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https://www.bbc.co.uk/news/articles/cr411lzn1qwo
Not sure how I feel about this. I've worked with enough civil and pseudo civil servants who lack the necessary skills, training and interpersonal skills to do their job effectively, but I'm not sure naming and shaming is helpful to anyone.
Senior leadership - maybe
Folk on the ground trying to do their best in difficult circumstances - definitely not
Where is the line though?
I'm guessing that lots of actions were made more difficult by his diagnosed conditions. The whole judgement makes things more difficult for the overworked and undersupported services. Who's going to take up these roles if blame and name becomes the norm.
The whole judgement makes things more difficult for the overworked and undersupported services. Who's going to take up these roles if blame and name becomes the norm.
Been with my social worker other half for over 30 years . When we met, her office was dealing with the Ricky Neave tragedy/**** up.
Every decision she makes gets signed off by a manager and/or judge. Both will throw her to the lions if they need to. Anyone in the public sector making what are literally life and death decisions know this and it hangs over them every minute of every day. The strain, when they are so stretched and under resourced is immense, is constant and unforgiving.
Everyone makes genuine errors in their job. Some jobs mean that errors result in tragedies. No way should a social worker, teacher, police officer, health professional be named and shamed for an error or systemic failure.
That's not to say that they should be protected in all circumstances, and the higher up the chain they are, the less protection they deserve.
Governments - of all colours - have failed to provide the funding, resources, policies and guidelines that are recommended after all these tragedies to minimise* the risk of them happening again, and thats where blame should be pointed.
* we also have to accept that the risk can never be nil in a free country.
I don't think that episodes like these are preventable without incarcerating huge amounts of people.
There are loads of strange people out there making all sorts of threats to people. Fortunately very few of them follow up on them to any great degree. Unfortunately the ones who do only tend to become obvious in retrospect.
Folk on the ground trying to do their best in difficult circumstances - definitely not
This.
If they've failed within the system, then they should be disciplined, or even charged. If the system has failed, then that needs to be addressed as a whole (be that locally or nationally).
"Naming and shaming" people on the ground, doing a difficult job that next to nobody wants to take on... it'll have obvious negative effects on getting the right people into those roles in future.
Naming and shaming is just modern day lynch mob mentality. The lawyers in this case should be the ones getting their collars felt for whipping up the hysteria. Also why is it always the public sector workers solely getting blamed and held accountable. What about the individuals carrying out these atrocities (ok in this case he might genuinely have been unfit to be held responsible),what about parents, other people in the community?
I don't think that episodes like these are preventable without incarcerating huge amounts of people.
At which point the civil servants would be attacked for doing so. I wonder how this lawyers track record would stack up. Never a mistake anywhere?
The emphasis on Prevent seems particularly odd.
There's this idea that somehow you can do risk stratification and somehow intervene only in the cases that are most likely to benefit. From what I am aware this doesn't fit with reality, where interventions need to be systematic and relatively broad based in order to be effective.
I don't think that episodes like these are preventable without incarcerating huge amounts of people.
There are loads of strange people out there making all sorts of threats to people. Fortunately very few of them follow up on them to any great degree. Unfortunately the ones who do only tend to become obvious in retrospect.
That me in general be true, but the retired high court judge was very clear having chaired the public enquiry that THIS case was entirely predictable and preventable. Presumably none of the agencies he criticised gave evidence that "if we acted on every individual with these behaviours we would be incarcerating huge numbers who will actually never go on to cause harm". He wasn't just a bit strange - he was reported to Prevent three times but they failed to intervene because he wasn't motivated by a recognised ideology - just a crazy hatred for people and desire for violence! He was picked up by police on a bus in possession of a knife, and simply taken home - had he/his house been searched they would have found ricin and terrorism manuals. But mostly the conclusion of the enquiry wasn't that nobody thought this was a serious and credible risk, rather that it wasn't their job and they could make it someone else's problem.
I'm not comfortable with the idea of naming and shaming individual ordinary employees working under difficult circumstances. I don't know if that is what is proposed, it will lead to even greater secrecy and cover up on future screw ups. However if the same people are still doing similar roles and all saying "don't blame us", "nothing to learn here" and "bad shit happens" then there is clearly a governance and cultural issue where people above them need to change. If people work in an organisation that is culturally broken and lacks governance to learn from tragic errors then they may be part of the problem.
Naming and shaming is just modern day lynch mob mentality. The lawyers in this case should be the ones getting their collars felt for whipping up the hysteria.I'm sure a modern day lynch mob is not the answer, and if the inquiry has granted anonymity to the individuals it would be a perilous course to breach that BUT there can be no expectation that public officials, acting in their public role are automatically anonymous when things go wrong on their watch. They should of course have a fair and proper opportunity to put their side of events, but presumably that is either the public inquiry or the disciplinary processes the lawyer is expecting.
because they are employed by the state with sometimes significant powersAlso why is it always the public sector workers solely getting blamed and held accountable.
he was sentenced to a minimum of 52 years in prisonWhat about the individuals carrying out these atrocities (ok in this case he might genuinely have been unfit to be held responsible),
His parents, and his father in particular came under significant criticism at the inquiry. His name is very publicly known.what about parents, other people in the community?
I'm not sure what you mean by "other people in the community" (the inquiry described him as becoming increasingly reclusive - so not sure he was part of any community).
The emphasis on Prevent seems particularly odd.
It seems there's a failing - if he had a religious motivation Prevent would have acted, the concern as I understand it is that Prevent didn't recognise his motivations as being an ideology and so said "not our problem", whilst the other agencies were presumably thinking "this is the sort of thing Prevent do not us".
I'm not comfortable with the idea of naming and shaming individual ordinary employees working under difficult circumstances. I don't know if that is what is proposed, it will lead to even greater secrecy and cover up on future screw ups.
It's what victims families are threatening, and I agree, will be totally counterproductive.
Prevent are there to deal with "terrorists", which he wasn't. It's presumably up to the mental health services to deal with people dangerously fixated on violence. And we know how stretched and under resourced they are.
Needs an approach like the aviation industry which doesn't seek to blame individuals, it seeks to find the weak points of a system to prevent individuals making the mistakes in the first place.
The rail industry has taken significant steps in that direction as well.
It's what victims families are threatening, and I agree, will be totally counterproductive.
we don’t know exactly who they are planning to “out” - it may well be senior figures who were directing others rather than individual case workers etc.
it depends how you define terrorism - technically within their scope/remit they may be correct, but I think it’s fair enough to ask if that remit is right, and if there were gaps where some “mass murderer” risks fell outside the terrorism banner who knew that and who said “not my problem”. if they were referred serious threats, assessed them and said “no action required” rather than “clearly a risk but not our remit so we refer to X” then it’s legit to ask questions, if the person did their job right then presumably “outing” them has minimal negative consequences?Prevent are there to deal with "terrorists", which he wasn't.
he was assessed as both fit for trial and seems to have met the definition for sanity at the time of the offence. I’ve not studied what was said at the inquiry - but there’s an assumption that people who do “crazy” stuff must be mentally ill.It's presumably up to the mental health services to deal with people dangerously fixated on violence.
indeed - and it seems unlikely that the aim is to throw an individual under the bus for trying but being snowed under; but if someone senior told the grass roots staff it’s not their responsibility and to ignore it - that feels like something we shouldn’t sweep under the carpet or mark down to “we’ll try harder next time”. I’ve no idea if that is the case here - but the assumption that it’s not is no more valid than the possibility it is.And we know how stretched and under resourced they are.
I think both are needed, and the right balance is very difficult.
If people do their jobs properly, and things still go wrong then there needs to be an appropriate response to that; as CrazyLegs says reporting without fear of blame so that the weak spots in the system, process, equipment, whatever, can be removed.
But if the problem is people not doing their jobs properly then there must be an appropriate response to that as well. It might be 'a telling off', it might be additional training or supervision, in some cases it could be some form of disciplinary or even prosecution (eg: corporate prosecutions). I'm not saying that public naming and shaming is the right option but there were catastrophic failings in the Southport case that aren't limited to systems and processes, there were people that didn't do their jobs properly.
Similarly with the murder of Sara Sharif in Woking. I'm trustee of a children's charity in a neighbouring area and we had a debrief from some of the people involved in that and there is little doubt that there were several chances for interventions missed, and which were counter to policy and procedure - people who should have acted but did not. Direct quote from the report "robust safeguarding procedures were not followed"
And the complexity is really that often it's a combination, substandard procedures, job pressures, lack of time to do the job properly all can contribute to why people don't do their jobs well enough. But the idea that individuals must never be 'blamed' when things go wrong is false.
Needs an approach like the aviation industry which doesn't seek to blame individuals, it seeks to find the weak points of a system to prevent individuals making the mistakes in the first place.
The rail industry has taken significant steps in that direction as well.
Human Factors/Ergonomics. It's a really interesting approach to incident analysis, that's applicable in a lot of areas. I've seen some great presentations of it used for rail and air incidents, but it can be used for lots of different things, including healthcare.
But the idea that individuals must never be 'blamed' when things go wrong is false.
But it is ultimately fruitless. It doesn't actually achieve anything more than satisfy bloodlust, other than shift focus from the potential that broader systems or processes allow individuals to perform poorly. "Oh, a bad person did that... they're gone now so we can carry on as before."
that feels like something we shouldn’t sweep under the carpet or mark down to “we’ll try harder next time”
I agree, but threats to name people by victims in the current day and age strikes me as being an invite to vigilantism. Not sure I want my gouse burning down because MrsMC was unable to get a kid taken into care because the only place available was 300 miles away and cost £1500 a week and the director wouldn't sign it off.
that feels like something we shouldn’t sweep under the carpet or mark down to “we’ll try harder next time”
I agree, but threats to name people by victims in the current day and age strikes me as being an invite to vigilantism. Not sure I want my gouse burning down because MrsMC was unable to get a kid taken into care because the only place available was 300 miles away and cost £1500 a week and the director wouldn't sign it off.
I agree the language is incendiary. However in that scenario I doubt the lawyer is aiming to “out” your wife - she’s followed the “correct” course of action. Someone more senior has then refused to sign it off (it doesn’t even follow that the lawyer would want to name the more senior person - he believes that disciplinary action should have been taken and hasn’t, without the privilege of access to the information and the time to review it - it’s pure speculation if his claims are founded or unfounded, but the Inquiry chairman (who has had that benefit) is far from suggesting this was simply unforseable, or even that budget was the limiting factor.
Needs an approach like the aviation industry which doesn't seek to blame individuals, it seeks to find the weak points of a system to prevent individuals making the mistakes in the first place.
The rail industry has taken significant steps in that direction as well.
there’s been a massive public inquiry - there’s no suggestion of a coverup at the inquiry, the concern seems to be that the same people are still sitting doing the same jobs (or maybe promoted) despite potentially personal rather than institutional failings.
if the air accident investigation branch concluded that an air traffic controller had nipped outside for an unauthorised fag break, a pilot had a known medical condition he didn’t disclose or the maintenance technician was not actually replacing the fuel filters but instead flogging them on eBay - we would expect disciplinary processes.
often failings are not those of individuals, and even when they are they are caused by cultural issues of lack of structural safeguards, but sometimes there are people who just don’t do their job properly and “oops” isn’t going to be enough - not least because the rest of the workforce gets a message that not doing what you are supposed to do is OK.
Of course perhaps the reason no action is taken is the person above them is actually at fault and there is a fear of reprisal.
Needs an approach like the aviation industry which doesn't seek to blame individuals, it seeks to find the weak points of a system to prevent individuals making the mistakes in the first place.
The rail industry has taken significant steps in that direction as well.
thus so much. I have been arguing this for years for medical mishaps.
people being people if they think they are going to be personally blamed will slant their evidence. If we want to prevent further incidents then we need the real data.
This does not mean that criminal actions are ignored
As ever with thissort of thing its not a single mistake. Its a number of minor errors adding up together. the swiss cheese theory of errors
I agree, but threats to name people by victims in the current day and age strikes me as being an invite to vigilantism.
Those were my thoughts exactly. Also; it's somewhat ironic, given the disorder fueled by what turned out to be complete misinformation spread by social media after the Southport killings. I know they must be frustrated, but of all people you'd think they'd know that this really isn't the answer, for obvious reasons.
If they do this, it would set a very dangerous precedent, one which the same forces who were responsible for the disorder in Southport and elsewhere would be more than happy to exploit for their own ends.
and so said "not our problem"
Or rather, we don't have the tools to deal with this individual, as he doesn't come into scope.
If individuals are to be named and shamed, then first make sure that those individuals are culpable, had all the budget, tools, training, and capacity etc to actually do the thing and neglected to do so because they were bored, lazy, incompetent, or ignorant or otherwise deficient. If they are just swimming against a tide of under-funding, mission creep, overwhelming case loads etc etc, then its more rightly systemic failure.
The parents have my sympathy, but there's a reason we don't let victims set tariff.
Needs an approach like the aviation industry which doesn't seek to blame individuals, it seeks to find the weak points of a system to prevent individuals making the mistakes in the first place.
Most aviation mishaps have a final line that says "pilot error" Read any number of aviation journals dedicated to sterile examination of things that have gone wrong end with this as a judgement, and most of the time, it's pretty accurate. Even the aviation industry cannot account for 'outside context' problems, see for example; pilots who want to commit suicide (Greenwings 9525, Malaysia MH370)
As @Kramer points out if we take the view that risk must be eliminated to the furthest extent, we're going to have to put large amounts of mostly innocent people behind bars for thought crime JIC
A theoretical version of events and then back to Sara Sharif.
Imagine that reports have been made by a school that they have noticed what appear to be bruises and cigarette burn scars on a child's arms and legs. The authorities make a home visit and the kid's dressed head to toe in long sleeves and long trousers. The social worker / health visitor / copper, whoever's made the visit comes away again and can truthfully say 'I saw no burns or bruises'
Whether the procedures specifically say that you have to ask to see their arms uncovered - clearly I think we'd say that the person hasn't done their job. And anyone going, 'well they followed procedures, which don't specifically say to ask for arms to be uncovered, so it's not their fault' - sorry but no. At the very least they have to see the arms uncovered or report that they were unable to / parent(s) refused to allow it. Yes, you can also argue the procedure can be improved but 'no blame'? Really?
That's similar to the SS incident except the bruising and swellings were on her head and she was now being dressed in a hijab, with the complicating factor that an inexperienced social worker felt culturally inhibited from asking it to be taken off. So they didn't, missed a chance to intervene, eventually leading to....
I get it, that these are pressurized and difficult situations, lack of funding, and so on, and that the fear of being 'blamed' makes it harder and harder to recruit and train people to do this. I'm full of admiration for those that do, but if they don't do their jobs properly, then there needs to be some kind of 'repercussion'. Which absolutely is not the same as calling for naming and shaming with all the risk that entails.
You make it seem so simple. Fancy a career change?
Whilst those who run agencies and have the authority to make changes should be held accountable I notice this is glossing over the criticism of the parents of the attacker and their role in the incident
I suspect that the judge in this review doesn't have the slightest understanding of the mathematics of screening and Baye's theorem, and neither did the politicians who set up "Prevent" as a knee jerk response to an atrocity (I can't remember which one), which handily put social workers into the firing line.
I don't need a career change to have a valid opinion. As I said above, I'm a trustee for a children's charity, our staff and volunteers do home visits and have a statutory responsibility to report concerns, etc. I also have to do all the safeguarding training, and as a trustee could ultimately be accountable if we aren't doing things properly. I'm not throwing stones from a safe distance behind a barrier, I'm 'part of the system' and still feel that at some level 'doing the job properly' is something that has to be part of the control.
https://www.home-start.org.uk/
glossing over the criticism of the parents
I don't think that's happened at all. Just that discussion has been around "naming and shaming" staff, as per the OP.
As I said above, I'm a trustee for a children's charity, our staff and volunteers do home visits and have a statutory responsibility to report concerns, etc.
Lovely work.
Mistakes (and/or poor work) by individual members of staff should result in disciplinary actions (and where applicable prosecution)... but that shouldn't mean being judged at a distance, by those of us with only a slice of the facts, no matter how experienced we are, IHMO.
ie.
If they've failed within the system, then they should be disciplined, or even charged. If the system has failed, then that needs to be addressed as a whole (be that locally or nationally).
The social worker / health visitor / copper, whoever's made the visit comes away again and can truthfully say 'I saw no burns or bruises'
In this particular case, there was an incident where two (apparently) inexperienced cops arrested him at school and discovered he had a knife. They took him home, and (according to media reporting) told the parents to essentially hide the knife from him. They then left after conducting a rudimentary search in which they didn't speak with his mother or father. You can read it here. On the face of it, it looks like the cop's just doing their job, but you can tell it's pretty cursory. Is that the fault of overworked cop rushing because they have a million and one other things to do? Covering their ass? Poor judgement? I presume they were he inquest and gave evidence, and that the families saw the cop and have decided they were deficient?
Mistakes (and/or poor work) by individual members of staff should result in disciplinary actions (and where applicable prosecution)... but that shouldn't mean being judged at a distance, by those of us with only a slice of the facts, no matter how experienced we are, IHMO.
I think in the end we're in agreement, I'm definitely not advocating for trial by media or at a distance, but equally a 'no blame, ever' culture as some seem to suggest is desirable just can't be realistic.
The Sara Sharif is definitely not at a distance, an adjacent HS (we're a federated charity, so local HS operate in adjacent areas) attended the house several times, flagged issues and were broadly ignored. They were still answerable to the enquiry nonetheless, and then their Chair did a debriefing / learnings with other local HS trustees. So there is some second hand knowledge of this terrible case.
The social worker / health visitor / copper, whoever's made the visit comes away again and can truthfully say 'I saw no burns or bruises'
In this particular case, there was an incident where two (apparently) inexperienced cops arrested him at school and discovered he had a knife. They took him home, and (according to media reporting) told the parents to essentially hide the knife from him. They then left after conducting a rudimentary search in which they didn't speak with his mother or father. You can read it here. On the face of it, it looks like the cop's just doing their job, but you can tell it's pretty cursory. Is that the fault of overworked cop rushing because they have a million and one other things to do? Covering their ass? Poor judgement? I presume they were he inquest and gave evidence, and that the families saw the cop and have decided they were deficient?
There's a huge push to try and avoid criminalising children because of the generally very poor outcomes for them. From a friend who works at a PRU he's seen other members of staff assaulted, including broken bones, that weren't reported to the police. There's definite pressure in the police to deal with children without arresting them, even if they're known. Some officers will take the view that a child with a knife should be automatically arrested but others won't.
Is that the fault of overworked cop rushing because they have a million and one other things to do? Covering their ass? Poor judgement?
The Judge said of any failures by the police in this aspect "This was an error of significance that would likely have been made by many others, and it should not be taken as demonstrating incompetence on their part. The causes of this mistake were essentially systemic rather than being the responsibility of these two response officers."
They took him home, and (according to media reporting) told the parents to essentially hide the knife from him
And the parents didn’t even manage that. Why they didn’t just dispose of the knife? Why didn’t the police confiscate the knife?
you misunderstand the role of the judge - he is there to obtain, review and weigh up the evidence not to be the expert himself. Any of the agencies involved could have led evidence on the statistics of Bayes and the likely rate of “false positives”. You really should read both volumes of the report before you dismiss his conclusions - this wasn’t a case with one or two red flags or even “with hindsight it should have been obvious”. Various people flagged him up on numerous occasions, he had a conviction for modifying a hockey stick and going to his former school to attack someone (and then just attacking someone else when he couldn’t get the intended target). He had been taking knives to school regularly and stated it was to kill people. He was found on a bus with a knife. He had made ricin at home, owned multiple weapons including knives and crossbows, and a terrorism manual. That is on top of all the intention / sinister interest stuff. Individually any of those could be ok but Bayes stats are all about combining the probabilities as more evidence becomes available — it seems to me that IF you want to mathematically assess risk this guy would have been in the very highest risk category. Now I don’t have the benefit of knowing how many other 13-18 yr olds would also trigger the same number of red flags and how many of them are ultimately just “weird” rather than “evil”. The agencies presenting to the inquiry would (or should) be able to justify if indeed he was just one of hundreds of otherwise “innocent” people.I suspect that the judge in this review doesn't have the slightest understanding of the mathematics of screening and Baye's theorem, and neither did the politicians who set up "Prevent" as a knee jerk response to an atrocity (I can't remember which one), which handily put social workers into the firing line.
Now I don’t have the benefit of knowing how many other 13-18 yr olds would also trigger the same number of red flags and how many of them are ultimately just “weird” rather than “evil”.
Indeed you don't.
The agencies presenting to the inquiry would (or should) be able to justify if indeed he was just one of hundreds of otherwise “innocent” people.
Not if it wasn't within the scope of the enquiry, which likely it wasn't. Plus we don't know what legal advice they're received either.
I'm not dismissing the conclusions, just stating that I am not convinced of the premise for the whole system of intervention.
It's funny how we have these repeated enquiries, and they keep on coming up with same conclusions, and yet nothing really changes. IMO they don't really focus on the root causes, probably by design, and instead keep on coming up with the easy route of "missed opportunities."
If individuals are to be named and shamed, then first make sure that those individuals are culpable, had all the budget, tools, training, and capacity etc to actually do the thing and neglected to do so because they were bored, lazy, incompetent, or ignorant or otherwise deficient. If they are just swimming against a tide of under-funding, mission creep, overwhelming case loads etc etc, then its more rightly systemic failure.
I’m 100% with you there. If I understood the lawyer - they were promised that certain individuals would be subject to disciplinary processes and their “threat” is because the promised processes don’t seem to have happened and those they believe are culpable are still doing the same jobs with no evidence that anything has changed.
now you might think that anyone in those roles would have been a witness to the inquiry? As far as I can see whilst a number of people asked to be anonymous the inquiry rejected all but two of those applications - which came from two anti-terrorism officers.
The flipside to “anonymity” is that people with the power (police officers, judges, MH nurses, doctors, solicitors) can do so with impunity. And it’s appropriate that the inquiry is generally averse to anonymity because it means others can stand up and say “What he said is really not true, and here’s my evidence that contradicts it”.
so how frequent are people with as many warning signs as this guy was? And how frequently do they go on to commit serious crimes?Now I don’t have the benefit of knowing how many other 13-18 yr olds would also trigger the same number of red flags and how many of them are ultimately just “weird” rather than “evil”.Indeed you don't.
which bit of that would be outside the scope of the inquiry? https://www.southport.public-inquiry.uk/terms-of-reference/The agencies presenting to the inquiry would (or should) be able to justify if indeed he was just one of hundreds of otherwise “innocent” people.Not if it wasn't within the scope of the enquiry, which likely it wasn't.
of course - but your argument seems to be that the risk statistics exonerate them as doing the best in difficult circumstances - hard to see why none of the agencies involved would want to make that point.Plus we don't know what legal advice they're received either.
I’d posit that is because organisational and cultural change is really hard to bring about and people become blinkered to “doing their job” (driven by management processes and KPIs) rather than “prioritising their professional responsibilities”. Nobody is going to thank you (and quite possibly will bollock you) for doing the right thing for society if you exceed your official remit. We praise the hero’s who try to stop attackers wielding weapons but not those who try to stop them picking up a weapon in the first place.I'm not dismissing the conclusions, just stating that I am not convinced of the premise for the whole system of intervention.It's funny how we have these repeated enquiries, and they keep on coming up with same conclusions, and yet nothing really changes.
which route causes - the 5 bullet point summary for phase 1 of the inquiry seems to actually point out the fundamental issues. Phase 2 seems to be be about “how do we change it”.IMO they don't really focus on the root causes, probably by design, and instead keep on coming up with the easy route of "missed opportunities."
Apologies for the simplistic approach in what's a complex, thoughtful, informative, polite and well-informed debate but as time goes on, I'm increasingly of the opinion that those who chose to inflict a decade and a half of pointless, crushing austerity on the nation should be dropped into a giant pot and boiled alive for the damage they wilfully inflicted.
There seem to be a few people with educated views in this thread so forgive me for asking. For all the talk about who is to blame in this case, could someone lay out what interventions could have been done that would have prevented the outcome?
Even if the police had arrested him for the knife, he’d still have been free later.
If Prevent had taken him in for counselling they might have been effective in changing his mindset. As they have stated Prevent structured for is de-radicalisation and he wasn’t radicalised.
Social workers? What could they have done? Should he have been sectioned under the mental health act?
It seems to me there isn’t anything much that any organisation could have done within our current legal framework?
I’d posit that is because organisational and cultural change is really hard to bring about and people become blinkered to “doing their job” (driven by management processes and KPIs) rather than “prioritising their professional responsibilities
Also the culture of blame means we never find out the real truth as folk slant their evidence.
if we want to stop these things happening we need the real truth and the only way to get that is remove the fear of being blamed and scapegoated
Sure, why not. Might actually make senior people responsible for their incompetence for once. Big salaries for responsibility and 'risk' yet seemingly no actual consequences....
Be better than hiding things away after years of enquiries and 'lessons learned'.