Audrey King

Identity and status

Coronial concern

Eldercare used paper notes while the surgical team relied on NerveCentre. A recommendation to restart anticoagulation was not surfaced through the digital workflow, no alert indicated that important handwritten notes existed, and EPMA had no automatic flag requiring review of the ongoing medication suspension.

Respondent account

No respondent account is used in this case profile. The summary is limited to the primary Judiciary report and the review's transparent coding.

Reviewer-coded mechanism

The review codes this as a safety-critical recommendation split across paper and electronic representations, combined with no forced review of an ongoing medicine hold. These are reviewer classifications:

• VIS and ALERT: neither the paper recommendation nor the need to review suspension was made salient in the digital workflow.
• LOOP: the medicine hold lacked an owned, time-bounded review state.
• HF: teams preferred and relied on different record representations.
• PROV: the longitudinal account was split across paper and digital sources.

Limitations

The report concerns one trust and workflow and does not establish the prevalence of hybrid-record divergence or current NerveCentre/EPMA behaviour elsewhere. CLM-015 records the case-level concern; the broader fallback, migration and synchronisation implications remain analytical translations.

Defence applicability

The mechanism is relevant to paper fallback, bandwidth-limited care, mixed coalition/civilian records and restoration after outage. It informs REQ-007 safe hybrid operation, REQ-009 decision support and, indirectly, REQ-012 degraded operation. Defence fallback and synchronisation controls require direct evidence.

Source documents

• SRC-022: Audrey King PFD, Judiciary

Last verified

14 July 2026. Primary Judiciary report checked; the extracted concern is registered as CLM-015.