They must all be held accountable.
IT goes without saying that the Welsh NHS is a massive organisation dealing with many thousands of patients every single day. In a typical month the Welsh Ambulance Service responds to 40,000 emergency calls, A&E departments deal with 90,000 patients and hospitals contend with more than 100,000 outpatient appointments.
The vast majority of these patient interactions are positive and will lead to a satisfactory outcome - but inevitably errors are going to occur. According to latest figures from the Welsh Government, 77 patients died between June 2018 and May 2019 as a direct result of mistakes in our health service.
Similarly, over the same period 372 patients suffered "severe" harm, while a further 8,463 experienced "moderate" harm.
By our calculations, it means that six moderate, severe or fatal incidents are occurring in the Welsh NHS every day due to these blunders - a frightening thought to say the least.
It must also be noted that these figures could be substantially higher as staff currently record these serious incidents on the National Reporting and Learning System (NRLS) voluntarily.
According to the experts, there are a myriad of reasons why such mistakes are being made - but there are one or two which will come as no surprise to most.
The Royal College of Nursing in Wales says a shortage of staff on duty, along with their excessive workload, is contributing to patient harm.
A greater influx of patients coming through the system with complex chronic conditions is also going to put a severe strain on the NHS system as a whole.
We are all human. No matter how skilled a person is at their job, no matter how experienced they are in their roles, errors are inevitable.
However, there is plenty health boards and trusts can do to ensure they learn from these mistakes and put procedures in place to improve. Sadly, these incidents currently show no sign of decreasing in frequency.
When a doctor makes an error or brings the profession into disrepute they are held accountable by the General Medical Council (GMC).
However, this is not the case for senior managers in Wales or elsewhere in the UK.
Following on from the Cwm Taf maternity scandal, in which dozens of babies died, this surely needs to be changed.