A workplace harm event is experienced as a single set of circumstances. It may involve harassment, violence, discrimination, reprisal, or safety concerns. To the individual involved, it is cohesive and continuous. Institutional response, however, is not cohesive. Once formal processes are triggered, the event is routed into distinct institutional pathways, each governed by different procedural rules, documentation standards, decision-makers, and statutory mandates. What appea

Across sectors and decades, we see the same pattern - inconsistent application of policy and informal handling of serious concerns. Investigations without meaningful closure, and the follow-up that never happens. Responsibility that migrates until no one is accountable. It is rarely a single catastrophic act that produces harm, it is systemic response failure. The Dupont Inquest identified these patterns clearly. It warned that policy without enforcement creates predictable r