Just Culture, 2nd Edition

Preface

Keith Ramstead was a British cardiothoracic surgeon who moved to New Zealand. There, three patients died during or immediately after his operations, and he was charged with manslaughter.¹ Not long before, a professional college had pointed to serious deficiencies in the surgeon's work and found that seven of his cases had been managed incompetently. The report found its way to the police, who subsequently investigated the cases. This in turn led to the criminal prosecution against Ramstead.

From Acts of God to Culpable Mismanagement of Risk

We have not always looked at three dead patients as evidence of a possible crime, or as any form of reprehensible behavior. Turning to human error as explanation for an accident, and making it into ...