Mavis Reeves
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-129 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2018-0035 |
| Registered primary source | SRC-129 |
| Report date | 2018-02-06 |
| Coroner area | Bedfordshire and Luton |
| Clinical setting | Retirement housing telecare |
| Care transition | Resident Careline call to ambulance access |
| Primary workflow group | Triage, observations and decision support |
| Primary browsing context | Primary and community care |
| Predominant information boundary | Patient-to-service channel |
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 | Patient or home, Police, local authority or other non-health agency, Ambulance, NHS 111 or urgent response |
| Information or work-item origin | Patient or home |
| Origin care context(s) | Patient or public |
| Expected action destination | Ambulance, NHS 111 or urgent response |
| Destination care context(s) | Ambulance or urgent response |
| Directional pathway | Patient or home → Ambulance, NHS 111 or urgent response |
| Care-setting span | One care setting |
| Sector boundary | Health and non-health sectors |
| Failure point | Transfer or interface |
| Classification confidence | high |
Classification note: The resident's Careline emergency call passed through a retirement-housing telecare provider to ambulance responders. Analogue-line contention and delayed or incorrect access-code delivery impeded the patient-to-service transfer.
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 | RES, HF, VIS, GOV |
Qualification recorded in the dataset: Included as a bounded telecare and health-IT design case rather than an EHR case; the conclusion was natural causes and the report did not find that the system delay 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
Analogue telecare architecture and emergency-access arrangements created delay and single-point-of-failure risk
Requested action
FirstPort Retirement Property Services Limited to act
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | Analogue Careline and automated building-entry system |
| Digital function | Emergency telecare connection and access |
| Failure mode | A single analogue line meant an active Careline call could block the entry call and other residents, while access-code delivery and connection were delayed |
| Human-factors issue | The system behaviour was not apparent to residents or responders and the available code could be late or incorrect |
| Workflow issue | There was no resilient alternative that guaranteed emergency-service entry while the telecare line was occupied |
| Information issue | Caller data and building-access information were transmitted slowly and did not reliably reach the responder at the point of need |
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.