In the case of case B, the information about his ill health when he was discharged from hospital was not shared with Healthline, despite it being recorded by the hospital staff. The administration of medication that created an artificial sense of patient wellbeing was never considered in an initial or follow-up clinical assessment. Data from his pulse oximeter was not adequately collected, because he had difficulty using it. And a backlogged system meant the appropriate action was not taken when he was determined to be in need of urgent medical review.