Case flow
- System failure
- Where did the design fail?
- What evidence would show improvement?
- Redesign
- Assurance
Professional case file · Chief executives, directors and senior leads
Redesign the System
Present one decision at a time. Do not treat the case as a pupil exercise. Reveal law and evidence when it becomes relevant.
Professional debrief
A safer system needs clear ownership, competent training, usable procedures, feedback, data and independent assurance.
Use current official law, guidance and local procedure. Jurisdiction: check before delivery.