Reviewer comments: This PDS based eSEA is written in a bullet point style. Often this type of report is too brief and does not demonstrate enough depth of analysis to provide an action plan that is of any use. In this eSEA the layout provides a logical list of thoughts and a step by step analysis of the event coming to conclusions about what went well and what could have gone better. It contains good reflection about staff assumptions, on clinical ability and staff communication. The learning is shared throughout the organisation.
This e SEA contains useful information about patient assessment, communication and planning treatment on patients with limited support at home.