British official and office language has many ways to describe a failure without naming a person.
The decision was taken: Someone decided, but the sentence does not say who.
There were failings: Things went wrong, and no one is named as the cause.
It fell between two stools: Two people or departments each thought it was the other’s job.
With hindsight: Nobody could have known at the time.
Lessons will be learned: The matter is closed, and nobody will be punished.
On 25 October 1854, at Balaclava in the Crimean War, the British Light Brigade charged straight at Russian guns. Alfred, Lord Tennyson wrote “The Charge of the Light Brigade” on 2 December 1854, and The Examiner published it the following week. Its best-known line names no one: “Someone had blunder’d.”
Captain Louis Nolan delivered Lord Raglan’s order to Lord Lucan, who sent the Light Brigade under Lord Cardigan forward. Nolan was the first casualty of the charge. Contemporary accounts blamed Nolan. Some modern historians share the blame among Nolan, Raglan and the cavalry commanders.
Charles Dickens published Little Dorrit as a serial from December 1855 to June 1857. His working title for the novel was Nobody’s Fault.
The novel’s government department, the fictional Circumlocution Office, has one guiding principle: “How not to do it.”
On 6 March 1987, the ferry Herald of Free Enterprise capsized moments after leaving Zeebrugge, killing 193 passengers and crew. The official inquiry found negligence at every level of the company. In its words, “from top to bottom the body corporate was infected with the disease of sloppiness.”
Seven people at the company were charged with manslaughter, and the company with corporate manslaughter. The case collapsed. The judge directed the jury to acquit the company and the five most senior defendants, because the various acts of negligence could not be attributed to any individual who was a “controlling mind.”
On 6 February 2013, Robert Francis QC published the report of his public inquiry into the failures of care at Mid Staffordshire NHS Foundation Trust. His statement said: “Regrettably there was a failure of the NHS system at every level to detect and take the action patients and the public were entitled to expect.”
He rejected the usual response. When a disaster occurs in the NHS, he said, “the usual approach has been to blame and sack individuals or to propose major reorganisations.” What had gone wrong “cannot be cured by finding scapegoats.”
On 14 June 2017, a fire in Grenfell Tower, a block of flats in West London, killed 72 people. The public inquiry published its final report on 4 September 2024. The inquiry, led by Sir Martin Moore-Bick, found that “the simple truth is that the deaths that occurred were all avoidable.”
The report set out how a chain of failures across government and the private sector made the tower a death trap. It found fault with government, industry, cladding suppliers, the local council, the tenant management organization and the fire brigade. News reports summarized its findings as “decades of failure.”
On 20 May 2024, Sir Brian Langstaff published the final report of the Infected Blood Inquiry, on patients infected through contaminated blood and blood products. He wrote: “I have to report a catalogue of failures which caused this to happen.”
He found that “responsibility for much lies with successive governments” and that “clinicians and the health service in particular failed them.” He also wrote: “It was not a tragic accident, in the sense of something that was unavoidable.”
In April 2016, new inquests into the Hillsborough disaster of 1989 concluded that the 96 Liverpool fans who died at the football ground had been unlawfully killed. The jury found that the fans’ behavior had not contributed. South Yorkshire Police had claimed that drunkenness among fans contributed to the disaster.
In November 2017, Bishop James Jones published his review of the families’ experience. He called it “The Patronising Disposition of Unaccountable Power.” It described how the institution had closed ranks and refused to disclose information.
The Ministerial Code, the rulebook for British government ministers, states: “Decisions reached by the cabinet or ministerial committees are binding on all members of the government.”
NHS England publishes A Just Culture Guide for managers whose staff are involved in a patient safety incident. It encourages managers to treat such staff “in a consistent, constructive and fair way.” Where the cause of an incident is wider than one person, the guide says, “singling out the individual is often unfair and counter-productive.”