great staff incident point incidents important framework learning key resources support joining process lot agree blame reporting thanks provided chatting diagram existing exploring principles investigate elements events chat absolutely reminder share Thoughts tweet ultimately answers asks built culture investigation investigations involved industry Lack generates half poll Problem problems open listening happened focus Human conducting error experience factual families feel fewer clinical training similar sectors reflecting review risk Root reduces Protected role reflection Safety sharing Start started understood timelines addressed Factors correctly counsel discuss ignorance hear lecture lets Interesting nurses personal Patient occasions organisation person motivation move Lilian mins intention keeping knowledge helpful fearful Francis freeing guys committments family ensure directly excellent accepting answer case background big things team watch worry worth statement single Sir releasing report Robert quote reflect recommend proper quality safeguarding requires SIs situation slow Sally senior Standardisation starting strongly studies Wow writing working victims views understand teams