Articles for tag: control, death, failure, homicide, inquiry, lessons, management, murder, patient, risk

The 2024 Southport stabbings: A Case of Risk Lacunae and Protective Nets

The 2024 Southport stabbings refers to a heinous attack carried out Axel Rudakubana. He committed three murders and ten attempted murders. This article is constructed largely from information in the public domain and is being updated at intervals, as new information comes to light. Note again our ‘Fat Disclaimer‘. Rudakubana was 17 years old at …

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Fires in Los Angeles compels review of tail risk

The tranquillity of a sunny afternoon can quickly transform into a scene of chaos when a wildfire erupts, engulfing homes and livelihoods in its path. Recent events, such as the devastating fires in Los Angeles, serve as stark reminders of the ever-present danger of tail risk. While cutting costs might seem prudent in the short …

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No new lessons here: Retired consultant killed by son who suffered with schizophrenia.

The case of Daniel Harrison, who was convicted of manslaughter by diminished responsibility after killing his father, Dr Nicholas Kim Harrison, highlights significant failings in mental health care management.  The Coroner gave a narrative verdict on 16/04/2024. The homicide had happened in March 2022. [References and sources at the end] While the publisher and author(s) have …

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The crossover between CPIA and Mental Health Act

This is a somewhat obscure part of the law in England & Wales that may cause some confusion. Experience this week (on 16/05/2024) shows how misunderstanding and errors can occur. This is where an individual is found to be ‘under disability’ in the Criminal Procedure (Insanity) Act 1964 and is disposed of by the court. …

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Why lessons are not so easy to learn

The context of this exploration is twofold a) to examine how lessons may not be learned by individuals and b) difficulty for organisations in learning lessons. What ordinary people expect Let us start by understanding how ordinary people might decide what is a lesson learned. I suggest that they may expect the following: Cause and …

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