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What about the coroner and regulatory bodies? When there was a death in an outpatient cosmetic surgery office many years ago here in Canada, office based anaesthesia guidelines became much more stringent even though the death was not attributable to the anaesthesiaFind something to attribute it to. Put a band-aid on. Then business as usual.
This is not an exact science.
The patient was very sick. Had lots of stuff going on.
Stuff happens.
No mistake was made- just one of those things.
Even if a mistake was made, carelessness or incompetence was not present. It was a judgement call.
Allergic reaction.
Unusual anatomy.
God’s will.
We did our best.
The patient was fat, smoked, used drugs. Didn’t take care of themselves.
The equipment failed. Was poorly made.
It was a perfect storm.
It was one individual’s fault. Not a systemic problem.
Etc., etc.,