Sitting across from them was unexpectedly difficult.

They looked exhausted and anxious, like people who had replayed an awful night a thousand times.

The director began by acknowledging that the procedures meant to establish and independently confirm a death had not functioned as required.

There was no attempt to dress those words up.

The internal review had identified gaps in handoffs, escalation, and verification, and an outside review was still assessing the full sequence.

Nobody presented a dramatic explanation that made everything simple.