We concurred with the Board’s findings and conclusions regarding the patient’s clinical assessment and privileging and with the Board’s finding that nurses did not recognize, in a timely manner, the patient was missing. However, we concluded that the Board's efforts to identify individual responsibility for this delay were insufficient and found the Board did not accurately assess the responsibility of individual police officers during the search. We addressed management’s responsibility for some search deficiencies, including inadequate search policies and employee training. We found that, while the Board made several recommendations to improve the management of future medical emergency scenes, it did not accurately assess some actions that occurred after the patient’s body was found. Finally, we concluded that the Director’s decision to convene the Board was appropriate, but that management failed to assess adequately the sufficiency of the evidence before taking administrative action against the employees involved.