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 | GOV, VIS, HF, RES |
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.
Return to all included reports · Open the corpus profile · Review assurance and uncertainty · Open the case–mechanism/evidence map