do so having taken into account the contents of written submissions sent to me by and on behalf of the Health Board on 4 October 2017 _ (1) There remains uncertainty about the circumstances in which a sick child should be seen by a senior Paediatrician (Registrar or above) prior to discharge. During the hearing was shown a document headed 'Guidance to Paediatric Junior Doctors on Discharge [sic] Children From Assessment Unit' which was given to understand reflects current practice and represents an improvement on the positon in 2006. The information in the letter of 4 October 2017 is broadly consistent with it_ Both documents are silent as to whether a parental request for a second opinion should automatically lead to an examination of the child by the senior doctor_ as was opined in court; where the importance and significance of parents' views were noted. am concerned that a lack of clarity about the Health Board's expectations in this respect may continue to allow for the possibility of a child being discharged without a sufficient (and sufficiently senior) assessment having be made (2) heard evidence at length from the Health Board's current Clinical Lead for Paediatrics about (inter alia) the measures which are in place to ensure that lessons can be learnt (and acted upon) promptly when things do not go to plan_ Specifically heard about steps taken to learn lessons from situations in which a child might re-present in a worse condition following an earlier discharge situation which might result a missed diagnosis did not emerge from this evidence with any confidence that there exist clearly defined and consistently applied criteria from ensuring that learning opportunities are being actively sought out acted upon: For example, was told that there is no defined list of triggers; with much Ieft to judgement of individuals in the senior management team_ This evidence, supplemented by the relevant contents of the letter of 4 October 2017 , leaves me concerned that too much is left to chance in the identification of matters requiring investigation; in the selection of the investigating staff and in the urgency of lessons learnt and acted upon The current system might therefore warrant a review (perhaps including consideration of best practice elsewhere, in other hospitals outside the Health Board) to see whether grounds for improvement exist.