Learning Point 1:
The after-hours process was new for the agency and was in process regarding smoothing out the progression of case duties when cases come in after-hours.

Learning Point 2:
When the case came in after the critical incident, it was received by agency after-hours staff, which was just recently added to the agency's work tasks as it was previously contracted out. This new process created gaps in communication during transitions between after-hour workers and subsequently-assigned FA/FI workers.