Redesign the System

You will be able toWhich policy, supervision or referral failure allowed risk to grow?

Case opening

What do you know?

A serious case review shows that several staff noticed different warning signs, training was outdated, responsibility was unclear and nobody knew which specialist service to contact.

First decision

Choose before opening the debrief.

Find the one employee who made the biggest mistakeMap system conditions: policy, training, supervision, escalation, information sharing, leadership assurance and specialist accessWrite a longer policy onlyRequire annual awareness training and close the review

Record your rationale: what is known, reported, inferred, assumed or unknown?

Help