A devastating hospital mistake in Glasgow was described as “human error,” even as leaders acknowledged that “very rigorous processes” were not followed.
In this Mistake of the Week, I examine why suspensions and discipline don’t guarantee improvement — and what leaders must fix in the system if they want to prevent the same harm from happening again.
Listen:
Check out all episodes on the My Favorite Mistake main page.
This week’s Mistake of the Week comes from healthcare in Glasgow, Scotland — and it’s a tragedy that cannot be undone.
Two families gathered to say goodbye to loved ones. One attended a cremation. The other prepared for a burial. Only afterward did the hospital discover that the bodies had been mislabeled and the wrong remains had been released. By the time the mistake was identified, one body had already been cremated.
Hospital leaders apologized publicly. Scott Davidson, medical director of NHS Greater Glasgow and Clyde, said the hospital has “very rigorous processes” for identifying and releasing bodies — and acknowledged that those processes “have not been adhered to on this occasion.” The incident was described as “human error,” staff were suspended, and an investigation was launched.
Those actions may feel like accountability — but they don’t guarantee improvement.
In this episode, Mark Graban examines why punishment and discipline don’t prevent recurrence if the underlying system remains unchanged. When procedures exist but aren’t followed, it often signals a gap between how work is designed and how it actually happens under real conditions.
This episode explores:
- Why labeling events as “human error” often stops learning too soon
- How suspensions and punishment can create the illusion of safety without reducing risk
- Why workarounds usually exist long before a catastrophic outcome
- What leaders must redesign if they truly want to prevent harm
Removing people does not remove problems.
Only fixing the work does.
Some mistakes don’t offer closure.
They offer responsibility — to redesign systems, surface problems earlier, and make it safe for people to speak up before tragedy occurs.
Subscribe, Follow, Support, Rate, and Review!
Please follow, rate, and review via Apple Podcasts, Podchaser, or your favorite app—that helps others find this content, and you'll be sure to get future episodes as they are released.
Don't miss an episode! You can sign up to receive new episodes via email.
This podcast is part of the Lean Communicators network.
Other Ways to Subscribe or Follow — Apps & Email
Mistake of the Week: Releasing the Wrong Body Is Never Just “Human Error”
Hi, I’m Mark Graban — from My Favorite Mistake.
This week’s mistake comes from healthcare in Glasgow, Scotland.
It’s a story that’s painful to hear.
Two families gathered to say goodbye to loved ones — one at a cremation, the other at a burial.
Only afterward did Queen Elizabeth University Hospital discover the truth.
The bodies had been mislabeled.
The wrong remains were released to each family.
And by the time anyone realized what had happened, one body had already been cremated.
There was no way to undo the harm.
Hospital leaders apologized publicly.
Scott Davidson, the medical director of NHS Greater Glasgow and Clyde, said the hospital has “very rigorous processes” for identifying and labeling bodies — from arrival in the mortuary until release to funeral directors.
And then he acknowledged something just as important.
He said those processes “have not been adhered to on this occasion.”
That statement matters.
Because when leaders say, “We have very rigorous processes,” and also say, “Those processes were not followed,” they’re describing more than a single mistake.
They’re describing a gap between how work is imagined and how work actually happens.
The hospital also described the incident as the result of “human error.”
Staff involved were suspended.
A full investigation was launched.
Those actions may feel decisive.
But they do not guarantee improvement.
Suspending or firing people after a tragedy does not fix the conditions that made the mistake possible. If nothing else changes, the same risk remains — even if different people are doing the work next time.
And it’s important to say this plainly:
When mistakes like this happen, it’s almost never the first time procedures weren’t followed.
Steps have likely been skipped before.
Workarounds have crept in.
People have quietly adapted the process to get the work done.
And often, leaders don’t hear about those adaptations until something catastrophic happens.
No one comes to work in a hospital mortuary intending to misidentify a body and devastate two families.
But people do work under pressure.
They get busy.
They get interrupted.
They face competing demands.
And unless leaders create real psychological safety, people don’t always feel able to say things like:
“We’re too busy to follow all of these steps.”
“This process doesn’t work the way it’s written.”
“I’m not confident this handoff always catches errors.”
When those conversations aren’t safe — or welcomed — procedures slowly become aspirational instead of real.
That’s why punishment can actually make things worse.
When people see colleagues suspended after an error, the lesson isn’t “follow procedures better.”
The lesson is “don’t speak up when something feels risky.”
So when leaders ask the familiar question —
“What can we do about human error?” —
that question shouldn’t end the discussion.
It should start it.
Because real improvement comes from designing systems that make it easy to do the right thing — and hard to do the wrong thing.
That means building in verification steps that can’t be skipped.
Reducing reliance on memory and vigilance.
Designing labels, handoffs, and checks so errors are caught early — or not possible at all.
Accountability matters.
But accountability without system change only creates the illusion of safety.
Removing people does not remove problems.
Only fixing the work does.
Some mistakes don’t offer closure.
They offer responsibility — to redesign systems, to surface problems earlier, and to make it safe for people to say, “This doesn’t work the way you think it does.”
I’m Mark Graban.
And this has been The Mistake of the Week — one that reminds leaders everywhere that punishment is not prevention, and that improvement begins with fixing systems, not blaming people.