Rachelle Ross
Identity and status
| Field | Value |
|---|---|
| PFD reference | 2023-0067 |
| Report date | 17 February 2023 |
| Coroner area | Newcastle upon Tyne and North Tyneside |
| Setting and transition | Primary care/screening; national programme to GP |
| Systems described | National Screening Service feed, EMIS and SystmOne |
| Verification status | Primary report and EMIS/TPP responses verified |
| Evidence claim | CLM-002 |
| Corpus record | 2023-0067 in the all-reports catalogue |
Coronial concern
The coroner heard that a patient's National Screening Service non-responder status was not automatically supplied into EMIS or SystmOne as a computable warning. A non-responder warning therefore depended on manual entry by an individual GP practice. The report stated that an automatic non-responder flag could standardise the approach and increase patient safety.
Respondent account
The vendor responses said that due/outstanding smear alerts already existed. The missing information flow described in the evidence was the national non-responder status, not every form of screening alert. This respondent clarification constrains the scope of the coronial concern.
Reviewer-coded mechanism
The review codes this as a computable-status, cohort visibility and manual safety-netting problem. These are reviewer classifications:
IDPOPandINT: a national programme status did not arrive as computable data in the GP workflow.ALERT: the specific non-responder warning depended on local manual entry.LOOP: accountable follow-up depended on the locally created state.GOV: standardisation and responsibility crossed national, vendor and practice boundaries.
Limitations
The evidence must not be generalised into a claim that EMIS or SystmOne lacked all cervical-screening alerts. Current product, national-feed and local configuration behaviour requires recheck. One PFD does not estimate the frequency of missing or manually entered non-responder status.
Defence applicability
An eligible person can be visible in an individual record while remaining operationally absent from a search, alert or recall workflow. This is an analogue for screening, immunisation, readiness and safety-search denominators in mobile populations. It informs REQ-001 identity and responsibility, REQ-002 population visibility and REQ-009 decision support, but it is not evidence about DMICP cohort completeness.
Source documents
Last verified
14 July 2026. Primary Judiciary page and both official vendor responses checked; the non-responder distinction is preserved in CLM-002.