Stephen Stringer: digital enquiry routing
Identity and status
| Field | Value |
|---|---|
| PFD reference | 2024-0555 |
| Report date | 15 October 2024 |
| Coroner area | Manchester South |
| Setting and transition | Primary care; patient digital channel to practice |
| Systems described | Electronic patient-enquiry service and GP electronic record |
| Verification status | Primary report and Derby and Derbyshire ICB response verified |
| Evidence claim | CLM-005 |
| Corpus record | 2024-0555 in the all-reports catalogue |
Coronial concern
The GP practice's electronic patient-enquiry service asked patients to select a stream, but headings did not reliably convey whether a GP or administrative team would receive the message. Information routed to the administrative stream did not enter the patient record and was not seen by a doctor. Patients and GPs were unaware of that behaviour.
Respondent account
The Derby and Derbyshire ICB response confirmed the concern and said automated integration with EMIS and SystmOne could be declined in some online-consultation implementations. It discussed AccuRx in the general history of local deployment but did not identify the incident supplier. This profile therefore leaves the supplier unnamed.
Reviewer-coded mechanism
The review codes the case as ambiguous routing that separated patient-supplied clinical information from clinical triage and the longitudinal record. These are reviewer classifications:
LOOP: destination, clinical ownership, escalation and completion were unclear.VIS: headings did not make the receiving pathway clear.HF: patient and clinician mental models differed from system behaviour.PROV: the submitted information was absent from the clinical record.GOV: configuration and integration choices affected the safety control.
Limitations
The official materials do not identify the incident software supplier. Discussion of a product in the response's implementation history is not attribution. The case concerns one implementation and cannot establish the behaviour of every electronic enquiry service, EMIS/SystmOne integration or current configuration.
Defence applicability
Remote consultation and distributed teams can expose the same difference between message receipt and accountable clinical work. The case informs REQ-005 auditable routing and, for record incorporation, REQ-008 provenance. It is not evidence about any Defence messaging channel.
Source documents
Last verified
14 July 2026. Primary Judiciary report and official ICB response checked; supplier non-attribution and source roles remain explicit in CLM-005.