It`s easy to say that those with the longest memories appreciate the old adage that George Santayana, the Spanish philosopher famously warned, "Those who cannot remember the past are condemned to repeat it." Age and long memories in this country count for little. Whereas some societies large and small venerate the wisdom of the ages or the aged others like to think that their opinions, decisions and subsequent actions are using innovative methods and controls to eradicate situations and problems failed by opposing factions. Today we might describe our society as rule by supervisory quango; a conniving government method of supposed supervision of many public bodies and institutions but at a "nothing to do with us" arms length from 10 Downing Street and Whitehall.
This week Valerie Amos, a Labour peer and former diplomat, published her long-awaited review into maternity and neonatal care across England. It was damning. But it and others similar as I will explore, are not unique.
This site was quiet whilst my wife and I were in Crete. At one of the most luxurious [and expensive] hotels on the island during a face to face digital check in staff were at pains to note on their system whether either of us had any allergies. We made it very clear that my wife was allergic to shellfish to such sensitivity that she has to investigate if any prescribed medicament for oral or topical use contains oil from shellfish; many do. Before sitting for dinner at the hotel`s ethnic Greek restaurant we were asked by the manager if there were any allergy that could be significant. Of course we made clear that of shellfish as above. During the meal we were served with a plate for two which I immediately recognised as prawns. Needless to say I prevented my wife putting her fork anywhere near the platter and spoke to the manager in rather vociferous terms. Later that evening I told the reception staff and they assured me that the catering and banqueting manager would be informed. I, in my fading belief in the efficiency of management when things go wrong, expected a reply and apology in person, by phone or by e mail. None was received. Four days after coming home I had a "we would love to have your feedback on your stay" e mail from the hotel manager which I answered in direct but polite terms. There came back a reply which was an abject apology and nothing more: not even an offer of a free day`s accommodation if we return not that we will.
Thus is management today at whatever level it functions.
Between 1945 and 1950 this country functioned on an almost laissez faire basis. In 1948 the NHS was created but hospitals before that were a patchwork; voluntary hospitals, municipal hospitals and cottage hospitals each with their own boards of governors answerable to local trustees or local councils. There was no national regulator.
Police forces were entirely local answerable to Watch Committees (borough forces) or Standing Joint Committees (county forces) made up of local councillors and magistrates. The Home Office had only limited oversight powers. Chief Constables were directly hired and fired by local elected bodies. This created inconsistency and local corruption but also genuine local democratic accountability.
When building and/or housing safety is considered local authorities were both builders and inspectors of their own housing stock; an obvious conflict of interest but decisions were made by elected councillors directly answerable to local voters. There was no national building regulator. Central government guidance was minimal.
Taking public corporations as an example the Post Office had always been a Crown body under direct ministerial control with a Postmaster General sitting in Cabinet and answerable daily to Parliament through questions. It was therefore more directly democratically supervised than the arm's-length commercial model that later allowed the Horizon scandal to fester for decades.
And what do we have now three quarters of a century and three generations later? Some might say we have multiple supervisory authorities whose members are appointed by a relatively small coterie itself selected by the great and the good of the establishment. Indeed we can go further down this road of "not me guv" and see where it leads.
The outcome of the Manchester Arena Inquiry (Report: 2021–2023) into the 2017 bombing found serious failings in how MI5 and the police handled prior intelligence about the attacker and criticised the emergency response, including the actions of security staff on the night.
Child protection or its failings always gets top billing. The Casey Report exposed systemic failures in tackling group-based child sexual exploitation leading to the announcement of a new Grooming Gangs Inquiry in June 2025. Councils and police in Rotherham, Telford, Oldham and Greater Manchester were specifically found to have ignored or downplayed abuse over many years. Multiple police forces, councils and social services were found to have failed children catastrophically. No chief constable or director of children's services was dismissed as a direct result of the inquiry findings but some councils were placed in special measures.
The Grenfell Inquiry (2024) led to 58 recommendations to overhaul "seriously defective" regulation of the construction industry, calling for defragmentation of the sector and bringing different wings of the industry under a single regulator. Royal Borough of Kensington and Chelsea (as landlord) was also criticised for its indifferent relationship with residents.
As of April 2026 the proposed Hillsborough Law which would impose a statutory duty of candour on public bodies during inquiries has still not been passed, despite the Prime Minister having committed to introducing it. It seems likely this current PM will have another example for the historians of his proving Peter`s Principle of having risen to his level of incompetence.
The recurring culprits across these inquiries are NHS bodies, police forces, local councils, central government departments, regulatory agencies and quasi-public corporations with the justice system itself (courts and prosecutors) also implicated in several cases.
Despite the scale of the scandals uncovered the number of people actually dismissed as a direct consequence of inquiry findings is remarkably small and in most cases even that distinction blurs between being fired, being pushed out, or choosing to resign. Former health secretary Wes Streeting has said that those senior staff who refused to engage with the largest maternity scandal in NHS history should be hauled before Parliament. Who would wager that will happen or that those culpable will not return to their highly pensioned new senior posts or enjoy a well financially cushioned retirement?
Competing for one of the most disgraceful examples of successive governments turning blind eyes to blatant law breaking by senior management was aforementioned Post Office scandal. Paula Vennells (CEO of Post Office 2012–2019) was not fired. She had already left the role before the inquiry concluded. Under enormous public pressure following the ITV drama Mr Bates vs The Post Office she resigned from her non-executive directorships at Dunelm and Morrisons in 2021 after 39 subpostmasters' convictions were quashed. Her CBE, awarded in 2019, was revoked in 2024 for "bringing the honours system into disrepute". She was not prosecuted. Currently no Post Office or Fujitsu employee has been held criminally accountable, though the Metropolitan Police is investigating potential offences including perverting the course of justice and perjury.
When policing goes wrong there is the appearance that those at the top sail on blithely to their tax payer funded pensions. Such is the case of Dame Cressida Dick not fired but effectively forced out. On 10 February 2022 Dick announced her resignation as Met Commissioner stating that "the Mayor no longer has sufficient confidence in my leadership." The triggers included the murder of Sarah Everard by PC Wayne Couzens, the subsequent mishandling of the vigil and the serial rape case of PC David Carrick. She reportedly felt "entitled" to a £500,000 severance after being pushed to stand aside. She was not disciplined through any formal misconduct process.
No senior council official, government minister or building industry executive has been fired or prosecuted as a direct result of the Grenfell Tower Inquiry.
Perhaps the most atrocious example of government collusion and cover up on a grand scale is the Infected Blood Inquiry. There was a a deliberate cover-up spanning decades across government and the NHS. The then Prime Minister Rishi Sunak issued a full apology in May 2024. He acknowledged that victims had "died without seeing anyone held to account." That remains the situation: no prosecutions, no dismissals of senior figures and the Health Secretaries over that prolonged period of scandalous indifference during which thousands of families lost their loved ones.
Decade after decade, inquiry after inquiry, the ritual is identical: shock, sympathy, solemn promises, a report, some recommendations partially implemented, then silence until the next catastrophe. The centralised post-war settlement replaced local democratic messiness with professional expertise and national consistency. What it could not replace was the simple, brutal accountability of an elected councillor facing angry neighbours at the town hall. Instead it created elaborate supervisory architecture; boards, regulators, inspectorates, audit committees whose very complexity obscures the question of who is actually responsible when children are abused, patients poisoned,or buildings burn. How it is that the Criminal Cases Review Commission, the very last resort for those wrongly convicted, demands an admission of guilt before it can recommend parole the case of Andrew Malkinson being just about the most defining example of an institution not fit for purpose although Helen Pitcher former chair and Karen Kneller former CEO both resigned albeit with some reluctance.
Those of us who sat on the bench long enough developed a certain immunity to surprise. We watched defendants appear before us for the third, fourth and fifth time for offences whose causes nobody in authority had seen fit to seriously address. The pattern repeats. The paperwork multiplies. Nothing changes.
It would appear that those who govern our great institutions have acquired the same habit. Grenfell, Infected Blood, The Post Office, Maternity services, Child sexual exploitation. One reaches for the word unprecedented and then recalls that one reached for exactly that word the last time and the time before that.
What strikes this observer and it is not an original observation, merely one that is consistently ignored, is that the supervisory bodies which fail so spectacularly are not staffed by villains. They are staffed by people who know one another rather well. Estimates of the pool from which non-executive directors, quango chairs, NHS trust boards, police authorities and regulatory bodies are drawn tend toward a figure somewhere between three and five thousand individuals nationally. They lunch together. They sit on each others advisory panels. They write each others references. It is not a conspiracy. It is something rather more comfortable and therefore considerably more dangerous than a conspiracy. It is a disposition.
The appointers bear examination here. When a board appointment goes wrong, when a trust chair fails to notice what any competent ward sister could have told him in five minutes the question rarely asked is who put him there and on what basis. The answer is almost invariably: someone very much like him, applying criteria very much like the ones by which he himself was appointed.
The Curtis Report of 1946, exposed conditions in children`s homes that would shame a Victorian poorhouse. One might have supposed that 75 years of legislative activity since then would have resolved the matter. The Independent Inquiry into Child Sexual Abuse reported in 2022 that institutional failure remained widespread. Rotherham, Telford, Oldham; the files are thick. The consequences for those at the top have been notably thin.
During my time as an active presiding magistrate when a pattern of offending repeated we enquired via the probation service carefully into the conditions which produced it. We did not simply fine the offender and congratulate ourselves on a proper process. Those who design the supervisory architecture of this country might with profit adopt a similar approach. The inquiry is not the accountability. It is, too often, the substitute for it.
That the Hillsborough Law requiring simple honesty from public servants remains unenacted tells one everything one needs to know about the appetite for genuine reform among those in a position to deliver it. The pattern will repeat. It always does.
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