The situation
A credential incident showed that completion records were not proof of safer decisions. Staff knew the standard advice, but reporting and escalation still broke down under pressure.
What changed
The response connected a sanitised version of the incident to the decisions staff actually face. Owners agreed what should trigger a report, where it should go and what evidence should be retained.
Why it matters for ACP
Policy becomes useful when it is attached to a decision and an accountable person. Behaviour-change support is included with paid ACP to reinforce that operating model; it is not a separate purchase.
