Case–mechanism/evidence map
This is a case–mechanism/evidence map, not an evidence-gap map. It shows how the 71 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 | 8 | 8 | 6 | 5 | 6 | 1 | 7 | 0 | 3 | 0 |
| Identity and population management | 2 | 1 | 2 | 2 | 0 | 2 | 0 | 1 | 0 | 2 |
| Medication and prescribing | 21 | 17 | 15 | 12 | 14 | 8 | 17 | 7 | 2 | 2 |
| Messaging, tasking and follow-up | 3 | 3 | 2 | 2 | 2 | 1 | 0 | 1 | 2 | 0 |
| Record access and continuity | 10 | 5 | 9 | 9 | 3 | 10 | 0 | 2 | 3 | 0 |
| Record integrity and provenance | 4 | 1 | 4 | 3 | 3 | 1 | 0 | 4 | 0 | 0 |
| Referral, handover and transfer | 5 | 5 | 4 | 2 | 3 | 4 | 0 | 2 | 1 | 0 |
| Risk, care planning and safeguarding | 10 | 9 | 10 | 6 | 5 | 9 | 2 | 5 | 2 | 1 |
| Screening and longitudinal surveillance | 3 | 3 | 3 | 1 | 2 | 1 | 2 | 0 | 1 | 2 |
| Triage, observations and decision support | 5 | 2 | 5 | 3 | 5 | 2 | 3 | 2 | 1 | 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 |
|---|---|---|---|---|---|---|---|---|---|---|---|
| 2026-0235 | Edward Muwanga | SRC-067 |
Yes | Yes | Yes | Yes | Yes | Yes | — | — | — |
| 2026-0244 | Theresa Lydon | SRC-048 |
Yes | Yes | Yes | Yes | Yes | — | — | — | — |
| 2026-0200 | Jonathan Thornton | SRC-066 |
Yes | Yes | 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 | — | — |
| 2026-0083 | Stephen Rhodes | SRC-001 |
Yes | Yes | Yes | Yes | — | Yes | — | — | — |
| 2026-0048 | Avery Hall | SRC-056 |
Yes | Yes | — | — | — | Yes | — | — | Yes |
| 2026-0045 | Akhona Moyo | SRC-065 |
— | Yes | Yes | Yes | Yes | — | — | — | — |
| 2026-0006 | Theo Tuikubulau | SRC-070 |
— | 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 |
| 2025-0511 | Paula Doreen Hughes | SRC-041 |
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 | — | — |
| 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 | — |
Other controlled dimensions
Primary setting
| Setting group | Reports |
|---|---|
| Acute and emergency care | 19 |
| Cross-setting and multi-agency care | 12 |
| Maternity and paediatric care | 5 |
| Mental health care | 11 |
| Primary and community care | 18 |
| Secure and custodial care | 6 |
Predominant information boundary
| Boundary type | Reports |
|---|---|
| Across health and non-health sectors | 5 |
| Between care settings | 38 |
| Hybrid paper and digital record | 7 |
| National-to-local information flow | 2 |
| Patient-to-service channel | 4 |
| Within a care setting | 15 |