1.0 Introduction
1.1 Purpose and Scope of the Report
Health service organisations have a responsibility to ensure that adept clinical governance systems are in place to provide consistent, safe and high quality patient-centred care.(1) Quality improvement processes often incorporate different approaches in an attempt to identify and analyse contributing root causes. The Health Service Ombudsman produced a report documenting the care provided to ten older people by the United Kingdom’s National Health Service (NHS).(2) This report analyses the quality and safety of care provided in the case of Mrs H. To do this, a fishbone diagram is utilised to identify possible contributing root causes and some of the issues identified are discussed with specific reference to the National Safety and Quality Health Service (NSQHS) Standards. Actions taken post Ombudsman investigation are discussed and further recommendations are provided.

1.2 Limitations
The length of this report is restricted by a 1,500-word limit which impacts the depth of analysis that can be undertaken. The construction of the fishbone diagram did not involve consultation with any of the key stakeholders and, as such, a true and accurate root analysis could not be presented. This is due to a limited understanding of contributing factors and hospital policies/ procedures. Finally, further testing was not conducted to confirm the true root causes.