Michalla Sweeting
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-117 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2018-0165 |
| Registered primary source | SRC-117 |
| Report date | 2018-05-21 |
| Coroner area | Avon |
| Clinical setting | Custodial and community healthcare |
| Care transition | Custody healthcare assessment and follow-up |
| Primary workflow group | Referral, handover and transfer |
| Primary browsing context | Secure and custodial 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 | Prison, custody or secure healthcare |
| Information or work-item origin | Prison, custody or secure healthcare |
| Origin care context(s) | Secure or custodial healthcare |
| Expected action destination | Prison, custody or secure healthcare |
| Destination care context(s) | Secure or custodial healthcare |
| Directional pathway | Prison, custody or secure healthcare → Prison, custody or secure healthcare |
| Care-setting span | One care setting |
| Sector boundary | Health services only |
| Failure point | Multiple points |
| Classification confidence | high |
Classification note: The oversedation observation arose and required review within custodial healthcare. Delayed or incomplete recording and failure to review or act affected both creation and use of the work item.
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, VIS, PROV, HF |
Qualification recorded in the dataset: The jury found that combined neglect contributed to the death; the SystmOne and documentation mechanisms were among several factors and are 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
Recording and review arrangements did not ensure that oversedation risk prompted clinical action
Requested action
Bristol Community Health to act
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | SystmOne |
| Digital function | Medication-risk documentation and action |
| Failure mode | An oversedation observation recorded in SystmOne was not reliably reviewed or acted on, and documentation was incomplete or delayed |
| Human-factors issue | Record availability was treated as equivalent to active communication |
| Workflow issue | No owned escalation closed the loop on the recorded medication risk |
| Information issue | The longitudinal record did not provide a timely, actioned account of the deterioration |
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.