It should have triggered an immediate patient safety investigation but the hospital was at first reluctant to admit fault.

The carmakers said they had settled given 'the scope of the recall' but did not admit fault or liability.

Companies which send stand-ardised letters in reply to a specific inquiry get short shrift in the report, as do companies that refuse to admit fault.

At least he had the sense to admit fault.

Among the charges was a claim that she had undermined the medical director's judgment when she attempted to ensure that the hospital admitted fault over two clinical errors.