Information not sought; lack of professional curiosity; capacity not considered
"Failure of policy, process, practice or professionalism" is a catch-all category for issues that relate to communication and information sharing but don’t fall squarely within the previous two categories.
A recurring phrase is “lack of clinical curiosity” or “lack of professional curiosity”. This refers to failures to follow up on information received, think through its implications, or consider whether the information is reliable and trustworthy.
In a number of cases people’s mental capacity was not given proper consideration, e.g. where an independent advocate could have been involved but wasn’t.
There were several instances of a lack of professional leadership or co-ordination across multiple services, where no one professional had (or took) overall responsibility for the person’s care, safety and/or wellbeing.
A significant number of cases fell into several categories, but also displayed an overarching lack of basic professionalism – a failure in the fundamental duty of care. This appears to be particularly visible in the criminal justice system.
