John Hazlewood
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-119 · Return to all included reports · Open the case–mechanism/evidence map
Report metadata
| Field | Value |
|---|---|
| PFD reference | 2018-0189 |
| Registered primary source | SRC-119 |
| Report date | 2018-06-21 |
| Coroner area | Leicester City and Leicestershire South |
| Clinical setting | Mental-health and acute care |
| Care transition | Out-of-hours psychiatry to hospital team |
| Primary workflow group | Record access and continuity |
| 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 | Secondary acute or outpatient care, Community mental-health care |
| Information or work-item origin | Multiple settings or services |
| Origin care context(s) | Secondary care, Community care |
| Expected action destination | Multiple settings or services |
| Destination care context(s) | Secondary care, Community care |
| Directional pathway | Multiple settings or services → Multiple settings or services |
| Care-setting span | Multiple care settings |
| Sector boundary | Health services only |
| Failure point | Transfer or interface |
| Classification confidence | high |
Classification note: The primary report describes a bidirectional boundary: the on-call psychiatrist could not retrieve the community psychiatric history while managing an acute attendance and could not record the self-discharge discussion for the community consultant to act on.
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 | Response evidence noted |
| Registered response sources | SRC-170, SRC-171 |
| Non-exclusive mechanism codes | LOOP, INT, PROV, RES |
Qualification recorded in the dataset: The report identifies failures in access, documentation and escalation; it does not support attributing the outcome to a single system defect
“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
Lack of remote record access and documentation undermined safety-netting and escalation
Requested action
Leicestershire Partnership NHS Trust and University Hospitals of Leicester NHS Trust to act
Digital safety characterisation
| Dimension | Project extraction |
|---|---|
| System or record type | Remote access to electronic clinical records |
| Digital function | Out-of-hours record retrieval and documentation |
| Failure mode | The on-call psychiatrist could neither retrieve the relevant record remotely nor enter the assessment for other clinicians to see |
| Human-factors issue | The system boundary forced decisions from incomplete information and displaced documentation into fragile alternatives |
| Workflow issue | No resilient workflow preserved and escalated the assessment when normal access was unavailable |
| Information issue | The contemporaneous assessment was unavailable to the teams responsible for subsequent action |
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.
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