Thе Tоpіс is the pathology of negligenсe inquiry and this is the article related to the inquiry
I need you to write a summary for this article and follow the instructions below
The 2000 +/- 10% word summary must contain
a. An introduction
b. A summary of key information
c. Information about the issues as below
d. A conclusion
e. References

The chosen inquiry need to address the

following issues:

What happened? How it happened?

Who was involved?
Why did it go undetected for the period of time ?
What recommendations were made?
Revisit literature to find out if any comments made about the implications of the recommendations, Examine issues for example
Has it occurred anywhere else?

What group(s) of professionals were involved? Who discovered the problem?

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