It's an interesting read. I guess the difference between this situation and the ideal case is that he would have been admitted for observation as a precaution in a world where there was plenty of room and staff to take care of even the less obvious emergency cases.

Even in a very well functioning system similar cases might happen eventually, anyway (but at a much lower frequency). ROC plots come to mind.

https://en.wikipedia.org/wiki/Receiver_operating_characteris...