There had been significant errors in the hospital's "systems and procedures", as the patient had not been properly supervised, training of staff was inadequate, information had not been passed on correctly, and warnings had not been heeded.
職員の訓練が不十分で患者は適切に管理されず、情報が正しく伝達されず、そして警告が留意されていなかったというように、病院の「システムと処置」に重大な誤りがあった。