'Monitoring was applied over-literally as regards returns and visits. Procedures were generally followed conscientiously but for much of the time without flair and imagination.
'There seems to have been insufficient senior control and review and the planning and timing of visits was in the hands of the relevant team rather than conducted according to a co-ordinated overall plan.'
'The response to the crisis of the last few days was not adequate to the needs of the situation; there was insufficient management understanding of urgency, and of measures to cope until the last minute . . . it would probably have made little difference in this case, but as a general matter such a response is not acceptable.'
'Some of the procedures can now be seen to have been overdogmatic, giving insufficient scope for swift 'one-off' modification; partly as a result, and partly for other less formal reasons, there were lapses of judgement, characterised by failure of alertness to pick up signals of possible trouble and by failure to relate diverse pieces of intelligence to make a whole picture.'
'. . .judged by absolute standards, not those of what might-have-been, Imro's verdict on itself is 'not good enough' '.