Judith; As a healthcare provider, I find this case terrifying. I agree with the need for a RCA. My concern is there is not a culture of safety. Everyone was busy documenting the patients continuing deterioration, but failing to respond. I understand the pressures of understaffing and the burden for documenting in the chart. The fear is no-one wanted to harm this child, but no-one took the time to truly provide care. The RCA will identify the care issues, I am not sure how you document the safety culture issues. There seem to be so many holes in the care process. I think they should also perform a Failure Mode and Effects Analysis on their other patient care
