Joan Lunt
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-116 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2018-0164 |
| Registered primary source | SRC-116 |
| Report date | 2018-05-29 |
| Coroner area | Manchester (South) |
| Clinical setting | Residential care |
| Care transition | Agency staffing within a care home |
| Primary workflow group | Record integrity and provenance |
| Primary browsing context | Primary and community care |
| Predominant information boundary | Within a care setting |
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 |
| Information or work-item origin | Social care, care home or supported living |
| Origin care context(s) | Social care |
| Expected action destination | Social care, care home or supported living |
| Destination care context(s) | Social care |
| Directional pathway | Social care, care home or supported living → Social care, care home or supported living |
| Care-setting span | One care setting |
| Sector boundary | Social care only |
| Failure point | Originating service |
| Classification confidence | high |
Classification note: Agency staff created care entries under proxy or generic identities inside one residential-care setting, so provenance was defective at record creation.
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 | PROV, HF, GOV |
Qualification recorded in the dataset: The death was from natural causes; inclusion is based on the explicit future-risk concern about electronic identity and provenance
“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
Shared identity in the electronic record undermined accountability and safe investigation
Requested action
Harbour Healthcare Limited to act
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | Electronic care record using proxy or generic user identity |
| Digital function | Authentication and record provenance |
| Failure mode | Agency staff recorded care through proxy or generic electronic identities, obscuring who entered or performed care |
| Human-factors issue | The access arrangement normalised recording under another identity |
| Workflow issue | Governance did not ensure timely individual access for temporary staff |
| Information issue | Electronic entries could not be reliably attributed to the actual author or actor |
Downstream Defence trace
Canonical candidate requirements that cite this report: REQ-008. These links are analytical translations and do not make the requirement a coronial recommendation or a validated Defence control.
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.