One box of chemicals mistaken for another. Ingredients intended to be life-sustaining are instead life-taking. Families in shock, healthcare providers reeling and fingers starting to point. A large healthcare system’s reputation hangs in the balance while decisions need to be made, quickly. More questions than answers. People have to be held accountable – does this mean they get fired? Should the media and therefore the public be informed? What are family members and the providers involved feeling? When the dust settles, will remaining patients be more safe or less safe? In this provocative true story of tragedy, the authors recount the journey travelled and what was learned by, at the time, Canada’s largest fully integrated health region. They weave this story together with the theory about why things fall apart and how to put them back together again. Building on the writings and wisdom of James Reason and other experts, the book explores new ways of thinking about Just Culture, and what this would mean for patients and family members, in addition to healthcare providers. With afterwords by two of the major players in this story, the authors make a compelling case that Just Culture is as much about fairness and healing as it is about supporting a safety culture.

In this new mystery Inspector Chard is confronted with another murder in bustling Victorian Pontypridd. On the face of it the case appears unremarkable, even if it isn't obviously solvable, but following new leads takes Chard into unexpected places. A second murder, a sexual predator, industrial espionage and a mining disaster crowd into the investigation, baffling the Inspector and his colleagues and putting his own life at risk as the murderer attempts to avoid capture. Once again Leslie Scase takes the reader back to a time and place where, despite the pretensions of Victorian society, life is cheap and passions strong. His research brings Pontypridd vividly to life, and historical events drive along the plot of this page-turning story of detection, as Chard navigates a way through the clues and red herrings, and a lengthening list of suspects, towards the poisoner. Atmospheric, authentic, Chard and the reader are left guessing until the final page.