After reading this thread (and the report) I can't help thinking if this will finally be the case where the role of 'Accountable Manager' is put under the spotlight.
None of the replies in this post consider management oversight / responsibility or the contribution of a sound and constantly applied Quality Management System may have had in preventing this incident happening in the first place.
The report should help those who ask the question 'what is the cost of quality'......... more importantly the report (and unfortunately the incident) in my view identify the cost of not having quality.
I hope the bean counters and ladder climbers of the world take note and that the court fully understand the deffinition of 'Accountable Manager' and do the right thing.... if it has the teeth that is.