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And one of the things you put in there under the possible contributing factors, you've said a safety check pause may not have occurred or may not have identified the insecure sling loop. This safety check pause, where where does it talk about that in our policy or procedure? I thought just because you you the way it's worded, the safety check pause may not have occurred. And I guess my question is then, if it's not in the policy, then well but our procedure then would need to reflect that we require staff to do this. So we may need to amend the procedure. That's what I was trying to figure out. Where where is this thing? The manual task procedure. Yeah. So so A safety check pause may not have occurred, which implies that it should have occurred, and staff need staff would know that it had to have occurred. And so the question is why would staff know that? So I'm not saying it's a bad thing. I'm just trying to work out is it already in there. Yeah. So I'm looking at the procedure, which is manual tasks, and it's sort of I'm wondering if I can search this. No. The verification that all clips and loops are correctly attached before lifting. Yeah. I guess we probably just need to look at the wording on it. And and I guess probably then what we would do, which is what I thought before, was that if we are gonna say there is a pause or a check, Someone clips the loops on and someone else, because there's always two people, checks it. So in doing this, you've got possible contributing factors. If you were to draw a conclusion from it, what would your conclusion be? Yep. Didn't Kiara Esteban say that sizing wise, the thing he had was appropriate? She has and and she's and and I guess my take on that was that it would fit into either. And the the you got another account. It's there's the bottom left sling loop unhooked from the hoist clip during the transfer. So So again, just to get this right, it unclipped when he fell out or it unclipped causing the fallout? Alright. Can you then just amend your document, Deb? Because it it's not really clear then. So observe fax, the last one. Another state's left hand button, unhook from the hoist clip during the transfer is what you've said. And I guess, great. You need to elaborate on that and then say, as a result of Bevan becoming stiff and going backwards. Sling pleasant may have allowed in adequate posture once the rep is moving. So probably that bit there needs to be elaborated on. Sling pleasant may have allowed inadequate posture, upper body support, essentially. What you're saying is the sling might the sling wasn't fine above his back. So so that sort of make that a bit more obvious and clearer. And then the safety pause check, if what we're saying is then the the sling under under loops were correctly in place. Would the safety pause check have identified anything? Potentially, that it may not have been fired or put his back, but it wouldn't have identified that the loops were in the wrong spot or one was missing because, allegedly, it was in place. I don't believe. No. That's what I'm saying. So if we're saying that they were in place and we didn't do a safety pause check, it wouldn't have picked that up because they were in place. So even if we did do it but would it have picked up that this thing was too far down his back, maybe? Okay. Okay. So I guess just in that one then, you said a safety posture may not have occurred and may not have identified the insecure sling loop, which what we're then saying is that it wouldn't have because it was we're saying it it was in place and that it became unsecure at the point the transfer was happening. So you're suggesting that well, no. You're suggesting on point two then that had the safety pause check occurred, it could have identified the insecure sling loop, but you're also saying it was in place and only became insecure during the transfer because he became rigid. So so what I'm saying is it wouldn't have identified it anyway, But maybe it would have identified that the sling was too far down his back. And I guess the bits then that's missing on the whole statement, you've got what happened to the timeline, what the observed facts about, what we actually know, what we are speculating, which is the contributing factors, and then what the actions were. But there's a key action missing, and these are actions that have happened. You got the statement. You had to train some stuff. We've reported the service one. What are we gonna do to stop it happening again? That's not mentioned. Okay. So I guess we're gonna action that, and maybe you can put a separate and that's fine. So maybe a separate heading, you know, reduction of future risk or something. He's always on memo to staff, this and that, and then, probably, we need to update the procedure that talks about there's a pause and a check on safety critical things. Maybe we could list them what they are. You know, is it the right size sling? Is it fine enough for his back? Is it other other loops correctly connected? You know, whatever whatever we think it should be, and then we can incorporate that in the procedure. Because that's what Zenith's gonna ask me. He's he's gonna say, great. I've got that's what Zenith from the board is gonna ask me. And now if I send them this, he's gonna say, okay. Great. We'll amend the contributing factor. So we said, for want of a better word, looks like some sort of human error. It could have been human error at one or two or three or four or whatever. Great. What are you gonna do to fix this, Mike? That's that's the question. Okay. Sounds good. K. 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It's me again. But where are you out of interest? It sounds a bit echoey. Oh.\n\nOh, that's alright. Just I'm just reading through the incident review for Bevan Brown. And one of the things you put in there under the possible contributing factors, you've said a safety check pause may not have occurred or may not have identified the insecure sling loop. This safety check pause, where where does it talk about that in our policy or procedure? I thought just because you you the way it's worded, the safety check pause may not have occurred.\n\nAnd I guess my question is then, if it's not in the policy, then well but our procedure then would need to reflect that we require staff to do this. So we may need to amend the procedure. That's what I was trying to figure out. Where where is this thing? The manual task procedure.\n\nYeah. So so A safety check pause may not have occurred, which implies that it should have occurred, and staff need staff would know that it had to have occurred. And so the question is why would staff know that? So I'm not saying it's a bad thing. I'm just trying to work out is it already in there.\n\nYeah. So I'm looking at the procedure, which is manual tasks, and it's sort of I'm wondering if I can search this. No. The verification that all clips and loops are correctly attached before lifting. Yeah.\n\nI guess we probably just need to look at the wording on it. And and I guess probably then what we would do, which is what I thought before, was that if we are gonna say there is a pause or a check, Someone clips the loops on and someone else, because there's always two people, checks it. So in doing this, you've got possible contributing factors. If you were to draw a conclusion from it, what would your conclusion be? Yep.\n\nDidn't Kiara Esteban say that sizing wise, the thing he had was appropriate? She has and and she's and and I guess my take on that was that it would fit into either. And the the you got another account. It's there's the bottom left sling loop unhooked from the hoist clip during the transfer. So So again, just to get this right, it unclipped when he fell out or it unclipped causing the fallout?\n\nAlright. Can you then just amend your document, Deb? Because it it's not really clear then. So observe fax, the last one. Another state's left hand button, unhook from the hoist clip during the transfer is what you've said.\n\nAnd I guess, great. You need to elaborate on that and then say, as a result of Bevan becoming stiff and going backwards. Sling pleasant may have allowed in adequate posture once the rep is moving. So probably that bit there needs to be elaborated on. Sling pleasant may have allowed inadequate posture, upper body support, essentially.\n\nWhat you're saying is the sling might the sling wasn't fine above his back. So so that sort of make that a bit more obvious and clearer. And then the safety pause check, if what we're saying is then the the sling under under loops were correctly in place. Would the safety pause check have identified anything? Potentially, that it may not have been fired or put his back, but it wouldn't have identified that the loops were in the wrong spot or one was missing because, allegedly, it was in place.\n\nI don't believe. No. That's what I'm saying. So if we're saying that they were in place and we didn't do a safety pause check, it wouldn't have picked that up because they were in place. So even if we did do it but would it have picked up that this thing was too far down his back, maybe?\n\nOkay. Okay. So I guess just in that one then, you said a safety posture may not have occurred and may not have identified the insecure sling loop, which what we're then saying is that it wouldn't have because it was we're saying it it was in place and that it became unsecure at the point the transfer was happening. So you're suggesting that well, no. You're suggesting on point two then that had the safety pause check occurred, it could have identified the insecure sling loop, but you're also saying it was in place and only became insecure during the transfer because he became rigid.\n\nSo so what I'm saying is it wouldn't have identified it anyway, But maybe it would have identified that the sling was too far down his back. And I guess the bits then that's missing on the whole statement, you've got what happened to the timeline, what the observed facts about, what we actually know, what we are speculating, which is the contributing factors, and then what the actions were. But there's a key action missing, and these are actions that have happened. You got the statement. You had to train some stuff.\n\nWe've reported the service one. What are we gonna do to stop it happening again? That's not mentioned. Okay. So I guess we're gonna action that, and maybe you can put a separate and that's fine.\n\nSo maybe a separate heading, you know, reduction of future risk or something. He's always on memo to staff, this and that, and then, probably, we need to update the procedure that talks about there's a pause and a check on safety critical things. Maybe we could list them what they are. You know, is it the right size sling? Is it fine enough for his back?\n\nIs it other other loops correctly connected? You know, whatever whatever we think it should be, and then we can incorporate that in the procedure. Because that's what Zenith's gonna ask me. He's he's gonna say, great. I've got that's what Zenith from the board is gonna ask me.\n\nAnd now if I send them this, he's gonna say, okay. Great. We'll amend the contributing factor. So we said, for want of a better word, looks like some sort of human error. It could have been human error at one or two or three or four or whatever.\n\nGreat. What are you gonna do to fix this, Mike? That's that's the question. Okay. Sounds good.\n\nK. Bye.","paragraphs":[{"sentences":[{"text":"Hello.","start":2.72,"end":3.12,"sentiment":"neutral","sentiment_score":0.1143903061747551},{"text":"It's me again.","start":3.12,"end":4.1,"sentiment":"neutral","sentiment_score":-0.06467274576425552},{"text":"But where are you out of interest?","start":5.3599997,"end":6.7999997,"sentiment":"neutral","sentiment_score":-0.3200089292866843},{"text":"It sounds a bit echoey.","start":6.7999997,"end":7.94,"sentiment":"negative","sentiment_score":-0.371081280708313},{"text":"Oh.","start":11.44,"end":11.94,"sentiment":"neutral","sentiment_score":-0.05171741545200348}],"sentiment":"neutral","sentiment_score":-0.24863613265402176,"num_words":17,"start":2.72,"end":11.94},{"sentences":[{"text":"Oh, that's alright.","start":13.485,"end":14.545,"sentiment":"neutral","sentiment_score":-0.030854887639482815},{"text":"Just I'm just reading through the incident review for Bevan Brown.","start":15.164999,"end":19.425,"sentiment":"neutral","sentiment_score":-0.0666231330145489},{"text":"And one of the things you put in there under the possible contributing factors, you've said a safety check pause may not have occurred or may not have identified the insecure sling loop.","start":20.365,"end":33.46,"sentiment":"neutral","sentiment_score":-0.14637389914555984},{"text":"This safety check pause, where where does it talk about that in our policy or procedure?","start":35.2,"end":41.845,"sentiment":"neutral","sentiment_score":-0.0672559926752001},{"text":"I thought just because you you the way it's worded, the safety check pause may not have occurred.","start":68.045,"end":73.985,"sentiment":"neutral","sentiment_score":-0.24692456920941672}],"sentiment":"neutral","sentiment_score":-0.1379814311907983,"num_words":81,"start":13.485,"end":73.985},{"sentences":[{"text":"And I guess my question is then, if it's not in the policy, then well but our procedure then would need to reflect that we require staff to do this.","start":74.524994,"end":93.84,"sentiment":"neutral","sentiment_score":-0.2051880697409312},{"text":"So we may need to amend the procedure.","start":96.375,"end":98.455,"sentiment":"neutral","sentiment_score":-0.1595824845135212},{"text":"That's what I was trying to figure out.","start":98.455,"end":100.855,"sentiment":"neutral","sentiment_score":-0.12899231351912022},{"text":"Where where is this thing?","start":100.855,"end":102.475,"sentiment":"neutral","sentiment_score":-0.14310217499732972},{"text":"The manual task procedure.","start":105.655,"end":107.195,"sentiment":"neutral","sentiment_score":-0.07290762476623058}],"sentiment":"neutral","sentiment_score":-0.17220694273710252,"num_words":55,"start":74.524994,"end":107.195},{"sentences":[{"text":"Yeah.","start":111.770004,"end":112.270004,"sentiment":"neutral","sentiment_score":-0.06277300417423248},{"text":"So so A safety check pause may not have occurred, which implies that it should have occurred, and staff need staff would know that it had to have occurred.","start":113.05,"end":138.795,"sentiment":"neutral","sentiment_score":-0.24850440307937818},{"text":"And so the question is why would staff know that?","start":138.935,"end":141.39,"sentiment":"negative","sentiment_score":-0.3548024982213974},{"text":"So I'm not saying it's a bad thing.","start":146.11,"end":148.85,"sentiment":"negative","sentiment_score":-0.5042748600244522},{"text":"I'm just trying to work out is it already in there.","start":148.91,"end":152.53,"sentiment":"neutral","sentiment_score":0.03319145366549492}],"sentiment":"neutral","sentiment_score":-0.24553421297568387,"num_words":59,"start":111.770004,"end":152.53},{"sentences":[{"text":"Yeah.","start":160.86499,"end":161.265,"sentiment":"neutral","sentiment_score":0.041199058294296265},{"text":"So I'm looking at the procedure, which is manual tasks, and it's sort of I'm wondering if I can search this.","start":161.265,"end":168.18,"sentiment":"neutral","sentiment_score":0.0304187120248874},{"text":"No.","start":171.84,"end":172.34,"sentiment":"neutral","sentiment_score":-0.22754518687725067},{"text":"The verification that all clips and loops are correctly attached before lifting.","start":176.72,"end":180.73999,"sentiment":"neutral","sentiment_score":-0.08958369555572669},{"text":"Yeah.","start":193.68999,"end":194.09,"sentiment":"neutral","sentiment_score":0.010293105617165564}],"sentiment":"neutral","sentiment_score":-0.017007344919774268,"num_words":36,"start":160.86499,"end":194.09},{"sentences":[{"text":"I guess we probably just need to look at the wording on it.","start":194.09,"end":197.06999,"sentiment":"neutral","sentiment_score":-0.032309052462761216},{"text":"And and I guess probably then what we would do, which is what I thought before, was that if we are gonna say there is a pause or a check, Someone clips the loops on and someone else, because there's always two people, checks it.","start":197.45,"end":216.155,"sentiment":"neutral","sentiment_score":-0.006884998579819997},{"text":"So in doing this, you've got possible contributing factors.","start":225.34999,"end":230.09,"sentiment":"neutral","sentiment_score":0.022666594634453457},{"text":"If you were to draw a conclusion from it, what would your conclusion be?","start":230.63,"end":235.69,"sentiment":"neutral","sentiment_score":0.006223503234130996},{"text":"Yep.","start":262.9,"end":263.4,"sentiment":"neutral","sentiment_score":-0.04491214081645012}],"sentiment":"neutral","sentiment_score":-0.0058978824626381805,"num_words":82,"start":194.09,"end":263.4},{"sentences":[{"text":"Didn't Kiara Esteban say that sizing wise, the thing he had was appropriate?","start":266.175,"end":271.955,"sentiment":"neutral","sentiment_score":-0.14037557404774886},{"text":"She has and and she's and and I guess my take on that was that it would fit into either.","start":275.695,"end":280.595,"sentiment":"neutral","sentiment_score":-0.0912697957828641},{"text":"And the the you got another account.","start":315.99,"end":325.12997,"sentiment":"neutral","sentiment_score":-0.03773610879267965},{"text":"It's there's the bottom left sling loop unhooked from the hoist clip during the transfer.","start":325.18997,"end":329.845,"sentiment":"neutral","sentiment_score":-0.05987643500169118},{"text":"So So again, just to get this right, it unclipped when he fell out or it unclipped causing the fallout?","start":332.385,"end":350.86,"sentiment":"neutral","sentiment_score":-0.1183501297608018}],"sentiment":"neutral","sentiment_score":-0.09572773680090904,"num_words":75,"start":266.175,"end":350.86},{"sentences":[{"text":"Alright.","start":383.245,"end":383.745,"sentiment":"neutral","sentiment_score":0.0070555852726101875},{"text":"Can you then just amend your document, Deb?","start":384.36502,"end":388.70502,"sentiment":"neutral","sentiment_score":0.013204668182879686},{"text":"Because it it's not really clear then.","start":389.405,"end":392.36502,"sentiment":"neutral","sentiment_score":-0.19343156473977224},{"text":"So observe fax, the last one.","start":392.36502,"end":394.52502,"sentiment":"neutral","sentiment_score":-0.060771264135837555},{"text":"Another state's left hand button, unhook from the hoist clip during the transfer is what you've said.","start":394.52502,"end":399.77002,"sentiment":"neutral","sentiment_score":-0.07200224829070709}],"sentiment":"neutral","sentiment_score":-0.07256394431281549,"num_words":39,"start":383.245,"end":399.77002},{"sentences":[{"text":"And I guess, great.","start":400.79,"end":401.59,"sentiment":"neutral","sentiment_score":-0.06968558114022017},{"text":"You need to elaborate on that and then say, as a result of Bevan becoming stiff and going backwards.","start":401.59,"end":408.25,"sentiment":"neutral","sentiment_score":-0.17417968299828077},{"text":"Sling pleasant may have allowed in adequate posture once the rep is moving.","start":414.115,"end":418.115,"sentiment":"neutral","sentiment_score":-0.058619062487895675},{"text":"So probably that bit there needs to be elaborated on.","start":418.115,"end":421.77,"sentiment":"neutral","sentiment_score":-0.12234691381454468},{"text":"Sling pleasant may have allowed inadequate posture, upper body support, essentially.","start":422.16998,"end":426.83,"sentiment":"negative","sentiment_score":-0.35509341819719836}],"sentiment":"neutral","sentiment_score":-0.16631054126641207,"num_words":57,"start":400.79,"end":426.83},{"sentences":[{"text":"What you're saying is the sling might the sling wasn't fine above his back.","start":426.97,"end":430.59,"sentiment":"neutral","sentiment_score":-0.3251966152872358},{"text":"So so that sort of make that a bit more obvious and clearer.","start":432.49,"end":437.38998,"sentiment":"neutral","sentiment_score":0.08740559736123452},{"text":"And then the safety pause check, if what we're saying is then the the sling under under loops were correctly in place.","start":441.82498,"end":456.55002,"sentiment":"neutral","sentiment_score":0.04442925217815421},{"text":"Would the safety pause check have identified anything?","start":457.33002,"end":461.03,"sentiment":"neutral","sentiment_score":-0.011322442907840014},{"text":"Potentially, that it may not have been fired or put his back, but it wouldn't have identified that the loops were in the wrong spot or one was missing because, allegedly, it was in place.","start":464.695,"end":478.17,"sentiment":"neutral","sentiment_score":-0.26798790310110365}],"sentiment":"neutral","sentiment_score":-0.1294477440457305,"num_words":92,"start":426.97,"end":478.17},{"sentences":[{"text":"I don't believe.","start":482.33002,"end":483.39,"sentiment":"negative","sentiment_score":-0.35938116908073425},{"text":"No.","start":502.39,"end":502.63,"sentiment":"negative","sentiment_score":-0.3446137309074402},{"text":"That's what I'm saying.","start":502.63,"end":503.69,"sentiment":"neutral","sentiment_score":-0.3278653845191002},{"text":"So if we're saying that they were in place and we didn't do a safety pause check, it wouldn't have picked that up because they were in place.","start":503.83002,"end":518.09,"sentiment":"neutral","sentiment_score":-0.25327249456729206},{"text":"So even if we did do it but would it have picked up that this thing was too far down his back, maybe?","start":519.245,"end":525.825,"sentiment":"neutral","sentiment_score":-0.32256578492081683}],"sentiment":"neutral","sentiment_score":-0.2922857911404917,"num_words":59,"start":482.33002,"end":525.825},{"sentences":[{"text":"Okay.","start":527.885,"end":528.385,"sentiment":"neutral","sentiment_score":-0.09693586826324464},{"text":"Okay.","start":533.39,"end":533.79004,"sentiment":"neutral","sentiment_score":-0.10691679269075394},{"text":"So I guess just in that one then, you said a safety posture may not have occurred and may not have identified the insecure sling loop, which what we're then saying is that it wouldn't have because it was we're saying it it was in place and that it became unsecure at the point the transfer was happening.","start":533.79004,"end":554.085,"sentiment":"neutral","sentiment_score":-0.29258840505419104},{"text":"So you're suggesting that well, no.","start":558.065,"end":563.32,"sentiment":"neutral","sentiment_score":-0.13490061337749162},{"text":"You're suggesting on point two then that had the safety pause check occurred, it could have identified the insecure sling loop, but you're also saying it was in place and only became insecure during the transfer because he became rigid.","start":563.32,"end":581.165,"sentiment":"neutral","sentiment_score":-0.31050631776452065}],"sentiment":"neutral","sentiment_score":-0.2868267598579515,"num_words":106,"start":527.885,"end":581.165},{"sentences":[{"text":"So so what I'm saying is it wouldn't have identified it anyway, But maybe it would have identified that the sling was too far down his back.","start":583.305,"end":594.91003,"sentiment":"neutral","sentiment_score":-0.2677619374460644},{"text":"And I guess the bits then that's missing on the whole statement, you've got what happened to the timeline, what the observed facts about, what we actually know, what we are speculating, which is the contributing factors, and then what the actions were.","start":601.105,"end":618.87,"sentiment":"neutral","sentiment_score":-0.07278934944161149},{"text":"But there's a key action missing, and these are actions that have happened.","start":620.20996,"end":623.32996,"sentiment":"neutral","sentiment_score":-0.08472284072866806},{"text":"You got the statement.","start":623.32996,"end":624.47,"sentiment":"neutral","sentiment_score":-0.06214154325425625},{"text":"You had to train some stuff.","start":626.05,"end":627.25,"sentiment":"neutral","sentiment_score":-0.06037853161493937}],"sentiment":"neutral","sentiment_score":-0.1298037487012084,"num_words":93,"start":583.305,"end":627.25},{"sentences":[{"text":"We've reported the service one.","start":627.25,"end":628.785,"sentiment":"neutral","sentiment_score":-0.05304756090044975},{"text":"What are we gonna do to stop it happening again?","start":628.865,"end":630.96497,"sentiment":"neutral","sentiment_score":-0.1093579538166523},{"text":"That's not mentioned.","start":631.58496,"end":632.64496,"sentiment":"neutral","sentiment_score":-0.10444542020559311},{"text":"Okay.","start":641.27997,"end":641.76,"sentiment":"neutral","sentiment_score":0.04060538113117218},{"text":"So I guess we're gonna action that, and maybe you can put a separate and that's fine.","start":641.76,"end":649.2,"sentiment":"neutral","sentiment_score":0.0465234642410103}],"sentiment":"neutral","sentiment_score":-0.023351370279366773,"num_words":36,"start":627.25,"end":649.2},{"sentences":[{"text":"So maybe a separate heading, you know, reduction of future risk or something.","start":649.2,"end":653.86,"sentiment":"neutral","sentiment_score":0.06963139399886131},{"text":"He's always on memo to staff, this and that, and then, probably, we need to update the procedure that talks about there's a pause and a check on safety critical things.","start":654.14496,"end":668.565,"sentiment":"neutral","sentiment_score":0.027023768337864067},{"text":"Maybe we could list them what they are.","start":669.20996,"end":671.55,"sentiment":"neutral","sentiment_score":0.07354253064841032},{"text":"You know, is it the right size sling?","start":671.61,"end":673.44995,"sentiment":"neutral","sentiment_score":0.07315924530848861},{"text":"Is it fine enough for his back?","start":673.44995,"end":674.97,"sentiment":"neutral","sentiment_score":0.07869132767830576}],"sentiment":"neutral","sentiment_score":0.051752215550183805,"num_words":67,"start":649.2,"end":674.97},{"sentences":[{"text":"Is it other other loops correctly connected?","start":674.97,"end":679.79,"sentiment":"neutral","sentiment_score":0.055287392543894906},{"text":"You know, whatever whatever we think it should be, and then we can incorporate that in the procedure.","start":680.64996,"end":684.885,"sentiment":"neutral","sentiment_score":0.10534151871171263},{"text":"Because that's what Zenith's gonna ask me.","start":684.885,"end":687.065,"sentiment":"neutral","sentiment_score":-0.03109875773744924},{"text":"He's he's gonna say, great.","start":688.565,"end":689.765,"sentiment":"neutral","sentiment_score":-0.027789131551980973},{"text":"I've got that's what Zenith from the board is gonna ask me.","start":689.765,"end":692.645,"sentiment":"neutral","sentiment_score":-0.019476113996158045}],"sentiment":"neutral","sentiment_score":0.03454711744371725,"num_words":49,"start":674.97,"end":692.645},{"sentences":[{"text":"And now if I send them this, he's gonna say, okay.","start":692.645,"end":694.965,"sentiment":"neutral","sentiment_score":-0.06388547305356372},{"text":"Great.","start":694.965,"end":695.465,"sentiment":"neutral","sentiment_score":0.2198275476694107},{"text":"We'll amend the contributing factor.","start":695.68506,"end":697.60504,"sentiment":"neutral","sentiment_score":-0.04870503656566143},{"text":"So we said, for want of a better word, looks like some sort of human error.","start":697.60504,"end":701.58997,"sentiment":"neutral","sentiment_score":-0.3081334391608834},{"text":"It could have been human error at one or two or three or four or whatever.","start":701.65,"end":705.83,"sentiment":"neutral","sentiment_score":-0.20544759929180145}],"sentiment":"neutral","sentiment_score":-0.18252519293859296,"num_words":49,"start":692.645,"end":705.83},{"sentences":[{"text":"Great.","start":706.21,"end":706.45,"sentiment":"neutral","sentiment_score":0.30766579508781433},{"text":"What are you gonna do to fix this, Mike?","start":706.45,"end":708.39,"sentiment":"neutral","sentiment_score":0.006211696399582757},{"text":"That's that's the question.","start":709.41,"end":710.71,"sentiment":"neutral","sentiment_score":-0.02755099581554532},{"text":"Okay.","start":718.435,"end":718.91504,"sentiment":"neutral","sentiment_score":0.22092142701148987},{"text":"Sounds good.","start":718.91504,"end":721.23505,"sentiment":"positive","sentiment_score":0.3602322190999985}],"sentiment":"neutral","sentiment_score":0.07027958497843322,"num_words":17,"start":706.21,"end":721.23505},{"sentences":[{"text":"K.","start":721.23505,"end":721.55505,"sentiment":"neutral","sentiment_score":0.12944522500038147},{"text":"Bye.","start":721.55505,"end":722.05505,"sentiment":"neutral","sentiment_score":0.18400529026985168}],"sentiment":"neutral","sentiment_score":0.15672525763511658,"num_words":2,"start":721.23505,"end":722.05505}]}}]},{"alternatives":[{"transcript":"Hello? How are you doing? Yeah. Oh, I was in the clinical office, and now I'm walking down the corridor. Mhmm. Well, I don't know. So this is our policy and procedure. It is because they are trained by the but they're always trained to stop and check. So that's what it is. It's a stop and check. Have we got all the hooks and the colors before we move? So that's a a standard process, but I don't know about whether it's in a policy. I would imagine it's only training, but then we're not doing the training. The other company's doing it. Right. You mean the procedure? I could look at that. I I have no idea. I didn't look at the procedure. I just know it is a standard behavior, a standard thing to do that. Okay. So is it in the policy or is it in the procedure or are they or are they trained in it is what you're asking? That would be your safety pause. Yeah. Yeah. Yeah. My take on my conclusion is that I think the sling was too far down the back and possibly with his rigidity. That's the only thing I can imagine. The more that he went straight over the back. So if he if that changed it to a medium sling, it'll be further up just below his neck, so he won't be able to tip in that manner. I don't I don't believe it was up far enough. She did, but she's changed it because he yeah. Yes. But if when and putting it on, when the staff put it on, they may may not have realized or may not notice, and they may have had it too well, they must have done. They had it too far down the top of his back. And then if he's like, he was fine when they lifted him, but the moment he went out over the floor, maybe he stiffened. Not sure. And he's he's flung straight out of the top of it. So it must have been, I reckon, mid back rather than higher up towards the shoulders or over the shoulders. Yep. One of them did say that she she believed that it unhooked when he flipped out, So it's forced it up. I'm not sure if that's correct or not. My understanding is it's Winnie fell out. That's what the person has said. And I had one of them come in to see me herself actually this morning, and she said, you know, that they it looked fine, and she was beside herself with apologies. And I said, you know, we're not really sure other than he did go over the back. I said I did wonder if the sling was too far down his back. Yep. Mhmm. Yep. Yep. Alright. Yep. You don't believe it was in place? Well, I think the student who was being taught, so we're talking about her she's had twelve months of RN training, just about just about finishing her year. She she was quite clear that they were in place, I'm sure. A safety check. Yeah. It wouldn't have picked yeah. Yes. If if the staff are aware of that enough. Yeah. Well, it's presumption, isn't it? Yeah. Okay. No. No. It wouldn't have done. Yeah. So I did positioning. Well, I've sent a memo out for staff. They're all being trained at Huddl's. Yep. Well, he went out last week. Yep. Yep. Okay. Yep. Sorry? Yeah. Yep. Okay. Alright. I will try and remember all that, and I'll start doing it. When you need it. Bye. 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How are you doing? Yeah. Oh, I was in the clinical office, and now I'm walking down the corridor. Mhmm.\n\nWell, I don't know. So this is our policy and procedure. It is because they are trained by the but they're always trained to stop and check. So that's what it is. It's a stop and check.\n\nHave we got all the hooks and the colors before we move? So that's a a standard process, but I don't know about whether it's in a policy. I would imagine it's only training, but then we're not doing the training. The other company's doing it. Right.\n\nYou mean the procedure? I could look at that. I I have no idea. I didn't look at the procedure. I just know it is a standard behavior, a standard thing to do that.\n\nOkay. So is it in the policy or is it in the procedure or are they or are they trained in it is what you're asking? That would be your safety pause. Yeah. Yeah.\n\nYeah. My take on my conclusion is that I think the sling was too far down the back and possibly with his rigidity. That's the only thing I can imagine. The more that he went straight over the back. So if he if that changed it to a medium sling, it'll be further up just below his neck, so he won't be able to tip in that manner.\n\nI don't I don't believe it was up far enough. She did, but she's changed it because he yeah. Yes. But if when and putting it on, when the staff put it on, they may may not have realized or may not notice, and they may have had it too well, they must have done. They had it too far down the top of his back.\n\nAnd then if he's like, he was fine when they lifted him, but the moment he went out over the floor, maybe he stiffened. Not sure. And he's he's flung straight out of the top of it. So it must have been, I reckon, mid back rather than higher up towards the shoulders or over the shoulders. Yep.\n\nOne of them did say that she she believed that it unhooked when he flipped out, So it's forced it up. I'm not sure if that's correct or not. My understanding is it's Winnie fell out. That's what the person has said. And I had one of them come in to see me herself actually this morning, and she said, you know, that they it looked fine, and she was beside herself with apologies.\n\nAnd I said, you know, we're not really sure other than he did go over the back. I said I did wonder if the sling was too far down his back. Yep. Mhmm. Yep.\n\nYep. Alright. Yep. You don't believe it was in place? Well, I think the student who was being taught, so we're talking about her she's had twelve months of RN training, just about just about finishing her year.\n\nShe she was quite clear that they were in place, I'm sure. A safety check. Yeah. It wouldn't have picked yeah. Yes.\n\nIf if the staff are aware of that enough. Yeah. Well, it's presumption, isn't it? Yeah. Okay.\n\nNo. No. It wouldn't have done. Yeah. So I did positioning.\n\nWell, I've sent a memo out for staff. They're all being trained at Huddl's. Yep. Well, he went out last week. Yep.\n\nYep. Okay. Yep. Sorry? Yeah.\n\nYep. Okay. Alright. I will try and remember all that, and I'll start doing it. When you need it.\n\nBye. Bye.","paragraphs":[{"sentences":[{"text":"Hello?","start":1.1999999,"end":1.6999999,"sentiment":"neutral","sentiment_score":0.050438717007637024},{"text":"How are you doing?","start":2.48,"end":3.3799999,"sentiment":"neutral","sentiment_score":0.1185743547976017},{"text":"Yeah.","start":4.48,"end":4.98,"sentiment":"neutral","sentiment_score":-0.10933225601911543},{"text":"Oh, I was in the clinical office, and now I'm walking down the corridor.","start":8.639999,"end":12.74,"sentiment":"neutral","sentiment_score":-0.06272085596408163},{"text":"Mhmm.","start":34.21,"end":34.71,"sentiment":"neutral","sentiment_score":-0.04090392217040062}],"sentiment":"neutral","sentiment_score":-0.023980572642315002,"num_words":21,"start":1.1999999,"end":34.71},{"sentences":[{"text":"Well, I don't know.","start":44.805,"end":45.845,"sentiment":"neutral","sentiment_score":-0.14900102466344833},{"text":"So this is our policy and 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back.","start":251.45,"end":253.87,"sentiment":"negative","sentiment_score":-0.45862746569845414},{"text":"So if he if that changed it to a medium sling, it'll be further up just below his neck, so he won't be able to tip in that manner.","start":254.01,"end":263.05,"sentiment":"negative","sentiment_score":-0.37442544616501905}],"sentiment":"negative","sentiment_score":-0.4699547880274408,"num_words":68,"start":216.495,"end":263.05},{"sentences":[{"text":"I don't I don't believe it was up far enough.","start":263.05,"end":265.47,"sentiment":"negative","sentiment_score":-0.3688100934028625},{"text":"She did, but she's changed it because he yeah.","start":273.225,"end":277.56,"sentiment":"neutral","sentiment_score":-0.08154308216439353},{"text":"Yes.","start":282.36,"end":282.84,"sentiment":"neutral","sentiment_score":0.002102479338645935},{"text":"But if when and putting it on, when the staff put it on, they may may not have realized or may not notice, and they may have had it too well, they must have done.","start":282.84,"end":292.99503,"sentiment":"neutral","sentiment_score":-0.32748903738600865},{"text":"They had it too far down the top of his back.","start":292.99503,"end":296.295,"sentiment":"negative","sentiment_score":-0.42870619893074036}],"sentiment":"neutral","sentiment_score":-0.3120874347108783,"num_words":66,"start":263.05,"end":296.295},{"sentences":[{"text":"And then if he's like, he was fine when they lifted him, but the moment he went out over the floor, maybe he stiffened.","start":297.875,"end":304.375,"sentiment":"neutral","sentiment_score":-0.2334763940113286},{"text":"Not sure.","start":304.515,"end":305.15503,"sentiment":"neutral","sentiment_score":-0.30904605984687805},{"text":"And he's he's flung straight out of the top of it.","start":305.15503,"end":308.77002,"sentiment":"negative","sentiment_score":-0.35783881761811},{"text":"So it must have been, I reckon, mid back rather than higher up towards the shoulders or over the shoulders.","start":308.77002,"end":316.63,"sentiment":"neutral","sentiment_score":-0.13377834390848875},{"text":"Yep.","start":330.66498,"end":331.16498,"sentiment":"neutral","sentiment_score":-0.00805945135653019}],"sentiment":"neutral","sentiment_score":-0.2214030844705372,"num_words":58,"start":297.875,"end":331.16498},{"sentences":[{"text":"One of them did say that she she believed that it unhooked when he flipped out, So it's forced it up.","start":332.025,"end":339.11,"sentiment":"neutral","sentiment_score":-0.10279404717896666},{"text":"I'm not sure if that's correct or not.","start":339.11,"end":341.53,"sentiment":"neutral","sentiment_score":-0.22369812615215778},{"text":"My understanding is it's Winnie fell out.","start":355.505,"end":358.165,"sentiment":"neutral","sentiment_score":-0.14796025518860137},{"text":"That's what the person has said.","start":359.265,"end":361.445,"sentiment":"neutral","sentiment_score":-0.09847324838240941},{"text":"And I had one of them come in to see me herself actually this morning, and she said, you know, that they it looked fine, and she was beside herself with apologies.","start":361.505,"end":371.9,"sentiment":"neutral","sentiment_score":-0.15930237888824195}],"sentiment":"neutral","sentiment_score":-0.14422293785154014,"num_words":74,"start":332.025,"end":371.9},{"sentences":[{"text":"And I said, you know, we're not really sure other than he did go over the back.","start":372.84,"end":377.88,"sentiment":"neutral","sentiment_score":-0.22783256891895742},{"text":"I said I did wonder if the sling was too far down his back.","start":377.88,"end":380.78,"sentiment":"neutral","sentiment_score":-0.2576062242899622},{"text":"Yep.","start":388.735,"end":389.235,"sentiment":"neutral","sentiment_score":-0.024773558601737022},{"text":"Mhmm.","start":393.31,"end":393.81,"sentiment":"neutral","sentiment_score":-0.05244429409503937},{"text":"Yep.","start":407.63,"end":407.985,"sentiment":"neutral","sentiment_score":-0.08392512798309326}],"sentiment":"neutral","sentiment_score":-0.22472893506945932,"num_words":34,"start":372.84,"end":407.985},{"sentences":[{"text":"Yep.","start":431.31,"end":431.63,"sentiment":"neutral","sentiment_score":-0.01658318191766739},{"text":"Alright.","start":431.63,"end":432.13,"sentiment":"neutral","sentiment_score":-0.02765517868101597},{"text":"Yep.","start":437.02502,"end":437.52502,"sentiment":"neutral","sentiment_score":0.19280573725700376},{"text":"You don't believe it was in place?","start":480.01,"end":481.55002,"sentiment":"neutral","sentiment_score":-0.244693609220641},{"text":"Well, I think the student who was being taught, so we're talking about her she's had twelve months of RN training, just about just about finishing her year.","start":484.73,"end":496.79498,"sentiment":"neutral","sentiment_score":-0.034029310036982806}],"sentiment":"neutral","sentiment_score":-0.06623969918214961,"num_words":38,"start":431.31,"end":496.79498},{"sentences":[{"text":"She she was quite clear that they were in place, I'm sure.","start":498.055,"end":501.755,"sentiment":"neutral","sentiment_score":0.02110813030352195},{"text":"A safety check.","start":513.06,"end":514.12,"sentiment":"neutral","sentiment_score":-0.2104017585515976},{"text":"Yeah.","start":519.06,"end":519.38,"sentiment":"neutral","sentiment_score":-0.11217305809259416},{"text":"It wouldn't have picked yeah.","start":519.38,"end":520.92,"sentiment":"neutral","sentiment_score":-0.2390773266553879},{"text":"Yes.","start":526.375,"end":526.875,"sentiment":"neutral","sentiment_score":-0.07351041585206985}],"sentiment":"neutral","sentiment_score":-0.07995353723791512,"num_words":22,"start":498.055,"end":526.875},{"sentences":[{"text":"If if the staff are aware of that enough.","start":528.375,"end":531.91504,"sentiment":"neutral","sentiment_score":-0.17976981235875023},{"text":"Yeah.","start":556.945,"end":557.445,"sentiment":"neutral","sentiment_score":-0.0778842568397522},{"text":"Well, it's presumption, isn't it?","start":560.305,"end":562.32495,"sentiment":"neutral","sentiment_score":-0.09358928203582764},{"text":"Yeah.","start":582.515,"end":582.91504,"sentiment":"neutral","sentiment_score":-0.10798155516386032},{"text":"Okay.","start":582.91504,"end":583.41504,"sentiment":"neutral","sentiment_score":-0.11275345832109453}],"sentiment":"neutral","sentiment_score":-0.14026435245485866,"num_words":17,"start":528.375,"end":583.41504},{"sentences":[{"text":"No.","start":586.835,"end":587.315,"sentiment":"negative","sentiment_score":-0.4578703641891479},{"text":"No.","start":587.315,"end":587.55505,"sentiment":"negative","sentiment_score":-0.5572813153266907},{"text":"It wouldn't have done.","start":587.55505,"end":588.695,"sentiment":"negative","sentiment_score":-0.4324086159467697},{"text":"Yeah.","start":594.99,"end":595.49,"sentiment":"neutral","sentiment_score":-0.0681115984916687},{"text":"So I did positioning.","start":596.865,"end":599.73,"sentiment":"neutral","sentiment_score":-0.05952613800764084}],"sentiment":"neutral","sentiment_score":-0.27736384489319543,"num_words":11,"start":586.835,"end":599.73},{"sentences":[{"text":"Well, I've sent a memo out for staff.","start":636.145,"end":638.945,"sentiment":"neutral","sentiment_score":0.023907039198093116},{"text":"They're all being trained at Huddl's.","start":638.945,"end":641.125,"sentiment":"neutral","sentiment_score":0.054434401293595634},{"text":"Yep.","start":645.10504,"end":645.585,"sentiment":"neutral","sentiment_score":0.028061237186193463},{"text":"Well, he went out last week.","start":645.585,"end":647.265,"sentiment":"neutral","sentiment_score":0.012511474701265493},{"text":"Yep.","start":647.265,"end":647.765,"sentiment":"neutral","sentiment_score":0.09056483954191208}],"sentiment":"neutral","sentiment_score":0.03234352937645533,"num_words":22,"start":636.145,"end":647.765},{"sentences":[{"text":"Yep.","start":668.505,"end":669.005,"sentiment":"neutral","sentiment_score":0.07129804790019989},{"text":"Okay.","start":672.345,"end":672.845,"sentiment":"neutral","sentiment_score":0.08736371248960495},{"text":"Yep.","start":681.27,"end":681.77,"sentiment":"neutral","sentiment_score":0.07698939740657806},{"text":"Sorry?","start":689.26495,"end":689.76495,"sentiment":"neutral","sentiment_score":-0.0762849897146225},{"text":"Yeah.","start":692.865,"end":693.365,"sentiment":"neutral","sentiment_score":-0.03812437877058983}],"sentiment":"neutral","sentiment_score":0.024248357862234116,"num_words":5,"start":668.505,"end":693.365},{"sentences":[{"text":"Yep.","start":711.25,"end":711.57,"sentiment":"neutral","sentiment_score":0.12005271017551422},{"text":"Okay.","start":711.57,"end":712.07,"sentiment":"neutral","sentiment_score":0.1621231734752655},{"text":"Alright.","start":712.37,"end":712.69,"sentiment":"neutral","sentiment_score":0.21158158779144287},{"text":"I will try and remember all that, and I'll start doing it.","start":712.69,"end":715.8889,"sentiment":"neutral","sentiment_score":0.2780905415614446},{"text":"When you need it.","start":718.9889,"end":719.9489,"sentiment":"neutral","sentiment_score":0.2833690457046032}],"sentiment":"neutral","sentiment_score":0.26128000805252477,"num_words":19,"start":711.25,"end":719.9489},{"sentences":[{"text":"Bye.","start":719.9489,"end":720.4489,"sentiment":"neutral","sentiment_score":0.2857922613620758},{"text":"Bye.","start":722.9889,"end":723.4889,"sentiment":"neutral","sentiment_score":-0.10543259233236311}],"sentiment":"neutral","sentiment_score":0.09017983451485634,"num_words":2,"start":719.9489,"end":723.4889}]}}]}],"paragraphs":{"transcript":"\nChannel 1: Hello? How are you\n\nChannel 0: Hello.\n\nChannel 1: doing?\n\nChannel 0: It's me again.\n\nChannel 1: Yeah.\n\nChannel 0: But where are you out of interest? It sounds a bit echoey.\n\nChannel 1: Oh, I was in the clinical office, and now\n\nChannel 0: Oh.\n\nChannel 1: I'm walking down the corridor.\n\nChannel 0: Oh, that's alright. Just I'm just reading through the incident review for Bevan Brown. And one of the things you put in there under the possible contributing factors, you've said a safety check pause may not have occurred or may not have identified the insecure sling loop.\n\nChannel 1: Mhmm.\n\nChannel 0: This safety check pause, where where does it talk about that in our policy or procedure?\n\nChannel 1: Well, I don't know. So this is our policy and procedure. It is because they are trained by the but they're always trained to stop and check. So that's what it is. It's a stop and check.\n\nHave we got all the hooks and the colors before we move? So that's a a standard process, but I don't know about whether it's in a policy.\n\nChannel 0: I thought just because you you the way it's worded, the safety check pause may not have occurred. And I guess my question is then, if it's not in the policy,\n\nChannel 1: I would\n\nChannel 0: then\n\nChannel 1: imagine it's only training, but then we're not doing the training. The other company's doing it.\n\nChannel 0: well but our procedure then would need to reflect that we require staff to do this.\n\nChannel 1: Right.\n\nChannel 0: So we may need to amend the procedure. That's what I was trying to figure out. Where where is this thing?\n\nChannel 1: You mean the procedure?\n\nChannel 0: The manual task procedure. Yeah. So so\n\nChannel 1: I could look at that. I I have no idea. I didn't look at the procedure. I just know it is a standard behavior, a standard thing to do that.\n\nChannel 0: A safety check pause may not have occurred, which implies that it should have occurred, and staff need staff would know that it had to have occurred. And so the question is why would staff know that? So I'm not\n\nChannel 1: Okay.\n\nChannel 0: saying it's a bad thing. I'm just trying to work out is it already in there.\n\nChannel 1: So is it in the policy or is it in the procedure or are they or are they trained in it is what you're asking?\n\nChannel 0: Yeah. So I'm looking at the procedure, which is manual tasks, and it's sort of I'm wondering if I can search this. No. The verification that all clips and loops are correctly attached before lifting.\n\nChannel 1: That would be your safety pause.\n\nChannel 0: Yeah. I guess we probably just need to look at the wording on it.\n\nChannel 1: Yeah.\n\nChannel 0: And and I guess probably then what we would do, which is what I thought before, was that if we are gonna say there is a pause or a check, Someone clips the loops on and someone else, because there's always two people, checks it.\n\nChannel 1: Yeah. Yeah.\n\nChannel 0: So in doing this, you've got possible contributing factors. If you were to draw a conclusion from it, what would your conclusion be?\n\nChannel 1: My take on my conclusion is that I think the sling was too far down the back and possibly with his rigidity. That's the only thing I can imagine. The more that he went straight over the back. So if he if that changed it to a medium sling, it'll be further up just below his neck, so he won't be able to tip in that manner.\n\nChannel 0: Yep.\n\nChannel 1: I don't I don't believe it was up far enough.\n\nChannel 0: Didn't Kiara Esteban say that sizing wise, the thing he had was appropriate?\n\nChannel 1: She did, but she's changed it\n\nChannel 0: She\n\nChannel 1: because\n\nChannel 0: has and\n\nChannel 1: he\n\nChannel 0: and she's\n\nChannel 1: yeah.\n\nChannel 0: and and I guess my take on that was that it would fit into either.\n\nChannel 1: Yes. But if when and putting it on, when the staff put it on, they may may not have realized or may not notice, and they may have had it too well, they must have done. They had it too far down the top of his back. And then if he's like, he was fine when they lifted him, but the moment he went out over the floor, maybe he stiffened. Not sure.\n\nAnd he's he's flung straight out of the top of it. So it must have been, I reckon, mid back rather than higher up towards the shoulders or over the\n\nChannel 0: And\n\nChannel 1: shoulders.\n\nChannel 0: the the you got another account. It's there's the bottom left sling loop unhooked from the hoist clip during the transfer.\n\nChannel 1: Yep. One of them\n\nChannel 0: So\n\nChannel 1: did say that she she believed that it unhooked when he flipped out, So it's forced it up. I'm not sure if that's correct or not.\n\nChannel 0: So again, just to get this right, it unclipped when he fell out or it unclipped causing the fallout?\n\nChannel 1: My understanding is it's Winnie fell out. That's what the person has said. And I had one of them come in to see me herself actually this morning, and she said, you know, that they it looked fine, and she was beside herself with apologies. And I said, you know, we're not really sure other than he did go over the back. I said I did wonder if the sling was too far down his back.\n\nChannel 0: Alright. Can you then just amend your document, Deb?\n\nChannel 1: Yep.\n\nChannel 0: Because it it's not really clear then. So observe\n\nChannel 1: Mhmm.\n\nChannel 0: fax, the last one. Another state's left hand button, unhook from the hoist clip during the transfer is what you've said. And I guess, great. You need to elaborate on that and then say, as a result of Bevan becoming stiff and going\n\nChannel 1: Yep.\n\nChannel 0: backwards. Sling pleasant may have allowed in adequate posture once the rep is moving. So probably that bit there needs to be elaborated on. Sling pleasant may have allowed inadequate posture, upper body support, essentially. What you're saying is the sling might the sling wasn't fine above his back.\n\nChannel 1: Yep. Alright.\n\nChannel 0: So so that sort of make that a bit more obvious and clearer.\n\nChannel 1: Yep.\n\nChannel 0: And then the safety pause check, if what we're saying is then the the sling under under loops were correctly in place. Would the safety pause check have identified anything? Potentially, that it may not have been fired or put his back, but it wouldn't have identified that the loops were in the wrong spot or one was missing because, allegedly, it was in place.\n\nChannel 1: You don't believe it was in place?\n\nChannel 0: I don't believe.\n\nChannel 1: Well, I think the student who was being taught, so we're talking about her she's had twelve months of RN training, just about just about finishing her year. She she was quite clear that they were in place, I'm sure.\n\nChannel 0: No. That's what I'm saying. So if we're saying that they were in place and we didn't do a safety\n\nChannel 1: A safety check.\n\nChannel 0: pause check, it wouldn't have picked that up because they were in place.\n\nChannel 1: Yeah.\n\nChannel 0: So\n\nChannel 1: It\n\nChannel 0: even\n\nChannel 1: wouldn't\n\nChannel 0: if\n\nChannel 1: have\n\nChannel 0: we\n\nChannel 1: picked\n\nChannel 0: did do it\n\nChannel 1: yeah.\n\nChannel 0: but would it have picked up that this thing was too far down his back, maybe?\n\nChannel 1: Yes.\n\nChannel 0: Okay.\n\nChannel 1: If if the staff are aware of that enough.\n\nChannel 0: Okay. So I guess just in that one then, you said a safety posture may not have occurred and may not have identified the insecure sling loop, which what we're then saying is that it wouldn't have because it was we're saying it it was in place and that it became unsecure at the point the transfer was happening.\n\nChannel 1: Yeah.\n\nChannel 0: So you're suggesting that\n\nChannel 1: Well, it's presumption, isn't it?\n\nChannel 0: well, no. You're suggesting on point two then that had the safety pause check occurred, it could have identified the insecure sling loop, but you're also saying it was in place and only became insecure during the transfer because he became rigid.\n\nChannel 1: Yeah. Okay.\n\nChannel 0: So so what I'm saying is it wouldn't have identified it anyway,\n\nChannel 1: No. No. It wouldn't have done.\n\nChannel 0: But maybe it would have identified that the sling was too far down his back.\n\nChannel 1: Yeah. So I did positioning.\n\nChannel 0: And I guess the bits then that's missing on the whole statement, you've got what happened to the timeline, what the observed facts about, what we actually know, what we are speculating, which is the contributing factors, and then what the actions were. But there's a key action missing, and these are actions that have happened. You got the statement. You had to train some stuff. We've reported the service one.\n\nWhat are we gonna do to stop it happening again? That's not mentioned.\n\nChannel 1: Well, I've sent a memo out for staff. They're all being trained at Huddl's.\n\nChannel 0: Okay. So I guess we're gonna action that,\n\nChannel 1: Yep.\n\nChannel 0: and maybe\n\nChannel 1: Well,\n\nChannel 0: you can put\n\nChannel 1: he\n\nChannel 0: a separate\n\nChannel 1: went out last week. Yep.\n\nChannel 0: and that's fine. So maybe a separate heading, you know, reduction of future risk or something. He's always on memo to staff, this and that, and then, probably, we need to update the procedure that talks about there's a pause and a check on safety critical things.\n\nChannel 1: Yep.\n\nChannel 0: Maybe we could list them what they are. You know, is it\n\nChannel 1: Okay.\n\nChannel 0: the right size sling? Is it fine enough for his back? Is it other other loops correctly connected? You know, whatever\n\nChannel 1: Yep.\n\nChannel 0: whatever we think it should be, and then we can incorporate that in the procedure. Because that's what Zenith's gonna ask me. He's he's gonna\n\nChannel 1: Sorry?\n\nChannel 0: say, great. I've got that's what Zenith from the board is gonna ask me. And\n\nChannel 1: Yeah.\n\nChannel 0: now if I send them this, he's gonna say, okay. Great. We'll amend the contributing factor. So we said, for want of a better word, looks like some sort of human error. It could have been human error at one or two or three or four or whatever.\n\nGreat. What are you gonna do to fix this, Mike? That's that's the question.\n\nChannel 1: Yep. Okay. Alright. I will try and remember all that, and I'll start doing it.\n\nChannel 0: Okay. Sounds\n\nChannel 1: When you need it. Bye.\n\nChannel 0: good. K. Bye.\n\nChannel 1: Bye.","paragraphs":[{"sentences":[{"text":"Hello?","start":1.1999999,"end":1.6999999,"sentiment":"neutral","sentiment_score":0.050438717007637024},{"text":"How are you","start":2.48,"end":2.8799999,"sentiment":"neutral","sentiment_score":0.11681649088859558}],"sentiment":"neutral","sentiment_score":0.10022204741835594,"channel":1,"num_words":4,"start":1.1999999,"end":2.8799999},{"sentences":[{"text":"Hello.","start":2.72,"end":3.12,"sentiment":"neutral","sentiment_score":0.1143903061747551}],"sentiment":"neutral","sentiment_score":0.1143903061747551,"channel":0,"num_words":1,"start":2.72,"end":3.12},{"sentences":[{"text":"doing?","start":2.8799999,"end":3.3799999,"sentiment":"neutral","sentiment_score":0.12384794652462006}],"sentiment":"neutral","sentiment_score":0.12384794652462006,"channel":1,"num_words":1,"start":2.8799999,"end":3.3799999},{"sentences":[{"text":"It's me again.","start":3.12,"end":4.1,"sentiment":"neutral","sentiment_score":-0.06467274576425552}],"sentiment":"neutral","sentiment_score":-0.06467274576425552,"channel":0,"num_words":3,"start":3.12,"end":4.1},{"sentences":[{"text":"Yeah.","start":4.48,"end":4.98,"sentiment":"neutral","sentiment_score":-0.10933225601911543}],"sentiment":"neutral","sentiment_score":-0.10933225601911543,"channel":1,"num_words":1,"start":4.48,"end":4.98},{"sentences":[{"text":"But where are you out of interest?","start":5.3599997,"end":6.7999997,"sentiment":"neutral","sentiment_score":-0.3200089292866843},{"text":"It sounds a bit echoey.","start":6.7999997,"end":7.94,"sentiment":"negative","sentiment_score":-0.371081280708313}],"sentiment":"negative","sentiment_score":-0.34128907571236294,"channel":0,"num_words":12,"start":5.3599997,"end":7.94},{"sentences":[{"text":"Oh, I was in the clinical office, and now","start":8.639999,"end":11.5199995,"sentiment":"neutral","sentiment_score":-0.07480884343385696}],"sentiment":"neutral","sentiment_score":-0.07480884343385696,"channel":1,"num_words":9,"start":8.639999,"end":11.5199995},{"sentences":[{"text":"Oh.","start":11.44,"end":11.94,"sentiment":"neutral","sentiment_score":-0.05171741545200348}],"sentiment":"neutral","sentiment_score":-0.05171741545200348,"channel":0,"num_words":1,"start":11.44,"end":11.94},{"sentences":[{"text":"I'm walking down the corridor.","start":11.5199995,"end":12.74,"sentiment":"neutral","sentiment_score":-0.04096247851848602}],"sentiment":"neutral","sentiment_score":-0.04096247851848602,"channel":1,"num_words":5,"start":11.5199995,"end":12.74},{"sentences":[{"text":"Oh, that's alright.","start":13.485,"end":14.545,"sentiment":"neutral","sentiment_score":-0.030854887639482815},{"text":"Just I'm just reading through the incident review for Bevan Brown.","start":15.164999,"end":19.425,"sentiment":"neutral","sentiment_score":-0.0666231330145489},{"text":"And one of the things you put in there under the possible contributing factors, you've said a safety check pause may not have occurred or may not have identified the insecure sling loop.","start":20.365,"end":33.46,"sentiment":"neutral","sentiment_score":-0.14637389914555984}],"sentiment":"neutral","sentiment_score":-0.12033527229536087,"channel":0,"num_words":47,"start":13.485,"end":33.46},{"sentences":[{"text":"Mhmm.","start":34.21,"end":34.71,"sentiment":"neutral","sentiment_score":-0.04090392217040062}],"sentiment":"neutral","sentiment_score":-0.04090392217040062,"channel":1,"num_words":1,"start":34.21,"end":34.71},{"sentences":[{"text":"This safety check pause, where where does it talk about that in our policy or procedure?","start":35.2,"end":41.845,"sentiment":"neutral","sentiment_score":-0.0672559926752001}],"sentiment":"neutral","sentiment_score":-0.0672559926752001,"channel":0,"num_words":16,"start":35.2,"end":41.845},{"sentences":[{"text":"Well, I don't know.","start":44.805,"end":45.845,"sentiment":"neutral","sentiment_score":-0.14900102466344833},{"text":"So this is our policy and procedure.","start":45.845,"end":47.365,"sentiment":"neutral","sentiment_score":-0.11051573072160993},{"text":"It is because they are trained by the but they're always trained to stop and check.","start":47.365,"end":53.385002,"sentiment":"neutral","sentiment_score":-0.08931152755394578},{"text":"So that's what it is.","start":54.030003,"end":54.99,"sentiment":"neutral","sentiment_score":-0.05768116265535354},{"text":"It's a stop and check.","start":54.99,"end":55.95,"sentiment":"neutral","sentiment_score":-0.0402780469506979}],"sentiment":"neutral","sentiment_score":-0.08887553250266088,"channel":1,"num_words":37,"start":44.805,"end":55.95},{"sentences":[{"text":"Have we got all the hooks and the colors before we move?","start":55.95,"end":59.09,"sentiment":"neutral","sentiment_score":-0.04439518662790457},{"text":"So that's a a standard process, but I don't know about whether it's in a policy.","start":59.95,"end":65.57,"sentiment":"neutral","sentiment_score":-0.17374845407903194}],"sentiment":"neutral","sentiment_score":-0.11831133945712022,"channel":1,"num_words":28,"start":55.95,"end":65.57},{"sentences":[{"text":"I thought just because you you the way it's worded, the safety check pause may not have occurred.","start":68.045,"end":73.985,"sentiment":"neutral","sentiment_score":-0.24692456920941672},{"text":"And I guess my question is then, if it's not in the 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customer discusses a safety check with the agent, questioning whether it was included in the policy or procedure. The agent explains that it is a safety check that needs to be done and suggests the customer may need to change the procedure if the safety check is not found. The speakers also discuss proper positioning and safety posture for a sling that was not properly in place during a transfer, and the potential impact of a safety check and reduction of future risk."},"intents":{"segments":[{"text":"Just I'm just reading through the incident review for Bevan Brown. And one of the things you put in there under the possible contributing factors, you've said a safety check pause may not have occurred or may not have identified the insecure sling loop. Mhmm.","start_word":40,"end_word":84,"intents":[{"intent":"Discuss safety check pause and sling loop issue","confidence_score":0.000101332866},{"intent":"Clarify incident review and policy","confidence_score":0.00003452454}]},{"text":"This safety check pause, where where does it talk about that in our policy or procedure? Well, I don't know. So this is our policy and procedure. It is because they are trained by the but they're always trained to stop and check. So that's what it is. It's a stop and check. Have we got all the hooks and the colors before we move?","start_word":85,"end_word":149,"intents":[{"intent":"Clarify procedure details","confidence_score":0.0004043747}]},{"text":"So we may need to amend the procedure.","start_word":233,"end_word":240,"intents":[{"intent":"Amend procedure","confidence_score":0.51329845}]},{"text":"You mean the procedure? The manual task procedure. Yeah.","start_word":254,"end_word":262,"intents":[{"intent":"Clarify procedures","confidence_score":0.016670017}]},{"text":"I'm just trying to work out is it already in there. So is it in the policy or is it in the procedure or are they or are they trained in it is what you're asking? Yeah.","start_word":342,"end_word":378,"intents":[{"intent":"Explain product usage","confidence_score":0.000008055137}]},{"text":"The verification that all clips and loops are correctly attached before lifting. That would be your safety pause.","start_word":400,"end_word":417,"intents":[{"intent":"Verify clip and loops","confidence_score":0.038266353}]},{"text":"If you were to draw a conclusion from it, what would your conclusion be?","start_word":489,"end_word":502,"intents":[{"intent":"Draw conclusion","confidence_score":0.7055515}]},{"text":"My take on my conclusion is that I think the sling was too far down the back and possibly with his rigidity. That's the only thing I can imagine. The more that he went straight over the back. So if he if that changed it to a medium sling, it'll be further up just below his neck, so he won't be able to tip in that manner. Yep.","start_word":503,"end_word":570,"intents":[{"intent":"Change sling size","confidence_score":0.40852752},{"intent":"Adjust sling","confidence_score":0.0197652},{"intent":"Explain purpose of change","confidence_score":0.0009301991}]},{"text":"Didn't Kiara Esteban say that sizing wise, the thing he had was appropriate?","start_word":581,"end_word":593,"intents":[{"intent":"Check sizing","confidence_score":0.008798183}]},{"text":"So again, just to get this right, it unclipped when he fell out or it unclipped causing the fallout?","start_word":780,"end_word":798,"intents":[{"intent":"Specify location of fallout","confidence_score":0.003169581}]},{"text":"Can you then just amend your document, Deb? Yep.","start_word":876,"end_word":884,"intents":[{"intent":"Amend document","confidence_score":0.20005818}]},{"text":"And then the safety pause check, if what we're saying is then the the sling under under loops were correctly in place. Would the safety pause check have identified anything? Potentially, that it may not have been fired or put his back, but it wouldn't have identified that the loops were in the wrong spot or one was missing because, allegedly, it was in place.","start_word":1004,"end_word":1068,"intents":[{"intent":"Verify safety check","confidence_score":0.012429547}]},{"text":"Well, I think the student who was being taught, so we're talking about her she's had twelve months of RN training, just about just about finishing her year. She she was quite clear that they were in place, I'm sure.","start_word":1079,"end_word":1118,"intents":[{"intent":"Explain rn training","confidence_score":0.00070313964}]},{"text":"So I guess just in that one then, you said a safety posture may not have occurred and may not have identified the insecure sling loop, which what we're then saying is that it wouldn't have because it was we're saying it it was in place and that it became unsecure at the point the transfer was happening. Yeah.","start_word":1196,"end_word":1254,"intents":[{"intent":"Verify safety posture","confidence_score":0.0010571264},{"intent":"Clarify safety posture","confidence_score":0.0075788125}]},{"text":"What are you gonna do to fix this, Mike?","start_word":1641,"end_word":1649,"intents":[{"intent":"Fix error","confidence_score":0.1029917}]}]},"sentiments":{"segments":[{"text":"Hello? How are Hello. you doing? It's me again. Yeah. But where are you out of interest?","start_word":0,"end_word":16,"sentiment":"neutral","sentiment_score":-0.08870871365070343},{"text":"It sounds a bit echoey.","start_word":17,"end_word":21,"sentiment":"negative","sentiment_score":-0.3680780827999115},{"text":"Oh, I was in the clinical office, and now Oh. I'm walking down the corridor. Oh, that's alright. Just I'm just reading through the incident review for Bevan Brown. And one of the things you put in there under the possible contributing factors, you've said a safety check pause may not have occurred or may not have identified the insecure sling loop. Mhmm. This safety check pause, where where does it talk about that in our policy or procedure? Well, I don't know. So this is our policy and procedure. It is because they are trained by the but they're always trained to stop and check. So that's what it is. It's a stop and check. Have we got all the hooks and the colors before we move? So that's a a standard process, but I don't know about whether it's in a policy. I thought just because you you the way it's worded, the safety check pause may not have occurred. And I guess my question is then, if it's not in the policy, I would then imagine it's only training, but then we're not doing the training. The other company's doing it. well but our procedure then would need to reflect that we require staff to do this. Right. So we may need to amend the procedure. That's what I was trying to figure out. Where where is this thing? You mean the procedure? The manual task procedure. Yeah. So so I could look at that.","start_word":22,"end_word":269,"sentiment":"neutral","sentiment_score":-0.13177362084388733},{"text":"I I have no idea.","start_word":270,"end_word":274,"sentiment":"negative","sentiment_score":-0.3368206024169922},{"text":"I didn't look at the procedure. I just know it is a standard behavior, a standard thing to do that. A safety check pause may not have occurred, which implies that it should have occurred, and staff need staff would know that it had to have occurred.","start_word":275,"end_word":321,"sentiment":"neutral","sentiment_score":-0.27288979291915894},{"text":"And so the question is why would staff know that? So I'm not Okay. saying it's a bad thing.","start_word":322,"end_word":340,"sentiment":"negative","sentiment_score":-0.46677595376968384},{"text":"I'm just trying to work out is it already in there. So is it in the policy or is it in the procedure or are they or are they trained in it is what you're asking? Yeah. So I'm looking at the procedure, which is manual tasks, and it's sort of I'm wondering if I can search this. No. The verification that all clips and loops are correctly attached before lifting. That would be your safety pause. Yeah. I guess we probably just need to look at the wording on it. Yeah. And and I guess probably then what we would do, which is what I thought before, was that if we are gonna say there is a pause or a check, Someone clips the loops on and someone else, because there's always two people, checks it. Yeah. Yeah. So in doing this, you've got possible contributing factors. If you were to draw a conclusion from it, what would your conclusion be?","start_word":341,"end_word":502,"sentiment":"neutral","sentiment_score":-0.0031323982402682304},{"text":"My take on my conclusion is that I think the sling was too far down the back and possibly with his rigidity. That's the only thing I can imagine. The more that he went straight over the back. So if he if that changed it to a medium sling, it'll be further up just below his neck, so he won't be able to tip in that manner.","start_word":503,"end_word":569,"sentiment":"negative","sentiment_score":-0.4738766849040985},{"text":"Yep.","start_word":570,"end_word":570,"sentiment":"neutral","sentiment_score":-0.04491214081645012},{"text":"I don't I don't believe it was up far enough.","start_word":571,"end_word":580,"sentiment":"negative","sentiment_score":-0.35618123412132263},{"text":"Didn't Kiara Esteban say that sizing wise, the thing he had was appropriate? She did, but she's changed it She because has and he and she's yeah. and and I guess my take on that was that it would fit into either. Yes. But if when and putting it on, when the staff put it on, they may may not have realized or may not notice, and they may have had it too well, they must have done.","start_word":581,"end_word":658,"sentiment":"neutral","sentiment_score":-0.19175179302692413},{"text":"They had it too far down the top of his back.","start_word":659,"end_word":669,"sentiment":"negative","sentiment_score":-0.44106948375701904},{"text":"And then if he's like, he was fine when they lifted him, but the moment he went out over the floor, maybe he stiffened. Not sure.","start_word":670,"end_word":695,"sentiment":"neutral","sentiment_score":-0.24356670677661896},{"text":"And he's he's flung straight out of the top of it.","start_word":696,"end_word":706,"sentiment":"negative","sentiment_score":-0.3475518822669983},{"text":"So it must have been, I reckon, mid back rather than higher up towards the shoulders or over the And shoulders. the the you got another account. It's there's the bottom left sling loop unhooked from the hoist clip during the transfer. Yep. One of them So did say that she she believed that it unhooked when he flipped out, So it's forced it up. I'm not sure if that's correct or not. So again, just to get this right, it unclipped when he fell out or it unclipped causing the fallout? My understanding is it's Winnie fell out. That's what the person has said. And I had one of them come in to see me herself actually this morning, and she said, you know, that they it looked fine, and she was beside herself with apologies. And I said, you know, we're not really sure other than he did go over the back. I said I did wonder if the sling was too far down his back. Alright. Can you then just amend your document, Deb? Yep. Because it it's not really clear then. So observe Mhmm. fax, the last one. Another state's left hand button, unhook from the hoist clip during the transfer is what you've said. And I guess, great. You need to elaborate on that and then say, as a result of Bevan becoming stiff and going Yep. backwards. Sling pleasant may have allowed in adequate posture once the rep is moving. So probably that bit there needs to be elaborated on.","start_word":707,"end_word":962,"sentiment":"neutral","sentiment_score":-0.1292547583580017},{"text":"Sling pleasant may have allowed inadequate posture, upper body support, essentially.","start_word":963,"end_word":973,"sentiment":"negative","sentiment_score":-0.3492495119571686},{"text":"What you're saying is the sling might the sling wasn't fine above his back. Yep. Alright. So so that sort of make that a bit more obvious and clearer. Yep. And then the safety pause check, if what we're saying is then the the sling under under loops were correctly in place. Would the safety pause check have identified anything? Potentially, that it may not have been fired or put his back, but it wouldn't have identified that the loops were in the wrong spot or one was missing because, allegedly, it was in place. You don't believe it was in place?","start_word":974,"end_word":1075,"sentiment":"neutral","sentiment_score":-0.12182523076440774},{"text":"I don't believe.","start_word":1076,"end_word":1078,"sentiment":"negative","sentiment_score":-0.34736403822898865},{"text":"Well, I think the student who was being taught, so we're talking about her she's had twelve months of RN training, just about just about finishing her year. She she was quite clear that they were in place, I'm sure.","start_word":1079,"end_word":1118,"sentiment":"neutral","sentiment_score":-0.021208537742495537},{"text":"No.","start_word":1119,"end_word":1119,"sentiment":"negative","sentiment_score":-0.3446137309074402},{"text":"That's what I'm saying. So if we're saying that they were in place and we didn't do a safety A safety check. pause check, it wouldn't have picked that up because they were in place. Yeah. So It even wouldn't if have we picked did do it yeah.","start_word":1120,"end_word":1167,"sentiment":"neutral","sentiment_score":-0.2497606575489044},{"text":"but would it have picked up that this thing was too far down his back, maybe?","start_word":1168,"end_word":1183,"sentiment":"negative","sentiment_score":-0.3612290322780609},{"text":"Yes. Okay. If if the staff are aware of that enough. Okay. So I guess just in that one then, you said a safety posture may not have occurred and may not have identified the insecure sling loop, which what we're then saying is that it wouldn't have because it was we're saying it it was in place and that it became unsecure at the point the transfer was happening. Yeah. So you're suggesting that Well, it's presumption, isn't it? well, no. You're suggesting on point two then that had the safety pause check occurred, it could have identified the insecure sling loop, but you're also saying it was in place and only became insecure during the transfer because he became rigid. Yeah. Okay. So so what I'm saying is it wouldn't have identified it anyway, No.","start_word":1184,"end_word":1320,"sentiment":"neutral","sentiment_score":-0.25104740262031555},{"text":"No. It wouldn't have done.","start_word":1321,"end_word":1325,"sentiment":"negative","sentiment_score":-0.5018880367279053},{"text":"But maybe it would have identified that the sling was too far down his back. Yeah. So I did positioning. And I guess the bits then that's missing on the whole statement, you've got what happened to the timeline, what the observed facts about, what we actually know, what we are speculating, which is the contributing factors, and then what the actions were. But there's a key action missing, and these are actions that have happened. You got the statement. You had to train some stuff. We've reported the service one. What are we gonna do to stop it happening again? That's not mentioned. Well, I've sent a memo out for staff. They're all being trained at Huddl's. Okay. So I guess we're gonna action that, Yep. and maybe Well, you can put he a separate went out last week. Yep. and that's fine. So maybe a separate heading, you know, reduction of future risk or something. He's always on memo to staff, this and that, and then, probably, we need to update the procedure that talks about there's a pause and a check on safety critical things. Yep. Maybe we could list them what they are. You know, is it Okay. the right size sling? Is it fine enough for his back? Is it other other loops correctly connected? You know, whatever Yep. whatever we think it should be, and then we can incorporate that in the procedure. Because that's what Zenith's gonna ask me. He's he's gonna Sorry? say, great. I've got that's what Zenith from the board is gonna ask me. And Yeah. now if I send them this, he's gonna say, okay. Great. We'll amend the contributing factor. So we said, for want of a better word, looks like some sort of human error. It could have been human error at one or two or three or four or whatever. Great. What are you gonna do to fix this, Mike? That's that's the question. Yep. Okay. Alright. I will try and remember all that, and I'll start doing it. Okay. Sounds When you need it. Bye.","start_word":1326,"end_word":1675,"sentiment":"neutral","sentiment_score":-0.01608991699559348},{"text":"good.","start_word":1676,"end_word":1676,"sentiment":"positive","sentiment_score":0.4424321055412293},{"text":"K. Bye. Bye.","start_word":1677,"end_word":1679,"sentiment":"neutral","sentiment_score":0.14358821511268616}],"average":{"sentiment":"neutral","sentiment_score":-0.13916751050726558}}}}