Another damning report - will anyone be accountable?
It is always distressing to see patients being shockingly let down. But too often a death or injury is investigated in isolation and the wider underlying causes and contributory factors are not fully explored.
The investigation into the standards of care at Portlaoise Hospital promises to not just look at the maternity unit where five babies died in similar circumstances, but at its entire services and how it was run from the top down.
It will also be unique in that the Health Information and Quality Authority (Hiqa) has widened the net of responsibility to HSE corporate level and in the strongest terms castigates the failure of senior executives to act decisively to reduce the risk to patients.