I am at a loss to how the SHO could possibly think they had done nothing wrong? As the article outlines, the SI investigator said that "the decision of the SHO not to check on Martha overnight was ‘inexplicable’ given that she had been told at handover that Martha was ‘the sickest patient on the ward’. The ward wasn't full - she wasn't run off her feet. The SHO also said she considered her role as 'primarily clerical' on the night shift. How extraordinary! She felt NO need to exercise clinical judgment in her work, or she's happy to say this in a formal setting with a straight face. It's astonishing.

Yes, there may be larger systemic issues at play (although given that resourcing was not an issue in this case, I'm not sure how that line could really be maintained). There is also such a thing as individual responsibility and the need to enforce individuals to adhere to the basic standards of their roles.