Incident Pattern Lens — structural mock

What incident management looks like when the system reads across incidents, not just one at a time. Every record below is synthetic. Start on Individual review — the way it works today — then switch to The pattern.

Site Severity Type

Select an incident to review it.

Notice what you can't see here

Each record is complete, closed, and individually unremarkable. Reviewing them one at a time — which is how the process works today — gives you no way to see what they have in common.

Incidents in window

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Mar – Jun 2026, 4 sites

Mealtime incidents

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all at one site

Staff without IDDSI competency

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involved in those incidents

No recorded review

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nothing verifies escalation

Where they happened

The cross-tab nobody runs

Every mealtime incident, against whether the staff member on shift held the Mealtime Management (IDDSI) competency at the time.

How it escalated

Severity of the mealtime cluster over time. Four months of minor coughing episodes, then a choking incident with ambulance attendance.

The finding

This is not nine incidents. It is one training gap, reported nine times. Every mealtime incident in the window occurred at Willoughby, and every one involved a staff member from the February 2026 intake who had not completed Mealtime Management (IDDSI). Two of the three participants involved have a mealtime management plan that expired before the first incident. Individually each was graded minor and closed. Together they describe a foreseeable, preventable escalation — and no one saw it, because nothing in the process looks across incidents.

The second gap — escalation is unverified

Nothing in the workflow confirms a team leader reviewed the record or escalated it. The ALERT → ERT → CERT pathway exists on paper; nothing checks it ran.