There’s a difference here in responsibility vs accountability
procedures, reporting structures etc are about defining who has responsibility to carry out actions to prevent this sort of thing. This could be inspectors, procedure and policies writers, accountants etc
but ultimate ACCOUNTABILITY stops with the COE. That’s the point of a COE - he is accountability for the culture, ensuring his senior board are supported and directed to ensure policies, training , procedures are followed. That should be done with smart metrics etc . and a CEOs own behaviour reflecting the culture he expects his board to follow.
imho all over civil service people don’t understand there’s a difference between responsibility vs accountability. I’ve had mental health team supporting my ex tell me “we’re all accountable”. Bollocks. They are all responsible for their task. But You must only have one single person of accountability to oversee those responsibilities . And if you don’t then you merely have no accountability. And then shit happens like this.
whether the CEO deserves jail is a debatable point in a court to say did he break the law in his lack of accountability. Unless you have clear policies for how a CEO behaves in law it is tricky. I worked in Pharma industry and I can tell you there is plenty of stuff a CEO and “Qualified Person” (the ultimate person accountable for each batch release to public), could go to jail on based on Regulatory requirement by medicines agencies right around the world.
But are there same regulations for CEOs of councils . Doubt it cos successive government aren’t interested in defining such laws. Which is why they can get away with it.