This essay discusses the importance of clinical governance in healthcare, particularly in reducing sentinel events within the Hong Kong healthcare system. Using Ishikawa's Fishbone model, the essay analyzes the causes of inpatient suicides, a significant category of sentinel events reported by the Hospital Authority Hong Kong. Key contributing factors identified include poor communication, inadequate risk analysis, delays in activating suicide prevention strategies, and insufficient follow-up with patients on home leave. The essay then explores clinical governance strategies to address these root causes, such as improving communication skills through training, conducting thorough risk assessments, ensuring timely activation of prevention protocols, and implementing integrated care pathways with multidisciplinary teams for comprehensive patient support. Lewin's Force Field Model is employed to understand the driving and restraining forces affecting the implementation of change, highlighting the need to address restraining forces like poor communication and lack of knowledge while strengthening driving forces such as leadership, evidence-based practice, and risk analysis. The essay concludes by emphasizing the importance of a proactive and multifaceted approach to clinical governance to enhance patient safety and reduce the occurrence of sentinel events. Desklib provides access to similar essays and study resources for students.