Patricia Heslop
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-110 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2018-0102 |
| Registered primary source | SRC-110 |
| Report date | 2018-04-12 |
| Coroner area | Sunderland |
| Clinical setting | Care home and community healthcare |
| Care transition | Care home, primary care and external review |
| Primary workflow group | Risk, care planning and safeguarding |
| 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, Primary care, Community health or rehabilitation |
| Information or work-item origin | Social care, care home or supported living |
| Origin care context(s) | Social care |
| Expected action destination | Multiple settings or services |
| Destination care context(s) | Social care, Primary care, Community care |
| Directional pathway | Social care, care home or supported living → Multiple settings or services |
| Care-setting span | Multiple care settings |
| Sector boundary | Health and social care |
| Failure point | Multiple points |
| Classification confidence | medium |
Classification note: Changes in presentation and care-plan information arose principally in the care home and were needed by care-home staff, primary care and external reviewers. The source does not isolate a single recipient or failure point across the fragmented forms.
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, PROV, HF, GOV |
Qualification recorded in the dataset: The report expressly stated that the identified delay did not cause or contribute to this death; inclusion is based on the explicit concern that numerous forms were used instead of an integrated IT system
“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
Multiple forms in place of integrated IT, incomplete records and unclear responsibility created continuing risk
Requested action
Department of Health and HC-One to act
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | Multiple forms without an integrated IT system |
| Digital function | Care-plan and documentation integration |
| Failure mode | Numerous forms, incomplete records and absent integration did not create a coherent current account of care |
| Human-factors issue | Staff were unsure who should complete forms for themselves or on behalf of others |
| Workflow issue | Care plans were not consistently updated and documents were not reliably reviewed or read |
| Information issue | Material changes in presentation were not collated and records were incomplete or inaccurate |
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.