Reviewer comments: This eSEA describes a real-life distressing situation. The author describes the difficulties of the situation with exceptional clarity. The report picks up on the chain of events which can sometimes lead to disaster but fortunately in this case the event could be regarded as a near miss. The report shows thoughtful reflection and the action plan will benefit the practice when dealing with future events of this nature.
The content of this eSEA could help practices deal with cases of suspected neglect.
