Table 4.

Contributing factors categorised and summarised.

	Protocols		Delay			Equipment and Staff		Communication
	Presence of Adequate Protocol	Not Following Protocol	Delay in Referral/Transfer	Delay in Diagnostics	Delay in Decision-Making/Therapy	Lack of Equipment	Lack of (Well Trained) Staff	Verbal	Medical File
Individual healthcare worker		5.9% [18] 70% [24]	0.9% [21] 5.2% [20] 5.6% [14] 26% [32]	4.5% [22] 13.7% [20] 17% [25] 36.4% [21] 41.3% [15]	5.8% [15] 6.5% [20] 27.8% [14] 28.6% [20] 33.3% [29] 44.3% [21] 46.0% [24] 48% [25] 61% [32]		13% [32] 18.2% [21] 56% [25] 60% [29]	1.6% [18] 6.25% [22]	5% [24] 6.3% [22]
Teamwork							14% [24] 39% [25] 43.3% [29]	10% [18]
System	46.4% [29]			42.9% [29]		6.9% [18] 55.5% [14] 5.8% [15] 3.1% [20]	2.6% [18] 5.1% [20] 11.1% [14] 28% [34] 39.3% [29]	18.8% [20]	14.5% [18]