Knee Surgery Disaster at UCI Medical

This story is blowing my mind and I really wanted to hear some other takes on what went down from professionals. It reads like the Dr. was trying to CHA but could it have been all accidental? There seems like there were failures at multiple levels to follow up on obvious assessment findings and the spouse being an ICU nurse begging staff to do something is heartbreaking. What do you all think? Do the nurses involved also bear some blame? What could they have done if the Dr. was actively blocking treatment? This case is really bothering me. I’m not sure what kind of justice can even be done in this situation.