Chloe Moffat was 26, a personal assistant at HM Treasury with an exemplary record and nearly three years of service. In August, a coroner ruled that the department had "materially contributed" to her death by suicide. The mechanism was a disciplinary meeting — described as "informal" — that denied her advance notice, denied her a support person, refused to tell her whether she faced dismissal, stripped her email access, and changed her responsibilities. She left the room devastated. The next morning she was dead. The Treasury's response to the coroner's prevention of future deaths report, obtained by the Guardian, accepts the findings "in full." The department says it has stopped using informal fact-finding meetings for allegations of potential serious or gross misconduct, introduced procedural and wellbeing safeguards, issued interim guidance, and is hiring an on-site occupational therapist. Staff may now bring a colleague for support. These are real changes. They are also changes that should never have required a death to implement. What the Treasury has not done is hold any individual to account. Moffat's line manager told the inquest she would have done nothing differently: "I think we did all we could at the time with the information and advice we were given." The department's spokesperson frames the events as staff acting "in good faith and with a duty of care throughout" — a characterization difficult to reconcile with the coroner's finding that the institution materially contributed to a young woman's death. David and Anne Moffat have spent more than a year fighting to extract answers from a department that initially took no responsibility. Their meeting with permanent secretary James Bowler carries a pointed demand: if Chloe was held to account for anonymous allegations she denied, the managers and HR staff who designed and executed the meeting should face equivalent scrutiny. The asymmetry is the core of the story — a junior employee was subjected to a process that a Cabinet Office review later found had been replicated across the civil service, yet the architects of that process face no named consequence. The Cabinet Office review is a significant detail. It found that the conditions Moffat experienced were not an isolated failure but a systemic pattern — surprise disciplinary meetings without notice, without support, and without clarity on consequences. This transforms the story from a single tragedy into an institutional design problem. The civil service has put safeguards in place, but the review's existence confirms that Moffat's treatment was standard operating procedure, not a rogue manager's improvisation. Anne Moffat frames her family's mission as legacy work: "We are also trying to think how we want lessons to be learned so no other young person suffers in the same way." The parents have not yet been able to grieve properly. They are considering a second celebration of life. Chloe's friends run marathons for Shooting Stars Children's Hospice and volunteer for Samaritans. The gap between the human cost and the bureaucratic response — "an independent review found staff acted in good faith" — is where the real accountability question lives. The Treasury's procedural reforms are necessary and welcome. But procedural reform without individual accountability sends a specific message to every manager in the civil service: the institution will change its rules after a death, but no person will face consequences for the conduct that caused it. That is a policy choice, and it has downstream effects on how seriously future managers take duty-of-care obligations when they conflict with expedient HR processes.