Pauline Pryor
Evidence boundary. This page is a structured project extraction from the linked primary Prevention of Future Deaths source. It is not the report text. Do not infer cause, prevalence or product-wide performance beyond the source and the explicit qualification below.
Open the primary Judiciary source · Source register: SRC-107 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2018-0009 |
| Registered primary source | SRC-107 |
| Report date | 2018-01-12 |
| Coroner area | Cornwall and the Isles of Scilly |
| Clinical setting | Primary care |
| Care transition | Hospital, GP and community monitoring |
| Primary workflow group | Medication and prescribing |
| Primary browsing context | Primary and community care |
| Predominant information boundary | Between care settings |
The workflow, browsing-context and predominant-boundary fields are retained navigation aids. They are not additional coronial findings, and a single primary value cannot express every aspect of a multi-setting or multi-mechanism report.
Care-pathway classification
This classification distinguishes where safety-relevant information or work arose, where action was expected and where the digital or information workflow failed. It is a project coding of the source, not a coronial statement. “Origin” does not mean the organisation caused the harm.
| Dimension | Project classification |
|---|---|
| Settings and pathway participants | Social care, care home or supported living, Community mental-health care, Primary care |
| Information or work-item origin | Multiple settings or services |
| Origin care context(s) | Social care, Community care, Primary care |
| Expected action destination | Primary care |
| Destination care context(s) | Primary care |
| Directional pathway | Multiple settings or services → Primary care |
| Care-setting span | Multiple care settings |
| Sector boundary | Health and social care |
| Failure point | Multiple points |
| Classification confidence | high |
Classification note: The primary report identifies shared monitoring between a nursing home, mental-health service and GP. The nursing-home request, GP renal result and psychiatrist's email created multiple inputs for GP action; incomplete QOF prompting and failed communication affected several points.
Classification confidence applies only to this care-pathway coding. It is separate from extraction confidence, source authority and causal certainty.
Evidence status and qualification
| Field | Status |
|---|---|
| Extraction confidence | high |
| Verification status | Primary source linked; high-confidence extraction |
| Response evidence status | Not assessed in this dataset |
| Registered response sources | None registered for this row |
| Non-exclusive mechanism codes | ALERT, LOOP, INT, RES, GOV |
Qualification recorded in the dataset: Lithium toxicity formed part of the sequence leading to death; the reminder and email mechanisms were contributory workflow concerns but were not isolated as the sole cause
“Response evidence noted” means only that the row qualification refers to response/respondent evidence or records a recipient's post-report position. The linked IDs enumerate the official response attachments registered for this row; they do not imply that every response supports every part of the qualification, and they do not establish implementation. “Not assessed” makes no claim about whether a response exists.
Structured project extraction
These fields are analytical summaries, not quotations.
Project summary of the coroner's concern
Monitoring systems and follow-up did not reliably prompt and complete lithium surveillance
Requested action
NHS England to act
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | GP electronic record, QOF reminder and email |
| Digital function | Lithium monitoring reminder and follow-up |
| Failure mode | The QOF reminder did not include the required lithium-monitoring action and an email identifying concern was neither seen nor chased |
| Human-factors issue | Users depended on an incomplete reminder and an email channel without dependable visibility |
| Workflow issue | No owned task, acknowledgement or escalation closed the monitoring loop |
| Information issue | Monitoring need and concern were fragmented between the coded reminder and email |
Downstream Defence trace
No canonical candidate Defence requirement currently cites this report. This does not imply that the mechanism is irrelevant; any mapping must be added and qualified in the controlled requirements register.
The included-case dataset preserves early legacy_military_relevance and legacy_derived_requirement fields for audit history. They are not published here as requirements and must not override the canonical REQ register. New report rows do not need to populate them.