These failures "should not be viewed as rare anomalies, but rather as systemic weaknesses that if not remedied, are likely to result in future harm to children in CBP custody,"
So in actuality her death wasn't preventable. It could have been if the system was something else than what it is, but it isn't and likely won't be.
Mr Wise's report stated that border patrol staff were told about her medical condition when she arrived at the site where she was held in Harlington, Texas. But that information was not passed on to other agents, he wrote.
Both can be true at the same time.
So, again, her death would have been preventable if the system was different and staffed by different people, which it isn't.
The cruelty is the point.