In the aftermath, we should perhaps beware that hindsight does not render us self-righteous in our indignant pursuit of those people who failed to foresee or prevent these dreadful events.
This crime was so rare, bizarre and awful as to be almost beyond the imaginings of any sane mind. The hospital management that did not make provision for such a crime should at least be entitled to a little sympathy from us all.
That having been said, however, there appear to have been major failures in management that need to be investigated publicly, particularly the lack of communication between various hospital staff. In recent years it has become increasingly common for hospitals to impose contracts of employment on clinical staff that forbid the unauthorised transmission of information on pain of disciplinary action or dismissal. Doctors and nurses are thus unable either to express proper criticism or voice their fears of mismanagement or inappropriate patient care.
This muzzling of even senior medical staff goes far beyond the normal professional rules of patient confidentiality. It would seem likely that such regulations, designed for the convenience of hospital management, are liable to produce just the failures of communication that have so tragically dogged these events. Only a public inquiry where witnesses are compelled to divulge facts even in breach of their contract with management will enable a full assessment of these failures to be made.
Anything less than a public inquiry would, however assiduously undertaken, leave staff, parents and the public at large deeply mistrustful of the outcome.