Morris Reddington
Identity and status
| Field | Value |
|---|---|
| PFD reference | 2021-0312 |
| Report date | 21 May 2021 |
| Coroner area | Nottingham and Nottinghamshire |
| Setting and transition | Ambulance/emergency care; ambulance to emergency department |
| Systems described | Ambulance ePRF portal and hospital electronic record workflow |
| Verification status | Primary report and joint hospital/ambulance response verified |
| Evidence claim | CLM-004 |
| Corpus record | 2021-0312 in the all-reports catalogue |
Coronial concern
The coroner found a future risk from failures in ambulance-to-hospital information handover. Emergency-department staff needed separate credentials and unfamiliar navigation to retrieve the ambulance electronic Patient Report Form (ePRF), so ePRFs were routinely not reviewed and staff relied on verbal handover.
Respondent account
The official joint response recorded that the ePRF did not automatically link to hospital records and proposed FHIR delivery of draft and final ePRFs. The proposed interface and implementation plan are respondent actions, not coronial findings or evidence that the remedy was subsequently implemented.
Reviewer-coded mechanism
The review codes the case as a record that existed technically but remained operationally absent from the receiving workflow. These are reviewer classifications:
INT: the ambulance record did not enter the receiving record automatically.LOOP: arrival, review and finalisation were not a reliable closed loop.HF: separate credentials and unfamiliar navigation discouraged retrieval.RES: the workflow fell back to verbal handover.GOV: organisational and commissioning boundaries shared responsibility for the control.
Limitations
The case describes the systems and practice examined at that time and place; it does not quantify all ePRF review or handover failures. FHIR delivery was a proposed respondent remedy and must not be presented as the coroner's prescribed solution or proof of implementation.
Defence applicability
The mechanism is relevant to ambulance, aeromedical, maritime, civilian and unit-transfer handovers: a retrievable record is not necessarily received clinical work. It informs REQ-006 transfer-record delivery and, indirectly, REQ-012 degraded operation. Defence transfer workflows require separate validation.
Source documents
Last verified
14 July 2026. Primary Judiciary report and official joint response checked; the coronial concern and respondent FHIR proposal remain separated in CLM-004.