Adrian Jennings
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-111 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2018-0111 |
| Registered primary source | SRC-111 |
| Report date | 2018-04-19 |
| Coroner area | Manchester (South) |
| Clinical setting | Mental-health and acute care |
| Care transition | Mental-health teams, GP and hospital |
| Primary workflow group | Referral, handover and transfer |
| Primary browsing context | Mental health 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 | Inpatient or secure mental-health care, Community mental-health care, Secondary acute or outpatient care |
| Information or work-item origin | Multiple settings or services |
| Origin care context(s) | Secondary care, Community care |
| Expected action destination | Multiple settings or services |
| Destination care context(s) | Secondary care, Community care |
| Directional pathway | Multiple settings or services → Multiple settings or services |
| Care-setting span | Multiple care settings |
| Sector boundary | Health services only |
| Failure point | Multiple points |
| Classification confidence | high |
Classification note: The primary report describes separate IT systems between mental-health teams, a failed joined-up inpatient-to-community discharge plan and a separate acute-hospital booking-record limitation; there are multiple information origins, action points and failures.
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, LOOP, HF, GOV |
Qualification recorded in the dataset: The report said lack of support and communication probably contributed to the death; the IT mechanisms were part of that wider pathway and were not isolated causally
“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 systems and inflexible recording contributed to inadequate support and communication
Requested action
Pennine Care NHS Foundation Trust to act
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | Separate clinical IT systems and Lorenzo |
| Digital function | Cross-team information transfer and structured recording |
| Failure mode | Relevant information was held in separate systems and Lorenzo fields did not readily represent the required clinical context |
| Human-factors issue | Rigid fields and different system mental models impeded a shared understanding |
| Workflow issue | Communication and follow-up depended on manual transfer between teams |
| Information issue | Material care information was fragmented across systems and constrained fields |
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.