// Decision Autopsies · Boardroom Reality Checks

Documented failures. Constructed cases. Decision chains examined.

Six decision autopsies and five boardroom reality checks, each mapped through the Decision Integrity Chain™. Documented cases draw on public records; constructed cases illustrate recurring institutional patterns.

// Decision Autopsies — The Record Shows

DA-2025-001 · Credit · UK GSIB
640 loans approved. Every dashboard green. Credit committee signed off. The exposure was invisible — until it wasn't.
The model scored correctly. The rules were followed. The intent was never encoded. L3 was absent for 1Post-failure before anyone asked the right question.
DIC™ layer that broke: L3 Intent — L4 Rules (drift between intended and executed policy)
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DA-2025-002 · Home Health · US Healthcare
Scheduling algorithms optimised for efficiency. Patient outcome indicators deteriorated across an entire region. No single decision was wrong.
Every individual scheduling decision was defensible. The emergent pattern — resource concentration, outcome drift — was visible only at L7. Nobody had designed a feedback loop.
DIC™ layer that broke: L7 Outcome — L8 Feedback (no mechanism to detect emergent harm)
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DA-2025-003 · Acute Care · Hospital Network
Triage protocols updated. Clinical judgment delegated to a scoring engine. Outcomes shifted — not dramatically, but consistently and in one direction.
The scoring engine was validated. The delegation was not auditable. L5 Judgment was fully automated without an authority boundary being defined.
DIC™ layer that broke: L5 Judgment (authority scope undefined at delegation)
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DA-2025-004 · Onboarding · Asian Digital Bank
KYC pass rates were improving. Fraud rates were also improving. Regulatory findings arrived two quarters later about a segment that had been systematically under-screened.
The rules were consistent. The intent behind the rules had changed — but only in board documents. L3 was updated in policy. L4 was not re-encoded. The gap was 8 months wide.
DIC™ layer that broke: L3–L4 gap (intent updated in policy, not in rules)
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DA-2025-005 · Pricing · Regional Insurance Group
Algorithmic pricing delivered margin improvement. Three segments were systematically disadvantaged. The pricing model had never been reviewed for fairness.
L1 Purpose stated "fair outcomes for customers." L4 Rules optimised for margin. The contradiction had been operating for 22 months before a regulatory inquiry surfaced it.
DIC™ layer that broke: L1–L4 contradiction (purpose and rules in direct conflict)
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DA-2025-006 · Agentic Credit · Cross-border Platform · In progress
Seven agents. Three jurisdictions. Seven seconds. One outcome that no institution authorised.
Based on the scenario constructed in Paper 3 — When the Protocol Decides. Publishing shortly.
DIC™ layers that broke: L3 · L4 · L5 · L8 — simultaneously, across institutions
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// About the section above

Decision Autopsies — composite cases constructed from documented institutional failure patterns. Not tied to any specific named institution beyond what is explicitly stated. Analytical and educational in nature.

// About the section below

Questions Boards Struggle To Answer — practitioner intelligence published on Substack. Questions drawn from pattern recognition across 25 years of institutional advisory work. Subscribe to read the full analysis.

// Questions Boards Struggle To Answer — Five published cases

What boards actually ask when something can no longer be explained.

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// 01 · Diagnosis — what the data shows

Four failures. Three boards — and one system.
One structural finding across all of them.

SVB · March 2023
Post-failure

The decision sequence had to be reconstructed after the collapse, when the opportunity to intervene had already passed.

DIC™ L6 — no replay infrastructure
Knight Capital · August 2012
>$460m · 45 min

A deployment decision made and executed. No verification record. No reachable kill switch. The institution could not prove what had been authorised at the moment trading began.

DIC™ L6 — no deployment decision record
Theranos · 2013–2016
2013 → 2022

Patient-facing deployment before independent validation. No traceable link between result and machine. The record that would have made it defensible was never built.

DIC™ L6 — no clinical deployment decision record
UK LDI crisis · September 2022
£65bn

Every LDI fund was individually compliant. No single decision wrong. No feedback loop at network scale.

DIC™ L8 — no cross-institutional feedback
The structural finding — across all cases
Loss often compounds after the original error

Across several failures analysed, much of the eventual loss arose after the original error, when the institution could not detect, reconstruct or stop what followed.

This is the governance gap Decision Engineering™ is designed to examine.

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// Decision Autopsy — available on Cases page

Each case is mapped in full through the DIC™ — the layer that broke, the decision that could not be stopped, and the structural change that would have prevented it. Not commentary. Architecture.

Read the six case autopsies →
// The question each autopsy answers
Which DIC™ layer failed first?
At what point was the loss still recoverable?
What governance architecture would have caught it in time?
What does the same gap look like in your institution today?

Every term used across this work — replayability, the Decision Integrity Chain™, the Fiduciary Gap™, decision drift — is defined once in the glossary.

// Disclaimer & Legal Notices

The views, analyses, and perspectives expressed on this site are solely those of Deepak Aggarwal, presented in a personal and independent capacity. They do not represent or reflect the views, policies, or positions of any current or past employer, client, institution, or affiliated entity.

All institutional case references — including but not limited to SVB, Knight Capital Group, Wirecard AG, Credit Suisse, Wells Fargo, Coutts, Orpea Group, Kaiser Permanente, and NHS entities — are cited solely on the basis of publicly documented regulatory findings, official investigations, court records, parliamentary reports, and other published primary sources. No non-public information has been used. All analysis is independent, educational, and analytical in nature.

Nothing on this site constitutes legal, regulatory, financial, investment, or professional advice of any kind. The Decision Integrity Chain™, Decision Engineering™ as developed and presented in this body of work, together with the Decision Integrity Chain™, DIC™, the Fiduciary Gap™, FUSE™, STAGE™, DIC ChainTrace™, the Decision Trace Payload™, the Decision Drift Audit™ and associated original frameworks, diagrams and materials, is the intellectual property of Deepak Aggarwal. Unauthorised reproduction, adaptation or commercial use of these original materials is prohibited without prior written consent.

Case studies and scenarios described as "constructed" or "composite" are hypothetical illustrations based on documented failure patterns. They do not refer to any specific institution, transaction, or individual beyond what is explicitly stated.

© Deepak Aggarwal 2025–2026. All rights reserved. Decision Engineering™ · Decision Integrity Chain™ · DIC™ · FUSE™ · STAGE™ are trademarks of Deepak Aggarwal.