Greg Hutchins
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-112 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2018-0129 |
| Registered primary source | SRC-112 |
| Report date | 2018-09-12 |
| Coroner area | Warwickshire |
| Clinical setting | Community mental-health care |
| Care transition | Telephone triage, GP and mental-health services |
| Primary workflow group | Risk, care planning and safeguarding |
| 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 | Community mental-health care, Primary care |
| Information or work-item origin | Community mental-health care |
| Origin care context(s) | Community care |
| Expected action destination | Multiple settings or services |
| Destination care context(s) | Community care, Primary care |
| Directional pathway | Community mental-health care → Multiple settings or services |
| Care-setting span | Multiple care settings |
| Sector boundary | Health services only |
| Failure point | Multiple points |
| Classification confidence | medium |
Classification note: The telephone-triage contact arose in a community mental-health service, was not recorded in RiO and could not be shared rapidly for a patient from outside the area. The canonical extraction includes GP and mental-health services but the primary report does not identify one later accountable destination.
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, LOOP, GOV |
Qualification recorded in the dataset: The inquest concerned suicide; the report records documentation and sharing concerns but does not make a separate causal finding about RiO or national interoperability
“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
Mental-health contacts and risk information were not consistently recorded and available across services
Requested action
Birmingham and Solihull Mental Health NHS Foundation Trust to act
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | RiO and separate national or primary-care records |
| Digital function | Telephone-contact documentation and record sharing |
| Failure mode | A material telephone triage contact was not recorded in RiO and the available systems did not provide dependable cross-service sharing |
| Human-factors issue | Clinicians assessing later risk could not see the complete recent contact history |
| Workflow issue | No reliable workflow ensured that telephone assessment entered the longitudinal record and was shared |
| Information issue | Risk-relevant information remained local or absent from the accessible record |
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.