The responsibility began at the top - at the board - and trickled down successive layers of management.

"There was inadequate oversight and a lack of ownership of key risks at the executive committee level,overly complex and bureaucratic decision-making processes that favoured collaboration over timely and effective outcomes and slowed the detection of risk failings,"it said.

And even when problems were identified,there was a lack of financial consequences -"there was little sting for senior managers and above when poor risk or customer outcomes materialised".

It is a damning indictment of the recently departed chief executive,Ian Narev,his successor,Matt Comyn,and the board under the chairmanship of Catherine Livingstone.

The rhetoric around CBA’s attention to customers has been seriously challenged by APRA’s panel that undertook a forensic examination of the inner workings of bank.

"Notwithstanding the customer focus enshrined in CBA’s Vision and Values,and its industry-leading customer satisfaction scores,the customer voice[in particular,customer complaints] did not always ring loudly in decision-making forums and product design,"it said.

The panel noted the bank had attempted to change tack and had a new approach to compensation but flagged the process was not a solution of itself.

"CBA’s new remediation program is ambitious and on a scale that exceeds previous risk-management initiatives ... To succeed,it will be critical that the program breaks the mould – it cannot succumb to the weight of bureaucracy,unclear accountabilities and porous deadlines that have challenged earlier CBA projects,"it said.

Comyn now has a framework and plenty of incentive to fix this institution in a way that his predecessors have comprehensively failed to do.