A review is announced. Lessons will be learned. An inquiry eventually explains that a failure was systemic. The explanation may be correct, but the public is still entitled to ask who had the power to prevent it and what will now change.
Calling a failure systemic should help us understand responsibility. Too often it seems to make responsibility harder to locate.
Why power was put at a distance
There are good reasons for keeping ministers out of some operational decisions. Independence can protect an institution from political interference. Complex failures may involve many decisions, and blaming one convenient person can conceal more than it explains.
A culture that punishes every admission of error can also make people hide mistakes. There is value in investigating what happened without beginning from a demand for a scapegoat.
But protection from unfair blame isn't the same as protection from accountability. An investigation needs to establish who could decide what, whether they acted reasonably and how the system should be corrected. Otherwise the explanation becomes a substitute for a remedy.
Who could have acted?
Responsibility can become difficult to follow through a minister, regulator, public body, contractor and subcontractor. Each relationship may have a purpose. Taken together, they can leave the public struggling to identify who had authority over the decision that mattered.
The Post Office Horizon scandal and the infected blood scandal show why that question can't be left until decades later. The people harmed need more than a sincere apology from someone who wasn't responsible for the original decisions.
Thomas Dugdale's resignation over Crichel Down in 1954 is often invoked as an example of ministerial responsibility. We shouldn't pretend the past always supplied clear accountability. We can still ask what it means for someone to answer for a department they have the power to direct.
What should follow an inquiry?
There should be a clear account of who owns each public function, who can intervene when it fails and who must answer for the response. Recommendations need deadlines, named responsibility and public follow-up.
Faster inquiries can help, but speed alone isn't enough. Nor should findings automatically be treated as binding without considering their substance and legal effect. The purpose is to make correction happen, not to create another procedure that can be completed without changing anything.
People should be protected from unfair blame and held responsible for decisions within their power. A system that can't do either deserves more than another promise to learn lessons.