It is unrealistic to expect an organisation with 67,000 direct employees, and a further 35,000 people employed by agencies that organisation funds, to be error free.
An organisation like the HSE involving more than 100,000 people is bound to make mistakes but it is defined by how it responds to those mistakes, by how it learns from them.
The scandal surrounding Vicky Phelan, who was given incorrect cancer test results and is terminally ill, points to an inability to learn that must condemn the process that failed her.
That there may be others in her position confirms that. That Health Minister Simon Harris does not have confidence in the management of the CervicalCheck programme also and sadly confirms that.
That this discourse, if not its exact details, seems all too familiar adds to the sadness that undermines the faith any of us can have in the integrity of our health system.
The HSE has expressed its regret at Ms Phelan’s situation, just as it did the last time, the time before that and as it probably will the next time someone’s life is put in jeopardy by its failings.
This is an endless spiral without any real consequences. Surely, if this cycle of failure, sometimes lethal failure, is to be broken then persuasive sanctions must become the norm.
It is hard not to think that there would be fewer of these mistakes if HSE workers or agents faced the prospect of being sacked if they make such catastrophic errors.