It's been shown on numerous occasions that when there is a disaster in the way a patient is treated it's almost never due to a single failing in the system. It's usually a series of errors and deficiencies that add up to the disaster, which could have been averted if just one step on the pathway had been rectified. If you are one of those who watches TV programmes about aircraft crashes you will be familiar with a similar phenomenon at work here.
Something similar has recently happened in the world of architecture. Here you have a building that was designed presumably by a team of architects. They will have submitted their design to their clients for approval. The design will have been examined by civil engineers, planners, building constuctors etc, scores, perhaps hundreds of people. Why did no-one say anything? Did they not notice?
What a cock up!