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Case–mechanism/evidence map

This is a case–mechanism/evidence map, not an evidence-gap map. It shows how the 112 reports in the current focused series were coded. An em dash means only that the project did not assign that code to that extracted row; it does not show that a hazard is absent, rare or unsupported in the wider PFD corpus.

Evidence-base guide · All included reports

Mechanism code key

Code Sociotechnical mechanism
LOOP Action ownership and closed loop
GOV Governance and assurance
VIS Information visibility
HF Human factors and usability
INT Interoperability and continuity
ALERT Decision support and alerting
PROV Data quality, provenance and auditability
RES Resilience and degraded operation
IDPOP Identity, registration and population management

Codes are non-exclusive. Counts therefore must not be summed as reports or deaths.

Workflow by mechanism

Primary workflow group Reports LOOP GOV VIS HF INT ALERT PROV RES IDPOP
Diagnostic results and investigations 9 9 7 5 7 2 8 0 4 0
Identity and population management 3 1 3 2 1 2 0 2 1 3
Medication and prescribing 28 21 22 16 18 12 23 10 2 2
Messaging, tasking and follow-up 3 3 2 2 2 1 0 1 2 0
Record access and continuity 14 7 13 13 5 12 0 3 3 0
Record integrity and provenance 6 1 6 4 5 1 0 6 1 0
Referral, handover and transfer 9 9 8 5 5 8 0 5 3 0
Risk, care planning and safeguarding 20 17 20 14 11 16 3 11 4 2
Screening and longitudinal surveillance 3 3 3 1 2 1 2 0 1 2
Triage, observations and decision support 17 8 17 6 15 3 11 7 7 0

This aggregate combines a single primary browsing group with multi-valued analytical codes. It supports navigation and pattern-finding, not prevalence estimates or causal comparison.

Report-level coding matrix

Reference Report Source LOOP GOV VIS HF INT ALERT PROV RES IDPOP
2026-0237 Joseph Cooper SRC-183 — Yes Yes — Yes — — — —
2026-0248 Kenneth Cully SRC-181 Yes Yes — Yes — Yes Yes — —
2026-0247 Amy Chapman SRC-182 Yes Yes Yes Yes — Yes Yes — —
2026-0235 Edward Muwanga SRC-067 Yes Yes Yes Yes Yes Yes — — —
2026-0244 Theresa Lydon SRC-048 Yes Yes Yes Yes Yes — — — —
2026-0242 Paul Harries SRC-184 Yes Yes Yes Yes Yes — Yes — —
2026-0216 Kiefer Fraser-Phillips SRC-185 — Yes — Yes — — Yes Yes —
2026-0200 Jonathan Thornton SRC-066 Yes Yes Yes Yes Yes Yes — — —
2026-0193 Hollie Loraine SRC-186 Yes Yes — Yes — Yes — — —
2026-0229 Ethan Hanson SRC-071 — Yes — Yes Yes Yes Yes — —
2026-0166 John Fisher SRC-053 Yes — — Yes Yes — Yes — —
2026-0165 Delwyn Preece SRC-187 — Yes Yes Yes — — Yes — —
2026-0138 Ruairi Stewart SRC-190 Yes Yes Yes — Yes — Yes — —
2026-0152 Darryl Johnson SRC-188 — Yes — Yes — — Yes Yes Yes
2026-0148 Roman Barr SRC-189 Yes Yes — Yes — Yes — — —
2026-0115 Emma Turner SRC-191 — Yes Yes Yes Yes — Yes — —
2026-0073 Gareth Chumber-Kelly SRC-193 Yes Yes Yes — Yes — Yes Yes —
2026-0078 Elise Sebastian SRC-192 Yes Yes — Yes — Yes Yes Yes —
2026-0069 Roger Smith SRC-194 Yes Yes Yes Yes — Yes — — —
2026-0083 Stephen Rhodes SRC-001 Yes Yes Yes Yes — Yes — — —
2026-0053 Lyn Maher SRC-196 — Yes Yes — Yes Yes — — —
2026-0048 Avery Hall SRC-056 Yes Yes — — — Yes — — Yes
2026-0045 Akhona Moyo SRC-065 — Yes Yes Yes Yes — — — —
2026-0047 Nigel Feckey SRC-197 Yes Yes Yes Yes Yes — — Yes —
2026-0042 Pippa Gillibrand SRC-198 — Yes Yes Yes — — — Yes —
2026-0015 Stuart Berry SRC-199 Yes Yes Yes Yes Yes — Yes — —
2026-0004 Robert Gracey SRC-200 — Yes — Yes — Yes — — —
2026-0006 Theo Tuikubulau SRC-070 — Yes — Yes — Yes — — —
2025-0642 Colin Brown SRC-201 Yes Yes Yes Yes Yes — — Yes —
2025-0630 Valerie Gibson SRC-043 Yes Yes — Yes Yes — Yes — —
2025-0615 Hannah Booth SRC-046 Yes Yes Yes — Yes — Yes — Yes
2025-0609 Alan Peet SRC-221 — Yes — Yes — — Yes Yes —
2025-0584 Ethel Robertson SRC-202 Yes Yes Yes — Yes — — — —
2025-0577 Alan Mitchell SRC-203 Yes Yes — — — Yes Yes — —
2026-0068 Anthony Card SRC-195 Yes Yes — — Yes — — — —
2025-0554 Gloria Simon SRC-204 — Yes Yes Yes — — Yes — —
2025-0556 Stephen Neville SRC-220 Yes Yes Yes Yes — — Yes — —
2025-0531 Amy Cross SRC-219 Yes Yes — — Yes — Yes — —
2025-0529 Melanie Walker SRC-205 — Yes — Yes — Yes — Yes —
2025-0511 Paula Doreen Hughes SRC-041 Yes Yes — Yes — Yes — — —
2025-0515 Thompson Elliott SRC-206 Yes Yes — Yes Yes — Yes — —
2025-0506 Jillian Steedman SRC-207 Yes Yes Yes — Yes — Yes — —
2025-0500 Derek Crowther SRC-208 — Yes Yes — — — Yes Yes —
2025-0454 James Cochrane SRC-209 — Yes Yes Yes — — Yes — —
2025-0427 Venetia Pierce SRC-210 — Yes — — Yes Yes — — —
2025-0415 Jessica Smithson SRC-211 Yes Yes — — Yes — — Yes Yes
2025-0410 John Bell SRC-212 Yes Yes Yes Yes — — — — —
2025-0397 Margaret McNaughton SRC-214 — Yes Yes Yes Yes Yes Yes — —
2025-0357 Myles Scriven SRC-215 Yes Yes Yes Yes — — — — —
2025-0340 Miles Robinson SRC-216 — Yes — Yes — Yes — — —
2025-0336 Jason Clemens SRC-217 Yes Yes Yes Yes — Yes — — —
2025-0333 Thomas Mallinson SRC-218 Yes Yes — — Yes Yes — Yes —
2025-0232 John Spencer SRC-045 — Yes Yes — Yes — — — —
2025-0144 Darren Turner SRC-047 Yes Yes — — — — Yes — Yes
2025-0121 Chloe Burgess SRC-055 — Yes Yes — — Yes — — —
2025-0079 Anthony Binfield; David Richards; Rolandas Karbauskas SRC-074 Yes Yes Yes Yes Yes — Yes Yes —
2025-0027 Tammy Milward SRC-075 Yes Yes Yes Yes Yes — — — —
2024-0660 Elton Deutekom SRC-068 Yes Yes Yes Yes Yes — Yes — —
2024-0656 Oliver Billings SRC-042 Yes — Yes — Yes — — Yes —
2024-0646 Emma Sanders SRC-038 Yes Yes Yes — Yes — — — —
2024-0555 Stephen Stringer SRC-014 Yes Yes Yes Yes — — Yes — —
2024-0323 Eric Thompson SRC-019 Yes Yes Yes — — Yes — Yes —
2024-0304 Bernard Compton SRC-073 Yes Yes — Yes — Yes — — —
2024-0280 Tracy McCarthy SRC-072 Yes Yes Yes Yes — Yes Yes — —
2024-0273 Lily Jahany SRC-039 Yes Yes Yes — Yes — — — —
2024-0116 Jennifer Trigger SRC-051 Yes — Yes Yes — — — Yes —
2024-0082 Michael Nye SRC-044 Yes Yes — Yes — Yes — Yes —
2024-0076 Ethel Reed SRC-069 Yes Yes Yes Yes Yes — Yes — —
2024-0056 Samuel Jordan SRC-021 — Yes Yes — Yes — — — Yes
2024-0126 John Singleton SRC-062 Yes Yes Yes — — Yes — — Yes
2023-0417 Francis Barnes SRC-059 Yes Yes — — Yes — Yes — —
2023-0392 Jason Bayley SRC-063 Yes Yes Yes Yes Yes Yes Yes — —
2023-0346 Sebastian Daniels SRC-050 Yes — Yes Yes — Yes — — —
2023-0337 Stephen Cassidy SRC-020 — Yes Yes Yes Yes — — — —
2023-0436 Jack Farrington SRC-058 Yes Yes Yes — Yes — Yes Yes —
2023-0312 Audrey King SRC-022 Yes — Yes Yes — Yes Yes — —
2025-0402 Lee Dryden SRC-213 Yes Yes — Yes Yes Yes — Yes —
2023-0259 Michael Amesbury SRC-052 Yes Yes Yes — Yes — — — —
2023-0252 Colin Greenway SRC-040 Yes Yes — Yes — Yes — — —
2023-0242 John James SRC-057 Yes — Yes — — Yes — — —
2023-0067 Rachelle Ross SRC-002 Yes Yes — — Yes Yes — — Yes
2023-0046 Ania Sohail SRC-064 Yes Yes Yes Yes Yes Yes Yes — —
2023-0038 Hugo Carlos SRC-061 Yes Yes Yes Yes — Yes — — Yes
2022-0407 Alexander Braund SRC-003 — Yes Yes — — — Yes — —
2022-0090 Donald Compton SRC-054 — Yes Yes Yes — Yes — — —
2022-0011 Darran Busby SRC-049 Yes — Yes Yes — Yes — — —
2021-0361 Christopher Collinson SRC-060 Yes Yes Yes Yes — Yes — — —
2021-0312 Morris Reddington SRC-004 Yes Yes — Yes Yes — — Yes —
2018-0405 Deceased name redacted SRC-127 — Yes Yes Yes — — Yes — —
UNREF-2018-PAUL-PRICE Paul Price SRC-126 Yes Yes — — Yes — — Yes —
UNREF-2018-MARIAN-GRANT Marian Grant SRC-125 Yes — Yes Yes — Yes — — —
2018-0129 Greg Hutchins SRC-112 Yes Yes — — Yes — Yes — —
2018-0259 Michael Drewell SRC-121 Yes — Yes Yes — — Yes — —
2018-0256 Karl Willis SRC-128 Yes Yes — Yes Yes Yes — — —
2018-0267 Steven Welch SRC-122 Yes Yes — — Yes — — Yes —
2018-0280 Cuthbert Hingert SRC-123 — Yes Yes Yes — Yes — — —
2018-0252 Jacob Sulaiman SRC-120 Yes Yes Yes — Yes — — — —
2018-0189 John Hazlewood SRC-119 Yes — — — Yes — Yes Yes —
2018-0181 Darren Carrington SRC-118 Yes Yes — Yes — Yes — — —
2018-0164 Joan Lunt SRC-116 — Yes — Yes — — Yes — —
2018-0277 Brian Bicat SRC-124 — Yes — — Yes Yes — — —
2018-0162 Grahame Searby SRC-115 — Yes Yes — Yes — — — —
2018-0165 Michalla Sweeting SRC-117 Yes — Yes Yes — — Yes — —
2018-0134 Joanne Richardson SRC-113 Yes Yes Yes — Yes — — — —
2018-0140 Stephen Tidey SRC-114 Yes Yes — — Yes — Yes Yes —
2018-0111 Adrian Jennings SRC-111 Yes Yes — Yes Yes — — — —
2018-0102 Patricia Heslop SRC-110 — Yes — Yes Yes — Yes — —
UNREF-2018-MARGARET-SPENCER Margaret Spencer SRC-109 Yes Yes — Yes — — — Yes —
2018-0035 Mavis Reeves SRC-129 — Yes Yes Yes — — — Yes —
UNREF-2018-CALIEL-SMITH-KWAMI Caliel Smith-Kwami SRC-106 Yes Yes Yes Yes — Yes — — —
2018-0009 Pauline Pryor SRC-107 Yes Yes — — Yes Yes — Yes —
2018-0010 David Buttriss SRC-108 — Yes Yes — Yes — — Yes —

Reports by mechanism

These stable lists make complete code membership directly browsable without reading across the wide matrix. A report can appear in several lists.

LOOP — Action ownership and closed loop

79 coded reports. Membership is non-exclusive and expresses the project's current analytical coding, not causal weight.

GOV — Governance and assurance

101 coded reports. Membership is non-exclusive and expresses the project's current analytical coding, not causal weight.

VIS — Information visibility

68 coded reports. Membership is non-exclusive and expresses the project's current analytical coding, not causal weight.

HF — Human factors and usability

71 coded reports. Membership is non-exclusive and expresses the project's current analytical coding, not causal weight.

INT — Interoperability and continuity

58 coded reports. Membership is non-exclusive and expresses the project's current analytical coding, not causal weight.

ALERT — Decision support and alerting

47 coded reports. Membership is non-exclusive and expresses the project's current analytical coding, not causal weight.

PROV — Data quality, provenance and auditability

45 coded reports. Membership is non-exclusive and expresses the project's current analytical coding, not causal weight.

RES — Resilience and degraded operation

28 coded reports. Membership is non-exclusive and expresses the project's current analytical coding, not causal weight.

IDPOP — Identity, registration and population management

9 coded reports. Membership is non-exclusive and expresses the project's current analytical coding, not causal weight.

Other controlled dimensions

Care-setting span

Care-setting span Reports
Multiple care settings 67
One care setting 45

Sector boundary

Sector boundary Reports
Health and non-health sectors 11
Health services only 88
Health, social care and other non-health sectors 4
Health and social care 7
Social care only 2

Origin care context

Counts are non-exclusive.

Origin context Reports
Ambulance or urgent response 5
Community care 23
Diagnostic service 10
National programme or service 3
Non-health agency 11
Patient or public 16
Pharmacy 2
Primary care 21
Private healthcare 3
Secondary care 43
Secure or custodial healthcare 7
Social care 9
Tertiary or specialist care 1
Unclear 1

Information origin

Origin setting Reports
Ambulance, NHS 111 or urgent response 1
Community health or rehabilitation 1
Community mental-health care 4
Laboratory, radiology or diagnostic service 6
Inpatient or secure mental-health care 7
Community maternity care 1
Multiple settings or services 35
National programme or service 3
Police, local authority or other non-health agency 2
Patient or home 9
Primary care 10
Private healthcare provider 2
Secondary acute or outpatient care 23
Prison, custody or secure healthcare 3
Social care, care home or supported living 4
Unclear 1

Settings and pathway participants

Counts are non-exclusive.

Setting or pathway participant Reports
Acute maternity or neonatal care 2
Acute paediatric care 3
Ambulance, NHS 111 or urgent response 17
Community health or rehabilitation 4
Community maternity care 2
Community mental-health care 28
Inpatient or secure mental-health care 12
Laboratory, radiology or diagnostic service 11
National programme or service 3
Patient or home 17
Pharmacy or dispensing service 7
Police, local authority or other non-health agency 15
Primary care 40
Prison, custody or secure healthcare 10
Private healthcare provider 4
Secondary acute or outpatient care 38
Social care, care home or supported living 13
Tertiary or specialist care 3

Primary browsing context

Browsing context Reports
Acute and emergency care 32
Cross-setting and multi-agency care 20
Maternity and paediatric care 6
Mental health care 21
Primary and community care 23
Secure and custodial care 10

Predominant information boundary

Boundary type Reports
Across health and non-health sectors 11
Between care settings 52
Hybrid paper and digital record 9
National-to-local information flow 3
Patient-to-service channel 11
Within a care setting 26