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A serious case review shows that several staff noticed different warning signs, training was outdated, responsibility was unclear and nobody knew which specialist service to contact.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

Make your decision before reading the explanation.

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

Choose the reason that best supports your decision.It addresses policy, capability, supervision, escalation, specialist access and assurance as linked system conditions.It finds one employee to blame and treats the review as complete.It measures success through training attendance alone.

Optional private reflection

What single measure would show safer practice rather than simple completion? Free text is not marked and does not unlock the explanation.

Help