Stephen Tidey
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-114 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2018-0140 |
| Registered primary source | SRC-114 |
| Report date | 2018-05-08 |
| Coroner area | Surrey |
| Clinical setting | Police and mental-health crisis care |
| Care transition | Police, local authority and mental-health safeguarding |
| Primary workflow group | Risk, care planning and safeguarding |
| Primary browsing context | Cross-setting and multi-agency care |
| Predominant information boundary | Across health and non-health sectors |
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 | Police, local authority or other non-health agency, Social care, care home or supported living, Community mental-health care |
| Information or work-item origin | Multiple settings or services |
| Origin care context(s) | Non-health agency, Community care |
| Expected action destination | Multiple settings or services |
| Destination care context(s) | Social care, Community care |
| Directional pathway | Multiple settings or services → Multiple settings or services |
| Care-setting span | Multiple care settings |
| Sector boundary | Health, social care and other non-health sectors |
| Failure point | Multiple points |
| Classification confidence | high |
Classification note: Police and liaison-service risk information fed a local-authority MASH pathway and community mental-health follow-up. Missing records, emailed hand-offs and unowned referral action affected multiple points across health, policing and safeguarding.
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 | LOOP, INT, PROV, RES, GOV |
Qualification recorded in the dataset: The report concerned a suicide and wider failures in managing risk; the email and record mechanisms were part of that pathway and cannot be isolated as the sole cause
“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
Fragmented risk information and unowned referral action left foreseeable risk unmanaged
Requested action
Surrey and Borders Partnership NHS Foundation Trust, Surrey County Council and Surrey Police to act
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | Police and mental-health records plus emailed MASH referral |
| Digital function | Multi-agency risk recording and referral ownership |
| Failure mode | Known risk was not consistently visible across police and mental-health systems and an emailed safeguarding referral lacked reliable ownership and follow-up |
| Human-factors issue | Users saw different partial risk pictures and email appeared to complete a process that had no closed loop |
| Workflow issue | No accountable workflow acknowledged, triaged and completed the MASH referral |
| Information issue | Material risk and referral state were distributed across agency systems |
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.