People doing their jobs could've saved murdered Zara Aleena

With sophisticated phone systems, messaging, video, portals and simple old emails, there can be no excuse for not passing on information and following simple processes.

Yet, failure to communicate and pass on crucial knowledge, is so often highlighted as a root cause of catastrophic failures and tragic deaths. Human error happens however fancy and expensive communication systems might be, and no technology is a substitute for rock solid training.

A common denominator are public sector organisations with impenetrable multi-layer management systems saturated with bureaucracy, processes and procedures that drown and tangle efficiency and lose essential information sharing in the muddle of systems that don’t work.

Sprinkling titles like confetti around an organisation – everyone is a manger, head of, director or president nowadays. So many lofty titles. Who is doing the doing? It all adds to the muddle of who is accountable for what with so m any people taking decisions, not sharing decisions and passing the buck.

Process prevents progress; process so turgid, rigid and management-heavy can lead to tragedies with vital information lost in the unnavigable maze organisations call ‘process.’.

Aspiring lawyer Zara Aleena was a victim of such organisational failure, leaving fairground worker Jordan McSweeney to ambush, sexually assault and attacked her so badly she later died days after he had been released from prison amid multiple system failures and people simply not doing their jobs.

Zara was building a career with a bright future ahead and had hers cut short by people not doing theirs properly. 

The failures allowed a man who should not have been on the streets to prey on Zara because the agencies charged with supervision his release from prison on licence a few days earlier had not talked to each other as they should.

He dragged her into a driveway before sexually assaulting her and repeatedly kicking and stamping on her. He returned moments later to attack her again and later left the scene. She was discovered partially naked and struggling to breathe. She died in hospital.

At her inquest, it was revealed that failures “across multiple agencies” had contributed to her death – how many times have we heard this before in tragedies?

The jury found that Zara’s death was contributed to by the failure of multiple state agencies “to act in accordance to policies and procedures – to share intelligence, accurately assess risk of serious harm, (and) act and plan in response to the risk in a sufficient, timely and coordinated way.”

The HM Prison and Probation Service (HMPPS) committed “significant failures to appropriately assess risk and registered McSweeney at medium risk when it should have been high.”

He had been released from prison on licence for robbery and had been accused of a series of offences while he was in prison the year before Zara’s murder, including attacking an inmate with the base of a kettle.

However, his offender manager failed to share reports of the allegations because he was on annual leave and didn’t chase it up when he returned

HMPPS failed to identify “significant events” that should have led to the risk being evaluated and information sharing, decision making, supervision and training were “inadequate,” the jury said.

As if that wasn’t damning enough for the organisation responsible for dangerous criminals being released back into the community, there was “failure to define, understand and execute roles and responsibilities across multiple agencies to manage the offender effectively.”

McSweeney had 28 previous convictions for 69 offences, including burglary, vehicle theft, assaults on police and assaults on members of the public.

The jury said there had been “a failure to define, understand and execute roles and responsibilities across multiple agencies to manage the offender effectively.”

Basic communication, in other words.

“Attempts by the Met Police to arrest the offender post-recall were impeded by a number of factors including inaccurate data on the recall and a lack of professional curiosity and follow ups.” Says it all.

Another brutal murder that could and should have been prevented with effective communication, simpler organisational structure and people doing their jobs.

Talk about changing face

Multiple MPs face the chop next week and are busy trying to shape new livings once the pay out to tide them over from the public purse runs out.

On BBC Radio 4 Broadcasting House last week Edwina Currie spoke about how she reinvented herself after losing her seat in the 1997 Labour landslide.

Spent her “redundancy money”, as she called it, on a face lift to launch a media career.

You could hear the national gasp.

I’ll leave it there, but is that the way we want our public servants to spend our money?

One older gentleman and a bouncy bright pup with the characteristic Labrador emotional intelligence and intuition, they instantly soothed, entertained, calmed and comforted.

As years pass, dogs beat people hands down as great company.

Just 24 hours with walking these hounds, working with them by my feet, playing in the garden and just sitting quietly rhythmically stroking them was just what the doctor ordered.