Looking for heads to roll isn’t productive IMO, it’ll just end with scapegoats. I’m more interested in systemic changes to keep this from happening again. Although I do think it would be worthwhile to see if anyone tried to cover this up.
Rolling heads are effective deterrents. People should be really afraid of such a bug hapening in their system.
Look at the safety culture amongst pilots vs doctors for an example.
Perhaps if doctors were held so directly accountable, there would be fewer incidents of medical malpractice.
What do you mean by "directly accountable"? Doctors do get sued for malpractice regularly and that sounds pretty direct. Also how do you define an "incident of malpractice"? Many lawsuits are entirely frivolous so the definition cannot be initiated lawsuits. Also the lawsuits can be very expensive and representationally damaging, so the definition can't even be lawsuits that ended in settlements (since that can make sense regardless of validity). So frankly the situation seems much more complicated to even measure than many let on.
Ignoring that those issues, if doctors were held to higher account for the mistakes they make, you probably would expect some drop in malpractice (however you measure it). However you should also expect fewer doctors to do risky procedures. The overall result would not necessarily clearly be a net win for society even if malpractice were to drop. Incentives are complicated.
But criminal charges? Maybe if people were getting killed over it. Otherwise it's just a civil matter.
Edit: fat fingers
But consider medical malpractice. Even when a surgeon screws up, and the patient is disabled for life, there are rarely criminal charges. And this is lots more indefinite than that. I mean, you're going to put some employee in jail because they screwed up paperwork?
We put people in jail for drinking too much when that leads to bad consequences, why not for sloppy paperwork that get someone falsely imprisoned or killed?