Immediately was reminded of another case of a grossly negligent surgeon, Christopher Duntsch: https://en.wikipedia.org/wiki/Christopher_Duntsch

I'm sure I and many other concerned patients and potential-patients are asking; how does something like this even occur? What institutional failures in medicine led to two grossly negligent and incompetent surgeons being given the controls to peoples' lives? What safeguards were neglected at the academic and organisational layers, and what are we doing so that this does not occur again? If institutions are doing their job, no case like this should ever get to the point where a prosecutor needs to stop and clean things up, much less to the first maiming of a patient.