I'm involved in work around reviewing medical care. Generally, a "People" section that mentions processes not being followed is an incomplete root cause analys

I'm involved in work around reviewing medical care. Generally, a "People" section that mentions processes not being followed is an incomplete root cause analysis. Why was it was possible for the process not to be followed? There's obviously a limit to how far it makes sense to drill down with why why why, but stopping at "someone didn't follow guidance" is too early.