For incidents needing formal analysis the Commission describes a five-step approach: define the problem, determine the root cause, develop possible solutions, select and implement one, and evaluate the outcome. Policies state how and when incidents are analysed, the criteria and process for internal investigation, how serious incidents escalate, and how the provider takes part in external investigations. Police or a coroner decide external investigation of crimes or unexpected deaths.
The graph holds this control, the 0 it maps to, and the evidence behind each claim, over MCP and REST.