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In-depth failure investigations provide improvement insights for individuals and organizations alike. This report analyzes a collection of UK National Health Service incident examinations and provides recommendations for improvement on themes related to care transitions and access, decision making, communication, and point-of-care activity.

This investigation examined care coordination, screening and other factors that contributed to a patient death by suicide shortly after discharge from a Veteran’s Hospital. Event reporting, disclosure and evaluation gaps were identified as process weaknesses to be addressed.