The tragic death of Lewis Blackman can be understood in the context of errors in

The tragic death of Lewis Blackman can be understood in the context of errors in decision making. Write a three-page case analysis, focusing on the list of prompts below. An important part of your response should include an analysis of the situation and a thorough identification of issues/actions described in the case that may be problematic.
Focus the analysis on the following:
What actions were taken in the case?
Were these actions the most appropriate and why?
Were there any consequences of the taken actions?
Was anything omitted or not considered?
Were actions/procedures in line with existing codes of practice, policy or theories in global health?