title: Inquest produces change.
authors.forename: M
authors.initials: M
authors.lastname: Fletcher
mesh_terms: D002983:Clinical Competence / Q000592:standards; D017052:Hospital Mortality; D006776:Hospitals, Pediatric / Q000592:standards*; D006801:Humans; D019300:Medical Errors; D009741:Nursing Staff, Hospital / Q000193:education; D009864:Ontario; D010344:Patient Advocacy; D017410:Practice Guidelines as Topic / Q000592:standards*; D011785:Quality Assurance, Health Care / Q000458:organization & administration*; D012308:Risk Management / Q000592:standards*; D017751:Safety Management / Q000592:standards*