With Savita Halappanavar's death, we have an example of the term 'system failure' being offered as a distraction from consideration of the source of the problem.
This is not the first time this phrase has been trotted out in inquiries about adverse events in healthcare systems.
In the effort of bending over backwards in case we apportion blame to anyone, we subvert the English language.
In my lexicon, a 'system failure' might involve some machine part breaking, or wearing out, thus causing the whole apparatus to stop working.
The phrase would cover situations where there is no direct or immediate human agency.
If a patient's vital signs are not being checked when the rules say they should be, there are human beings to answer for it.
In all walks of life, people make mistakes all the time – it is part of the human condition.
It will not help anybody to avoid such mistakes in future by being able to shift responsibility on to some system for which, it appears, nobody is deemed responsible.