Learning from mistakes or seeking vilification and pillory?

On the back of this other thread, I’m going to make a brief mention of “inquiries”. I’ve never really thought about it to the extent of whether inquiries are of use or not – tho I think they are when done as Root Cause Analysis.

But what is apparent is – there’s a difference of flavour in how an analysis is conducted and it’s outcome. I don’t know if there are any “rules” on how this happens – and I know there are times where incompetence has to be stamped out – but who decides when it’s merely a ’system error’ and when it’s an ‘unacceptable error of personal judgement’?

I direct the reader to another incident that was subject to inquiry – the loss of data disks carrying the details of 25 million people last November.

The BBC carries this report on the results of the inquiry. The opening paragrpahs go like this…. but as you read it – compare it to the reports on the outcome of the Barret inquiry. I’d reprint them – but apparently the original story is no longer available. (See Doc C for conspiracy theories on this behaviour)

The loss of discs containing personal details of 25 million people was “entirely avoidable”, a report says.

The Poynter report does not blame individual officials, but highlights “serious institutional deficiencies” at HM Revenue and Customs (HMRC).

Chancellor Alistair Darling told MPs action was already being taken to improve data security.

The Tories said the report and another by the Independent Police Complaints Commission were “truly devastating”.

Shadow Chancellor George Osborne said they highlighted “incompetence and systemic failure at the heart of this government”.

They were “a guide to how not to govern this country”, he added.

Yet for another entirely avoidable situation… vis Barrett – heads must roll.

I’m not saying the loss of life is comparable to the loss of personal data – tho significant loss may ensue – but surely there has to be some comparity between one method and another; one outcome and another?

Of course, the opposition is blaming the prime minister and calling for political resignations – but that’s as predictable as night follows day. But an interesting phrase that crops up “Institutional Incompetence”.

Kieran Poynter’s report blames the loss of the two discs on poor communication between management and junior staff, and low morale at the HMRC’s offices in Washington, Tyne and Wear.

I note that, as a direct result of this embarrassment, Paul Gray, chairman of HMRC did resign. I doubt he was directly involved in the incident – but I find his actions commendable. Well it would be if he didn’t walk straight into another senior civil service job. To be fair – it was a temp job to fill out his contract after resigning – but I’d be interested to know if he left the civil service or took a quiet little job somewhere since he was set to retire in 2008 anyhow; it all went a bit ‘quiet’.

So why doesn’t the head of the relevant Trust resign? Or even the head of Psychiatry? Would it be as honourable?

Is this “institutional incompetence” nothing more and nothing less than what happened with Barrett/Mezey – or was she more directly and independently responsible for the incident than any other person? Was the loss of a life far more serious outcome than the loss of 25,000,000?

I’m not being facetious or seeking to minimise the loss of life – I’m asking because surely these are the only reasons we would treat one incident different to another. Aren’t they?