This case study delves into the organizational culture, leadership, and management issues that contributed to the health system failure at Djerriwarrh Health Services in Bacchus Marsh, Victoria, Australia, leading to high perinatal mortality rates. It highlights the importance of clinical governance, transparency, and accountability in healthcare settings. The analysis covers the role of whistleblowers, the influence of organizational culture on the quality of care, and how a flawed culture can conceal failures. Furthermore, the case study explores the characteristics of open and transparent leadership and their impact on patient safety, emphasizing the need for approachability, empowerment, and transparency to foster a culture of continuous improvement and minimize risks in healthcare delivery. The document also references multiple reports and articles relating to the case.