Editor's blog Thursday 11 November 2010: Oh no. Not again.
The Guardian reports that twin children have been killed by a serious untoward incident - it would appear, by a clinical error in rate of medication dosage - at Mid-Staffordshire NHS Foundation Trust.
Oh no. Not again.
A culture of learning from error - and patient safety - seems to be as far away as ever.
UPDATE: A Press Association report today suggests that the babies may have died from prematurity.
The Guardian also carries a report from the police that states, "preliminary results suggest that the twins died because of their prematurity rather than as a direct result of any medical treatment."".
So the infusion error - assuming that is what it was - may not have been to blame.