Carter was fielding calls from various people to let him know that the system he oversaw had boiled someone alive. The nurses were devastated, but to Carter’s way of thinking they were victims, too. The environment in which they worked, and which they had been encouraged to trust, had failed them. “When you go into the details of the cases, you see it’s not bad people,” he said. “It’s bad systems. When the systems depend on human vigilance, they will fail.”
