Following a medication error that led to the death of a patient, the nurse who administered the medication was sacked. Following an investigation by the Department of Health, no action was taken against the nurse or the hospital. However, following an anonymous complaint, another investigation found deficiencies in hospital systems and also led to the nurse being charged with criminal homicide. No disciplinary action was taken against the hospital, but the nurse was found guilty of criminally negligent homicide. This article examines the series of events and comments on the impact of this case on the health profession and patient safety.