MY AGENDA: LEARNING THE LESSONS FROM FAILURE ENQUIRIES

摘要

A yearago, Dame Judith Hackitt published her final report: Building a Safer Future: Independent review of building regulations and fire safety. This came almost 10 years after the Hadden-Cave enquiry reported on the loss of RAF Nimrod XV230 in 2006 and just a month before the Lord Darzi Review of Health and Care on behalf of the Institute for Public Policy and Research. Line them up and some common themes appear: a lack of systems and preventative thinking within the sector; regulatory systems not fit for purpose; risk management regimes ineffective; weaknesses in the area of personnel competence; procurement practices driven by lowest cost; lack of clear accountability; lack of stakeholder involvement; and cultures that have allowed 'doing business' to eclipse 'doing the right thing'.