So engaging the system would have resulted in an outcome that is worse than what actually happened? I don't think so.

It's a false choice. You can engage the system and change it at the same time. Of course you can.

The system was engaged with, that was the problem. People have a default assumption of adequacy when it comes to interaction with the state, this episode shows such a default assumption is not only unwarranted, but actually dangerous.

In my experience, the more you engage with the system, the more willing you are to rationalize or even overlook its failings.

I've spent time doing both, and I think we're just going to have to agree to disagree.