They are usually the result of a confluence of failures — poor training, poor communication, poor technology and a lack of vision.

In many hospitals, doctors cannot find nurses to accompany them on their ward rounds, which as good as guarantees poor communication and lapses of care.

Poor communication and a failure to speak to families was also slammed by experts.

Researchers believe that withdrawal was most often used as a way to avoid dealing with criticism, which led to poor communication and poor relationships.

Bad process, poor communication, institutional self-protection, isn't merely fodder for some government report that will never be read.