A case review is conducted after the event and is an opportunity to process the event and learn from experience. Ethical issues or situations don’t come with a label attached and often they crop up, fly by and just leave those involved with a nasty taste in the mouth. Case reviews can be done privately with the team involved, or more broadly as an activity that forms part of an ethics committee’s agenda. A key element of success is ensuring that the process does not lay blame or point fingers. It is an opportunity to share and to learn.