After the tragic death of a six-year-old child, Jack Adcock, a doctor and nurse have been removed from their professional registers and given two-year suspended prison sentences for manslaughter.
Fear and fury have engulfed health workers following the court's decision. 'It could have been me,' is the feeling of over-stretched staff everywhere, caring for patients with inadequate resources.
Jack's grieving family suffered a terrible loss. They have rightly demanded explanations and justice. But the criminals - successive government ministers starving the NHS of resources - have walked away from the scene. They are the ones who should be held responsible for the predictable consequences of their policies.
Jack's death exposed many failings at Leicester Royal Infirmary in 2011. Born with a heart condition, he had had successful surgery when younger. The Children's Congenital Heart Centre at nearby Glenfield Hospital was already under threat of closure that year. He was brought to hospital with a chest infection. Several mistakes, including drug administration later that day, resulted in a catastrophic blood pressure fall.
The most senior children's doctor on duty, Hadiza Bawa-Garba, had a previously unblemished record. She had just re-started work after 13 months maternity leave, in a new hospital but with no induction in the hospital procedures. That day was her first back in an acute setting. She was looking after six wards, spanning four floors, undertaking paediatric input to two surgical wards, giving advice to midwives and taking GP calls.
She was covering the Children's Assessment Unit as well as her wards. The colleague normally doing this was on a training day. The senior consultant was teaching in Warwick. Two other junior doctors had started paediatrics less than three weeks earlier.
The hospital's IT system failed so one junior spent the afternoon constantly phoning for test results. Dr Bawa-Garba was effectively doing the work of three doctors throughout the day - and four that afternoon. She had been working non-stop for over 12 hours when Jack died.
There was a shortage of nurses too. Jack's nurse, Isabel Amaro, was qualified in adult nursing, brought to the Children's Assessment Unit through an agency.
An investigation team concluded a single cause for Jack's death could not be identified. 79 actions were undertaken by the hospital as a result of their report.
Dr. Bawa-Garba and nurse Amaro have taken the blame for system failures.
Among many shocking aspects of this tragedy was the use of Dr Bawa-Garba's reflective learning journal as evidence against her. All health workers are expected to learn from mistakes and incidents. If health workers are to be criminalised for honestly trying to learn from these, they will think hard about concealing them, making patient care less safe.
Any health worker who feels staffing levels are unsafe should have the right to demand managers bring in extra staff within an hour. But it mustn't be left to individuals.
And many know of the case of Dr Chris Day, a junior doctor who blew the whistle on unsafe staffing levels of his intensive care unit in 2014 and had his training stopped by Health Education England, effectively blacklisting him since then.
The choice between working understaffed leading to criminal charges and the end of a professional career if someone dies - or blowing the whistle and being unable to find further work - is no choice at all.
All health trade unions should now organise workplace meetings, linking safe working to the need for decent pay to help retain staff and student bursaries to help recruitment. These meetings should build to an urgent national trade union-led demonstration, followed by national industrial action, both within the NHS and by the whole trade union movement, if the NHS remains under-funded to meet patient and staff safety.
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