Stephen Cassidy

Identity and status

Coronial concern

A known ceftriaxone allergy was recorded in the Summary Care Record. Ambulance staff could access that record, but hospital clinicians could not access it routinely or easily, and it was not integrated into Careflow/Connect or EMIS so the allergy would appear automatically. The inquest conclusion linked the unavailable allergy information to the fatal reaction.

Respondent account

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

Reviewer-coded mechanism

The review codes this as safety-critical information stranded in an external record across a receiving-care boundary. These are reviewer classifications:

• INT: the allergy did not transfer into the receiving workflow automatically.
• VIS: the safety-critical fact was unavailable in the view used.
• HF: access was not routine or easy and depended on a separate retrieval path.
• GOV: organisations and national services shared responsibility for routine access and integration.

Limitations

The finding applies to the systems, access and integration described at the report date. It does not establish current behaviour in those products or the content of a universally sufficient transfer dataset. Wider claims about every organisation or care transition require separate evidence.

Defence applicability

The case is an analogue for civilian, allied, ambulance and evacuation boundaries where a safety-critical fact exists but is not part of the receiving workflow. It informs REQ-003 minimum record and source completeness and REQ-006 transfer delivery. The Defence minimum dataset and supported boundaries remain to be agreed.

Source documents

• SRC-020: Stephen Cassidy PFD, Judiciary

Last verified

14 July 2026. Primary Judiciary report checked; system/date limits and the cross-boundary allergy claim remain explicit in CLM-009.