I have just watched Chernobyl. You have just described the mini-medical equivalent. Oh and not a dig at Oor NHS. It will happen all over.Health has an unfortunate habit of trying to conceal mishaps. Individuals and organisations denying responsibility which make such investigations far more complex.
And this is at every level.
The old lessons learned is complete BS. We just don't share information if something goes wrong.
An example, a colleague had a patient who had an allergic reaction in the surgery. That can happen, it's a known risk and due to no fault of the dental team. What happened next however we never have found out except that it was "The most horrible and stressful time" they had ever had as they dealt with the medical emergency. Patient survived but no one has been told what went wrong so that we can avoid the same thing. No changes made to our protocols.
In another instance a different colleague was trying a new sedation technique on a patient, not overly successful so reverted to a more traditional approach however due to not factoring in the drugs given in the first attempt, ended up overdosing the patient and reversal agents being used. If it was not for a chatty nurse, no one would know and could make the same error.
I have reported my own errors up the chain and seen them go nowhere when they could be useful learning points.