Stephen Rhodes
Identity and status
| Field | Value |
|---|---|
| PFD reference | 2026-0083 |
| Report date | 6 February 2026 |
| Coroner area | Black Country |
| Setting and transition | Primary care/laboratory; laboratory to GP |
| Systems described | Laboratory report, ICE message and EMIS GP record workflow |
| Verification status | Primary report and practice response verified |
| Evidence claim | CLM-001 |
| Corpus record | 2026-0083 in the all-reports catalogue |
Coronial concern
The coroner recorded that a markedly raised NT-proBNP result (3473, against an expected value below 400 for the age group) included advice for specialist assessment and echocardiography within two weeks, but was filed in the mistaken belief that there was no abnormal finding. Evidence suggested the abnormal result was not on the first page or highlighted in red. The laboratory subsequently changed reporting so abnormal results were flagged on the first page.
Respondent account
The practice response provides a more specific technical account: the ICE message did not carry an abnormal flag, and an EMIS manual filter therefore routed it through the normal pathway. This is the respondent's explanation and is not restated as the coroner's finding.
Reviewer-coded mechanism
The review codes this as a coupled high-volume result-review, salience and filing-workflow hazard. These codes are reviewer classifications, not additional coronial findings:
VISandALERT: severity and recommended action were insufficiently prominent or computable in the workflow used.LOOP: filing did not demonstrate clinical action or closure.HF: presentation, high-volume review and user expectation interacted.GOV: the report raised scrutiny and national flagging guidance.
Limitations
The evidence does not isolate interface design from workload, filtering, filing practice or other system factors, and it does not establish that interface design alone caused the death. The ICE/EMIS routing chain is a respondent account. Product and configuration behaviour outside the workflow and date examined remains unverified.
Defence applicability
The mechanism is relevant by analogy to fixed, remote and deployed result management, where connectivity, workload and recipient availability may vary. It informs REQ-004 critical-result delivery, REQ-005 task routing and REQ-009 decision support. This does not show that a Defence system has the same defect.
Source documents
Last verified
14 July 2026. Primary Judiciary page and official practice response checked; claim wording and source roles reconciled to the claims register.