Darren Carrington
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-118 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2018-0181 |
| Registered primary source | SRC-118 |
| Report date | 2018-06-15 |
| Coroner area | Brighton and Hove |
| Clinical setting | Primary care and pharmacy |
| Care transition | GP, online repeat request and pharmacy supply |
| Primary workflow group | Medication and prescribing |
| Primary browsing context | Primary and community care |
| Predominant information boundary | Patient-to-service channel |
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 | Patient or home, Primary care, Pharmacy or dispensing service |
| Information or work-item origin | Patient or home |
| Origin care context(s) | Patient or public |
| Expected action destination | Multiple settings or services |
| Destination care context(s) | Primary care, Pharmacy |
| Directional pathway | Patient or home → 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 online repeat request originated with the patient and required prescribing and supply decisions by primary care and pharmacy. Alert overrides, repeat issue, supply and absent review created failures at multiple stages of the patient-to-service pathway.
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 | ALERT, LOOP, HF, GOV |
Qualification recorded in the dataset: The death involved overdose and wider prescribing and patient factors; the report does not isolate the electronic alerts or online route 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
Existing alert and repeat-prescribing controls did not prevent unsafe continued access to medication
Requested action
North Laine Medical Centre and Brighton and Hove Clinical Commissioning Group to act
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | GP prescribing system and online repeat-prescription workflow |
| Digital function | Prescribing alerts, repeat issue and medication review |
| Failure mode | Warnings could be overridden and repeat or pharmacy supply pathways allowed high-risk medication to continue without dependable review |
| Human-factors issue | Frequent or non-specific warnings could be bypassed without making cumulative risk salient |
| Workflow issue | No closed-loop check reconciled online requests, repeat supply and the planned clinical review |
| Information issue | Prescribers and dispensers did not receive one reliable view of cumulative medication risk and supply |
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.