The case of Nicola Tweedy on today’s front page is first and foremost a terrible tragedy for her family and friends.
It is understood that surgery carries risk, but what patients should expect is that all agreed measures to mitigate that risk are followed as diligently as possible.
As South Norfolk MP Richard Bacon said in his statement, patients and families of patients should expect that hospitals are open and transparent in the way they have performed.
It is clear from the facts of the case that various professionals caring for Mrs Tweedy did not follow procedures as robustly as they should have.
The Norfolk and Norwich University Hospital’s statement after the case was that they will review the coroner’s recommendations for “further opportunities for improvement.”
It seems quite clear that improvements can be made.
Patients want to be reassured that steps to mitigate risks amount to more than just a ‘box-ticking exercise’.
The hospital has fine people working in very tough jobs, with unique pressures.
But it must be prepared to be honest about the times when standards fall short.