The mindset within government and among civil servants needs to shift toward greater transparency and accountability to move beyond performative responses to crises.

“it's the mindset that has to change because there's not much incentive is it for the government to announce an investigation into itself ever”

The historical governmental and clinical response to the scandal involved a systemic failure characterized by incompetence, cover-ups, and a lack of accountability.

“and there was the most colossal combination of arrogance cover up incompetence and insults to these people”