The Role of Health Service

(1) Identification of health staff (GPs, other doctors and medical staff, nursing staff, hospital staff and other health workers) and health agencies involved in the care of Victoria, Kouao or Manning in the relevant period.

(2) The extent and nature of the involvement of health staff and agencies in the care of Victoria, Kouao and Manning.

(3) In respect of each occasion on which Victoria, Kouao or Manning came into contact with health staff and agencies in the relevant period:

(i) the condition or complaints presented;

(ii) the assessments and diagnoses made;

(iii) the treatments provided;

(iv) the advice or assistance sought;

(v) the advice or assistance offered;

(vi) the arrangements for the future made;

(vii) the information about them passed to other individuals, departments or agencies; and

(viii) the follow up of such shared intelligence.

(4) Case management and monitoring arrangements for those responses.

(5) The evidence, if any, which should have alerted health staff or agencies to the need to take action on Victoria's behalf.

(6) The action which was taken as a consequence of such evidence and its effects.

(7) The further actions, if any, which should have been taken and the likely effect of the timely taking of such action.

(8) The way in which the response of health staff and health agencies took account of race and cultural issues.

(9) The training, experience and case loads of health staff who came into contact with Victoria during the relevant period.

(10) The supervision and management of the work of health staff with responsibility for Victoria.

(11) The extent to which local health agency policy and procedures reflected statutory requirements, national guidance and best practice and the extent to which local practice complied with such policy and procedures.