NL, whilst my flyer's head agrees absolutely with your sentiments regarding tool control, I find my lawyer's head shaking at certain of the deductions you make from the AAIB findings of fact - nuff said.
As for rank / titles etc. recently at my daughter's pre-op bedside. all who had been in attendance were a model of polite proffesionalism until..... an utterly arrogant "fellow" pushed aside the curtains and without a by your leave (and without consulting coleagues, or notes where all was recorded) launched into a rather nasty interrogation regarding her asthma inhaler on the bedside.
After taking a deep breath I found that " And you are ?",
was sufficient to deflate the arrogance and obtain a more reasonable conversation with Mr P...l (consultant anaesthetist). I have nothing but regard and respect for the operating surgeon and all in his team, save for the "don't you know who I am" attitude of that man.
As for VSO's, NL clearly caught a bad one, or at least one on a bad day. Happy to report that my experiences have been much more as they should be.