When Decisions Break

Forty-three seconds. That is how long it took a bank's lending platform to reject a loyal customer who deserved approval — and nobody inside the bank knew anything had gone wrong.
The dashboard was green. The audit trail was clean. Every rule had fired exactly as designed.
Six months earlier, the board had voted to fix this exact problem. The fix never reached the machine. Nobody disobeyed anyone. A technical change, logged correctly under the rules as written, quietly redefined what the system was measuring — and no document anywhere connected the two moments. It took sixteen months to notice.
This is what institutional control failure actually looks like. Not a bad model. Not a careless engineer. A slow drift between what leadership decides and what the system does, one reasonable step at a time.
When Decisions Break follows a constructed bank and a constructed hospital through the full arc of this failure — from the boardroom decision that should have closed the gap, to the customer and patient who paid for it, to the four mechanisms built to make sure it cannot happen again. Drawing on recurring failures across banking, healthcare, telecommunications, insurance, government, retail, and AI, the book gives boards, executives, risk leaders, technologists, and regulators the Decision Integrity Chain™: decision integrity infrastructure for verifying that the decisions an institution believes it is making are the decisions it is actually executing.
Is the decision we made six months ago still the decision we are implementing today?
If you cannot answer that with confidence, the failure is not coming. It is already running.