Whilst it seems to me that some of Peter's theories may have a degree of merit, I fear that he repeats one of the greatest mistakes that can be made. These mistakes are rarely about "other people's mishaps". To look for an individual to blame is the wrong place to go; we must learn to seek out the systemic causes (that complex interaction that includes environment (including leadership style), methods of working, and people). Whilst we continue to point the finger of blame, there is no hope.
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Glyn, I agree that Peter's suggestions do have some merit ,were it not for the fact that these would be undertaken within the same command and control, hierarchical, behaviourist, blame the people organisational and managerial paradigm. It won't make any difference. The fact that all these approaches have been done before should tell people that something fundamentally is wrong with the current system. All that happens is leaders and organisations doing the same things and expecting different results - it's plain stupid thinking! Nothing will change until leaders everywhere in this collosal system altyer their thinking. From what I've observed over the years, I despair of that ever happening - and I'm usually an optimist!
Andy
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I don't think that's what Peter was saying at all, Glyn. He's not blaming any individual as I read it. He's saying that where people make mistakes, and reports are written about them, the learning tends to fizzle out by the end of the process into a report no-one reads. But people do make mistakes, and then other people then can learn from them, you at least admit that surely?! If you looked at the financial crisis of the last few years and didn't look for culprits, you'd never learn anything about how it started and therefore wouldn't be able to prevent it happening again! What's the alternative? Saying 'well it just happened, let's move on and not dwell on it, lest someone get their feelings hurt by us saying they did wrong?'

Terry
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Reading the comments here I can understand the argument. However, its not ok to blame the system. if someone has made critical errors in judgement or not been able to communicate that there is a major problem in the case something is wrong and they should be accountability along the way. As professional employees we should look at how things work and if it does not work fix it by every means possible.

Yes its takes excellent communication between all departments and not just reliance that the system will work. Clearly it does not work as only high profile cases make the headlines.
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Of course people make mistakes, but I know from both personal experience and those of colleagues who work in this regime, the system is to blame. We have good people working in a c**p system. Go take a look at the system the social workers have to work in. Of course there will be people who are not up to it and yet despite sacking more and more people each time something goes wrong, we still have children dying every year! Nothing has been and will ever be learned until the regime, the advisers and the government learn to think differently.
May I recommend you read and watch some of the items on the systems thinking review website - here's the link. Listen to what John Seddon and his folks have learned over the past 20 years of what's wrong and a better way of working:
http://www.thesystemsthinkingreview.co.uk/index.php?pg=4&cat=1&title=Current+News
Watch the video first to get an overarching view of what John has discovered, and then see whether Glyn and I are correct in our view.
Andy
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