[JshWright]

I am neutral on the idea of criminal prosecution here (for the individual, I absolutely thing there should be accountability for the organization). I am generally opposed to criminal prosecution for medical errors, but it's hard to overstate how outlier this series of mistakes was in terms of the severity of the outcome and the degree of negligence demonstrated.

I think the question of "should we put this person in prison for these actions" is equivalent to any other criminal act (which isn't a clear cut answer either, in my opinion).