What are the most important lessons learned from an organization

What are the most important lessons learned from an organization

need answers based on attach case. questons are as follows.

1.What are the most important lessons learned from this case.

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2.As a Consultant to that organization, what would be your Specific recomandation to implement, in order to avoid this from happening again in the future? In fact, is it reasonable think it can be avoid in future

3.What did the individual or organization do , if anything to address this problem