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Radonda Vaught Is a Scapegoat
Radonda Vaught is a scapegoat. Nurses everywhere are in revolt. If you thought nursing was in trouble before (projected healthcare worker losses in the next 5 years are around 45%), nurses are choosing to quit based upon the precedent in this case.
Let us start from the beginning.
Radonda Vaught was a graduate of West Kentucky University, an experienced ICU nurse, preceptor, and leader at her hospital Vanderbilt University Medical Center. She had been employed there since 2015 with no previous incidents. She had a clean license and practiced as most nurses do; at the bedside at a hospital. One day, she was caring for her patient Charelene Murphey who was a 75-year-old with a brain bleed (technically a subdural hematoma). The medication error occurred on Dec. 26, 2017, when she was scheduled for a PET scan but was found to be incapable of lying still long enough to endure the study.
As was policy at the time and while precepting a trainee, Radonda overrode their Pyxis machine to grab versed (a sedative agent) and instead grabbed vecuronium (a paralytic agent). While practice is different everywhere, it seems that it was very common for them to give versed to patients undergoing tests if they had claustrophobia. Most hospital policies require the nurse to monitor the patient when being given a sedative, though some allow for the sedative to be given, the patient to be monitored for a short period of time (5 minutes or more), then sent to testing. All of this would depend on the doctor’s orders, the hospital policy, and common practice.
The patient appeared to the nurse to be comfortable and resting with her eyes closed.
Charelene Murphey was then sent to the PET scan unmonitored (no cardiac monitoring, no respiratory monitoring, no nurse to monitor her while in the scanner) as was ordered by the physician. Presumably, people transported her there and lifted her paralyzed body onto the gurney and into the scanner. Presumably, those people also had opportunity to notice that the patient was not breathing. However, this was apparently not the case as it has not been discussed in any articles that I have found. There are few details regarding the experiences of the transporters and radiology team, as I expect the hospital has made their position very clear to any employees involved in the case.
The patient underwent the PET scan and went into respiratory arrest, leading to cardiac arrest and anoxic brain damage. They were able to perform CPR and get a regular heart rhythm, however, 12 hours later the family was told that she was effectively left brain dead. They decided to withdraw treatment at that time.
On December 27 at 1 a.m., Charelene Murphey was declared dead.
Important points to note:
- Radonda Vaught never tried to hide her medication error. She reported it immediately to the physician in charge of her patient. She was devastated by her error.
- Vaught was investigated by the Department of Health, which licenses nurses in Tennessee. They declined any disciplinary action after their investigation in 2019. There are other sources about how she also faced this disciplinary case brought by the Department of Health, after the case became public due to an “anonymous tip”.
- Vaught is quoted as saying that at the time of Murphey’s death, Vanderbilt was instructing nurses to use overrides to overcome cabinet delays and constant technical problems caused by an ongoing overhaul of the hospital’s electronic health records system which was slow and incomplete.
- The physician in the case had ordered that the patient could go to the test unmonitored; if monitored, the error would have been apparent and rescue could have been performed more immediately.
- Two neurologists indicated on the death record that the death was of “natural causes”, not from a medication error. The error was known at this time but was obscured by the hospital.
- A Vanderbilt hospital doctor indicated that “(The patient) got such a small dose, and he/she was anxious about the test, so we can’t say it contributed to his/her demise.”
- It is entirely possible that the medication was not the sole cause of death, although it is probable.
- Murphey’s death resulted in the hospital’s Medicare reimbursement status being jeopardized, pending investigation and corrective action.
- Vanderbilt was already at risk due to other pending civil suits regarding varied errors such as: operating on the wrong kidney, removing the entire thyroid of a patient and losing it, accidentally puncturing the carotid artery of a patient and not reporting it to the family and the patient subsequently died, removing less than 20% of a pituitary tumor and declaring it “maximally resected” with no follow-up imaging prior to DC…. and the list goes on.
- Medication errors are very common in the hospital environment and include such diverse things as: giving the wrong medication, giving the correct medication late, not assessing the patient properly prior to administration, not assessing the patient properly after administration, giving the correct medication through the wrong route, and even preparing the medication incorrectly.
One can look at any licensing board if one enjoys looking at disciplinary actions and causes. Nurses, physicians, pharmacists, and other practitioners regularly have their licenses suspended or removed given various grievances. When convicted of a crime, one may also lose their license since they usually require federal clearance in order to practice.
Having professional newsletters delivered regularly, my family is privy to a number of the details of these cases. In discussion with my father (California Pharm D. for almost 45 years now with a current license), he was quite shocked about Vaught’s discipline. Given how often physicians and pharmacists give the wrong doses, mix the wrong medications, and perform pretty egregious oversights and wind up with merely a suspended license, rather than criminal charges, he was shocked. He was not familiar with the case, but will be providing me his opinion in short order (once he has a minute away from caretaking duties).
I have to agree.
I have seen doctors, personally, do things that I would question. They are still practicing. To my knowledge, they have not been suspended. Some have been sued in civil court, but have defended their practices fairly well. A number of them are wrongfully accused of negligence. A number of them are never accused at all. Frankly, that surprises me sometimes. I have never heard of a physician having criminal charges pressed for a genuine error that was not made while under the influence or so grossly negligent that it was criminal. It is so rare that when googling, I came across only one article which references NYT back from the ’90s.
Nurses are a fractious lot.
We do not often pull together. Despite the pandemic, nurses still had their dividing lines: masking/no masking, vaccines/no vaccines, shutdown/life as normal, politics, unions/anti-union, abortion, euthanasia. Even other more petty dividing lines: day shift vs. night shift, outpatient vs. inpatient, floor nurses vs. emergency nurses, ICU vs. emergency, doctors vs. nurses, old nurses vs. new grads, nurses vs. other nurses.
As I said, there is a whole lot of infighting.
It is astonishing that nursing organizations, which rarely unify for the best of nurses and instead are usually just political lobbyists, have released statements in support of Radonda. Even the ISMP (Institute for Safe Medication Practices) President was quoted in an article regarding the various systems errors that had to occur to even allow Vaught to make the error.
Nurses everywhere are second-guessing their choices in career. As this is becoming a bit of a trend, nurses are turning in their badges.
Pay that does not keep up with inflation. Impossible standards for patient care. No time for personal care. Inability to perform up to one’s standards due to patient pressures, staffing, and administrative demands. And now criminal culpability for honest mistakes? Even when there is no attempt to obfuscate? Malpractice insurance does not cover criminal charges and nurses do not make enough to retain an attorney just in case a DA determines that they need an easy win to pad their prosecution record.
Why bother?
Nurses are not just leaving for their sanity.
Now they are leaving for their freedom.
Somewhat related: Radonda Vaught is also being charged with perjury for incorrectly filling out paperwork to receive two rifles. She did not indicate that she was under indictment for a felony, which would have made her ineligible to receive the weapons. Her husband and she own a hunting business. She has been noted as a supporter of 2A on social media. Had she taken the stand, the DA intended to question her honest and integrity in this matter.
Articles of interest on the case or about nurse malpractice:
https://ajnoffthecharts.com/case-of-nurse-charged-with-homicide-for-medication-error-raises-concerns/
https://www.tennessean.com/story/money/2018/11/30/vanderbilt-patient-death-medication-error-medical-examiner/2155152002/
https://www.bigcountryhomepage.com/news/nashville-da-on-radonda-vaught-case-verdict-is-not-an-indictment-against-the-nursing-profession/
https://www.npr.org/sections/health-shots/2022/03/25/1088902487/former-nurse-found-guilty-in-accidental-injection-death-of-75-year-old-patient
https://www.usatoday.com/story/news/health/2021/07/23/ex-vanderbilt-nurse-radonda-vaught-loses-license-fatal-error/8069185002/
https://www.usatoday.com/story/news/health/2019/12/15/vanderbilt-vumc-radonda-vaught-medication-error-vecuronium-charlene-murphey/2454711001/?gnt-cfr=1
Published in Healthcare
You act like people who are nurses are never patients or that we simply excuse behavior because it was a nurse. I really doubt that you read most of what I wrote or the sources that I quotes.
In favor of “being the heavy”.
Good thing you’re not a nurse, because under your own guidance you’d be jailed.
It’s Midazolam.
I feel like you’re not reading and you’re really not understanding this at all.
No. Not “anything” can be dispensed, because one of the controls is not to have access to begin with. Additionally, wrong drug/doses occur all the time. Something even like tylenol can be fatal under the correct circumstances, so that isn’t exactly what the problem is either.
The problem is that it was a perfect storm. Had many of the suggested controls been in place, the error would never have occurred. You have been arguing, repeatedly, that Vaught was just free to commit whatever crimes she wanted, as if she had carte blanche. Me, and others, have tried to explain to you how the system actually works. And despite repeating that you didn’t read these things (which we are referring you to again and again), you’re claiming that your opinion is correct.
At this point, you’re not just ignorant. You’re willfully ignorant. The information is there. We’ve even paraphrased for you and given like situations to help you. But you just do not seem to be retaining any of it in your quest to mansplain to me.
But you do seem capable of going back and editing your comments to the menfolk. Nice.
Yes, that is absolutely what happens. Message fatigue, warning fatigue. A judicious use of color helps: there shouldn’t be nearly as many red boxes popping up as green and yellow and blue ones. (The accessibility people will complain about my use of color.)
It sounds like the machine should probably require a more positive confirmation for some things — having to type an actual response to confirm a dangerous drug, that kind of thing.
I would have liked to see the screens presented to the nurse when she retrieved the paralytic, versus what she would have seen had she retrieved the correct drug. I’ve looked, but have been unable to find that. If there was a big difference between what is displayed for a relatively benign, commonly-prescribed drug versus the one she actually administered, it would be good to know that.
But your point is a good one. I try to use alerts judiciously in my software, being fully aware that people will quickly be conditioned to ignore them. It becomes a trade-off between speed (something mentioned in various accounts of the incident) and safety.
Ultimately, people still have to pay attention. That’s largely a matter of training and self-discipline.
In fact, I typed it twice, the first time as miazapam. I was toggling between two screens, and still got it wrong.
I’d have been more careful if I were about to inject it into a patient’s veins. I guess that’s the point: a different level of care is appropriate when you’re taking that responsibility.
I don’t think I said that, the bit about the “crime.” I’m not expressing an opinion about criminality.
Once she bypassed the security mechanism, she had access to a larger list of drugs, some of them quite dangerous. If that wasn’t all the drugs in the machine, fine, I’ll accept that correction, because it doesn’t change my argument. And if she already had access to dangerous drugs, before she engaged the override, fine again: it still doesn’t change my argument that she knew what the machine could dispense and should have paid attention.
Whether she had access to every drug in the machine is irrelevant. She had access to drugs that could kill her patient, and she chose one of them (always assuming that the drug she administered was in fact the cause of death).
I try to correct typographical errors when I catch them, and of course I had to fix the wrongful attribution when I suggested that Flick wrote something that KE actually wrote. I couldn’t leave that.
But it honestly had nothing to do with menfolk versus womenfolk. I’d correct a typo for anyone. If you and I mix like oil and water, it has nothing to do with the fact that we’re from two different halves of our wonderful species. We’d spar as much if you were a guy. ;)
That’s what I would like to see [the notification screens that came up for each medicine]. Both drugs, the versed and the vecuronium, are dangerous and controlled to my understanding. Both would have warning screens or dialog boxes, I’m sure.
And I’m sure you know this better than I do, judging by your answer, after a while it’s not even a matter of ignoring the boxes, because from repetition you know them, or you think you do. And yes also, the smarter the machinery, the more you come to rely on the smartness of the machinery.
It seems to me clear that there was a systems problem here.
Unfortunately, in my experience, Healthcare systems often have fail points because they are broken. Then, individuals get blamed. I have seen it a lot.
Caryn @Caryn 1 Hour Ago
Indeed. But so is injecting a patient with a drug labeled around the stopper “WARNING PARALYZING AGENT.” A powder that had to be reconstituted to be injectable. When the desired drug is always liquid. Something there should have registered and made her stop and look at the label. It was not a case of picking up the wrong drug during the barely controlled chaos of a code. As described, it was a busy, but stable situation. She was also teaching. That’s a distraction, but what better teaching moment than walking the new nurse through the process of double-checking the drug label? Sure, that may not be done all the time in the real world, but it should be taught as the ideal. It was a potential teaching moment and instead killed a patient. That’s serious stuff that shouldn’t be excused.
I agree that the hospital was more culpable and engaged in much more dishonest behavior. I think it’s quite troubling that the investigation came from a still unidentified “anonymous tipster.” (What happened to the right to confront ones accuser?) There is a lot wrong with the case. But the nurse certainly did several steps wrong and, as a result, her patient died. That’s not excusable and I’m not sure why you seem to be taking this so personally and feel such a need to defend her.
She was also punished at the job and licensing level, so I do agree the criminal charges were excessive. As they were in the Chauvin case. Our justice system is broken. Maybe that’s the real problem.
An interesting question, I think, is whether we would think differently about the case — in terms of possible criminal charges — if it had occurred in a context other than health care.
For example, if a man operating heavy equipment ignored a warning beeper telling him that there were people behind him as he was backing up, would we agree that firing the man and preventing him from ever operating heavy machinery again was sufficient?
If an actor who was supposed to follow safety protocols on the set killed a camera woman with an improperly prepared stunt gun while ignoring said safety protocols, would we consider it sufficient to revoke his right to act in future performances?
If a police officer drew her Glock instead of her Taser and killed a man she had intended only to stun, would we think taking away her badge a sufficient consequence? What if she killed instead an innocent bystander standing next to her intended target?
Put differently: Do we think of medical malpractice differently than we do other kinds of lethal negligence? Do we simply accept that as a matter for disciplinary action and, sometimes, civil cases, rather than as something that might warrant criminal charges?
I don’t know. I haven’t given it much thought.
Caryn @ Caryn 1 Hour Ago
There were a few different things in this case that seem to be overlooked in this comment and others. First off: Radonda Vaught, though an ICU nurse, was not typically used to giving Versed OR Vecuronium. I had previously been unaware that this was not her patient and she was, instead, giving a medication for a nurse on break and sending the patient off to testing with a minimum of information. This all comes into play. If not used to giving such a medication, one would not be alarmed by reconstitution or by warnings. The anonymous complaint gives more details about how she was distracted and how the incident occurred.
https://www.documentcloud.org/documents/6542003-CMS-Complaint-Intake.html
As for why I am “taking this personally”: most nurses are. It is unusual that a licensing agency reverses course after already determining that a nurse should not lose their license. It’s also unusual that a nurse be held criminally liable for a mistake. While there were many oversights and many nurses support discipline against her license, most do not approve of her having criminal charges. It’s personal on many levels, not the least of which is because every nurse has made a medication error.
…to be continued.
…continued:
In other medical errors, even those that caused deaths like this heparin error that killed three babies, nurses are not criminally charged. The hospital is.
Nurses in that case didn’t notices that the vials said “heparin” not “hep-lock”, apparently not reading the label. They also didn’t notice that the vials were different colors from usual. They also didn’t read the concentration. Why weren’t these nurses prosecuted under the same circumstances? They killed three babies, not just one adult. They didn’t read the labels when drawing them up. They didn’t notice a difference in the containers.
My point is this: it is important to facilitate nurses and other medical professionals maintaining honesty about their activities. It is safest for everyone that this is the case. Otherwise, we will have nurses who, at the moment they do something wrong, hide it, refuse to document their error, and then lawyer up using the 5th to refuse to answer any questions.
In the meantime, patients die and people are left to wonder, “what exactly happened?”, some of those people being the people trying to take care of them after overdoses or wrong medication errors.
We do not criminally try medical professionals for the same reasons we do not (typically) criminally try police for justified mistakes. Instead of accepting that bad things happen, it appears that we are looking to shift blame to one party more and more.
While you may see this as a “why are nurses being so weird about it when she’s obviously guilty!”, you’re missing the larger picture. Nurses are used to being thrown under the bus by hospitals. Nurses are used to be blamed for all manner of shortcomings and even losing their licenses because of it. Nurses are not used to criminal prosecution for these things because typically, a DA has better things to do than to charge someone who has admitted their error, it was a genuine mistake, and it was something that had no egregious neglect or obviously malicious intent.
It sets off alarms now that they don’t.
And it should for everyone else, too. Not because nurses are all concerned about a nurse being charged, but because of what will happen to healthcare because of it and because of how nurses are preparing for the worse (or just quitting).
Well, for one thing, health-care people are arguably involved in more life-or-death decisions on a daily basis. Police don’t draw their gun or even their taser, nearly as often as medical people administer medication etc. And human fallibility being what it is, it’s both counterproductive and perhaps outright foolish to expect constant perfection. Especially if you want people to continue to be willing to take on either function.
Also, the heavy-equipment example fails because this would be more like when the beeper is ALWAYS on, or is ALWAYS on when backing up regardless of whether there are people behind him or not. (Although the beeper is more intended to warn those other people to keep clear; an option not usually available to hospital patients.) Or, for that matter, maybe more like the flashing warning light that is ALWAYS on, to warn people around the equipment, it’s not really meant to “warn” the operator.
They are also, presumably, trained to make life-or-death decisions on a daily basis. If I kill a man while attempting to perform CPR, I would expect a more lenient treatment than an EMT making the same mistake.
I get your point, and perhaps “beeper” was a bad example. Suppose a warning flashes, but the operator gets lots of warnings and so ignores it this time.
The point is, do we accept negligence that results in death more readily in a health care context than we do elsewhere and, if so, should we?
I understand that there’s a lot of ambiguity in health care, and so malpractice insurance and civil penalties make sense. But is it possible that we’re too inclined to write off true negligence as simply one of those unfortunate accidents that might befall any medical practitioner?
No. See my other post. When it is particularly blatantly criminal, people get charged. This was not one of those cases.
This, on the other hand, is. Except that this LVN received a temporary suspension and probation for lying, repeatedly and for intentionally neglecting her patient who was at high risk.
Again, there are lots of cases. You can just google “nurse charged with homicide” or “negligence” or whatever your delight is and restrict the dates to before the Redonda Vaught case. You will see plenty of cases. Then, you can google physicians, pharmacists, surgeons.
I think you are more disappointed and upset that there are as many medical errors as there are. I also think that, for whatever reason, you seem to think that nurses (and me in particular) see ourselves as entirely separate from other humans and beyond reproach. You seem to think that they unfairly bemoan their jobs, their treatment, and that they are given entirely too much free reign to do the sorts of things you would never do.
The thing is, we’re also asked to do the sorts of things that you would never do. We’re demanded, by our job descriptions, to do the sorts of things that many, many people would never do. While we are forgiving of distractions and true mistakes (especially when nurses admit it and come forward immediately), nurses also are some of the hardest on other nurses. It may not be something that you are privy to, but on a regular basis there are small mistakes, errors, delays, etc. that happen in the hospital. Nurses regularly comment on it to one another and will take one another to task for it. That may mean discipline through the hospital, through the board, or very rarely legal repercussions. We are understanding and very kind, but this means that the opposite is also true: real negligence, real criminality is shunned in ways that you wouldn’t believe. Even if found “innocent” of criminal charges, many of these nurses will never work again, even if they do maintain a license. Reputation is strong and no one trusts a nurse that is that off their game. Nurses are quietly isolated and exiled from the medical professions.
The biggest problem is that you cannot compare circumstances of nurses to almost any other profession without it being apples to oranges. People driving is not the same. People moving heavy machinery is not the same. You could compare doctors to nurses, however doctors generally lawyer up far, far sooner than any nurse would, so it isn’t even exactly the same situation with the same level or authority, exposure, or opportunity.
At the end of the day, nursing is a unique profession. This case has and will continue to make nurses second guess their careers.
If you’re attempting to perform CPR it’s more a case of they’re going to die anyway, so you might as well try it and if it doesn’t work, well that happens.
I’m pretty sure the point was made before, but a lot of those warnings happen even if you’re doing the right thing. Here’s one: my car has a backup camera on it. When I back out of my parking space in the morning, sometimes I get a warning because the parking lot is a little wonky. Sometimes I check it, sometimes I don’t. If anything there are probably too many warnings and it makes people complacent.
Yes, I think nurses are in a fairly unique position. They are like nurses taking care of helpless infants, people in their most vulnerable state who don’t know what’s going on, in an often hectic environment. No patient draws up his own medicines or knows what the nurse is doing when she draws them up. People can’t monitor their own vital signs, or do their own dressing changes. Often people can’t even turn themselves over in bed. Every patient has to trust his nurse, especially when taking medicines.
And what nurses do more than any other business, and with far more individuals, involves potential for life and death.
And yet, now hospitals are being run as for-profit business, with an emphasis on productivity, on what can be called shoe-string staffing, rather than as the essentially altruistic profession that it once started as.
I think the anonymous complaint to CMS may be because of what you wrote here. Not knowing anything else about her before this incident, she may have been “sloppy” in her work before. I don’t know. Just a guess. The other reason could have been because “anonymous” saw no changes were being made at the hospital and erroneously thought this would get that started. HAHA! Don’t make me laugh. Someone in our ER did that several years ago regarding a mental health patient. It only resulted in lots of surprise visits from CMS, JC, and DHHS to the entire hospital and “new and improved” restraint learning modules and classes. No changes in safety standards for the ER staff.
The point at which we become punitive on medical errors is the point at which they get hidden.
The same thing applies in aviation.
I guess wrath is more important than safer medicine and safer hospitals.
Med errors happen. They will continue to happen. We must analyze them to understand why and change systems to decrease them.
I would like to point out, yet again, that nurses are not choosing that.
Nurses are pushing for national ratio laws because of this. I would prefer for each state to perform altruistically and fix the situation, but they won’t. It is beyond dangerous.
One nurse for 4 cardiac telemetry patients in California (which has laws).
Other states? It could be 5, 6, 7 or more. I heard from one nurse I worked with that she used to take care of 8 or 9 telemetry patients at a time. That’s terrifying. Particularly if they are “real” tele patients; ones with known heart arrhythmias or are currently in one or have had an MI or stroke. We’re spoiled in CA in that regard. But even so, the patients are far, far sicker than they were 5 years ago or 10 years ago. Heck, 10 years ago, 4 tele patients was often a breeze.
Now, each patient has 10-20 individual 8 or 9 am medications, half are IV administration (scheduled at the same time, natch) or IV piggyback, patients are often on a cardiac or pain drip. They often have medications every 2-4 hours and blood sugar checks (because many are diabetic OR on TPN OR have a G-tube feed).
I cannot imagine the kind of breaking strain other nurses are in.
I was thinking about that too.
Given how many “witnesses” were listed in the report, however, it did feel like it might be personal. Heck, it could have been both. But the nurse was already fired, so listing her in the report was not entirely useful at that point (if the goal was hospital changes), but it would necessitate a review of that nurse’s license.
As demonstrated by other commenters, people who are not in the business of healthcare do not seem to know how ubiquitous they are. They have this idea that if you strictly punish the offenders, that people will somehow….be superhuman, I guess? Mistakes are often made through simple human error. That is why we have the technology.
Do you know how many errors I have reported in our root cause analysis system?
We had a pyxis that, for a number of months, was dispensing a medication that was *not* what was listed on the screen. On the screen, it described the same drug, but a much, much lower dose. If the nurse wasn’t being extra careful (and most weren’t, because I was the only one to catch it, multiple times), they would have read the drug name, the size of the vial, glanced at the vial, confirmed the name, and closed the pyxis.
That’s an error. Luckily, the drug wasn’t likely to kill someone if given too high of a dose.
But it was an error on many parts. People do not want to think that there are so many errors going on. Given how many things constitute an “error”, they happen all the time! But we can’t punish our way out of human limitations. It just won’t happen. We can punish our way out of compassion, understanding, and humane treatment of one another. If we do, there will be no nurses.
For the record: my point was that even you were distracted, typed it incorrectly twice, corrected it once, but still wrote the wrong word. This was when you were actively typing, something you have to actually think about when spelling an unknown word.
If you can get it wrong that easily and multiple times when you have no pressures, all the time in the world, and no one else depending on you, I’m surprised that you can’t understand how simple it would be to make a similar mistake in the real world in another job.
I’m sure you’d be a perfectly conscientious nurse. You’d follow every rule and do everything right because you would constantly be thinking about how you might kill someone. But if you did, you wouldn’t last more than one year. This constant fear would slow you down to the point of killing someone else and you would be fired for your inaction.
Yes, a lot of people assume that the “input” to such situations is perfect too, because a “machine” is doing it… overlooking or ignoring the many ways the “machine” can also be wrong: incorrectly programmed, incorrectly filled/loaded…
I was over more than one unit with nurses. I had to sign off every Med Error. Most were cat 1 or 2 . Sometimes…
Well, apparently not. You can violate building laws to such a degree that your warehouse goes up in flames… but whatever. No hail. Barely fined.
https://news.yahoo.com/no-jail-la-building-owner-001904012.html
(Content: The owner of a downtown Los Angeles building where an explosion injured 12 firefighters)
Yes, there are a lot of examples of people “getting away with things,” when perhaps they shouldn’t. We can probably find examples of it in virtually every field. That was kind of the point of my question about malpractice being seen as a disciplinary and sometimes civil tort issue. How often should we be holding people criminally liable?
I’m not claiming to know the answer, or even to have a strong opinion about it. I’m just thinking about it.