It's also why the government is showing every sign of being serious about a total overhaul to protect patients from harm.

Incredibly, Health Minister Jill Hennessy has already moved to replace her own health department as the safety and quality watchdog of hospitals, a job the department had failed to do for many years, a damning report has confirmed.

In its place, there will be a handful of new safeguards, new organisations with specific jobs that include monitoring and improving quality and safety, data collection and transparency and oversight of hospital boards.

A cluster of seven likely preventable deaths occurred at Djerriwarrh Health Service between 2013 and 2014, many of which had involved common and recurring deficiencies, but the alarm was not raised until 2015.

A subsequent review would later identify another four deaths dating back to 2001, suggesting issues had existed within the maternity ward for a long time.

Now an independent probe, headed by health services expert Stephen Duckett, has slammed the department for failure to adequately oversee health services, an issue that had been first identified more than a decade ago.

The pace of the government's response to the Duckett review - this person to be appointed by January, that law to be changed next year - suggests that while the failure to watch over Victoria's hospitals is not new, this time there could be real action to fix it.

Potentially avoidable perinatal deaths at the Bacchus Marsh Hospital from 2001 and 2014 should have set off alarms within the department earlier.

At least three official reports in a decade had identified issues with the department's oversight of safety and quality.

And the Duckett review now provides a powerful insight into how and why this important role was quietly shifted to individual hospital boards and away from public scrutiny.

It happened because budgets were cut over many years, because the jobs with the responsibility for quality control for our health system were stripped back and outsourced to contractors.

These holes in accountability suggest there could be other problems in other hospitals, not just Bacchus Marsh. Who knows what errors have been missed elsewhere?

It suggests lifesaving lessons have gone unlearned.

Research shows about 1 in 10 patients will experience an adverse event in hospital. These could include a misdiagnosis, a medication error, or not being turned enough to prevent a pressure ulcer.

It is not clear whether this regulatory shake up will reduce that number to zero but it certainly means that next time there's smoke, somebody should notice it.