment to resilience. Systems are built to survive and return to normal operation despite challenges. Redundancy is built in. This principle ensures that organizations have the capacity to react appropriately to crises and disasters, bouncing back from them as a wind-blown tree returns to its original upright state. There are early warning systems in place that pick up weak signals that may be the signs of imminent catastrophe. Communication is characterized by openness to and engagement with early warning signals and a lack of complacency about the potential for disaster. 2. Situational awareness and deference to experience. This implies a strong focus on and sensitivity to operations and an awareness of the big picture. Everyone is on the lookout for anything unusual. HROs encourage all workers to speak up and to see how their work links in with others. Deference to expertise, wherever this expertise is found, involves ensuring that decision-making and sense-making, particularly in times of crisis, are carried out by those who have specific knowledge of the event or issue. Weick and Sutcliffe report an example from their research into how firefighters work. Interviewed by Weick, the fire chief states: 'The next fire I walk into, I won't know anything … When I arrive on scene with that mind-set, I draw more disparate perspectives from others, I affirm uncertainty, and I get more people to own what they see and to communicate it. None of us has ever been on this fire ' (2007, 119). This approach implies knowing where expertise lies and ensuring that there is a sufficiently agile organizational structure to permit sense-making and decision-making to occur where it should. There is continuous learning from the experience of front-line staff. While there is a strong central command, those lower down the hierarchy are empowered to act when necessary. 3. Collective and individual consciousness of risk and failure. Everyone, both individually and together, is acutely aware that even small failures in protocols or processes can lead to catastrophic adverse existential outcomes. This means that mistakes and errors are taken as early warning indicators of possible future systemic failures and are investigated exhaustively, seeking to avoid explanations which oversimplify reality. For HROs, 'no news is good news' is not true. In Weick and Sutcliffe's (2015, 60) words: 'All news is good news, because it means that the system is responding. ( … ) The good system talks incessantly. When it goes silent, that's unexpected, that's trouble, and that's bad news'. Information which reports failure is particularly welcomed as it allows organizations to detect weaknesses before they escalate into full-blown crises. Emphasising success is considered as a recipe for complacency (Weick and Sutcliffe 2015). Looking for failure implies the acknowledgement that we have incomplete information. 4. Refusal to oversimplify the causes of errors. This has important implications for careful and respectful listening to all stakeholders, especially those who challenge the status quo. Organizations which seek not to oversimplify when attempting to understand their environment do not dismiss views that do not fit into the most easily available explanations. In this culture, people are encouraged to express diverse opinions and to question the status quo without being labelled as mavericks. Healthy skepticism is welcomed as enriching the information context. There is both an exhaustive analysis of errors and systems to capture errors including complaint processes. 5. Mindful leadership. This entails front-line engagement requiring active listening by leaders, transparency, crossing boundaries and encouraging cooperation and collaboration. Leadership challenges unthinking adherence to past routines and ways of understanding and doing things in the organization. A mindful leader seeks out bad news, proactively commissions audits to diagnose weaknesses, examines stakeholder feedback and engages in active listening with front-line staff through walk-arounds and face-to-face meetings. This kind of leadership 'walks the walk'. 6. Just culture. The organization is set up to learn from errors, correcting systems and processes where necessary, providing more training where it is required and sanctioning behaviour only where there are clear reasons to do so. A 'just culture' accepts that errors are inevitable, but that staff are accountable for at-risk and reckless behaviors. The development of just culture requires open reporting systems which encourage staff to speak up about errors in order to identify their root causes and remove them, recognizing that mistakes often have multiple causes including inadequate training or poor equipment or systems design. Staff are not blamed for these inadvertent errors, but organizations and staff use them as learning opportunities to improve organizational knowledge and understanding. It is an environment in which managers know what is happening because the workforce tells them. Mistakes are welcomed as a valuable source of information about the system. In organizations where just culture prevails, an environment of individual responsibility and accountability is encouraged (Provera, Montefusco and Canato 2010). Table 1 summarizes the communication characteristics of high and low reliability organizations.
This analysis will use these principles and their associated characteristics to examine British government communication during the first six months of the COVID-19 crisis. The COVID-19 pandemic and the British government In the words of medical historian, Frank Snowden (2020, ix): 'Like all pandemics, COVID-19 is not an accidental or random event'. Even though it provokes uncertainty, its occurrence does not belong to the realm of 'radical uncertainty' (Key and King 2020), where we simply do not know either what is the case in a given situation (whether my mother is taking a walk in the park as you read this) or where we cannot predict the event that comes to pass (the 9/11 attack on the Twin Towers, for example). In other words, the outbreak and spread of COVID-19 is not a 'black swan' event, defined by Taleb (2007) as an unexpected event (for the observer) with a significant impact. A pandemic was expected. In September, 2019, the Global Preparedness Monitoring Board (GPMR) had warned global leaders that: 'The world is at acute risk for devastating regional or global disease epidemics or pandemics that not only cause loss of life but upend economies and create social chaos' (2019, 11). When COVID-19 first struck, many observers pointed out how its spread could be curbed, including Taleb himself. In January 2020, with his co-authors, he urged governments to take immediate action to prevent the spread of the virus, stating: 'Decision-makers must act swiftly and avoid the fallacy that to have an appropriate respect for uncertainty in the face of possible irreversible catastrophe amounts to "paranoia"' (Norman, Bar-Yam and Taleb 2020). Notwithstanding these warnings, at the time of writing, since the World Health Organization (WHO) declared that a novel coronavirus was responsible for a number of cases in Wuhan City, China on 12 January, the virus has spread across the world: 809,011 people have died, of whom 41,515 are reported to have died of the virus in the UK (Johns Hopkins University of Medicine 2020). The excess death rate in Britainthe number of deaths from all causes above the historical average adjusted for populationwas stated in June to be the world's highest (although not all countries report the required data) (The Economist 2020). The UK Office for National Statistics (ONS) reported at the end of July that England's (not the other constituent nations of the UK) excess death figures between 21 February and 12 June were the highest in Europe (ONS 2020). As the statistician, David Spiegelhalter, points out (2020), it will take years to understand fully the impact of measures taken to stem the pandemic but there can be little doubt that Britain fared badly during the initial stage of its spread.
In Britain, the first reported cases occurred on 29 January 2020, just over a month after the Conservative Party, led by Boris Johnson, won a resounding 80-seat parliamentary majority in the 12 December, 2019 elections. Having fought a campaign in which the key message was 'Get Brexit Done', Johnson named the man credited with the success of the 2016 Brexit campaign, Dominic Cummings, as his chief advisor and appointed Cabinet ministers whose main job qualifications included loyalty to his Brexit project. The government's focus was firmly on the Brexit negotiations which they promised the British people would be concluded by the end of 2020 when -whether or not a deal had been concludedthe UK would make its way in the world outside the European Union (EU).
The scientists had upgraded the risk of the virus from 'very low' in January to 'low' on 21 January. As COVID-19 ravaged first Italy and then Spain in February and early March when both countries went into lockdown, the UK seemed at first to be following The government advises that anyone with a new continuous cough or a fever should self-isolate for seven days.

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The PM states that schools will not close nor does he join Scotland in banning gatherings of more than 500 people.

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The PM announces that people aged over 70 should not go on cruises and schools should not take pupils on trips abroad. Home testing ceases but continues in hospitals. 15 March -The government announces plans to hold daily televised press conferences to update the public on the fight against the coronavirus pandemic, starting the next day. Daily meetings were also held by the devolved governments of Wales, Scotland and Northern Ireland. 16 March -The PM advises against 'non-essential' travel and contact with others and to work from home if possible and avoid visiting social venues. Pregnant women, people over the age of 70 and those with certain health conditions are urged to consider the advice 'particularly important'. It is advised that large gatherings should not take place. Call with industry leaders to ask them to shift production to ventilators. 18 March -The government announces that all schools in the country will shut from the afternoon of Friday 20 March, except for those looking after the children of key workers and vulnerable children. 20 March -PM orders all cafes, pubs and restaurants to close from the evening. All the UK's nightclubs, theatres, cinemas, gyms and leisure centres are told to close 'as soon as they reasonably can'. 23 March -In a televised address, the PM announces a UK-wide partial lockdown. The British public are instructed that they must stay at home, except for certain 'very limited purposes'shopping for basic necessities; for 'one form of exercise a day'; for any medical need; and to travel to and from work when 'absolutely necessary'. 27 March -It is announced that the PM and the Health Minister tested positive for the virus. The PM's lead adviser, Dominic Cummings, drives 250 miles from London to north-east England. Reacting to later press controversy, he claims there was no one in London who could look after his child after his wife showed COVID-19 symptoms and he feared he would become ill. While there he also undertook a 60-mile round-trip to 'test his eyesight'. 29 March -The government sends a letter to 30 million households warning things will 'get worse before they get better' and that tighter restrictions could be implemented if necessary. The letter is also accompanied by a leaflet setting out the government's lockdown rules along with health information April (continued) a path of British exceptionalism. The Prime Minister (PM), Boris Johnson, held his first coronavirus press conference on 3 March; nine days' later, WHO declared COVID-19 to be a pandemic, and the PM announced lockdown on 23 March (see Table 2 for UK timeline).
Britain had initially followed the WHO's advice to test, trace and isolate. However, as cases escalated, on 12 March the home tracing programme was discontinued, although testing continued in hospitals. There were a number of reports that the 5 April -Queen Elizabeth II broadcasts to the country, only the fifth time she has done so. 5 Aprilthe PM is admitted to hospital after testing positive for coronavirus ten days earlier. 6 April -The PM is admitted to intensive care. 11 April -Queen Elizabeth II makes her first ever Easter address. Home Secretary Priti Patel says at the daily press conference that she is 'sorry if people feel there have been failings' in providing personal protection kit. 12 April -The PM is discharged from hospital. 27 April -In his first public statement since returning to work, the PM says the UK is 'at the moment of maximum risk' but 'we are now beginning to turn the tide'. 30 April -At the daily press conference, the PM says the UK is 'past the peak' of the COVID-19 outbreak and announces that he will set out a 'comprehensive plan' for easing the lockdown. May 6 May -At his first Prime Minister's Questions since returning to work the PM says he 'bitterly regrets' the crisis in care homes and is 'working very hard' to tackle it. Johnson also promises to reach a target of 200,000 daily UK coronavirus tests by the end of May. 10 May -The UK government updates its coronavirus message from 'stay at home, protect the NHS, save lives' to 'stay alert, control the virus, save lives'. The Labour Party expresses concern the slogan could be confusing, and leaders of the devolved governments in Scotland, Wales and Northern Ireland say they will keep the original slogan. 30 May -Some government scientific advisers warn of the risk associated with lifting lockdown restrictions in England too early, citing the still high number of cases and deaths. In response the government says it is following the data and evidence when making its decisions about the restrictions. 30 May -The PM announces a relaxing of lockdown restrictions for the 2.2 million people who have been 'shielding' in their homes. June 4 June -It is announced that face coverings will be compulsory on public transport from 15 June. 5 June -One of the scientists advising the UK government says he wishes the lockdown had been implemented earlier as the delay 'cost a lot of lives'. Responding to the comments, the Health Minister says the government 'took the right decision at the right time'. 8 June -Rules requiring travellers arriving into the UK to quarantine for 14 days come into force. 10 June -The PM announces a further easing of lockdown measures in England from 13 June that will allow people living alone to spend time in one other household as part of a 'support bubble'.
Sources: The Guardian 15 January -12 June 2020; Reuters Special Report 2020; Gov.uk 2020a;Gov.uk 2020b. government was now following a strategy of achieving what the Chief Scientific Adviser described as 'herd immunity' (Parker, Pickard and Hughes 2020), that is, allowing the spread of the disease in order to build up immunity in the population. This was despite the PM's statement in a morning breakfast programme (This Morning 2020) that 'it would be better if we take all the measures that we can now to stop the peak of the disease being as difficult for the NHS as it might be'. However, the measures taken at that stage still did not include working from home, physical distancing, wearing of face masks or bans on large meetings. Strong misgivings began to be expressed in the media and by opposition politicians. The Liberal Democrats' spokesperson was reported as saying (Parker, Pickard and Hughes 2020): 'What we are disappointed with is the way Conservative ministers have communicated that information. We feel they haven't really made a clear enough case as to why our position is so radically different to other countries.' According to Reuters (Kelly 2020): 'Johnson … moved more slowly than the leaders of many other prosperous countries to adopt a lockdown. He has been criticised for not moving more swiftly to organise mass tests and mobilise supplies of life-saving equipment and beds.' However, the same Reuters' report also shows that the interviews they conducted with scientists advising the government together with the minutes of their meetings 'reveal that for more than two months, the scientists whose advice guided Downing Street did not clearly signal their worsening fears to the public or the government' (Kelly 2020). It was more likely that there had been a failure on the part of government to question the scientists' assumptions rather than a failure to heed their advice. The report cites scientists who stated their awareness of the seriousness of the situation in January. However, analysis of committee minutes reveals that the 'scientists did not articulate their fears forcefully to the government' (Kelly 2020). One of the members of the Scientific Advisory Group for Emergencies (SAGE) stated that: 'We had milder interventions in place because no one thought it would be acceptable politically "to shut the country down."' It was not modelled because the scientists thought it wasn't 'on the politicians' agenda.' A partial lockdown was eventually announced by the PM on 23 March. This came after a radical shift in the government's strategy, moving from mitigationallowing 'herd immunity' to build upto suppressionapplying strict measures to ensure that as many people as possible are not infected. The change was announced at the PM's 16 March press conference. It was reported that the radical change had been prompted by the publication on 16 March of an Imperial College report commissioned by the government that showed that the consequences of the mitigation strategy would be over 250,000 deaths and the collapse of the National Health Service (NHS) (Kelly 2020). Johnson's government announced it would follow the example of a number of other European countries, requiring people to stay at home except in exceptional circumstances. Without question Britain was suffering its worst crisis since the Second World War. As the Global Preparedness Monitoring Board's (GPMR) 2019 report on the world's preparedness for the next pandemic, A World at Risk, demonstrated, Britain was not alone in being unprepared. In their words: 'Preparedness is hampered by the lack of continued political will at all levels. Although national leaders respond to health crises when fear and panic grow strong enough, most countries do not devote the consistent energy and resources needed to keep outbreaks from escalating into disasters' (GPMR 2019, 20).

Ontological and methodological considerations
British government communication is a highly professional and much praised service (Sanders 2014(Sanders , 2019. For the purposes of this article, I examine a narrow segment of this communication using thematic analysis, primarily focussing on the key messages and statements given by the Prime Minister at the UK COVID-19 news briefings. However, the study's main objective is to contextualize the PM's communication in relation to HRO principles. According to Braun, and Clarke (2006, 79), 'Thematic analysis is a method for identifying, analysing and reporting patterns (themes) within data.' Its strengths and weaknesses have been widely discussed (see Aronson 1995;Braun and Clarke 2006) and there is general agreement that it is a useful and flexible method for qualitative analysis of diverse data. It is not 'wedded to any pre-existing theoretical framework' (Braun and Clarke 2006, 81). However, to be clear about my own ontological and epistemological assumptions, I adopt a critical realist perspective (see O'Mahoney and Vincent 2014). This approach rejects straightforward positivistic realism that assumes that social scientific research is akin to the natural sciences in its attempt to find statistical regularities and correlations enabling universalizable propositions to be formulated. Critical realism understands the social world to be open and complex, requiring the understanding of context and the interrogation of discourses to ensure that we are achieving the best possible explanation of a given reality, which exists beyond texts and discourses.
Therefore, the study's research design uses a two-step process of analysis. First, a data set was gathered consisting of recorded material, available as transcribed text and accessed through government websites and mainstream and social media, of the PM's statements in a number of formal settings, mainly 10 Downing Street and the House of Commons. COVID-19 news conferences were held at 10 Downing Street daily until 5 June, after which weekend conferences were no longer held, and hosted by various ministers and health officials. The PM hosted 14 of the 56 COVID-19 news briefings from 16 March until 18 June, excluding the period of his illness. 1 He also attended PM Questions in the House of Commons on 14 occasions, appeared before the Parliamentary Liaisons Committee on 27 May and made his first and only Commons statement to date on the pandemic on 11 May. A semantic approach was used to identify the most prevalent themes, understood as the key public messages relating to the COVID-19 pandemic, within the explicit or surface meanings of the data. The second step was to position this discourse in relation to the wider context of the development of the pandemic, government interventions and public and media response. Table 3 provides a summary of all these data. Having established the context of and content of the PM's key messages, these were then compared and contrasted to the communicational principles of HROs as detailed below.

Prime ministerial communication
On the basis of a thematic content analysis, the PM's communication can be divided into five phases as set out in Table 3. In broad terms, the initial two phases from Press unease about low-key govt response. Growing public concern. Companies take preemptive action sending workers home.
Some sports organizations suspend events.

Mid-March-April Prime Minister/ Foreign Minister
Pandemic declared-High Lockdown for all but key workers.

Mass gatherings banned.
Will turn the tide, send coronavirus packing in 12 weeks and squash the sombrero. Stay at home. Protect the NHS. Save lives.
We are throwing everything at it. Public overwhelming-ly respond to government message to stay at home. Weekly clap the NHS event.
Media and public concern about shortage of personal protective equipment (PPE) and ventilators.
(continued) January to the beginning of March were characterised by a low-key communicational response. The third phase from the end of March to the end of April coincided with the virus' peak with clear messaging to the public about the need to stay at home. As the peak passed in May and lockdown measures began to be eased, there was significant confusion about what was intended as the messaging changed from 'Stay at home' to 'Stay alert'. This was compounded by the fact that the devolved government in Scotland refused to adopt the new message and by the scandal concerning the PM's chief aide's apparent flouting of the March lockdown measures. Finally, further loosening of the lockdown was announced in June, allowing among other things the return of the Premier League behind closed doors and the opening of non-essential businesses. However, the imposition of a 14-day quarantine on incoming visitors to the country caused some confusion about the coherence of the government's strategy.

PM communication and HRO principles
The following more detailed analysis of the Prime Minister's actions and messages in relation to high reliability principles during the first six months of the pandemic reveals, as we shall see, a worrying panorama of complacency about the UK's exceptional preparedness, overpromising on results and giving confused messages about how the public should respond to the pandemic. Adapting Lekka's (2011) approach to conceptualizing HR principles (see Figure 1), it is clear that a number of them were not taken into account in the communication response.

Problem anticipation and containment of unexpected events
Public Health England (PHE) knew that a pandemic was the number one risk to Britain and its CEO had stated that: 'Ensuring the country is fully prepared and able to respond quickly and effectively is a top priority for Public Health England and, of course, for the government' (Public Health England 2014, 5). However, as the 2017 National Risk Register makes clear, the UK's risk planning was based on the expectation that there would be a flu pandemic and that: 'The likelihood of an emerging infectious disease spreading within the UK is assessed to be lower than that of a flu pandemic' (Cabinet Office 2017, 34;NHS 2017). In 2016, a rehearsal for an influenza pandemic took place. Codenamed Exercise Cygnus, leaks to the press in April 2020 revealed that it had predicted a lack of personal protective equipment (PPE) and ventilators. According to the unnamed source cited in The Sunday Times' report, it was recognized that: 'Britain was in a poor state of readiness for a pandemic. Emergency stockpiles of PPE had severely dwindled and gone out of date after becoming a low priority in the years of austerity cuts' (Calvert et al. 2020).
In the words of risk specialists Bryce et al. (2020, 5): 'The findings of "Exercise Cygnus" and other such exercises in anticipation were clearly never acted upon in a meaningful way.' British capacity to act resiliently was compromised, in the view of Bryce et al. (2020), by overreliance on lean production and just-in-time delivery. Complacency about the risk of a pandemic and the country's capacity to react to it was reflected in the PM's communication, which lauded Britain's excellent resources and preparedness. This did not reflect the reality on the ground and, at the early stage of the pandemic, was unhelpful.
As northern Italy went into lockdown, the coronavirus epidemic was still not headline news on 21 February where it was being reported as an international news story from China and South Korea (The Guardian 2020a). It finally hit the headlines on 24 February when the Guardian reported that experts had said that the: 'World is approaching coronavirus tipping point' (The Guardian 2020b). Despite the increasingly harrowing images of the virus' impact in Italy, there was no sense from the government's communication that the virus was heading our way.
The January and February meetings of the Civil Contingencies Committee (known as 'COBRA' from the acronym for the Cabinet Office Briefing Rooms where the sessions take place), convened to tackle the coronavirus, were chaired by the Health Minister. The PM chaired his first meeting on 3 March. Two days later, in a morning breakfast show he declared that UK health workers 'have all preparations, all the kit that they need for us to get through' (This Morning 2020). This reassuring message was soon contradicted by appeals from the Health Minister and the PM on 16 March to British industry to fast- track the construction of ventilators as the COVID-19 pandemic was expected to peak in April 2020. There were also press stories of health staff and, later care staff, without appropriate Personal Protection Equipment (PPE) who subsequently caught the disease and died. At the 12 March press conference, the PM struck what was, for him, an unusually sombre note: 'I must level with you, the British public. More families, many more families, are going to lose loved ones before their time' (BBC 2020). These words sounded particularly ominous for people over 70 who were urged to stay at home and not go on cruises. However, the strategy remained that of mitigation or 'delay'. Testing and tracing were abandoned. More stringent measures such as banning mass gatherings or urging physical distancing remained in discussion.
As Britain's strategy for handling the pandemic changed four days' later from mitigation to suppression, so did the communication approach. At the press briefing that day, the PM announced a battery of interventions that the British were 'instructed' to follow, leading to some confusion as to how the measures would be enforced. His remarks were meant, in the view of the New York Times, 'to reset the government's communication strategy, which had come under fire for being muddled, opaque and failing to justify why Britain was out of step with other countries facing major outbreaks' (Landler and Castle 2020).
However, the PM's communication on Britain's preparedness continued to overestimate the country's true capacity to deal with a respiratory-related pandemic. It was also striking that at no point did he or any minister apologise or recognize any error in their management of the crisis, despite growing appeals from health and care staff and their families for him or his government to do so. The death from COVID-19 of an NHS doctor who had warned the PM about PPE shortages for health staff was a particularly poignant moment. A few weeks after his father's death, his son, Intisar Chowdhury, directly addressed the Health Minister on a radio phone-in in these words: The public is not expecting the government to handle this perfectly. We just want you to openly acknowledge there have been mistakes in handling this virus.
Openly acknowledging a mistake is not an admission of guilt, it is genuinely just making you seem more human. So can you please do that for me at the press conference today-make the public apology? (BBC 2020).
He told the BBC that a public apology would help improve public trust, adding: I definitely do want a public apology because I feel like the government's response in not only handling the PPE crisis but the whole virus in itself wasn't the best. I think we can forgive that as a country because it is such an unprecedented thing it is hard to know what to do. But they need to hold themselves accountable for that, learn from that and move on so that we can trust them more.
The Health Minister did not apologise and the nearest any minister came to saying sorry was when the Home Secretary, asked at the 11 April press conference whether she would apologise to NHS workers over a lack of PPE, said: 'I'm sorry if people feel there have been failings'. At his 30 April news briefing, the PM did acknowledge 'logistical problems' in obtaining PPE and his own 'frustrations' in expanding the number of tests. Appeals to recognize mistakes centred not only on the lack of PPE for care and health staff but also on the lack of an adequate test and tracing system and the spike of deaths of the elderly and their carers in residential care homes, who seemed to have been overlooked in the concern to 'protect the NHS': on 17 March NHS hospitals were instructed to free up beds and urgently discharge all inpatients medically fit to leave without a requirement for testing for COVID-19 until 15 April. This resulted in 25,000 patients being discharged into care homes. When the PM announced at the 18 March Prime Minister's Questions that the UK would be increasing the number of tests per day from 10,000 to 25,000 and was 'prioritising testing' for NHS staff, the doctors' representative body tweeted that this did not reflect 'the experiences of our members at the frontline of the health service' (BBC, 2020). In the 20 May PMQs, the PM declared that by 1 June, Britain would have a 'world-beating' test and trace system (Tolhurst and Langford 2020).
At the 10 June PMQs, the leader of the Labour opposition, Keir Starmer, stated: 'Everybody can see those figures [COVID-19 deaths in other countries] and see the disparity, and we need to learn from those other countrieswhat did they do more quickly than us, what did they do differently? We can learn those lessons and ensure that the numbers come down' (Hansard 2020, column 283). He went on to point to the Office for National Statistics data recording cases where COVID-19 is on the death certificate, standing at around 50,000 and the number of excess deaths at over 63,000. Starmers closing words to the Prime Minister were stark: 'Those are among the highest numbers anywhere in the world. Last week the Prime Minister said he was proud of the Government's record, but there is no pride in those figures, is there?' Johnson responded by insisting that it was too early to make international comparisons and that 'it was an astonishing thing that this country came together to drive down the curveto follow the social distancing rules, in spite of all the doubt that was cast on the advice, to follow those rules, to get the number of deaths down, to get the epidemic under control in the way that we have' (Hansard 2020, column 283).

Mindful leadership
As newly-elected Prime Minister, Boris Johnson, was the public face of British government communication on the coronavirus together with the Secretary of State (Minister) for Health, Matt Hancock. Until both men tested positive for the virus on 27 March, they were the main protagonists of the daily press conferences that began on 16 March, together with other ministers and various representatives of the health and scientific communities.
From early on in the crisis, press reports appeared criticising Johnson's apparently laissez-faire approach to the epidemic. He did not attend the first five civil contingency meetings of COBRA that discussed the coronavirus threat (Calvert et al. 2020). As the Parliament's half-term recess began on 13 February, Johnson spent a 'working holiday' at his country residence for the following 12 days. The Health Minister chaired the first meeting of COBRA on 24 January and declared the threat to be 'low'. That same day the PM's spokesperson stated that the country was 'well prepared for any new diseases'. The PM attended his first COBRA meeting on 2 March and at a press conference on 3 March attended by the Chief Medical Officer, when asked by a journalist whether we could shake people's hands, he replied that people would be 'pleased to know' that he had 'shaken hands with everybody' on a visit to a hospital where there were patients diagnosed with COVID-19 (Grey and MacAskill 2020). That same day, the government's Scientific Advisory Group for Emergencies (SAGE), advised against shaking hands or hugging because of the importance of hand hygiene (Mason 2020). At the 3 March press conference, Johnson reassured the British public that the country had 'world beating scientific experts' a 'fantastic NHS, fantastic testing systems and fantastic surveillance systems for the spread of the disease'. He claimed that: 'Our country remains extremely well-prepared'. These claims subsequently came to haunt him as the UK suffered shortages of PPE and ventilators and lack of testing capacity (Kelly 2020).
Johnson did not lead on dealing with the coronavirus outbreak in its initial phase in January and February. When he did engage in March 2020, the virus had already entered the country by multiple routes, mainly through travellers entering the country from Spain, France and Italy (Pybus 2020). His statements on the UK's preparedness showed, at best, an unawareness of the situation and, at worst, a willingness to provide misleading reassurance to the British public. On 7 March he attended an international rugby match as many people, who were watching the events in northern Italy, called for the cancellation of large-scale public events such as the Cheltenham horse races which took place between 10 and 13 March, attended by around 250,000 people.
As the seriousness of Britain's situation became apparent, the lockdown was put in place by late March by which time the pandemic had spread far and wide and the PM himself became extremely ill with the virus, disappearing from the public stage until 27 April. Until that time, Johnson had communicated frequently, although not as frequently as his Scottish, Northern Irish and Welsh counterparts. However, his communication seemed to lack a sense of the danger facing the nation, suggesting that we would 'send the virus packing in 12 weeks' or that we would 'flatten the sombrero', to get down the epidemic curve, something he repeated in a June press briefing (McGuinness, Sky News 16 June 2020).
Perhaps the most damaging incident in this period for Johnson's leadership was his response to the allegations that his chief aide had flouted the lockdown rules in late March. His fulsome support for Dominic Cummings and Cumming's own unapologetic press conference on 23 May seemed to demonstrate that they wouldn't have to 'walk the walk' as so many British citizens had. The Daily Mail, a Conservative-supporting newspaper, published polls showing that 66% thought Cummings should resign, 63% thought he should be sacked and 78% didn't believe that he had undertaken a 60-mile trip to test his eyesight. Johnson's instruction to journalists and MPs alike was to 'move on' from the issue (Hussain and Walters 2020). Cummings, he stated in the 24 May news briefing, had been following a 'father's instinct' in driving 250 miles from London to north-east England because he claimed there was no one in London who could look after his child after his wife showed COVID-19 symptoms and he feared he would become ill.

Preliminary conclusions
It is too early to give a definitive verdict on the PM's communication response to the pandemic. If the government turns round the health and economic situation in a year's time, the public may be more forgiving of the government's performance. However, at present the public has registered a 60-point drop in the net rating of its approval of the government's handling of the crisis, moving from a net rating plus 42 in March to minus 18 in June (Kellner 2020). A Sunday Times commentator and former Labour adviser wrote: It is hard to see how the verdict on its handling of the pandemic can be anything but harsh. Excess deaths in Britain appear to be one of the highest in the world and at no point has the government communicated a sense of being in control (Collins 2020).
In a leader article with the headline 'Not Britain's finest hour', echoing Winston Churchill's words, The Economist (2020, 7):'painfully' concluded that 'Britain has the wrong sort of government for a pandemic-and, in Boris Johnson, the wrong sort of prime minister … .Beating the coronavirus calls for attention to detail, consistency and implementation, but they are not his forte.' This harsh judgement is echoed by opinion polls measuring the public's assessment of how well the British government has managed the pandemic crisis. They show that trust fell by 18 points from April down to 51% in June (Reuters 2020).
The analysis shows that the PM's communication was not characterised by HRO practices. Problem anticipation was weak in the first two months of the virus. Despite the events in Wuhan City in January, the rapid contagion in northern Italy in February and the abundance of early warnings (Norman et al. 2020, Pueyo 2020, UK scientists and politicians seemed to have been complacent. The editor-in-chief of the prestigious medical journal The Lancet, Richard Horton, tweeted (quoted by Landler and Castle 2020): 'I can't help but feel angry that it has taken almost two months for politicians and even 'experts' to understand the scale of the danger from SARS-CoV-2. Those dangers were clear from the very beginning.' The prime minister's situational awareness, which would have allowed adequate explanatory communication to the British public, was insufficient at the early stage of the pandemic. This may have been, in part, because of the scientists' reluctance to advocate positions they thought political leaders did not support. According to the in-depth Reuters report, based on the minutes of the SAGE meetings and interviews with the scientists involved, 'the lesson from the British experience may be that governments and scientists worldwide must increase the transparency of their planning so that their thinking and assumptions are open to challenge' (Kelly 2020).
Johnson's initial approach to leadership was to delegate management of the crisis to the Health Minister. As the seriousness of the outbreak became apparent, he took a more central role, 'following the science' to justify the decisions being made. However, 'the science' did not always speak with one voice and, in the end, the responsibility for decision-making lay with the government, as the scientists made clear in the news briefings. At 3 June PMQs, Starmer referred to a news story that day in the Conservative-supporting newspaper, The Telegraph, reporting that Johnson had decided to take 'direct control of the government's response to the virus'. His question for the PM was 'who's been in direct control up to now?' Johnson's responded by stating: 'I take full responsibility for everything the government has been doing in tackling coronavirus. I'm very proud of our record. If you look at what we have achieved so far, it is very considerable' (UK Parliament 2020).
Complexity is now an operating feature of most modern organizations. In complex organizations events and decisions interact to produce unintended, unpredicted and unexpected outcomes (Axelrod and Cohen 2000), increasing the possibility of error. For this reason, among others, high reliability can no longer be thought of as a characteristic which is necessary for a specific kind of organization. Organizations with the order of magnitude of complexity of a national government, or indeed an international organization like the WHO, can particularly benefit from developing an organizational culture more focused on reliability. The ability to recognize, acknowledge and learn from error should not be alien to government or any other leaders' rule books. It is true that the UK's press can be harshly unforgiving of mistakes. However, politicians might be surprised to find that citizens are more grown up than they sometimes think. Intisar Chowdhury's words to the Health Minister about his father's death quoted earlier are evidence of this.
The communication practices associated with HRO principles, outlined in Table 1, provide a template not only for governments but for other organizations that manage risk and for whom public trust is key for their legitimacy. It is unlikely, indeed, that any organization can expect to escape crisis or scandal if it does not strive to eliminate a low reliability culture characterized by complacency, a focus on narrow interests, an inattentiveness to risk and failure, oversimplification, remote leadership and a punitive environment. It is also likely, however, that organizations will fall into low reliability practices without a powerful independent body charged with making sure they do not. Aviation companies have regulators such as the UK's Civil Aviation Authority or the US Federal Aviation Administration with the power to require the reporting of near misses, investigate accidents and ground whole fleets of planes if necessary. There is no equivalent agency at a national or international level empowered to safeguard public health from short-term political or economic calculations. Citizens expect governments to be prepared, to solve problems and, most importantly, to keep them safe. Without high reliability communication practices and an independent body with teeth to enforce them, it is difficult to know how they will reliably manage to do so in the future. Note 1. The PM was hospitalised on 27 March and he returned to work on 27 April.

Disclosure statement
No potential conflict of interest was reported by the author(s).

Notes on contributor
Karen Sanders, PhD, is Professor of Politics and Communication at St Mary's University, UK. She is co-editor of the Routledge Companion to Journalism Ethics (forthcoming 2020) and member of an international group of scholars researching populist communication. Karen has a special interest in understanding and fostering respectful, effective communication in highrisk organizations, and has run training courses on these subjects for hospitals, charities, banks, and universities. In spring 2020, she participated in the publication of a protocol for ethical criteria for the treatment of COVID-19 intensive care patients. She was previously professor in Madrid and Sheffield and lived for a time in Peru. Her Peruvian experiences resulted in the publication (in Spanish) of a widely used and respected account of the intellectual foundations of the modern Peruvian state and in the creation of a charity to aid development projects in the country. Karen has published widely and is the author of key texts such as Ethics and Journalism (Sage), translated into Chinese and Farsi, and Communicating Politics in the 21st Century (Palgrave Macmillan).