A follow-up investigation of the Cornelia Rau incident, where a mentally ill Australian woman was held in detention centers for 10 months while German and Australian governments determined her fate, reveled a lot of ‘no duh’ verdicts such as ‘we screwed up’. Yes, this is the same government that deported an Australian woman to her country of birth, but not citzenship.
Here’s the summary, if you don’t want to read the whole thing:
Processes failed. It was not a failure of instructions … the instructions were not followed. It was a serious failure of management process and corporate oversight.
Everyone saw themselves as “only a bit player”; no one was managing the process. The defined clinical pathways did not work effectively. The “system” failed Cornelia Rau.The mental health care delivered at Baxter is inadequate by any standards.
A culture that ignores criticism and is unduly defensive, process motivated and unwilling to question itself.Reform must come from the top. Executive management must demonstrate consistent commitment to establishing new values and perspectives. These will guide the new way of doing business.
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