Counter-positions, clarifications and documentary anomalies

This register makes respondent counter-positions and source anomalies visible without merging them into coronial findings or adjudicating by preference. It records only bounded differences already supported by the registered primary report and response sources.

These classes describe relationships between registered statements. They are not findings about truth, source credibility or organisational performance. A response can also report proposed or completed action; that remains a respondent claim until independently verified.

Canonical data: disagreements.csv · source register · response catalogue

DIS-001 — Compatible clarification

Report: Rachelle Ross — 2023-0067

Scope: Screening-alert and non-responder-state representation

Neutral account: Respondents narrow the coroner's concern to missing computable non-responder status rather than absence of all screening alerts.

Registered evidence: primary SRC-002; response SRC-016, SRC-076, SRC-077, SRC-078.

Qualification: Generic due or outstanding smear alerts and separate worklists do not establish that national non-responder status was supplied into the EPR as computable data.

DIS-002 — Compatible clarification

Report: Alexander Braund — 2022-0407

Scope: Visibility of amendment provenance across live and exported representations

Neutral account: The response clarifies that provenance existed in the live audit but was not visible in the representation used for investigation.

Registered evidence: primary SRC-003; response SRC-017.

Qualification: Compatible accounts about different system representations must not be collapsed into either complete absence or complete visibility of provenance.

DIS-003 — Counter-risk

Report: Christopher Collinson — 2021-0361

Scope: Proposed prescribing confirmation alert

Neutral account: The Trust does not erase the coroner's prescribing and allocation concerns but identifies alert fatigue as a hazard of one proposed remedy.

Registered evidence: primary SRC-060; response SRC-083.

Qualification: This is a counter-risk affecting control design, not a rebuttal of the report-specific concern or evidence that the replacement workflow is effective.

DIS-004 — Material disagreement

Report: Theo Tuikubulau — 2026-0006

Scope: Cross-system respiratory triage consistency and need for change

Neutral account: The coroner and respondent retain materially different accounts of cross-system consistency and the need for change.

Registered evidence: primary SRC-070; response SRC-100, SRC-101.

Qualification: NHS England's position depends on the full presentation being appropriately triaged and remains a respondent account, not an adjudication of the coronial concern.

DIS-005 — Material disagreement

Report: Elton Deutekom — 2024-0660

Scope: Retrospective transcription and disposal of contemporaneous notes

Neutral account: The Trust disputes the adverse interpretation of transcription and disposal, while the underlying provenance concern remains.

Registered evidence: primary SRC-068; response SRC-095.

Qualification: Only SRC-095 supports this counter-position; SRC-096 concerns separate national matters and is not included here.

DIS-006 — Material disagreement

Report: Bernard Compton — 2024-0304

Scope: Telephone-triage categorisation

Neutral account: The algorithm strand remains contested, separately from the unreviewed troponin and repeat-ECG failures.

Registered evidence: primary SRC-073; response SRC-103.

Qualification: SRC-103 reports the ambulance service's view indirectly; it is not a direct ambulance-service response and does not resolve the other concerns in the report.

DIS-007 — Material disagreement

Report: Alan Mitchell — 2025-0577

Scope: Medication-expiry behaviour and configuration

Neutral account: The source accounts materially disagree about default behaviour; the dataset retains that this medication issue was not causal in the death.

Registered evidence: primary SRC-203; response SRC-258.

Qualification: The supplier describes optional authorised configuration and movement to Past medication; this must not be generalised to every deployed configuration.

DIS-008 — Material disagreement

Report: Venetia Pierce — 2025-0427

Scope: Presentation of the specific medicine warning in the prescribing workflow

Neutral account: The supplier gives a materially different warning account, but it does not independently prove that the specific alert at issue appeared in the prescribing workflow.

Registered evidence: primary SRC-210; response SRC-268.

Qualification: The disagreement is narrowly scoped to warning presentation and access; it is not evidence that every relevant warning was visible or acted upon.

DIS-009 — Compatible clarification

Report: Margaret McNaughton — 2025-0397

Scope: Remedial allergy controls and planned audit

Neutral account: The response describes remedial controls consistent with the coroner's concern and is not implementation or effectiveness evidence.

Registered evidence: primary SRC-214; response SRC-275.

Qualification: Several actions were prospective; the registered response note does not safely support classifying the source-availability issue as a material disagreement.

DIS-010 — Documentary anomaly

Report: Thomas Mallinson — 2025-0333

Scope: Dates and report description in one registered recipient response

Neutral account: Conflicting dates in the response materially limit its documentary reliability without displacing the coroner's concern about referral ownership and repeat-contact escalation.

Registered evidence: primary SRC-218; response SRC-278.

Qualification: The anomaly applies to SRC-278; the other registered responses have separate, bounded support and are not characterised by this record.