Gunma University Hospital's final report on the deaths of eight patients following laparoscopic liver surgery gives an appalling picture of what happened at the institution. It brings to light the lack of common sense and professionalism on the part of the hospital, the surgeon and his boss to ensure the safety of their patients. Yet the report comes up short: Investigators apparently failed to interview the surgeon and his superior sufficiently on why such a mess continued. The hospital should delve into questions left unanswered.

The report issued in early March focused on laparoscopic liver operations that the surgeon performed from 2010 to 2014 on the eight patients, who died within two weeks to four months after their operations.

It concludes that in each of the operations, the surgeon was negligent. The most problematic behavior was his failure to determine the size of the patient's liver before operating and decide the maximum portion of the liver that could be excised. This is an indispensable procedure before such operations.