David Buttriss
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-108 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2018-0010 |
| Registered primary source | SRC-108 |
| Report date | 2018-01-12 |
| Coroner area | Cornwall and the Isles of Scilly |
| Clinical setting | Primary care and mental-health services |
| Care transition | GP, out-of-hours, mental-health and acute care |
| Primary workflow group | Record access and continuity |
| Primary browsing context | Cross-setting and multi-agency 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 | Primary care, Community mental-health care, Secondary acute or outpatient care |
| Information or work-item origin | Multiple settings or services |
| Origin care context(s) | Primary care, Community care, Secondary care |
| Expected action destination | Multiple settings or services |
| Destination care context(s) | Primary care, Community care, Secondary care |
| Directional pathway | Multiple settings or services → Multiple settings or services |
| Care-setting span | Multiple care settings |
| Sector boundary | Health services only |
| Failure point | Transfer or interface |
| Classification confidence | medium |
Classification note: Material risk and recent-contact information was held across GP, out-of-hours, mental-health and acute services. The report does not support one directional pathway, so origin and destination remain multiple; cross-service record access was the predominant failure.
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 | INT, VIS, RES, GOV |
Qualification recorded in the dataset: The inquest concerned suicide; the report identifies record fragmentation as a future-death risk but does not make a separate finding that the digital systems caused the death
“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
Separate records prevented a coherent view of the patient across services
Requested action
Cornwall NHS bodies and NHS England to act
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | Separate GP, out-of-hours and mental-health records |
| Digital function | Cross-service record access and continuity |
| Failure mode | Clinicians in different services could not reliably access the records held by the other services |
| Human-factors issue | Each clinician worked from a partial view and could reasonably assume that another record contained relevant information |
| Workflow issue | There was no dependable cross-service workflow for reconciling risk and recent contacts |
| Information issue | Material clinical and risk information was distributed across inaccessible records |
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.