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"The failure of staff and supervisors to question things that do not make sense must end".
Expert witnesses have told the coroner that Dhu's illness would have been detectable by her second visit to the hospital, and that a failure of staff to take her temperature or perform other investigations, such as a chest x-ray, contributed to her misdiagnosis.
In the report the ombudsman's clinical advisers were highly critical of the failure of staff to deal with the elderly woman's condition on arrival.
A hospital review into his death found staff shortages, failure of staff to recognise his deteriorating condition and poor communication with his parents had contributed.
Encouragingly, evidence is available to suggest that the failure of staff to facilitate adequate service user involvement does not have to be a fixed phenomenon.
These were failure to be looked after by a paediatrician, failure of sufficient supervision of junior staff, and failure of staff to administer adequate inotropes [ 14].
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She says she apologised many times for the failure of safeguarding staff to prevent the death, but she will never apologise in a way that suggests she was responsible for his death.
It has described the failure of senior staff to follow up on concerns voiced about Atherton's emotional state by subordinates as "unacceptable" and concluded the resulting lack of consideration given to the "welfare of the family and wider public" was "inexcusable".
Among the 19 samples culture-positive by both conventional culture and Flexicult Vet A, two were excluded for evaluation of species identification due to failure of clinical staff to provide interpretation of species on Flexicult Vet A plates.
The failure of VMA staff to visit all villages as scheduled (to identify poor pregnant women and distribute vouchers) also deprived many poor pregnant women of the chance to receive vouchers.
In 2007 the Quality and Safety Unit, Southern Health, Melbourne identified 11 sentinel cases in which significant patient harm occurred in association with the failure of bedside staff to call the medical emergency team.
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Justyna Jupowicz-Kozak
CEO of Professional Science Editing for Scientists @ prosciediting.com