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Toolkit:Safety and Justice/Consequences 7/Outbreak
In a special report, the Healthcare Inspectorate in the Netherlands said: "Especially the medical microbiologists have a heavy responsibility to ensure effective infection prevention and intervene when necessary. The Inspectorate found that they did not act as expected […]. All medical microbiologists were aware of the Klebsiella outbreak but did not respond adequately to the increasing number of infected patients. They neglected to take action which should have been their responsibility and sought insufficient help from above and from outside."
This can be seen as a deliberate violation of a rule: the rule was clear, people did not think it was necessary to act.