There would definitely be an investigation, as all sentinel events are investigated. Management would do their RCA and I'm sure the issue with alarm fatigue would be ignored or underplayed (Something bad happen? make sure an alarm sounded. If staff ignored it, it must be the fault of the staff). I doubt any one person would be in trouble as it was a collective/systemic failure, but I don't know exactly what would have come of it. Likely a policy change or daily reminders for the next few weeks about not ignoring the monitors even if it has been going off nonstop for hours. Maybe extra charting or peer audits. It's a lot less expensive and effort to put pressure on staff than it is to change technology (even if it is as little as setting different, more sane, defaults). Depending on what was recorded from the monitor to the chart, if it looked like there wasn't a delay in resuscitation/cardioversion (like if the lethal rhythm wasn't recorded initially), it may have been just put down as clinical course for the patient, like you suggested. My perspective of that place is a bit jaded (and therefore biased), that place was a toxic burn-out factory. BTW, "post mortem"? Thanks, the morbid humor made me laugh!